Adherence to Iron Deficiency Interventions Among Pregnant Women Attending Antenatal Clinics in Ubungo Municipality, Dar Es Salaam, Tanzania

doi:10.21203/rs.3.rs-5165531/v1

Background

Iron deficiency anaemia among pregnant women remains a public health concern despite the iron deficiency interventions put in place. This study investigated the level of adherence to the interventions and the associated factors among pregnant women attending antenatal clinics in Ubungo Municipality.

Methods

This cross-sectional study used a systematic random sampling technique to obtain 503 participants from the surveyed clinics. Interviews were conducted by using interviewer-administered questionnaires. Data were analysed using Stata version 17. The study employed binary and multivariable logistic regression analysis to determine factors associated with adherence to iron deficiency interventions.

Results

In this study, 72% of participants were non-adherent to the interventions. In multivariable regression analysis, participants who forgot to take their iron tables on most days (AOR = 2.35; 95% CI: 1.23–4.48) and those who reported that not enough time was spent on education and coun-selling during antenatal clinic visits (AOR = 3.87; 95% CI:1.08–13.84) were more likely to be non-adherent to iron deficiency interventions.

Conclusions

Majority of pregnant women in Ubungo Municipality were non-adherent to iron deficiency interventions. Non-adherence was associated with a tendency to forget taking iron tablets, and lack of enough time in providing health education and counselling. Improving the quality of health education and counselling could increase adherence to iron deficiency interventions and reduce maternal - child morbidity and mortality rates.

Iron

Adherence

Anaemia

Tablets

Foods

Iron is one of the essential micronutrients that contributes to growth and development (1). The majority of anaemia in women of childbearing age is due to low or absent iron stores, which remains to be a public health concern (2). Anaemia in pregnancy is associated with an increased risk of morbidity and mortality for both the mother and the child (3, 4). Iron requirements in pregnancy are increased due to the increasing blood volume of the mother as well as the additional iron requirements for foetal red blood cells production and fetoplacental growth (5). Other factors that may contribute to the depletion and deficiency of iron include reduced bioavailability and inadequate dietary intake of iron-rich foods (6). It is therefore important to increase iron intake through dietary and supplementary sources in order to prevent moderate and severe forms of iron deficiency anaemia in pregnancy (1). There are consequences of anaemia for women who enter in pregnancy with deplete iron stores which includes an increased risk of child’s neurodevelopment abnormalities, premature births, low birth weight and noteworthy, maternal mortality (7–9).

The prevalence of anaemia among pregnant women of all trimesters is 36.8% on a global scale compared to Africa which is 41.7%, the highest of all continents. Tanzania has a prevalence of 57.1% (10, 11). Several factors have been reported to contribute to the high prevalence of anaemia in Tanzania. These include a big household size; young maternal age; low level of education; insurance coverage; low number of antenatal care (ANC) visits; the low use of antimalarials prophylaxis to mother (4, 11). To combat the problem of iron deficiency anaemia, the World Health Organization (WHO) has recommended a daily elemental iron supplementation of 30 mg – 60 mg per day to all pregnant women from the first trimester throughout the pregnancy in all settings (2). These recommendations are practiced in all health facilities throughout the country by providing iron and folic acid supplements to pregnant women in every visit (12, 13).

The level of adherence to iron deficiency interventions in most Low- and Medium-Income Countries (LMIC) is concerning. The overall level of adherence in sub-Saharan countries is 39.2% with most countries having over half of pregnant women being non-adherent to iron supplementations (14). Adherence to iron deficiency interventions is supported by a comprehensive national reproductive and maternal system that addresses local concerns on non-adherence and hence contributing to increased adherence as seen in Sri-Lanka, whose level of adherence was as high as 80.1% (15). The surrounding factors to a pregnant woman such as partner involvement or family support has been found to increase adherence, while other studies also support the feasibility of direct observation in order for a pregnant woman to follow through with the interventions (16, 17).

Furthermore, advice on the intake of iron supplements provided during ANC visits has been shown to facilitate a positive attitude which in turn increase adherence (14). Providing early health education on the purpose, dosage and duration as well as possible side effects of the supplement has been associated to increased adherence to intake of iron supplements (18). Incorporation and refining dietary education, guidance on modification and intake to boost iron uptake has shown to not only reduce anaemia but also increase adherence (19).

