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A comprehensive review of iron folic acid supplementation among pregnant women: Redefining maternal nutrition
* Corresponding author: Mr. Ramcharan Bairwa, Department of Nursing, All India Institute of Medical Sciences Bhopal, Madhya Pradesh, India. ramcharanbscnursing1@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Bairwa R, Shafqat N, Verma R. A comprehensive review of iron folic acid supplementation among pregnant women: Redefining maternal nutrition. Future Health. doi: 10.25259/FH_51_2025
Abstract
Iron and folic acid (IFA) supplementation remains one of the most widely endorsed strategies in global maternal health, yet its promise is persistently undermined by poor compliance. Pregnancy amplifies nutritional demands, and untreated iron deficiency anemia continues to jeopardize maternal well-being and neonatal outcomes. Despite decades of evidence and strong policy advocacy, including World Health Organization (WHO) guidelines and national programs such as Anemia Mukt Bharat, gaps in adherence reveal a paradox: life-saving interventions often fail to reach or resonate with those most in need.
This review interrogates the complex interplay of socioeconomic, cultural, and systemic determinants that shape IFA adherence across contexts, with a particular emphasis on India and comparable low- and middle-income countries (LMICs). The findings expose how financial constraints, fragile health infrastructure, and limited health literacy intersect with cultural beliefs, traditional practices, and family dynamics to create a web of barriers that defy simple solutions. Myths linking supplementation to miscarriage or obstructed labor, alongside dietary inhibitors, side effects, and religious restrictions, reveal that the issue is not merely biomedical but deeply social. Equally, programmatic challenges, such as stock-outs, weak monitoring systems, and fragmented intersectoral coordination, further compromise the potential of supplementation campaigns.
Yet, emerging evidence also illuminates pathways. Culturally sensitive education, community-based counselling, and male or family involvement have shown measurable improvements in adherence. Innovative delivery approaches, from fortified foods and micronutrient powders to workplace supplementation, expand access beyond traditional channels. Digital health technologies, particularly SMS reminders and mobile applications, represent scalable tools to enhance daily compliance and strengthen supply-chain accountability. Public-private partnerships further highlight how collaboration can bridge systemic gaps and extend reach.
The analysis ultimately argues that IFA compliance must be reframed as more than a clinical prescription: it is a developmental challenge bound to women’s autonomy, education, and equity. Addressing maternal anemia requires integrated interventions that are simultaneously biomedical, behavioral, and political. Unless compliance is treated as both a health system responsibility and a societal priority, the cycle of preventable anemia and poor pregnancy outcomes will persist.
Keywords
Antenatal care
Compliance
Maternal nutrition
Iron and folic acid supplementation
Maternal anemia
Public health strategies
INTRODUCTION
Iron and folic acid (IFA) supplementation is a cornerstone of antenatal care (ANC) worldwide, aiming to prevent maternal anemia and associated adverse outcomes such as preterm birth, low birth weight, and neural tube defects. Pregnancy substantially increases iron requirements due to fetal growth and expansion of maternal blood volume, making iron deficiency anemia (IDA) one of the most common nutritional disorders during pregnancy.1 The World Health Organization (WHO) recommends daily oral IFA supplementation as a standard intervention to reduce anemia and its consequences during pregnancy.
Globally, anemia affects nearly 35.5% of pregnant women,1 with a higher burden in South Asia and Africa. Recent meta-analysis shows prevalence ranges from 5.2% to 65.7%, averaging around 40% in low- and middle-income countries (LMICs).2 Folic acid deficiency continues to contribute to neural tube defects, though supplementation coverage has improved in several regions.3
In India, anemia remains a major concern. According to National Family Health Survey (NFHS-5) (2019–21),4 52.2% of pregnant women are anemic. Government programs like Anemia Mukt Bharat (launched 2018)5 have improved access, but adherence remains inconsistent. Recent data indicate that only about 26% of mothers completed the recommended 180-day IFA regimen during pregnancy, with prevalence higher in urban areas (34.4%) compared to rural areas (22.7%).4 This reflects progress over earlier periods, but significant gaps remain.
This article synthesizes the barriers to IFA compliance and reviews evidence-based strategies from both global and Indian settings, with a particular focus on recent findings from LMICs. It examines the intersection of poverty, education, healthcare access, cultural beliefs, and policy-level challenges. By integrating international evidence, the paper highlights both systemic and individual-level factors affecting IFA compliance and proposes actionable strategies to improve maternal health outcomes.
