Determinants of compliance to antenatal micronutrient supplementation and women's perceptions of supplement use in rural Nepal

Abstract

We examined factors affecting compliance to antenatal micronutrient supplementation and women's perceptions of supplement use.
Randomized controlled supplementation trial of four alternative combinations of micronutrients given during pregnancy through to 3 months postpartum. Women were visited twice weekly to monitor compliance and to replenish tablets by female study workers. At 6 weeks postpartum women with live births (n 4096) were interviewed regarding their perceptions of the supplement. Median compliance calculated as percentage of total eligible doses received by women was high (84 %).
Rural southern Nepal.
Pregnant women.
Women with high compliance (above the median of 84 %) were likely to be older, less educated, poorer, undernourished, belong to lower caste and of Pahadi (hill) ethnicity compared with women with low compliance (at or below the median of 84 %). Smoking and drinking alcohol in the past week during pregnancy were strongly associated with low compliance. The major reason for irregular intake was forgetting to take supplements. A higher proportion of the high compliers liked taking the supplements but only half of them were willing to purchase them in the future. A large proportion of women (91 %) perceived a benefit from taking the supplement such as improved strength and health, whereas only about 10 % perceived any side-effects which were not a major barrier to compliance.
The present analysis highlights that poor, undernourished, uneducated women can have high compliance to antenatal supplementation if they are supplied with the tablets and reminded to take them regularly, and counselled about side-effects.

Full text

Public Health Nutrition: 13(1), 82–90 doi:10.1017/S1368980009005862
Determinants of compliance to antenatal micronutrient
supplementation and women’s perceptions of supplement
use in rural Nepal
Bharati Kulkarni
1
, Parul Christian
2,
*, Steven C LeClerq
2
and Subarna K Khatry
3
1
National Institute of Nutrition, Hyderabad, India:
2
Department of International Health, Center for Human
Nutrition, Bloomberg School of Public Health, 615 N. Wolfe Street – W2041, Baltimore, MD 21205, USA:
3
Nepal Nutrition Intervention Project, Sarlahi, Kathmandu, Nepal
Submitted 3 September 2008: Accepted 26 February 2009: First published online 19 May 2009
Abstract
Objective: We examined factors affecting compliance to antenatal micronutrient
supplementation and women’s perceptions of supplement use.
Design: Randomized controlled supplementation trial of four alternative combina-
tions of micronutrients given during pregnancy through to 3 months postpartum.
Women were visited twice weekly to monitor compliance and to replenish tablets by
female study workers. At 6 weeks postpartum women with live births (n4096) were
interviewed regarding their perceptions of the supplement. Median compliance
calculated as percentage of total eligible doses received by women was high (84 %).
Setting: Rural southern Nepal.
Subjects: Pregnant women.
Results: Women with high compliance (above the median of 84 %) were likely to
be older, less educated, poorer, undernourished, belong to lower caste and of
Pahadi (hill) ethnicity compared with women with low compliance (at or below
the median of 84 %). Smoking and drinking alcohol in the past week during
pregnancy were strongly associated with low compliance. The major reason for
irregular intake was forgetting to take supplements. A higher proportion of the
high compliers liked taking the supplements but only half of them were willing to
purchase them in the future. A large proportion of women (91 %) perceived a
benefit from taking the supplement such as improved strength and health,
whereas only about 10 % perceived any side-effects which were not a major
barrier to compliance.
Conclusions: The present analysis highlights that poor, undernourished, unedu-
cated women can have high compliance to antenatal supplementation if they are
supplied with the tablets and reminded to take them regularly, and counselled
about side-effects.
Keywords
Micronutrients
Pregnancy
Supplements
Compliance
Nepal
Micronutrient deficiencies during pregnancy are common
in developing countries such as Nepal. Data from the
2006 Nepal Demographic Health Survey indicated that
about one in three (36 %) women in Nepal is anaemic
(1)
.