The adherence to the intervention is negatively attributed by pathophysiological factors such as gastrointestinal side effects and intolerance as well as behavioural and socio-demographic factors (13). The latter include forgetfulness, considering one-self to be healthy, misconceptions on intervention, and lack of enough knowledge on the importance of the intervention. The frustrations that come along with service been provided and accessibility to medication has been shown to reduce adherence to pregnant women (20). Comparatively, good adherence of intervention is influenced by short distance of healthcare facilities from residential areas, availability of medications, and quality of care provided at the healthcare facilities that includes comfortability and satisfaction of ANC services which in turn influences adherence of the intervention to pregnant women (21).

Regardless of the presence of prophylactic efforts such as supplementations, anaemia in pregnant women remains to be a public health concern in Tanzania (11). Poor adherence to iron interventions could be a hindering factor towards reduction and lifting the burden of anaemia among pregnant women as evidenced in regions of North western Tanzanian zone, where adherence was 12% (21). Therefore, this study aimed to determine the level of adherence and assess factors affecting adherence to iron deficiency interventions in pregnant women

Study Design and Population

This was a cross sectional study conducted in the antenatal clinics of Sinza Hospital and Kimara Health Center in Ubungo Municipality, Dar es Salaam, Tanzania during the period March to April 2023. Inclusion criteria included a woman of any gravida status who had started iron supplementation or therapy for at least a month or more, and is in the second antenatal visit and above. Exclusion criteria included pregnant women with comorbidities such as sickle cell disease or other blood disorders, and those who were allergic to sulphur containing medications. The ferrous supplementation provided was combined with sulphur.

Sample Size and Sampling Procedure

The sample size was retrieved from Espa Rodriguez for infinite proportion (22) considering: n = the number of sample size obtained, t = standard normal deviate of a 95% confidence interval with 4.5% tolerable error, p = proportion, from presumed prevalence of adherence 50% used with a 5% nonresponse rate. A minimum of 503 respondents were acquired. A systematic random sampling technique was used to obtain the study participants. The study used a list of attendees of the day, one attendee from the list of one to ten was selected at random and thereafter every 5th attendee was selected to participate in the study.

Description of Variables

Adherence to iron deficiency interventions was the dependent variable which was measured using a composite score from four self-reported questions on daily intake and frequency of iron tablets and iron rich foods from the time of receiving the first health education and counselling at the antenatal clinic. The four questions included (i) when did they start taking iron tablets (score 1 = the day it was provided; score 0 = the following days); (ii) how often did they take the iron tablets in a span of a week over the past 1 month (score 1 = everyday; score 0 = 6 days or less per week); (iii) if they had started consuming iron rich foods (score 1 = yes; score 0 = no); and how often they consumed iron rich foods (score 1 = everyday; score 0 = 6 days or less per week). Participants who responded with a composite score of 4 out 4 from the questionnaire, were considered as adherent to iron deficiency interventions. Independent variables included behavioural factors which are daily practices related to adherence to iron deficiency interventions and health service factors which are enabling factors to adherence.

Data Management and Analysis

The collected data was imported into Stata software version 17.0 for further analysis whereby both descriptive and inferential analysis was deployed. On descriptive analysis proportions and frequency tables were used to summarize all categorical variables, which included behavioural factors and health service factors. Likewise, the level of adherence was measured by using self-reported questions provided to the respondents. Inferential analysis using bivariate and multivariable logistic regression was deployed to determine the factors associated with adherence to iron deficiency intervention (i.e., 1 = non adherence and 0 = adherence). Potential confounders added into the models included age, education and occupation. All statistical tests were done at 5% significant level.

Sociodemographic Characteristics of the participants

Out of 503 respondents, 279 of the respondent’s age (55.5% ) ranged from 25-35 years old with the median age of 26 [IQR, 23-31] (Table 1). Respondents with married or living together partners comprised of 83.7% (421/503) and those that had 1 – 3 children were 51.5% (259/503) respectively. This study noted that 65.4% (328/503) sometimes attend the antenatal visits with their partners mostly during the first visit. However, 31.1% (156/503) have never attended the antenatal clinics with their partners. It is important to note that slightly above half of women 51.8% (260/503) started attending antenatal clinic in the first trimester. Around three quarter of pregnant women of all ages were found to be adherent to iron deficiency interventions. Poor adherence was higher among the women with low education level and employed with p-value been 0.015 and 0.017 respectively (Table 1).