SEARCH METHODOLOGY
A structured search strategy was designed to identify relevant peer-reviewed articles, systematic reviews, and observational studies targeting literature on IFA adherence, effectiveness, barriers, and facilitators, focusing on maternal nutrition outcomes. Electronic databases, including PubMed/MEDLINE, Scopus, Web of Science, Cochrane Library, IndMED, Embase, and Google Scholar, were searched for studies published in English from January 2000 to September 2025. Additional sources include reference lists of selected articles and grey literature, such as WHO guidelines and National Health Mission reports, to capture policy insights. Search terms combined Medical Subject Headings (MeSH) and keywords related to the population (e.g., “Pregnant Women”[MeSH], “antenatal care”), intervention (e.g., “Folic Acid”[MeSH], “IFA supplementation”), and outcomes (e.g., “Medication Adherence”[MeSH], “maternal nutrition”). Boolean operators (AND, OR, NOT) will refine the search, with a sample PubMed string: (“Pregnant Women”[MeSH] OR “Pregnancy”[MeSH]) AND (“Folic Acid”[MeSH] OR “Iron Folic Acid”) AND (“Medication Adherence”[MeSH] OR “maternal health”). Inclusion criteria encompass studies on pregnant women receiving IFA, while non-English studies, those before 2000, or unrelated populations (e.g., children)were excluded.
REVIEW FINDINGS AND DISCUSSION
This section synthesizes evidence from diverse studies, highlighting key patterns and associations to inform public health strategies in resource-constrained settings like Bhopal District.
I. Socioeconomic determinants of IFA compliance
Socioeconomic factors, such as income, education, occupation, and access to healthcare, play a critical role in shaping health behaviors and outcomes during pregnancy. Understanding these determinants is essential for identifying barriers to IFA compliance and designing targeted interventions to improve maternal nutrition and reduce anemia prevalence.
A. Financial constraints
Several studies have highlighted financial barriers as a persistent determinant of poor adherence to IFA supplementation. Evidence from LMICs suggests that, despite large-scale government programs offering free distribution, frequent stock-outs force up to 35% of low-income households to purchase supplements from private sources, thereby increasing inequity in access.6 Beyond the direct cost of supplements, indirect expenses such as transportation to health facilities and the opportunity cost of clinic visits further discourage compliance among economically vulnerable groups.7 Reports from India and sub-Saharan Africa consistently demonstrate that interruptions in public-sector supply chains shift the financial burden onto women, many of whom rely on irregular or low household incomes. In contrast, literature from high-income countries indicates that financial barriers are minimal; however, adherence is still challenged by behavioral and lifestyle-related factors, such as forgetfulness or low prioritization of supplement intake. Collectively, these findings underscore the dual nature of financial constraints: while economic barriers dominate in resource-limited settings, behavioral adherence challenges remain relevant even where supplements are freely and reliably available.
B. Maternal education and health literacy
Maternal education has consistently been identified as a key determinant of IFA adherence across both global and regional studies. Evidence indicates that women with higher levels of education are more likely to understand the benefits of supplementation, recognize the early signs of anemia, and comply with medical advice during pregnancy. Conversely, limited literacy not only reduces awareness but also fosters misinformation, with common misconceptions including beliefs that IFA supplementation may cause miscarriage or lead to difficult labor. Communication gaps within healthcare systems further exacerbate this issue, as counseling materials and instructions are often not adapted to the comprehension levels of low-literacy populations. Empirical studies from India and similar LMIC contexts have reported a 25-30% higher likelihood of adherence among educated mothers compared with their less-educated counterparts.7,8 Nonetheless, the persistence of myths and misinformation, even among partially educated groups, underscores the need for context-specific, culturally sensitive health education strategies.
C. Healthcare accessibility and infrastructure
Access to quality healthcare services, particularly ANC, plays a central role in ensuring consistent IFA supplementation. Studies from LMICs demonstrate that weak health infrastructure, inadequate human resources, and irregular supply chains frequently disrupt supplement distribution.9,10 Even where IFA is theoretically available, systemic constraints such as staff shortages, overcrowded facilities, and long waiting times reduce ANC attendance and limit the opportunity for effective counselling. Geographic barriers further widen inequities, with women in remote and rural settings significantly less likely to access or adhere to IFA regimens compared to their urban counterparts. Research from India and other LMICs consistently highlights challenges, including intermittent IFA supply, limited ANC coverage, and overburdened frontline health workers. By contrast, high-income countries report fewer systemic supply-side barriers; however, adherence gaps are still observed among migrant and underserved populations, where healthcare access and communication challenges persist. Collectively, these findings emphasize the critical importance of strengthening health systems and ensuring equitable ANC access to improve IFA compliance globally.
