1. Introduction

Iron-deficiency, the predominant nutritional deficiency leading to prenatal anemia, significantly impacts the well-being of both mothers and developing fetuses [1]. Pregnant women require additional iron and folic acid to meet both their personal nutritional needs and those of the growing fetus [2]. Inadequate intake of iron–folic acid (IFA) during pregnancy has been associated with an increased risk of adverse birth outcomes, such as neural tube defects, cardiac abnormalities, and endocrine disorders. IFA supplementation (IFAS) is a recognized approach to prevent adverse birth outcomes and hematologic complications during pregnancy [3]. However, this issue represents a noteworthy global public health concern, affecting approximately 35 million women worldwide, with the highest prevalence observed in South Asia [4]. It is a major contributor to maternal mortality, accounting for 20%–40% of maternal deaths [5]. The rate of anemia during pregnancy varies significantly worldwide, even in developed countries [6]. For example, the rate is 18% in the USA, 20% in Australia, 67.8% in Singapore, and 70% in China. In contrast, the rate is higher in developing countries such as Ethiopia (50.1%), Sudan (53%), and Guinea (71%) [7]. According to the Nepal Demographic Health Survey of 2022 [8], the prevalence of anemia among women aged 15–49 is 34%, with a slightly lower rate of 33% among pregnant women. In the eastern part of Nepal, noncompliance with IFAS and the prevalence of anemia were found to be 42% among pregnant women [9].

Compared to other SAARC countries, Nepal’s anemia prevalence is lower than that of Bangladesh (50%) [10], Maldives (58.5%) [11], India (50%–70%) [12], and Pakistan (76.7%) [7]. According to Nepal’s annual health report for the fiscal year 2079/80, 64.5% of women received a 180-day supply of IFA during pregnancy; however, coverage remains only at 55.4%. Despite Nepal’s relatively lower anemia prevalence compared to other SAARC countries and an increase in the percentage of pregnant women receiving IFAS over the past three fiscal years, IDA remains a significant public health issue, affecting a considerable portion of the population, particularly women and children [13].

Several factors are associated with compliance with IFAS. These include the age of the woman, educational status, parents’ educational qualifications, household economic status, the number of antenatal care (ANC) visits, women’s self-efficacy, knowledge about anemia, and counseling during ANC services [14]. Additionally, the primary contributors to maternal anemia encompass factors such as iron deficiency, hookworm infection, and malaria. To address these issues, the Government of Nepal launched the Iron Intensification Programme (IIP) in 2003 to improve the reach and effectiveness of IFAS, along with anthelmintic treatment, during pregnancy [15]. This initiative aligns with global health recommendations, including those from the World Health Organization (WHO), which advocate early daily IFAS during pregnancy as part of ANC [6]. To date, several strategies have been implemented to control and prevent IDA. Among these approaches are supplementation programs, which provide pregnant women and lactating mothers with IFA supplements containing 60 mg elemental iron and 400 mg folic acid every day for 225 days (180 tablets during pregnancy and 45 tablets after delivery) starting in their second trimester. Similarly, deworming programs, mandatory fortification of wheat flour with iron, folic acid, and vitamins, and health education have been implemented [13, 16]. Many countries have implemented similar strategies and programs to address IDA, often following WHO guidelines. For instance, from 1963 to 2021, The National Nutritional Policy, National Iron Plus Initiative (NIPI), Anemia Mukt Bharat, and Mid-Day Meal Program were launched in India. Specifically for high-risk populations, including pregnant women and adolescent children, these programs involve food fortification, nutritional education, and IFAS, et cetera [17]. Similarly, Bangladesh [18] and the Maldives [5] have implemented programs and strategies aligned with WHO recommendations to combat IDA.

Despite IFAS being a prioritized program in Nepal, the persistence of anemia during pregnancy remains a significant public health concern [9]. Factors such as low education, poverty (household wealth), and regional disparities (lower compliance in the Terai region), as well as the quality of counseling, still remain major challenges in Nepal for IFAS [15]. Similarly, poor coverage, poor service quality, untimely procurement and supply of commodities, unsatisfactory transportation and storage at local levels, and limited allocation of financial resources are major weaknesses of the program [13]. Therefore, this study aimed to identify factors associated with compliance with IFAS and the prevalence of IDA among pregnant women attending a private hospital in Kathmandu, Nepal.