Table 1. Characteristics of the study participants

		Adherence		p-value (Chi-squared test)
Variable	N (%)	Yes N (%)	No N (%)	p-value (Chi-squared test)
	n = 503	141 (28)	362 (72)
Age(years)
18-25	178 (35.4)	48 (27.0)	130 (73.0)
26-35	279 (55.5)	82 (29.4)	197 (70.6)	0.690
Above 35	46 (9.1)	11 (23.9)	35 (76.1)
Marital status
With no partner	82 (16.3)	24 (29.3)	58 (70.7)	0.785
With partner	421 (83.7)	117 (27.8)	304 (72.2)	0.785
Education
No formal education	10 (2.0)	4 (40.0)	6 (60.0)
Basic education	402 (79.9)	101 (25.1)	301 (74.9)	0.015
Tertiary	91 (18.1)	36 (39.6)	55 (60.4)
Occupation
Unemployed	304 (60.4)	97 (31.9)	207 (68.1)	0.017
Employed	199 (39.6)	44 (22.1)	155 (77.9)	0.017
Number of biological children
None	236 (46.9)	63 (26.7)	173 (73.3)
1-3	259 (51.5)	76 (29.3)	183 (70.7)	0.792
4 and above	8 (1.6)	2 (25.0)	6 (75.0)
Attendance of ANC clinic with partner
Always	18 (3.6)	4 (22.2)	14 (77.8)
Sometimes	328 (65.4)	94 (28.7)	234 (71.3)	0.827
Never	156 (31.1)	43 (27.6)	113 (72.4)
Initiation of ANC clinic
First trimester	260 (51.8)	63 (24.3)	197 (75.8)
Second trimester	236 (47.0)	77 (32.6)	159 (67.4)	0.095
Third trimester	6 (1.2)	1 (16.7)	5 (83.3)
Anaemia (Current Hb)
Yes	264 (55.4)	71 (26.8)	193 (73.1)	0.517
No	213 (44.6)	63 (29.6)	150 (70.4)

Adherence characteristics with anaemia

This study found that 72% (362/503) of pregnant women were non-adherent to iron deficiency interventions with the level of anaemia among the non-adherent being 56.3% and 53.0% among those who were adherent (Table 2). Participants who began taking their iron tablets later than the day it was provided were found to have a higher score of anaemia (65.2%). And those who were taking iron tablets less than 4 days in a week were found to have anaemia of 71.7% which is higher compared to those who take their tablets every day. This study found that most 87.7% (441/503) of the participants did some sort of dietary modification on iron rich foods. Most participants reported that slightly over half, 51.9% (261/503) increased their iron-rich food intake to 2-6 times a week, and that 40% (201/503) take an iron-rich food every day (Table 2).

Table 2. Adherence to iron deficiency interventions related to the prevalence of anaemia

Variable	N (%)	Anaemia Prevalence (%)
Start of medication intake
The day it was provided	429 (85.3)	53.7
The following days	74 (14.7)	65.2
Uptake of medication
Everyday	412 (81.9)	53.3
Every other day	45 (8.9)	55.8
Less than 4 days in a week	46 (9.1)	71.7
Dietary modification on iron-rich foods
Yes	441 (87.7)	54.9
No	62 (12.3)	58.1
Frequency of uptake of iron rich foods
Everyday	201 (40)	55.2
Seldom (2 – 6 times)	261 (51.9)	54.9
Once a week	41 (8.1)	58.5
Adherence status
Adherence	141 (28)	53.0
Non-adherence	362 (72)	56.3

Behavioural factors associated with adherence to iron deficiency interventions

In all questions that were asked, almost three quarter of the participants were non-adherent to iron deficiency interventions. Respondents who reported that their partners reminded them to take iron tablets were found to be 0.71 less likely (OR 0.71: CI 0.33-1.54, p-value 0.391) to be non—adherent to iron deficiency interventions (Table 3). Some behaviours such as finding no problem in skipping uptake of iron tablets were found to be 1.4 times more likely (OR 1.4: CI 0.32-6.04 p-value 0.646) to be non-adherent. It is noteworthy that this study found that participants who had a tendency to forget taking iron tablets were 2.35 times more likely (OR 2.35: 1.23-4.48 p-value 0.009) to be non-adherent to iron deficiency interventions (Table 3).

