Folic Health Organization, (2008) defines Anemia in

Folic acid and iron are vital micronutrients for normal functioning, growth, maintenance and development of human body. Like other nutrients, their uptake demand in the body increases during pregnancy and in order to meet the daily requirement there is need for supplementation. The high demand for nutrients may not be easy to be met through regular diet since the diet has insufficient amount as well as its low bioavailability particularly in developing countries. This disproportion cause imbalances between body demand and supply of these micronutrients thus deficiency of folic acid and iron resulting to anemia (WHO, 2013).
Anemia is a significant public health problem throughout the world, affecting about two billion people. World Health Organization, (2008) defines Anemia in pregnancy as the decrease of hemoglobin concentration to below 11 g/Dl. Both Folic acid and Iron deficiency is the most common nutritional cause of anaemia and has been associated with poor pregnancy outcome. According to Yekta and others (2012) about 20% and 50% of pregnant women from developed and developing countries respectively suffer from iron deficiencies. On the other hand, lack of adequate folate intake prior to conception and during the early weeks of pregnancy increases the risk of the development of neural tube defects (Yekta et al., 2012).
Iron is a mineral that plays an important role in the production of red blood cells. The most practicable mass intervention for iron tablet supplementation is iron tablet administration along with folate in form of tablets. Foliate deficiency leads to anemia and several other unintended pregnancy outcomes. Pregnancy needs 30-60 mg of iron tablets as per the WHO’s recommendations and 400?g Folic acid daily in the gestation period which is received during ANC follow ups (WHO, 2012). Most women won’t have enough iron stores to provide this amount of iron each day throughout pregnancy. It’s almost impossible to get this much from diet and even if one overeats, which is not good for the baby. Because up to 20 percent of all pregnant women are iron-deficient, iron supplements are often prescribed during the second half of pregnancy (Bekele et al., 2015).
According to World health organization, (2015) anaemia is a major cause of morbidity and mortality of pregnant women and increases the risks of foetal, neonatal and infant mortality. Anaemia during pregnancy contributes to 20% of all maternal deaths. Globally, it is estimated that in the year 2013 two hundred and eighty-nine thousand (289,000) women died. Additionally, three million infants died in 2015 due to preventable reasons related to maternal nutritional status. It is clear that the world-wide prevalence of folic acid and iron supplements deficiency in the populace is silence due to lack of data from many parts of the world.
In developing countries anemia account for 99% (286 000) of the global maternal deaths with sub -Saharan Africa region alone accounting for 88%. According to UNICEF (2015) Sub Sahara Africa reported the highest maternal deaths of 546 per 100000 live births (maternal mortality) which implied 201,000 deaths a year. It was also noted that majority of the deaths happen among women of low income status as well as young maternal age. About 800 women a day are still dying from complications in pregnancy and childbirth globally (WHOa, 2015). Anaemia contributes to 20% of all maternal deaths (WHOb, 2015).
According to EDHS, (2012) report, about 17% of Ethiopian women of reproductive age suffers from the condition and 22% of pregnant women are anemic. A higher proportion of reproductive age women (35%) living in Afar reach region suffer from anemia. Studies show that women who access antenatal care service will have infants with a reduced danger from neonatal deaths. World Health Organization, (2012) in a report recommends Iron folic acid supplementation as one of the key interventions to alleviate anemia and folic iron deficiencies. Most countries aim in getting all pregnant women receives folic iron tablets during pregnancy as per the WHO recommendations. But, in regions where it is critically severe to more than 40% is of a public health concern and supplementation should be given up to three months of postpartum period. Anaemia during pregnancy is considered severe when Hb concentration is less than 7.0 g/dl, moderate when Hb level is 7.0 – 9.9 g/dl, and mild when Hb level is 10.0 – 10.9 g/dl (Salhan et al., 2012).
The National guideline for micronutrients deficiencies control and prevention indicates that daily folic iron supplementation for at least six months at pregnancy period and three months during postpartum is very vital. The national Iron Folic Supplementation strategy states a goal to enrich pregnancy and postpartum by fifty percent. Even though ANC is targeted as a key platform for folic iron supplementation, in national coverage only 47% of pregnant mothers complete four ANC visits with only 15% obtaining ANC services in the first trimester of pregnancy (Minstry of Health, National Iron and Folic Acid Supplementation , 2013).