Studies carried out in rural Nepal indicate deficiencies
of Zn, Fe, vitamins A, D, E, B
6
,B
12
and riboflavin during
early pregnancy to be common
(2,3)
. Simultaneous defi-
ciencies of two or more micronutrients affected .80 %
of women in early pregnancy in these studies. Dietary
deficits of micronutrient-rich foods such as meat, fish,
dairy products, fruits and green leafy vegetables could
help explain the high prevalence of micronutrient defi-
ciencies in Nepal and other South-East Asian coun-
tries
(4,5)
. High amounts of phytate in cereal-based diets
that inhibits mineral absorption add to the problem
(6)
.
Maternal micronutrient deficiencies may be an important
cause of adverse obstetric outcome such as fetal loss, still-
birth and low birth weight
(7–9)
. The effect of micronutrient
supplementation on pregnancy outcome is presently a topic
of considerable research interest. A number of studies have
been carried out in developing countries which show
equivocal results
(10–12)
. The present body of work on mul-
tiple micronutrient interventions is not sufficient to draw
conclusions on their effects on neonatal well-being
(13,14)
.
However, a few studies have indicated beneficial effects of
maternal multiple micronutrient supplementation on early
infant mortality and birth outcomes
(15,16)
.
WHO, UNICEF and the International Nutritional Anemia
Consultative Group recommend distribution of Fe and
folic acid supplements to pregnant women
(17)
. Many
*Corresponding author: Email pchristi@jhsph.edu rThe Authors 2009

developing countries have national programmes for Fe
and folic acid supplementation to pregnant women, but
these programmes have been shown to fail in reaching a
large proportion of women and coverage rates have been
low
(18)
. Studies in developing countries have indicated
that the major barrier to effective supplementation pro-
grammes is inadequate supply
(19)
. Other barriers include
poor compliance owing to side-effects, inadequate
counselling and dislike of the taste
(20,21)
. Facilitators of
compliance include women’s recognition of improved
physical well-being, better appetite, and increased per-
ception of benefits for the fetus
(22)
.
It is important to assess the determinants of compliance
to supplementation and women’s perceptions of supple-
ment use to examine the possible effectiveness of antenatal
micronutrient supplementation as a programme. A con-
trolled setting of a community trial provides an opportunity
to examine determinants of compliance since supply of
supplements and logistics of delivery are designed to be
optimal. The present study therefore assessed determinants
of compliance to antenatal micronutrient supplementation
and women’s perception of supplement use in a rando-
mized controlled trial in rural Nepal.
Experimental methods
The Nepal Nutrition Intervention Project Sarlahi 3 (NNIPS-3)
study was a cluster-randomized, double-blind, controlled
trial conducted in the rural plains district of Sarlahi, Nepal.
The objective of this study was to examine the effects of
prenatal and postnatal maternal micronutrient supple-
mentation on birth weight, fetal loss and early infant
mortality. Details regarding the study area, subjects and
supplementation are published elsewhere
(10)
. Some of
the relevant details are described below.
The study area, comprising thirty village development
communities with a total population of ,200 000, was
divided into 426 smaller communities called ‘sectors’
which served as the units of randomization. Randomiza-
tion was done in blocks of five within each village
development community. The sectors were randomly
assigned to one of five treatment arms. To identify preg-
nancies in early gestation, all eligible women of repro-
ductive age (married women, 15–45 years of age who
were not menopausal, sterilized or not already breast-
feeding an infant ,12 months of age) in the study area
were visited every 5 weeks and asked about their men-
struation in the past 30 d. Pregnancy was ascertained with
a urine test (human chorionic gonadotrophin antigen test;
Clue

R
, Orchid Biomedical Systems, Goa, India) among
women who reported not menstruating in the past 30 d.
Women who tested positive were enrolled after obtaining
consent. At enrolment, newly identified pregnant women
were administered a baseline interview to obtain data
on 30 d and 7 d frequencies of symptoms of morbidity,
7 d frequency of intake of selected foods, alcohol and
tobaccouse,7dworkhistory,andinformationonhouse-
hold socio-economic status and previous pregnancy
history. Anthropometric measurements including weight,
height and mid upper-arm circumference (MUAC) were
taken at enrolment. Similar interviews were repeated at
32 weeks of gestation and 6 weeks postpartum. During
the postpartum interview, questions regarding the intake
of the supplement (described below in detail) were
added. Women’s perceptions of the supplement, its use
and reasons for not taking the supplement were also
assessed as described below. Perceived side-effects due
to the supplements were also ascertained at this visit.