Table 3. Behavioural factors associated with adherence to iron deficiency interventions among pregnant women

		Adherence		COR		AOR
Variable	N (%)	Yes N (%)	No N (%)	OR, 95% CI	p-value	OR, 95% CI	p-value
	n= 503	141 (28)	362 (72)
Behavioural factors
Partner’s knowledge on importance of iron tablets
Disagree	47 (9.5)	14 (29.8)	33 (70.2)	1		1
Agree	446 (90.5)	124 (27.8)	322 (72.2)	1.10, (0.57-2.12)	0.773	2.53, (0.84-7.64)	0.098
Partner’s contribution in reminding the uptake of iron tablets
Disagree	105 (21.3)	25 (23.8)	80 (76.2)	1		1
Agree	388 (78.7)	112 (28.9)	276 (71.1)	0.77, (0.46-1.26)	0.306	0.71, (0.33-1.54)	0.391
I don’t need iron tablets if I look healthy
Disagree	423 (90.8)	119 (28.1)	304 (71.9)	1		1
Agree	42 (9.3)	12 (28.6)	30 (71.4)	0.97, (0.48-1.97)	0.952	0.96, (0.35-2.60)	0.940
There’s no problem in skipping uptake of iron tablets
Disagree	414 (90.9)	120 (29)	294 (71)	1		1
Agree	42 (9.1)	5 (23.8)	16 (76.2)	1.30, (0.46-3.64)	0.610	1.40, (0.32-6.04)	0.646
Iron tablets may harm the baby
Disagree	414 (95.2)	123 (28.8)	303 (71.1)	1		1
Agree	21 (4.8)	1 (20)	4 (80)	1.62, (0.17-14.67)	0.666	1.14, (0.10-12.67)	0.910
I take iron tablets when I feel sick
Disagree	426 (98.8)	103 (28)	265 (72)	1		1
Agree	5 (1.2)	35 (29.9)	82 (70.1)	0.91, (0.57-1.43)	0.688	1.19, (0.64-2.19)	0.576
I forget to take iron tablets in most days
Disagree	368 (75.8)	119 (32.7)	245 (67.3)	1		1
Agree	117 (24.1)	22 (16.1)	115 (83.9)	2.53, (1.53-4.21)	0.000	2.35, (1.23-4.48)	0.009
I take extra tablets the next time after an episode of forgetting
Disagree	491 (98)	139 (28.3)	352 (71.7)	1		1
Agree	10 (2.0)	1 (10.0)	9 (90.0)	3.55, (0.44-28.31)	0.231	NC¹	NC¹
I get bored taking tablets everyday
Disagree	308 (62.4)	89 (28.9)	219 (71.1)	1		1
Agree	186 (37.6)	49 (26.3)	137 (73.7)	1.13, (0.75-1.71)	0.540	1.18, (0.68-2.04)	0.549
I eat healthy as advised by the healthcare professional
Disagree	24 (4.8)	1 (4.2)	23 (95.8)	1		1
Agree	473 (95.2)	138 (29.2)	335 (70.8)	0.10, (0.01-0.78)	0.028	0.21, (0.02-1.88)	0.166
I do not like foods advised by the healthcare professional
Disagree	436 (88.1)	130 (29.8)	306 (70.2)	1		1
Agree	59 (11.9)	10 (17.0)	49 (83.0)	2.08, (1.02-4.23)	0.043	1.74, (0.77-3.93)	0.179

¹Non Calculable

Health service factors associated with adherence to iron deficiency interventions

This study found that 94.8% (477/503) received health education and counselling, and among those who received health education and counselling, 91.6% (437/503) reported being provided a complete maternal education including maternal nutrition. And that those who were provided with health education 2-4 times during their pregnancy, were (OR 0.79: CI 0.33-1.90) times less likely to be non-adherent and above 4 times were (OR 0.66: CI 0.26-1.66) less likely to be non-adherent to iron deficiency interventions (Table 4). On the account for the time that was used for education and counselling, the study found that those who reported that the time used for health education was not enough, were (OR 3.87: CI 1.08-13.8 p-value 0.037) times more likely to non-adherent to iron deficiency interventions. This study found that 97.2% (489/503) of the iron tablets were been distributed from the antenatal clinics. However, participants who reported that iron tablets were not enough to sustain them up to the next visit were (OR 1.75: CI 0.86- 3.59) times more likely to be on adherent to iron deficiency interventions, this was however not significant (Table 4).

