Percent of pregnant women who receive the recommended number of iron/folate supplements during pregnancy

Percent of pregnant women who receive the recommended number of iron/folate supplements during pregnancy

Percent of pregnant women who receive the recommended number of iron/folate supplements during pregnancy

The percent of women with a birth in the last two years who received or bought iron/folic acid supplements for at least six months during their last pregnancy in amounts that were in accordance with recommended protocols.

This indicator is calculated as:

(Number of pregnant women who received or purchased the recommended number of iron/folic acid tablets during last pregnancy /Total number of pregnant women with a birth in last two years) x 100

The current WHO recommendations are 60 mg of iron and 400 ug folic acid daily during pregnancy for all women, beginning as soon as possible during gestation and no later than the third month (WHO, 2010; WHO, 2011).

Data Requirement(s):

Information on the number of pregnant women who were issued or who purchased iron/folate tablets during last pregnancy; the number of tablets issued or purchased; and the total number of women who gave birth in the reference period

Health facility and antenatal care (ANC) clinic records; population based surveys (e.g., DHS, RHS, UNICEF Multiple Indicator Cluster Surveys)

This indicator measures the percentage of women who received or purchased the recommended amounts of supplements for iron and folic acid during pregnancy.  It provides information about the quality of ANC services and/or women’s access to purchasing supplements through local pharmacies and community-based sources.

Iron deficiency is a common nutrient deficiency and the resulting iron deficiency anemia is a major contributor to the global burden of disease (WHO/CDC, 2008). Anemia is a common problem among women of reproductive age, especially in low and middle income countries where low dietary intake of bioavailable iron combined with endemic infectious diseases such as helminthiasis puts women at increased risk in the preconception period. Low preconception hemoglobin and ferritin levels increase the risk of poor fetal growth and low birth weight (Dean, Lassi, Imam and Bhutta, 2014). Anemia during pregnancy (hemoglobin levels < 11g/dl) is associated with increased risks for maternal mortality, premature birth, and low birth weight.  Pregnant women need iron to support their enlarged blood volume, to provide for placental and fetal needs,and to replace blood loss in childbirth.  The fetus relies on maternal iron stores to create adequate reserves of its own, which in tandem with the iron in breast milk, will meet the iron needs of the normal birth weight infant through the first six months of life.  The 2008 Copenhagen Consensus panel ranked the provision of micronutrients, including iron and folic acid, as the world’s best investment for development (Micronutrient Initiative [MI], 2009). This indicator relates to three of the Millennium Development Goals: #1. Reduce poverty and hunger; #4. Reduce child mortality; and #5. Improve maternal health.

Iron supplementation is universally recommended during the second and third trimesters when iron stores become depleted over the course of pregnancy (WHO, 2010; MI, 2009).  The high physiologic requirement for iron during pregnancy is difficult to meet with most diets even where more iron-rich foods are available (INACG/WHO/UNICEF, 1998).  Providing iron/folate supplements for women pre-pregnancy or early in the pregnancy is desirable, particularly where deficiency levels are high (≥40%).  Because the efficiency of absorption of iron increases as iron deficiency anemia becomes more severe, the recommended 60 mg dose should provide adequate supplemental iron to women who do not have clinically severe anemia if it is given for an adequate duration.

Guidelines for treating severe anemia in pregnant women (Hg <7g/dl) includes three months of therapeutic supplementation (120 mg iron and 400 ug folic acid) followed by the preventive regimen (60 mg iron and 400 ug folic acid) for the duration of pregnancy and three months postpartum (INACG/WHO/UNICEF, 1998).  Complementary parasite control measures and dietary counseling are also recommended.

Supplementation with 400 µg of folic acid around the time of conception significantly reduces the incidence of neural tube defects.  These defects cause serious disabilities and infant mortality, and commonly arise in the first weeks of pregnancy before a woman may realize she is pregnant.  Folate supplementation begun after the first trimester of pregnancy is too late to prevent birth defects.  A daily dose of 400 µg folic acid is considered a safe and healthy intake for women during pregnancy and lactation but is more than the amount required to produce an optimal hemoglobin response in pregnant women.

An alternative indicator that reflects the adequacy of the program in meeting the needs of specific clients is ‘Number of iron/folate tablets distributed per eligible client.’

This indicator captures the distribution of iron/folate supplements, but not the actual consumption. Clients must receive appropriate counseling on why and how to take iron/folate supplements.  The best practice is for iron/folate supplementation to begin before pregnancy, but this indicator is primarily intended to measure supplementation during the last two trimesters of pregnancy.  Accurate reporting of the numbers of supplements received or purchased by women is problematic, even when measured specifically for the second and third trimesters of pregnancy.  Heath facility client records may not be consistently accurate.  Some women may be purchasing supplements from community-based pharmacies and other sources and their recall for amounts purchased may be subject to error.

access, nutrition, newborn (NB), safe motherhood (SM)

Dean SV, Lassi ZS, Imam AM, and Bhutta ZA. “Preconception care: nutritional risks and interventions”. Reproductive Health Volume 11 Supplement 2, 2014: Preconception interventions.

International Nutritional Anemia Consultative Group (INACG), WHO, UNICEF, 1998, Guidelines for the Use of Iron Supplements to Prevent and Treat Iron Deficiency Anemia, Ed. Rebecca J. Stoltzfus, Michele L. Dreyfuss.

The Micronutrient Initiative (MI), 2009, Investing in the future: A united call to action on vitamin and mineral deficiencies, Canadian International Development Agency. Ottawa.

WHO, Nutrition Landscape Information System (NLIS) 2010, Country Profile Indicators Interpretation Guide, Geneva: WHO.  

WHO, 2011, Evidence-Informed Guidelines: Daily iron and folic acid supplementation in pregnant women, Geneva: WHO.

WHO/CDC. 2008. Worldwide prevalence of anaemia 1993–2005 : WHO global database on anaemia. De Benoist B, McLean E, Egli I, Cogswell M eds. World Health Organization, Geneva. Available at

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