Supplement
The five supplement arms in the study were: (i) folic acid
(400 mg); (ii) folic acid–Fe (60 mg); (iii) folic acid–Fe–Zn
(30 mg); (iv) folic acid–Fe–Zn plus eleven other micro-
nutrients (10 mg vitamin D, 10 mg vitamin E, 1?6 mg thia-
min, 1?8 mg riboflavin, 20 mg niacin, 2?2 mg vitamin B
6
,
2?6mg vitamin B
12
, 100 mg vitamin C, 65 mg vitamin K,
2?0mg Cu, 100 mg Mg), all with vitamin A; and (v) vitamin A
alone (1000 mg retinol equivalents) as the control. At
the outset of the study, each pregnant woman received
a small bottle containing fifteen supplement caplets, with
instructions from the staff to take one caplet each day.
Women were subsequently visited twice each week by
the sector distributors, who replenished the caplets,
monitored their consumption and did pill counts, and
collected data on pregnancies and their outcomes. The
supplements were identical in shape, size and colour. The
supplements were to be taken daily from the time of
pregnancy detection through to 3 months postpartum
in the case of a live birth or through to 5 weeks after a
miscarriage or stillbirth. All the pregnant women in the
study received counselling on antenatal care and nutrition
at the time of enrolment. The women were encouraged to
visit health posts and to take Fe supplements during
pregnancy. The policy in Nepal is for all pregnant women
visiting health posts to receive Fe supplements, although
coverage and adherence are poor
(1)
.
Women’s perceptions
At 6 weeks postpartum, women who had a live birth were
visited in their homes by trained interviewers and were
asked about their perceptions of supplement use during
pregnancy and lactation. Specifically, they were asked
whether they liked taking the supplement and whether
they would take it in a future pregnancy, if offered. They
were also asked whether members of their family such as
husband and mother-in-law, who might influence their
decision, approved their intake of the supplement.
Women were also asked whether they took the supple-
ments regularly in order to assess the perception of their
own compliance. Women who responded that they did
not take the supplements regularly were probed further
Compliance to micronutrient supplementation 83

for the reasons. They were asked if their responses fitted
in any of the six coded reasons. They were then also
asked an open-ended question regarding reasons for not
taking the supplements and all responses were recorded
in their own words. These responses were later classified
and coded for analysis. Women were also asked whether
they suffered from any of seven side-effects due to the
supplement and whether they stopped taking the sup-
plement as a result of the side-effects. Those who said
that they stopped taking the supplement were further
asked whether they resumed taking the supplement later
on. Women were also asked whether they perceived any
benefit or harm as a result of the supplementation. Those
who said ‘yes’ were asked to specify the perceived benefit
or harm due to the tablets. All responses were recorded in
their own words and were later classified and coded for
analysis. They were also asked whether they were willing
to buy the tablets and what price they were willing to pay
for the tablets.
The study was approved by the ethical review com-
mittees of the Ministry of Health in Nepal and the Johns
Hopkins Bloomberg School of Public Health, Baltimore,
Maryland, USA.
Statistical analyses
For the present analysis, which included only live births,
data on compliance were analysed for 4096 women.
