Knowledge on Anemia and Benefit of Iron-Folic Acid Supplementation among Pregnant Women Attending Antenatal Care in Public health Facilities of Woldia town, Northeastern Ethiopia: Institution based cross-sectional study

Objective: this study aimed to assess the magnitude of knowledge on anemia and benefit of iron-folic-acid supplementation among pregnant mothers who gave birth at public health facilities in Woldia town, 2018. An institution based cross-sectional study design was conducted, on 414 pregnant mothers attending antenatal care which was selected by using systematic random samplings. The data was entered into Epi-data version 4.2 and analyzed using SPSS version 24. Bivariable and multivariable analysis was done to see the association between the dependent variable and independent variables. Results: this study revealed that 54.1% and 57.7% of pregnant women had good knowledge on anemia and benefit of IFAS respectively. Maternal education status (AOR=2.19, 95%CI: 1.32-3.64), good knowledge of IFAS (AOR=5.85, 95%CI: 3.60-9.50) and residence (AOR=5.43, 95%CI: 2.36-12.51) was statistically associated with pregnant mothers knowledge on anemia. Obtained counseling IFAS (AOR=2.04, 95%CI: 1.11-3.75), having four or more antenatal care visit (AOR=3.12, 95%CI: 1.38-7.07) and good knowledge of anemia (AOR=5.88, 95%CI: 3.63-9.50) was statistically associated with pregnant mothers knowledge on the benefit of IFAS.

pregnant women is reported to be29% which is a major public health problem [6].
Different studies conducted in Ethiopia also showed that the prevalence of anemia among pregnant women were ranged from 20% to 60% [7][8][9][10][11][12][13]. Iron supplementation is the most widely employed strategy to alleviate iron deficiency anemia both globally and nationally [14,15]. World health organization and National guideline current recommendation on the treatment of anemia during pregnancy include improvements in dietary diversity; food fortification with iron, folic acid, and other micronutrients; daily supplementation of iron and folic acid to each pregnant women and control of infections [15,16]. In Ethiopia, nationally only 5% of pregnant women took IFAS for greater than 90 days but 58% did not take any iron-folic acid tablets during their most recent pregnancy [6]. A study on the importance of antenatal use of iron and folic acid supplement showed that it can eliminate 50% of iron deficiency anemia in pregnant women [17]. Pregnant women in developing countries are at risk of anemia due to poverty, grand multiparty, too early pregnancies, too many and too frequent pregnancies spacing of < 1 year, low socioeconomic status, illiteracy, and late booking of pregnant women at antenatal care units [11,12,18]. Many of these risk factors can be minimized if the mother knowledge on cause and prevention of anemia will be improved. Despite anemia having been identified as a global public health problem for several years, no rapid progress has been observed, and the prevalence of the disease is still high globally and locally. Very few researches are done in Ethiopia regarding knowledge of anemia and benefit of iron-folic acid supplementation in pregnant mothers. Therefore, this study assessed knowledge on anemia and benefit of iron-folic acid supplementation and associated factors among pregnant mothers attending antenatal care in public health institutions of Woldia town, Northeastern Ethiopia.

Study Setting and Design
The institution-based quantitative cross-sectional study design was conducted at public health institutions in Woldia town, North Wollo zone. The town comprises governmental (one regional hospital, two health centers, four health posts), non-governmental (five small and eight medium private clinics, two private drug vendors and six private drugstores).

Source and Study Population
The source population was all pregnant women who were attending ANC services whereas all pregnant women who were attending antenatal care in the selected facilities during the study period were included in the study.

Inclusion and Exclusion Criteria
Pregnant women in the selected health facilities who came for ANC visit were included whereas non-volunteer and seriously ill were excluded.

Sample Size Determination and Sampling Procedure
The sample size was determined by a computer based on Epi info 7 software Stat Cal using single population proportion formula with the assumption of 95%confidence interval, P= knowledge of pregnant women on anemia in West Shoa Zone Ethiopia (p=57.3%) [19], d=is a tolerable margin of error (d=0.05) and 10% non-response rate, the final sample size for the study is 414.

Method of Data Collection
Information on socio-demographic factors, obstetrics related factors, and knowledge related factors were collected by face to face interview. The English language questionnaire was translated into the Amharic language (a language spoken in the study area) and was translated back to the English language comparison was made on the consistency of the two versions. The knowledge assessment tool was adapted from a study done in Kenya and South Ethiopia [19,20,21,23]. Knowledge of anemia was assessed by 25 reliable items (items on ever heard anemia, sign symptom, cause, consequences and prevention of anemia) and knowledge of benefit of IFAS was assessed by nine reliable items (items on the benefits of IFAS and frequency and duration of taking IFA supplements).