Table 4. Health service factors associated with adherence to iron deficiency interventions among pregnant women

		Adherence		COR		AOR
Variable	N (%)	Yes N (%)	No N (%)	OR, 95% CI	p-value	OR, 95% CI	p-value
	n= 503	141(28)	372(72)
Health Services
Education and counselling received during ANC visit
Yes	477 (94.8)	136 (28.5)	341 (71.5)	0.59, (0.22-1.61)	0.310	NC	NC
No	26 (5.2)	5 (19.2)	21 (80.7)	1		1
Frequency of education and counselling sessions received
Once	41 (8.6)	9 (21.9)	32 (78.5)	1		1
2 – 4	301 (63.1)	83 (27.6)	218 (72.4)	0.73, (0.33-1.61)	0.448	0.79, (0.33-1.90)	0.605
4 and above	135 (28.3)	44 (32.6)	91 (67.4)	0.58, (0.25-1.32)	0.197	0.66, (0.26-1.66)	0.383
Type of counselling received
Nutrition	14 (2.9)	4 (28.6)	10 (71.4)	1		1
Health (Danger signs etc)	26 (5.5)	7 (26.9)	19 (73.1)	1.08, (0.25-4.61)	0.911	1.02, (0.20-5.07)	0.976
All	437 (91.6)	125 (28.6)	312 (71.4)	0.99, (0.30-3.24)	0.998	1.06, (0.28-4.00)	0.922
Was enough time spent in education and counselling
Yes	451 (94.6)	133 (29.5)	318 (70.5)	1		1
No	26 (5.4)	3 (11.5)	23 (88.5)	3.20, (0.94-10.86)	0.061	3.87, (1.08-13.8)	0.037
Iron tablets were provided during ANC visits
Yes	499 (99.2)	141 (28.3)	358 (71.3)
No	4 (0.8)	0 (0.0)	4 (100.00)	NC¹	NC	NC	NC
Access to iron tablets
Healthy facility	489 (97.2)	139 (28.4)	350 (71.6)	1		1
Community Pharmacies	14 (2.8)	2 (14.3)	12 (85.7)	2.3, (0.52-10.78)	0.260	1.81, (0.34-9.51)	0.482
Iron tablets enough to sustain to the next visit
Often	414 (82.3)	124 (30)	290 (70)	1		1
Seldom	63 (12.5)	13 (20.6)	50 (79.4)	1.64, (0.86-3.13)	0.131	1.75, (0.86-3.59)	0.121
Never	26 (5.2)	4 (15.4)	22 (84.6)	2.35, (0.79-6.96)	0.123	1.78, (0.58-5.45)	0.312

¹Non Calculable

Iron deficiency and iron deficiency anaemia among pregnant women remains to be a public health concern in Tanzania (3, 11). In the current study, adherence to the iron deficiency interventions was found to be low at 28%. A tendency to forget taking iron tablets and lack of enough time for education and counselling were positively associated with low adherence to iron deficiency interventions.

This study found that adherence to iron deficiency interventions is significantly low and that among the non-adherent, the prevalence of anaemia was found to be slightly more than half, which is almost that of the national prevalence of anaemia among pregnant women. This implies that, with iron deficiency interventions not adhered to, secondary negative effects associated with anaemia that occurs to the mother and child will most likely persist (11, 23). The suboptimal level of adherence varies widely with other Low- and Middle-Income Countries (LMIC) across Africa ranging from 55.3% in Ethiopia, 56% in Cameroon and 79.7% in Kasulu Tanzania (24–26).

On account of uptake of iron rich foods, this study found that the lesser the frequency of uptake of iron rich foods, the higher the prevalence of anaemia, regardless of the presence of iron tablets. This finding is similar to a study in Sri-Lanka where by only a quarter of respondents adhered to iron rich foods while taking iron tablets with the prevalence of anaemia been over half, similar to that of this study. And though iron deficiency anaemia (IDA) can be solely managed with iron therapy, the inclusion of dietary modifications provides improved results in terms of haemoglobin levels and iron levels as whole (15). Incorporating a dietarian has also been shown to improve the intake of iron rich foods. In conditions with fewer human resources, training to healthcare providers on dietary guidance to pregnant women may also show similar results (14).