Descriptive statistics of the baseline characteristics of
these women, such as age, parity, education, socio-
economic status, history of fetal loss and anthropometry
(height, weight, MUAC), were calculated. The number
and proportion of women with night blindness, other
morbidities, and smoking and alcohol use in the third
trimester of pregnancy were calculated. For each partici-
pant, compliance was calculated as percentage of the
total eligible doses consumed during pregnancy through
the postpartum period. Median compliance was 84 %
(interquartile range 60–94 %) and did not differ by allo-
cation code. Similarly, prevalence of side-effects did not
differ by treatment
(10)
. Thus, all data in the present
analysis were combined across treatment groups. The
prevalence of Fe–folic acid supplement use during
pregnancy through the local primary health-care system
was low at 2?5 % and this was unlikely to impact the
present analyses. Compliance at or below the median
(#84 %) was classified as ‘low’ compliance and com-
pliance above the median (.84 %) was classified as ‘high’
compliance. Differences in various characteristics among
the two compliance groups were assessed using Student’s
ttest for continuous variables and the x
2
test for catego-
rical variables. Variables examined included age, parity,
gestational age at enrolment, history of stillbirth, weight,
height, MUAC, BMI (kg/m
2
), literacy, husband’s occupa-
tion, caste, ethnicity, tobacco/alcohol use, and indicators
of socio-economic status such as land ownership and
type of house construction. A stepwise multiple logistic
regression model was developed to identify determinants
of high compliance in this population. Variables sig-
nificant at P,0?05 were retained in the model. Percep-
tions regarding the supplement and its use were also
examined by high v. low categories of compliance and
tested using the x
2
test. Statistical analysis was carried out
using the STATA statistical software package version 10
(Stata Corporation, College Station, TX, USA).
Results
Comparison of subject characteristics by compliance
strata showed that women in the high compliance group
were significantly older (23?4v.22?6 years, P,0?001)
and a lower proportion were primiparas (23?0% v.
30?4%, P,0?001) compared with those in the low
compliance group (Table 1). Gestational age at enrolment
or previous history of stillbirth did not differ by com-
pliance category. High compliers were slightly more
undernourished than the low compliers. Mean height of
high compliers was lower than that of the low compliers
(150?0v. 150?5 cm, P50?01) and there was a trend of
lower weight among the high compliers compared with
the low compliers (43?4v.43?7 kg, P50?06).
Overall, the proportion of women who were literate
(able to read and write) was very low (20?9 %) and did
not differ between the two compliance groups. In the
high compliance group, a higher proportion of women’s
husbands were farmers or unskilled or contracted
labourers, indicating poorer socio-economic status than
women from the low compliance group (81?0%v.75?9%,
P,0?001). A higher proportion of women belonging to
the Pahadi ethnicity (36?5% v.22?7%, P,0?001) were in
the high compliance group. The high compliance group
owned less land and owned houses that were constructed
with poor-quality materials. A significantly higher pro-
portion of low compliers smoked and drank alcohol
during pregnancy.
The multiple logistic regression analysis revealed that
after adjusting for each other, variables significantly
associated with high compliance were older age, later
gestational age at enrolment, lower height and literacy
(Table 2). Other variables found to be significantly asso-
ciated with high compliance included husbands being
farmers or unskilled labourers, lower caste, and lower
rates of smoking and alcohol use during pregnancy.
A majority of the women (87 %) reported that they
liked taking the supplements, although a higher propor-
tion of high than low compliers said this (95?4%v.77?1%;
Table 3). A higher proportion of women in the high
compliance group perceived the supplements to be
beneficial (63?1% v.42?9 %), whereas the proportion
perceiving harm was lower in the high v. the low com-
pliance group (1?6%v.8?2 %). When women were asked
about the specific perceptions of benefit, the major benefits
84 B Kulkarni et al.

included gain in strength (40–50 %) and improvement in
health (20–25 %). Other benefits perceived by women
included having a healthier baby, improved appetite,
improvement in night blindness, increased blood and
milk flow. A very small percentage of women (14?0% in
the low and 4?5 % women in the high compliance group)
said that they suffered from adverse health or side-effects
as a result of the supplementation.
Importantly, about 90 % of women in the high com-
pliance group and 75 % women in the low compliance
group said that they would take the supplement in future
pregnancy, if offered. However, only half of the women
were willing to buy the tablets, with a higher proportion
of high compliers indicating willingness (53 % v. 44 %).
Among those willing to buy tablets, about ,10 % were
willing to pay up to Nepali paisa 10 (100 paisa 51 Nepali
rupee; Nepali rupees 60 51 US dollar) and about a third
each were willing to pay Nepali paisa 11–50 or Nepali
paisa 51–100 per tablet.