2. Materials and Methodology

This cross-sectional study was conducted at Blue Cross Hospital, a private 50-bedded facility situated in Tripureshwar, Kathmandu. This hospital was selected because of its central location, which provided easier access for pregnant women, as well as the researcher’s convenience and resource constraints, including limited time and self-funding.

The study focused on pregnant women in their 2nd and 3rd trimesters who attended ANC visits and were currently using IFA supplements. The initial sample size for this study was calculated to be 245 using the formula n = z²pq/e², where z = 1.96 (for a confidence level of 95%), p = 0.801 representing IFAS compliance during pregnancy [19], q = (1–p), e = 0.05 (acceptable margin of error). To account for a 10% non-response rate, the final sample size was adjusted to 270. The consecutive sampling technique was used to include all readily available pregnant women who met the inclusion criteria, making it a practical and efficient approach. Pregnant women with mental health issues or those who were unwilling to provide consent were excluded from the study.

Data were collected via face-to-face interviews conducted between March 26 and April 17, 2023. Sociodemographic, pregnancy and obstetric details, knowledge on IFAS and anemia, and IFASs were covered. Verification of sociodemographic, pregnancy, obstetric characteristics, and anemia status involved cross-referencing with maternal and newborn health cards. The questionnaire underwent validation by three subject experts in public health. A pilot study involving 27 pregnant women at Mandandeupur Hospital, Kavrepalanchok district, was conducted for reliability. Modifications were implemented, and data from this pilot were excluded from the final analysis.

In this study, knowledge of IFA refers to the respondents’ understanding of the correct timing for initiating IFA, recommended dosage, physical appearance of tablets (color), benefits, and side effects. This was assessed using six questions. Additionally, knowledge of anemia means a correct understanding of signs, symptoms, possible causes, effects, and prevention strategies. This was evaluated using four multiple-choice questions. Each correct answer received a score of “1,” while incorrect answers were scored as “0.” The scores were aggregated, and the mean was calculated. Pregnant women scoring above the mean were considered to have good knowledge, while those below were deemed to have poor knowledge [20].

Compliance in this study was defined as respondents following the recommended dose of IFA as per government protocol. It was determined through self-reported IFA tablet intake in the past 7 days, serving as a proxy for recommended (90+ days) IFA compliance. Pregnant mothers taking ≥4 tablets per week were categorized as compliant [20, 21].

Anemia prevalence was identified using laboratory results from the hemoglobin test. Pregnant women aged 15–49 years with hemoglobin levels below 11.0 g/dL were classified as having anemia [8].

All data were coded and analyzed using SPSS version 26. Descriptive analysis was conducted for categorical variables. The χ² test was employed to assess the association between sociodemographic characteristics, pregnancy, and obstetric-related variables, as well as knowledge levels, with adherence to IFAS and the prevalence of anemia. Variables showing a significant association were subsequently included in multivariate logistic regression analysis to identify the most influential factors. A significance level of p  < 0.05 was considered statistically significant.

3. Results

Table 1 summarizes the sociodemographic characteristics of the study participants. The majority fell within the age range of 25–34 years, with the highest frequencies in the 25–29 (34.1%, n = 92) and 30–34 (34.4%, n = 93) age groups. The average age was 30.09 years (SD ± 4.40). Brahmin/Chettri was the predominant ethnic group (46.3%, n = 125), and most participants were Hindu (69.6%, n = 188). Secondary education was the most common level of attainment for both the participants (57.8%, n = 156) and their husbands (46.7%, n = 126). Homemakers were the primary occupation of participants (57.4%, n = 155), while service was most frequent for husbands (49.6%, n = 134). A significant proportion lived in nuclear families (52.6%, n = 142), and reported a median income exceeding 50,000 (64.4%, n = 174). The majority resided within Kathmandu Valley (73.0%, n = 197).

The majority (58.9%) of the participants reported a history of prior pregnancy (n = 159). Among these women, 39.6% (n = 63) had a history of anemia during their previous pregnancy. More than half (58.1%, n = 157) were in their third trimester. A minority of patients (27.4%, n = 74) reported a prior medical history of illness (Table 2).

The respondents in our study demonstrated varying levels of knowledge regarding IFAS and anemia. Half (50.0%) of the respondents showed good knowledge of the IFAS, reflecting a balanced distribution between those with good and poor knowledge. In contrast, the majority (56.3%, n = 152) demonstrated good knowledge of anemia, while the remaining participants (43.7%) exhibited poor knowledge (Table 3).

