Enhancing the impact of iron and folic supplementation in Malawi.
Anaemia in pregnancy has devastating effects on both the mother and her unborn child. It is associated with significant morbidity and mortality. Mortality particularly increases because mothers who have anaemia are prone to infections because they fight poorly against it. They also compensate poorly to blood loss which increases the risk of death from haemorrhage.
World Health Organization estimates that about 1 in 5 pregnant women are anaemic and the prevalence is higher in low-income countries as compared to high-income countries. This is also true for maternal and new-born health indicators.
According to the 2015/16 Malawi Demographic Health Survey, anaemia affects nearly 40 percent of pregnant women in Malawi.
Evidence shows that routine iron and folic acid supplementation during pregnant can reduce the prevalence of anaemia in pregnancy by over half. WHO recommends daily routine iron and folic acid supplementation in all pregnant women during antenatal period for both prevention and correction of anaemia. Malawi adopted these guidelines and are implemented as part of antenatal care package.
The implementation of these WHO guidelines on iron and folic acid supplementation in Malawi is clinic-based. It mainly targets pregnant women who come for antenatal care. However, the Malawi DHS reported that just above 40 percent of pregnant mothers have 4 or more antenatal care visit as recommended in focused antenatal care. There is also no clear evidence of how adherence monitoring is done. These are some of the challenges that can affect effective iron and folic acid supplementation program.
A randomised trial in Tanzania reported over 60% reduction of risk of anaemia and 50% risk reduction of iron deficiency at the time of delivery with antenatal iron supplementation if adherence counselling and monitoring are scaled up during antenatal care. This is effective for women who make effective use of clinic antenatal care.
A community antenatal intervention program in Nepal reported over 50% reduction in the prevalence of anaemia in pregnancy with iron and folic acid supplementation. This also reported a massive increase (60%) in antenatal service utilisation. This program used the continuum of care model of providing antenatal care and bridged some of the gaps that hinder pregnant women from utilising antenatal care and promoted health education. The program also shifted some of the tasks to community health workers which are already close to the pregnant women in the communities.
Using the same continuum of care model, Nicaragua is reported to have reduced the prevalence of anaemia among pregnant women and in all women of reproductive age through non-selective supplementation of iron and folic acid to all women of reproductive age in 5 years (MCHIP 2011).
Malawi can achieve the levels of success reported in some countries using similar models as it also has similar structures in its health system. Nearly 30% of Malawi’s human resource for health is made up of the Health Surveillance Assistants (HSA). This cadre is similar to community health workers that helped successful program implementation in Nepal. They are wide spread in communities and are recognized highly by the members of communities.
To get the most from iron and folic acid supplementation there is need to scale up adherence counselling and monitoring during antenatal, facilitating early antenatal booking and on a long term, Iron supplementation for all women of reproductive age.
These can be achieved through community outreach antenatal clinics, to bring services closer to users. This will allow the skilled birth attendants who cannot be deployed to rural areas to provide services to the rural population. It will also reduce congestion in facility based clinics and enable health workers have time for health education.
The community outreach antenatal programme requires logistics one of which is transport. Therefore, integrating the program with others which have routine travel to rural areas will minimise the challenges.
On the other hand, shifting the task of supplying iron and folic acid to HSAs will enable access and promote health education regarding compliance. Similarly, on a long term, iron supplementation for all women of reproductive age will be the best approach to reduce the prevalence. The same HSAs working in the communities can support this. There are already other interventions that follow the same model in Malawi on deworming and malaria prevention. Iron supplementation can, therefore, be incorporated as a combined strategy to reduce prevalence of anaemia.
Can effective iron supplementation be achieved in Malawi? YES, with hard work and determination as well as collaborative effort this can achieved. The leadership in quality improvement of the program is required to enhance the impact of iron and folic acid supplementation in Malawi.
About the author
Kelvin Mwale was a student in CMNH's 2017 diploma in sexual and reproductive health (DSRH) programme. He currently works at Mzuzu Central Hospital. He is passionate about using his newly acquired knowledge and skills to improve maternal and newborn care in Malawi.