Women’s own perception regarding regularity of their
intake ranged between 60 % and 75 %, with 60 % of the
low compliers reporting their intake as irregular and 75 %
of high compliers reporting their intake as regular (data
not shown). When women who perceived their intake of
the supplement as irregular were asked for reasons of not
taking the tablets, 39 % said that they forgot to take the
supplement (Fig. 1). Another 16 % of women reported the
cause of not taking the supplement as going to parents’
home for delivery. These women did not receive sup-
plements from project distributors who did not know
their parents’ home address, which in some cases was
located in a different village. About 13 % said that they did
not take the tablets due to the side-effects they were
perceived to cause, whereas 10 % said that they did not
Table 1 Characteristics of the study subjects by compliance status: pregnant women, rural southern Nepal, participating in the Nepal
Nutrition Intervention Project Sarlahi 3
Low compliers (n2057) High compliers (n2023)
Mean SD Mean SD Pvalue*
Age (years) 22?65?723?45?6,0?001
Gestational age at enrolment (weeks) 11?55?311?45?10?40
Weight (kg) 43?75?643?45?40?06
Height (cm) 150?55?6 150?05?40?01
BMI (kg/m
2
)19?32?119?22?00?62
MUAC (cm) 22?01?821?81?80?87
n%n%
Parity
0 628 30?4 466 23?0,0?001
1–3 992 48?0 1060 52?2
.3 446 21?6 504 24?8
Previous stillbirth 90 6?2 115 7?20?28
Literate 433 21?2 415 20?50?52
Any schooling 430 20?8 379 18?70?08
Husband literacy 1033 50?7 1062 52?50?20
Husband’s occupation
Farmer, unskilled labourer 1568 75?9 1644 81?0,0?001
Business/service 498 24?1 386 19?0
Caste
Hindu – higher 299 14?5 341 16?80?04
Hindu – lower/non-Hindu 1767 85?5 1689 83?2
Ethnicity-
Pahadi 463 22?7 739 36?5,0?001
Madheshi 1572 77?1 1279 63?2
Land ownership
,0?2 ha 817 39?5 782 38?50?002
0?2–5?5 ha 962 46?6 1031 50?8
.5?5 ha 287 13?9 217 10?7
House construction material
Thatch/grass/sticks 1786 86?4 1774 87?40?37
Cement/wood 280 13?5 256 12?6
Roof material
Thatch/grass 361 17?5 434 21?40?002
Tile/tin/cement 1705 82?5 1596 78?6
Smoked tobacco in past 7 d 898 43?5 613 30?2,0?001
Drank alcohol in past 7 d 721 34?9 423 20?8,0?001
MUAC, mid upper-arm circumference.
*Differences in characteristics among the two compliance groups were assessed using Student’s ttest for continuous variables and the x
2
test for binary
variables. Compliance and age, n4096; gestational age at enrolment, n4028; parity, n4061; history of fetal loss, n3049; anthropometry, n3865; literacy,
education and socio-economic variables, n4061.
-Pahadis are people from the hills of Nepal who have settled in the plains and Madheshis are peoples of Indian origin who have migrated across the border.
Compliance to micronutrient supplementation 85

like the tablets. About 7 % perceived that the supplement
caused harm, whereas 4 % and 3 %, respectively, said they
did not take them around the days when they delivered a
baby or because they were taking some other medicine.
Other reasons were provided by ,1 % each of the women.
Overall, only 10 % of the women reported any side-
effects. A higher proportion of low compliers perceived
side-effects compared with the high compliers (13?3% v.
5?1 %; Table 4). Nausea and abdominal pain were the
most commonly reported symptoms. Other side-effects
were vomiting, black stools, diarrhoea and constipation.