Data Quality Assurance
Training was given for data collectors and supervisors about techniques of data collection and briefed on each question included in the data collection tool. The pre-test was conducted to ensure the validity of the tool, and then the correction was made before the actual data collection. Double data entry was done by two data clerks and consistency of the entered data was cross-checked by comparing the two separately entered data.

Data Processing and Analysis
The data were coded, cleaned, edited and entered into Epi-data version 4.

Socio-Demographic Characteristics
A total of 414 study participants were involved in the study making a response rate of 100%. The mean age of study participants was 26.35 (± 4.25 SD) years. All most all, 405 (97.8%) of the study participants were married, 294 (71.0%) were Orthodox by religion and 386 (93.2%) were Amhara by ethnicity [

Factors Associated with Knowledge of Anemia
In this multivariable model, maternal educational status, knowledge of IFAS and residence were statistically associated with knowledge of anemia.
Mothers who were from urban residents were 5.4 times more likely knowledgeable to anemia than their counter parts (AOR=5.43, 95%CI: 2.36-12.51). Mothers who had completed secondary education and above were two times more likely knowledgeable to anemia than mothers who attended non-formal education (AOR=2.19, 95%CI: 1.32-3.64).
Regarding knowledge of IFAS, those who had good knowledge on benefit IFAS were almost six times (AOR=5.85, 95%CI: 3.60-9.50) more likely knowledgeable to anemia than the counter parts [ Table 2].

Factors Associated with Knowledge on the Benefit of IFAS
In this study in the multivariable model ANC visit, knowledge of anemia and obtained counseling about IFAS was statistically associated with knowledge on the benefit of IFAS.
Mothers who had obtained counseling about IFAS were two times more likely knowledgeable on the benefit of IFAS than counterparts (AOR=2.04, 95%CI: 1.11-3.75).
Mothers who had four or more ANC visit were three times (AOR=3.12, 95%CI: 1.38-7.07) more likely knowledgeable on the benefit of IFAS than counterparts. Regarding knowledge of anemia, those who had good knowledge of anemia were almost six times (AOR=5.88, 95%CI: 3.63-9.50) more likely knowledgeable on the benefit of IFAS than counterparts [ Table 3].

Discussion
In this study, 54.1% of pregnant mother had good knowledge of anemia. . This might be currently due to increase information access for pregnant mothers and since the majority of the study participants were from urban residents and being from an urban resident is strongly associated with pregnant mother knowledge on anemia.
The knowledge of pregnant women about the benefit of IFAS was found to be 57.7%. This finding was higher than a study conducted in Singur, West Bengal India (39.9%) [22]. This difference might be due to the difference in sociodemographic characteristics and the time gap between the studies.
Pregnant mothers who completed secondary education and above were two times more likely knowledgeable to anemia as compared with those pregnant mothers who attended non-formal education. This is in line with the study conducted in South Ethiopia [24], North Showa Zone, Ethiopia [19], Amil Nadu, India (76.5%) [ 26] and Pune India (69%) [23]. This might be due to the fact that as educational level increases the ability of the pregnant mother understanding also rise which ultimately increases the knowledge level.
Pregnant mothers who were from urban residents were five times more likely knowledgeable to anemia as compared with pregnant mothers who were rural residents. This is supported with the study conducted in North Showa Zone, Ethiopia [19]. This might be due to pregnant mothers from urban residents will have more information access through mass media and they have more frequent and early antenatal care follow up which enables them to get more information.
Having good knowledge on the benefit of IFAS was significantly and positively associated with knowledge of anemia. This is supported with the study conducted in North Showa Zone, Ethiopia [19]. This might be due to the fact that having good knowledge on the benefit of IFAS helps women to understand the cause, consequence, prevention and treatment of anemia by taking IFAS which results in good knowledge of anemia.
Pregnant mothers who had four or more antenatal care visit were three times more knowledgeable as compared with those pregnant mothers who had less than four antenatal care visits. This is supported with a study conducted in South Ethiopia [24] but it is not supported with a study conducted in Pune India (69%) [23]. This might be due to the fact that having frequent ANC visits during pregnancy may have the high chance of getting counseling on the benefit of taking IFAS.

Conclusions
Our data demonstrate that the knowledge level of pregnant mother on anemia and benefit of IFAS was low. Educational status, knowledge of IFAS and residence were independent predictors of pregnant mother knowledge on anemia whereas ANC visit, knowledge of anemia, and obtaining counseling about IFAS were independent predictors of pregnant mother knowledge on benefit of IFAS. Health care providers should counsel pregnant mothers on early frequent ANC visit during pregnancy that focused on anemia cause, prevention and benefit of taking IFAS in the prevention of anemia during pregnancy and postpartum period.

Limitations
The cross-sectional nature of study design limits the applicability of the findings in establishing causality between the variables and it might also suffer from recall bias.