According to KDHS (2014) maternal mortality is defined as deaths that occur during pregnancy, delivery and post-delivery up to two months or at end of gestation period. The third SDG is premised at strengthening access to health care and nutrition services for pregnant women and newborns in Africa. Additionally, fourth SDG purposes at improving maternal nutrition with an aim of reducing mortalities linked to maternal problems including anaemia (UNICEF, 2012).
In Kenya, according to MOH, National Iron and Folic acid supplementation communication strategy (2013), the most current micronutrient survey in the country indicated the prevalence of anaemia among pregnant women to be high at 55.1% and 46.4% among non-pregnant women and 70% among pregnant women. All pregnant women are targeted for free folic acid and iron supplementation. However, statistics show that in Kenya adherence rate for iron-folic acid supplements consumption has been as low as 2.5% and coverage of 69% for pregnant women for less than 90 days (Mintry of Health, IFAS Strategic plan(2013-2017).
Despite the known effects of folic iron deficiencies, the available data regarding factors affecting utilization of folate and iron supplementation services among pregnant women attending ANC services in Kenya is limited. In Laikipia specifically, there are no documented studies on adherence rate, and factors affecting utilization of folate and iron supplementation services among pregnant women. Hence this study was aimed at determing factors affecting utilization of folate and iron supplementation services among pregnant women attending ANC services at Nyahururu Sub county Hospital.
1.2 Problem Statement
Globally, iron deficiency is the leading prevalent public health nutrient deficiency due to its potential consequences and high prevalence. The deficiency is connected to adverse pregnancy outcomes including neonatal and maternal mortality, still births, preterm delivery and low birth weight. Among the vulnerable individuals of iron deficiency are the infants, since there has been connecting between neonatal and maternal iron status. For that reason, interventions targeting the infants alone would be insignificant to reducing the infant iron status (Burke et al., 2014).
According to Samuel and others (2014) for each 1g/dl haemoglobin increase, death risk is reduced by 24% as well 1.8 million deaths in infants and children aged 28days to about 10 years will be avoided. The iron-folic acid supplementation strategies are most practicable ways to achieve such increase in haemoglobin.
A study conducted by Githigi and others (2013) indicated that Of the 381 participants, only 23.6 % received antenatal care in the first trimester; on the other hand 51.2 % and 69.3 obtained iron and folic acid tablets, respectively. Conversely, only half (45–58 %) got any information regarding supplementation. Most women interviewed had started on iron (67.7 %) or folic acid (80.7 %) late after 12 and 16 weeks of their pregnancy, respectively, after the WHO recommended time period.
Additionally, according to Titaley and Dibley (2012) in a study done in Nepal and Pakistan revealed that when iron tablets are taken more than 90 days and initiated before/at fifth month of conception, premature neonatal deaths are decreased by 57 and 45% respectively. And similarly death risks were reduced by more than half in the study subjects who consumed iron-folic acid during pregnancy.
Many developing countries have implemented iron-folic acid supplementation programs in their health facilities but few countries have had significant progress in anemia prevention and control.
Studies done in various parts of the globe especially in Africa, Latin America and Asia have revealed low utilization of daily iron-folic acid supplements by women and it has been the major reason as to why the program has been less significant in terms of results. There are various factors that can influence the utilization of iron-folic acid tablets, which are yet to be studied exhaustively (Wendt et al., 2015).
In Kenya, iron-folic acid tablets supplementation is the major strategy for anaemia prevention and control however utilization rate remains low. According to KDHS, 2014 the iron-folic acid coverage is 69% and utilization of 2.5% for more than 90 days. Even though utilization rate is a main problem in iron-folic acid supplementation program, few researches have been conducted and the best knowledge of the researcher no study has been documented in the study area with the same title. Consequently, this study will be conducted to determine factors affecting utilization of folate and iron supplements among pregnant women attending ANC in Nyahururu Sub County hospital, Laikipia County.
1.3 Justification
Iron-folic acid deficiency has adverse effects. According WHO recommendation and national nutritional policy in Kenya all pregnant women should consume a standard dose of 30 to 60 mg of iron tablets and 400 ?g folic acid tablet daily for 90 or more days, which should be initiated quite early during the pregnancy (WHO, 2012). One of the current routinely conducted programmes is supplementation to reduce anemia prevalence through ANC clinics. However, utilization rates of the supplements at various health facilities have not been documented thus and only a country estimate of 2.5%. It is not vivid whether pregnant women consume the supplements (WHO, 2012).
Since Nyahururu Sub county hospital is a level 4 hospital with a large catchment area in Laikipia county of Kenya, it would be more representative of the county and the region than other smaller facilities with lesser catchment area. On another note the facility provides supplementation services to women through ANC clinic.
1.4 Hypothesis
Utilization to iron-folic acid supplements is greatly associated with number of ANC visits, health facility distance, low social economic status, and personal beliefs of the pregnant women.
15. Research Questions
i. What is the receipt and use of folic acid and iron supplementation among pregnant women attending ANC at Nyahururu Sub county hospital?
ii. What is the effect of social economic factors on utilization of iron and folic acid supplementation among pregnant women attending ANC at Nyahururu Sub county hospital?
iii. What is the effect of personal beliefs on utilization of iron and folic acid supplementation among pregnant women attending ANC at Nyahururu Sub county hospital?
iv. What is the effect of health facility related factors on utilization of folate and iron supplementary services attending ANC at Nyahururu Sub county hospital?

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