A tendency to forget taking iron tablets has been found significant in this study. This could be explained by the limited support from male partners as evidenced in this study, whereby only 3% of women were accompanied to the clinic for all the visits. Similar studies in Zambia, Ethiopia and Nigeria report male involvement or the presence of a family in reminding and supporting the antenatal interventions as whole has been found to reduce forgetfulness in taking iron tablets among pregnant women (27–29). Furthermore, this study found that women with acceptance towards the modification of iron rich foods resulting from education provided, increases adherence to iron tablets and iron-rich foods hence, reduces the occurrence of anaemia. Contrary to this study, the study conducted in Nigeria reported that participants thought there is no need of iron tablets as long as the intake of iron rich food is good and adequate (29). However, living in a tropical environment where there is exposure to malaria infections and helminths which can lower the level of iron, supplementation is highly supported (1, 29).

Majority of the respondents agreed that health education is provided in the ANC clinics during visits in this study. However, lack of enough time in delivering health education and counselling that is patient-centred has been associated with non-adherence, as evidenced by this study findings. The findings imply that participants who do not get enough time for education and counselling may not know why they have to be adherent, hence making it difficult for them to practice. Similar findings have been found in Kigoma where shorter and noninteractive health education sessions lead to lower the rate of adherence to iron deficiency interventions. Another quasi-experimental study conducted in Indonesia found participants who received health counselling and education that included teaching aids such as pictures of iron interventions had a higher adherence in intake of iron rich foods and iron tablets compared to those who did not receive education and counselling (24, 30).

The current study also revealed that almost all participants accessed iron tablets from the health facility during ANC visits. However, for almost a quarter of the participants, the iron tablets were not enough to sustain them up to the next visit. This may encourage non- adherence and increase reluctancy to iron tablets among respondents by either skipping days in taking tablets or taking tablets until they run out and wait until the next visit. This is also supported by a study in Indonesia were enabling factors such as the availability and number of iron tablets taken, facilitated the consistent uptake of iron tablets (23).

The study concludes that the level of adherence to iron deficiency interventions in Ubungo municipality, Dar es Salaam is still low. Among the factors found to affect adherence to iron deficiency interventions includes a tendency to forget intake of iron tablets, acceptance of modifications to dietary practices, and lack of enough time in providing health education and counselling. To increase adherence to iron deficiency interventions, health centres are to improve on the provision of quality of education and patient centred counselling sessions. Further exploration on dietary modification strategies can be done in order to improve intake of iron rich foods.

ANC: Antenatal Clinics

IDA: Iron Deficiency Anemia

LMIC: Low – Middle Income Countries

WHO: World Health Organization

Ethics approval and consent to participate

Ethical approval to conduct the study was obtained from the Senate Research and Publications Committee of Muhimbili University of Health and Allied Sciences (MUHAS-REC-03-2023-1559). The committee serves as the Institutional Review Board. Permissions from Ubungo Municipality, the Head of Sinza Hospital and Kimara Health Centre, and the Head of Reproductive and Child Health Department were also obtained to collect the primary data. Respect was granted to the respondents in every aspect of interaction and communication.

Informed written consent for those who could read and write and fingerprints for those who could not read and write were obtained from respondents, for participation in the study. Participants were assured that their participation was voluntary and they could withdraw at any time during the study. Confidentiality was strictly upheld by ensuring that there are non-identifiers in the data collection tool.

Consent for publication

Not applicable

Availability of data and materials

The data set used and analysed during the current study are available from the corresponding author upon request.

Competing interests

The authors declare that they have no competing interests.

Funding

This research received no external funding. The authors covered all research expenses.

Authors’ contributions

GB and HM designed research; GB, NN, and HM conducted research; GB, AW, and EM analyzed data; and GB, HM, NN, AW wrote the paper. GB, HM and AW had primary responsibility for final content. HM was the overall overseer of the study. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to provide special appreciation to the administration of Ubungo Municipality, Sinza Hospital, and Kimara Health Centre as well as all pregnant women who responded to the study. Thanks to Mr Paul Sabuni and the data collecting team for their technical support.

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No competing interests reported.

Adherence to Iron Deficiency Interventions Among Pregnant Women Attending Antenatal Clinics in Ubungo Municipality, Dar Es Salaam, Tanzania

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Abstract

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Version 1