About 50 % of the women in each group who perceived
side-effects stopped taking the supplement. About 13 %
of them stopped taking the tablets for less than a week,
6–8 % stopped for 7–29 d and 30 % stopped for more
than a month. These proportions were not significantly
Table 2 Odds ratios and 95% confidence intervals* for determinants of high v. low compliance to supplementation: pregnant women, rural
southern Nepal, participating in the Nepal Nutrition Intervention Project Sarlahi 3
Variable Adjusted OR 95 % CI Pvalue
Age (years) 1?03 1?02, 1?04 ,0?001
Gestational age at enrolment (weeks) 1?03 1?01, 1?04 ,0?001
Height (cm) 0?98 0?97, 0?99 0?002
Literate-0?71 0?58, 0?87 0?001
Husband’s occupation – business/service-
-
0?76 0?64, 0?89 0?001
Lower castey1?31 1?04, 1?66 0?02
Madheshi ethnicity|| 0?36 0?29, 0?76 ,0?001
Smoked tobacco in the past 7 d 0?62 0?50, 0?76 ,0?001
Drank alcohol in the past 7 d 0?57 0?45, 0?73 ,0?001
*Using stepwise multiple logistic regression analysis to predict the odds of high compliance.
-Defined as the ability to read or write.
-
-
Farmer/unskilled labourer was the referent category.
yCaste was categorized as Hindu castes of Brahmins and Chhetris as higher castes v. Hindu castes of Vaishya, Shudra and non-Hindus as lower castes.
Higher caste was the referent category.
||Pahadis are people from the hills of Nepal who have settled in the plains and Madheshis are peoples of Indian origin who have migrated across the border.
Pahadi was the referent category.
Table 3 Perceptions of women regarding supplement use during pregnancy and lactation by compliance status*: pregnant women, rural
southern Nepal, participating in the Nepal Nutrition Intervention Project Sarlahi 3
Low compliers High compliers
n%n%
Perception towards supplement
Liked the supplement 1317 77?1 1874 95?4
Did not like the supplement 329 19?3412?1
Was indifferent (neither liked nor disliked the supplement) 56 3?3452?3
Didn’t know 6 0?440?2
Husband approved of supplement 1413 87?0 1851 94?4
Mother-in-law approved of supplement 1049 64?6 1390 70?9
Perception of benefit or harm caused by supplement
Benefit 697 42?9 1238 63?1
Harm 133 8?2321?6
Neither benefit nor harm 326 20?1 291 14?8
Both benefit and harm 13 0?8160?8
Didn’t know 454 28?0 383 19?5
Types of perceived benefits
Improved health 187 22?7 306 24?7
Gained strength 345 41?9 595 48?0
Increased appetite 50 6?1 100 8?1
Baby was healthier 63 7?6877?0
Cured night blindness 18 2?2252?0
Increased blood 7 0?8161?3
Increased breast milk 2 0?260?5
Types of perceived harm
Caused health problem to self 115 14?0564?5
Caused health problem to the baby 3 0?410?1
Willing to take supplement in future pregnancy 1227 75?5 1751 89?3
Willing to pay per tablet 711 43?8 1041 53?1
Willing to pay up to 10 paisa 86 12?1615?9
Willing to pay 11–50 paisa 216 30?4 366 35?2
Willing to pay 51–100 paisa 235 33?1 367 35?2
Willing to pay but amount unspecified 174 24?4 247 23?7
*Differences in perceptions in the two compliance groups were assessed using the x
2
test; all P,0?001 except for categories of types of perceived harm,
where P.0?05.
86 B Kulkarni et al.

different in the two compliance groups. However, only
40 % of the women in the low compliance group resumed
taking the tablets compared with 74 % of women in the
high compliance group.
Discussion
In the context of a randomized controlled trial of micro-
nutrient supplementation with high overall compliance,
we found that women who were older, poorer, less
educated, undernourished, belonging to lower castes and
of Pahadi ethnicity were likely to have high compliance.
Richer, more educated women, who may have had
adequate knowledge and resources to avail of antenatal
services on their own, on the other hand, may not have
perceived that the supplements provided any benefit and
were less likely to be compliant. In the trial we had two
supervisory visits by project staff to monitor compliance
and replenish supplements, a strategy that has poor
programmatic relevance. This was one of the reasons to
assess women’s perceptions of the supplement and their
willingness to use them in the future.
We found high compliers to be older and to have more
children. Earlier studies conducted in programmatic set-
tings have not reported these relationships
(20,21)
. Perhaps,
in the present study, women who had more children had
a longer exposure to the messages of antenatal supple-
ments that may have improved their compliance. But
more likely, many younger, primiparous women went to
their parents’ home for delivery for 2–3 months during
which they were not reached for supplement distribution
by the study workers. This reason, however, is unlikely to
have relevance for programmes, but was more specific to
the context of the present trial.