Table 4 details IFAS compliance and anemia prevalence among the participants. While the majority (68.5%, n = 185) initiated IFA at the recommended time (second trimester), overall compliance was 63.0% (n = 170). Forgetfulness (98.0%) and fear of side effects (96.0%) were the major barriers. Notably, 55.2% (n = 149) of patients experienced side effects. Knowledge of the benefits of IFA (87.6%) and family support (90.5%) positively influenced compliance. The prevalence of anemia in the current pregnancy was 28.5% (n = 77).

Multivariate logistic regression analysis was performed to explore associations between sociodemographic characteristics, pregnancy or obstetric-related factors, and knowledge in relation to respondents’ compliance with IFAS (Table 5) and the prevalence of anemia (Table 6). The model fitting employed the backward likelihood method, with the initial model demonstrating a satisfactory fit based on omnibus tests of model coefficients (χ² (8, n = 270) = 7.576; p = 0.001), Hosmer and Lemeshow test (χ² (5, n = 270) = 20.07; p = 0.476), and Nagelkerke pseudo-R square of 0.2. In the multivariate analysis, the odds of compliance were 2.6 times higher among respondents who were homemakers (adjusted odds ratio (AOR) = 2.6 and 95% confidence interval (CI) = 1.1–6.0), those who initiated IFA tablet consumption from the beginning of the second trimester (AOR = 2.2 and 95% CI = 1.1–5.0), and individuals with good knowledge of IFAS (AOR = 2.4 and 95% CI = 1.2–4.8; Table 5). The second model also exhibited a significant fit, supported by omnibus tests of model coefficients (χ² (6, n = 270) = 17.207; p = 0.009), the Hosmer and Lemeshow test (χ² (7, n = 270) = 4.102; p = 0.768), and a Nagelkerke pseudo-R square of 0.2. The odds of anemia were significantly higher among respondents with an education level at the basic level and below (AOR = 5.1 and 95% CI = 1.7–15.2), respondents with no medical history of illness (AOR = 4.0 and 95% CI = 1.5–10.6), and lower odds among those who were homemakers (AOR = 0.3 and 95% CI = 0.1–0.8; Table 6).

4. Discussion

This study investigated factors influencing IFA compliance and anemia prevalence among pregnant women attending a private hospital in Kathmandu, Nepal. Limited data exists on this topic in this specific context. The majority of our respondents belonged to the age group of 25–34 years, were homemakers with a good monthly income, had husbands with secondary and university-level education, had experienced multiple pregnancies and childbirths, and had no history of anemia in previous pregnancies. These characteristics align with previous studies [22], and reinforce the importance of considering sociodemographic factors in maternal health research. However, compliance and anemia rates are likely affected by regional differences in geography, economy, and healthcare infrastructure. Accessibility barriers (road connectivity and availability of health institutions) and lack of trained human resources often lead to irregular antenatal visits and poor adherence to the required number of IFA supplements in rural and remote areas. Furthermore, women from low-income areas may prefer to spend their money on household expenses rather than health expenses, which may lead to inconsistent supplement intake. The prevalence of medical history of illness was relatively low (27.4%), consistent with earlier findings [23], emphasizing the importance of exploring health histories in the context of maternal care.

Our study revealed that half (50%) of the respondents had good knowledge of IFA. These results align with previous studies [20, 24, 25]. Similarly, more than half (56.3%) had good knowledge of anemia. A similar result was also reported previously [20]. Notably, Arficho [26], reported a higher percentage (90%) of high knowledge on anemia. The variation could be attributed to differences in sample size, geographical context, and the study settings, further emphasizing the influence of location and healthcare infrastructure in these findings.

In our study, the majority (68.5%) initiated IFA tablet consumption from the first day of the second trimester, echoing findings from Pokhara, Nepal [27]. Forgetfulness and fear of side effects emerged as major reasons for noncompliance, consistent with previous research [28, 29]. Although these barriers to compliance are significant, healthcare providers can play a pivotal role in mitigating these challenges through improved patient education and counseling. Detailed information on the potential long-term health benefits and possible side effects of IFA, and exploring alternative supplementation options (such as liquid or chewable forms), health workers can reduce misconceptions and improve adherence. Additionally, engaging female community health volunteers (FCHVs) to provide follow-up home visits, reinforce counseling messages, and implement a reminder system (SMS alerts) may help address forgetfulness, and further enhance patient adherence.

More than half (55.2%) reported experiencing side effects after consumption, in line with earlier findings [30]. Despite these challenges, our study found that 63.0% of respondents were compliant with IFAS. This aligns with reports from the Annual Health Report 2021 [13] and NHDS 2021 [8] in Nepal and a hospital-based study in Ethiopia [31].

Our study reported a relatively low prevalence of anemia (28.5%) among pregnant women, similar to findings by Gebremariam et al. [24], and another study in Ethiopia also reported similar results [32]. However, Nepal Health Demographic Survey, 2021 [8], showed a slightly higher prevalence (32.7%). These differences may be attributed to variations in sample size, study coverage, and healthcare access across different regions.

Our study identified that respondents with secondary level or higher education had higher odds of IFA compliance, consistent with a study in Ethiopia [3]. Good knowledge was associated with a 2.4 times higher likelihood of compliance, consistent with previous research [3, 7, 20, 30, 33].

Homemakers demonstrated higher odds of compliance to IFAs and lower odds of anemia, supporting findings from a previous study [34]. From this result, we may conclude that higher compliance leads to lower anemia rates. Similar to this, a study conducted in the eastern Terai of Nepal [9], reported pregnant women with noncompliance had higher odds of anemia. Additionally, respondents with basic-level education or lower had higher odds of anemia, in line with earlier research [16, 35]. We also found that respondents who did not encounter IFA tablet shortages had lower odds of anemia, although this result was not statistically significant. A similar result was also reported in the previous study [36].

In this study, data were collected in a single private hospital, which may limit generalizability beyond urban Kathmandu. Self-reported compliance data may introduce bias by underestimating forgetfulness or overestimating IFA adherence. Future research should focus on community-based studies, particularly in rural areas of the Terai zone, especially in Madhesh Province and among vulnerable populations, especially targeting Muslim and Madhesi women. Investigating compliance, anemia rates and identifying the specific barriers in these groups will help to design targeted interventions to improve IFA compliance and reduce anemia. Additionally, evaluating the effectiveness of educational programs and family-based interventions on compliance and anemia reduction through intervention-based studies can provide actionable strategies for improving health outcomes. Despite these limitations, the study provides valuable insights into the private healthcare sector of Kathmandu, Nepal, contributing to the understanding of factors influencing IFA compliance and anemia prevalence among pregnant women in urban settings.

5. Conclusion

Our findings highlight the importance of sociodemographic characteristics, knowledge, and healthcare practices in achieving optimal maternal health outcomes. While the reported IFA compliance was moderate, they aligned with national figures. Forgetfulness and side effects were significant barriers. Here, healthcare workers, especially FCHVs, can play crucial role. Detailed information about long-term health benefits and possible side effects of IFA, and clear guidance on managing them can address this misconception. Follow-up and technology-based solutions (SMS reminders) can effectively mitigate forgetfulness. Proper counseling, and exploring alternative supplementation options can improve acceptability among women hesitant about side effects.

Despite these challenges, knowledge of IFA and anemia was good among the participants. The prevalence of anemia is lower than that of national data, but remains a public health concern. Higher education, good IFA knowledge, and homemakers were associated with better outcomes. Conversely, lower educational levels were associated with a higher risk of anemia. These findings emphasize the need for targeted interventions, especially focusing on women with lower educational attainment, to improve IFA compliance and reduce anemia prevalence. Future public health efforts should prioritize tailored education, community support, and improved healthcare access to address knowledge gaps, reduce anemia, and increase compliance with IFAS in pregnant women.

Ethics Statement

Ethical approval was obtained from the Institutional Review Committee of Yeti Health Science Academy (Ref. No. 079-81).

Conflicts of Interest

The authors declare no conflicts of interest.

Author Contributions

Rajesh Karki and Sudipa Khanal were responsible for conceptualization, project administration, and writing the original draft. Sudipa Khanal and Deepak Raj Joshi handled data curation and formal analysis. Rajesh Karki and Maheshar Kaphle developed the methodology. Maheshor Kaphle was responsible for writing review and editing. There was no funding acquisition.

Funding

No funding was received for this research.