High compliers were less educated and poorer as
indicated by husband’s occupation, land ownership and
type of housing, similar to what we previously reported in
a study involving vitamin A supplementation to pregnant
women in which characteristics that predicted higher
coverage rates included older age, higher parity, previous
child deaths and lower socio-economic status
(23)
.Ina
study in Indonesia that assessed determinants of com-
munity-based periodic vitamin A supplementation pro-
grammes in children also indicated that coverage was
higher in villages which were economically less devel-
oped
(25)
. In that study it was shown that the highest
performance was achieved by village distributors who
were less educated and represented the local status quo
rather than more upwardly mobile, highly educated
ones
(24)
. However, a weekly Fe–folic acid supplement
delivered with social marketing to pregnant women in
Cambodia found that compliance to the supplement was
higher among women of higher socio-economic status
(25)
and an Fe supplementation study in infants in southern
39 %
16 %
13 %
10 %
7%
4%
3%
8%
Fig. 1 Reasons reported by 1520 women for not taking tablets
regularly among those who perceived not taking them
regularly: , forgot to take; , was at parents’ home; , due
to side-effects; , did not like tablets; , would cause harm; ,
did not take around delivery; , taking other medicines; ,
other. ‘Other’ reasons included family did not allow, bad taste
or smell of tablet, tablet being too big, fear of baby being big,
misplacing the supplement bottle, due to festival, change in
residence and unknown reason (all prevalences ,1%)
Table 4 Perceived gastrointestinal side-effects due to supplementation by compliance group*: pregnant women, rural
southern Nepal, participating in the Nepal Nutrition Intervention Project Sarlahi 3
Low compliers (n1624) High compliers (n1961)
Side-effect n%n%
Nausea 81 5?038 1?9
Vomiting 49 3?018 0?9
Diarrhoea 27 1?790?5
Constipation 27 1?790?5
Pain in abdomen 58 3?628 1?4
Black stools 37 2?342 2?1
Any other 41 2?516 0?8
Any one of the above 215 13?399 5?1
*Differences in perceived side-effects in the two compliance groups were assessed using the x
2
test; all P,0?001 except black stools,
where P.0?05.
Compliance to micronutrient supplementation 87

Israel found that maternal education was positively related
to higher compliance to the supplement
(26)
. In general,
associations with schooling and literacy and compliance
are likely to be setting-specific.
Although there was a higher proportion of upper caste
women in the high compliance group when compared
with the low compliance group, belonging to lower caste
predicted higher compliance in the multiple logistic
regression analysis. It is possible that the relationship
of caste to compliance in the univariate analysis was
confounded by other variables included in the multiple
logistic regression model. Smoking and alcohol con-
sumption during pregnancy were strong predictors of
poor compliance. These have been shown to be asso-
ciated with poor health behaviours including lower
compliance with the prescribed treatment
(27,28)
. Fe sup-
plement use among pregnant Danish women was also
negatively associated with smoking during pregnancy
(29)
,
as observed in the present study.
A majority of the women (87 %) liked taking the sup-
plement and supplement use was largely approved by the
family members. Similarly, a large proportion of women
perceived benefits due to the supplements and few
perceived any adverse health effects. Benefits reported
by women included increased strength, improvement
in health, increased blood and having a healthy baby.
Perception of benefits was found to be an important
determinant of high compliance to the supplement,
which has been observed in previous studies in the
Philippines as well as in the MotherCare project carried
out in eight developing countries
(20,22)
. As micronutrient
deficiencies are widespread in this region and anaemia
and other micronutrient deficiencies lead to fatigue, loss
of appetite and sense of poor health, it is possible that
women felt that they gained strength due to the supple-
ments. This indicates the ‘hidden hunger’ for these impor-
tant nutrients in this population. More women in the low
compliance group perceived the supplement to cause
some harm (14?0%v.4?5 %), but largely the adverse effect
was perceived to be felt to themselves and not the baby,
and could be related to the gastrointestinal side-effects.
While a large proportion of women expressed will-
ingness to take similar supplements in a future preg-
nancy, only half of them were willing to buy them or pay
very small amounts of money for them, suggesting that
perhaps cost is the biggest barrier to access to micro-
nutrient supplements in this population.
The most frequently quoted reason ( ,40 %) for irre-
gular intake of the supplement was that they ‘forgot to
take the tablet’. In studies carried out in the Philippines
on compliance to Fe supplementation this was also found
to be the most common reason for low compliance
(20)
.
However, unlike in the Philippines study, women in the
present study received regular counselling and super-
vision through twice weekly visits. This reveals the diffi-
culty of ensuring daily, regular consumption of antenatal
supplements. Alternative strategies of communication to
ensure that women as well as their families understand
the importance of not forgetting to take their supplements
are needed. For example, Fe–folic acid supplementation
programmes in Cambodia as well as Vietnam utilized
social marketing and community mobilization approa-
ches to educate women about the benefits of taking Fe
and folic acid regularly
(27,30)
.
Perceived side-effects were reported as a reason for not
taking the supplement regularly by ,10 % of the women.
This proportion is similar to that reported by some earlier
studies in the Philippines, Mali and Tanzania and as part of
qualitative research carried out by the MotherCare project
in eight developing countries
(19,20,31,32)
. Contrary to the
belief that women stop taking tablets due to side-effects,
the major barrier to effective supplementation programme
was inadequate supply
(19)
. Also, in our study, although the
proportion of women who stopped taking the supplement
as a result of the side-effects was not different in the two
compliance groups, the percentage who resumed taking
the supplement was significantly higher in the high v.the
low compliance group (74 % v. 40 %), indica ting that
resumption of supplement consumption following side-
effects may be an important determinant of compliance. In
a study in Senegal, counselling by midwives to pregnant
women regarding the transient nature of side-effects with
Fe–folic acid supplements and specifically explaining to
them that the tablets would improve health were also
important determinants of compliance
(33)
.Duringpreg-
nancy many of the side-effects such as nausea, vomiting,
constipation and abdominal pain are likely to be mistaken
to result from the supplement
(34)
.
In conclusion, our study provides important informa-
tion on determinants of compliance and women’s per-
ceptions of supplement use in a rural community in
Nepal. Considering the current move towards multiple
micronutrient supplementation, these findings can help
inform policy and programme development for the
effective control of micronutrient deficiencies in pregnant
women in the South Asian context.
Acknowledgements
This work was carried out by the Center for Human
Nutrition, Department of International Health of the Johns
Hopkins Bloomberg School of Public Health, Baltimore,
MD, USA in collaboration with the National Society for
the Prevention of Blindness, Kathmandu, Nepal, under
the Micronutrients for Health Cooperative Agreement No.
HRN-A-00-97-00015-00 and the Global Research Activity
Cooperative Agreement No. GHS-A-00-03-00019-00
between the Johns Hopkins University and the Office of
Health, Infectious Diseases and Nutrition, US Agency for
International Development, Washington, DC, USA and
grants from the Bill and Melinda Gates Foundation,
88 B Kulkarni et al.

Seattle, WA, USA and the Sight and Life Research Institute,
Baltimore, MD, USA. The premix for the supplements was
provided by Roche, Brazil and manufactured by NutriCorp
International, CE Jamieson & Company Ltd, Windsor,
Canada. Apart from the authors, all members of the Nepal
study team helped in the successful implementation of the
study including Field Managers and Supervisors and the
Team Leader Interviewers who conducted the interviews;
Keith P. West Jr and Joanne Katz who were co-investigators;
and Gwendolyn Clemens who was responsible for com-
puter programming and data management. The authors
have no conflict of interest to declare. B.K. analysed the data
and wrote the paper; P.C. was the Principal Investigator of
the study and guided data analysis, helped with inter-
pretationofdata,andhelpedwithwritingandeditingthe
paper; S.C.L. helped with study implementation and field
procedures for the study; S.K.K. was the director of the
project and managed the overall study implementation and
organization.
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