D. Work and time constraints
Time and occupational demands represent an underrecognized barrier to IFA adherence, particularly among women engaged in labor-intensive occupations such as agriculture, domestic work, and factory labor. Studies indicate that over 40% of pregnant women in such occupations miss scheduled ANC appointments, reducing opportunities for counseling and supplement provision.11 Long working hours, inflexible schedules, and workplace environments that lack supportive health provisions further limit women’s ability to prioritize consistent supplement intake. Fatigue and physical strain associated with demanding work also contribute to forgetfulness or diminished motivation to adhere to daily regimens. In contrast, evidence from high-income countries suggests that flexible workplace policies and supportive health systems mitigate many of these barriers; however, lifestyle-related challenges such as forgetfulness or competing priorities continue to affect daily compliance. Collectively, this body of evidence underscores the need for workplace-sensitive health policies and innovative delivery models to ensure adherence among working women.
II. Cultural and behavioral influences on IFA adherence
A. Traditional beliefs and taboos
Cultural beliefs and pregnancy-related taboos strongly shape maternal health behaviors, including the acceptance of IFA supplementation. Evidence from South Asia and sub-Saharan Africa highlights widespread misconceptions that iron supplements cause excessive fetal growth, leading to obstructed labor or cesarean delivery.11,12 Such beliefs, often reinforced through intergenerational transmission, can override medical advice and contribute to intentional non-compliance. Additionally, dietary practices during pregnancy are frequently regulated by cultural norms, some of which discourage the use of biomedical interventions or restrict the intake of “hot” or “strengthening” foods and medicines that are believed to harm the fetus. These culturally rooted perceptions create a significant barrier to adherence, particularly in rural and traditional communities.13 By contrast, studies from high-income countries suggest that cultural taboos play a minimal role; instead, non-adherence is more commonly attributed to side effects, pill fatigue, or competing health priorities. Collectively, these findings underscore the importance of culturally sensitive communication strategies that address misconceptions while respecting community traditions.
B. Dietary practices and preferences
Cultural dietary patterns significantly influence iron intake and absorption, thereby affecting adherence to IFA supplementation. In many regions, particularly South Asia, vegetarian and predominantly plant-based diets provide iron mainly in the form of non-heme iron, which has lower bioavailability compared to heme iron found in animal sources. The inhibitory effects of phytates, polyphenols, and calcium-rich foods commonly present in these diets further compromise absorption, compounding the risk of iron deficiency.14 Beyond dietary composition, the side effects frequently associated with IFA supplements, including nausea, constipation, and dark stools, are consistently reported as leading causes of discontinuation, particularly when not adequately addressed by healthcare providers. Qualitative studies also highlight that aversion to the taste or smell of tablets, alongside a preference for “natural” remedies over “chemical” interventions, further discourages regular use. Collectively, these findings suggest that both biological factors (dietary inhibitors) and experiential factors (side effects and aversion) interact to reduce compliance, underscoring the need for context-specific counseling and formulation improvements.
C. Influence of family and community
In many LMICs, family dynamics play a decisive role in shaping maternal health behaviors, including adherence to IFA supplementation. Studies indicate that in patriarchal and community-oriented societies, pregnant women often lack autonomy in health-related decision-making, with husbands, mothers-in-law, and community elders exerting significant influence.15,16 In some cases, elder family members discourage supplement use due to outdated or incorrect beliefs, thereby reinforcing non-compliance. Conversely, evidence suggests that peer support, spousal encouragement, and community-wide endorsement of IFA can positively influence adherence, particularly when supplements are framed as a collective maternal and child health priority. Health behavior theories further emphasize the role of perceived social norms and the influence of role models in shaping supplement uptake decisions. By contrast, in high-income settings, adherence is less dependent on family approval and more strongly influenced by peer networks and maternal support groups. These findings underscore the importance of community- and family-centered strategies to improve IFA compliance in resource-limited settings.
D. Religious and ethical considerations
Religious beliefs and practices can significantly influence adherence to IFA supplementation. In some communities, supplements in gelatin-based capsules or containing animal-derived ingredients are rejected due to religious dietary restrictions, particularly among populations adhering to vegetarian or halal dietary laws.17 Additionally, fasting practices during religious observances may disrupt regular supplement intake, either because medication is discouraged during fasts or because dietary restrictions limit iron-rich food consumption. Such barriers highlight the need for culturally sensitive interventions, including the provision of vegetarian or halal-certified supplements and tailored counseling that respects religious practices while emphasizing maternal health benefits. Evidence from diverse settings suggests that the introduction of halal and vegetarian supplement options has improved acceptance, underscoring the importance of aligning medical interventions with cultural and religious contexts.
III. Policy and programmatic challenges
A. Gaps in government and public health policies
Despite global efforts to reduce IDA through large-scale IFA supplementation programs, many LMICs continue to face substantial policy and implementation challenges. While national guidelines frequently mandate the provision of IFA during ANC, weak enforcement mechanisms and fragmented health systems often limit their effectiveness. Inadequate integration of supplementation into broader maternal and child health services, particularly in rural and resource-poor settings, results in missed opportunities for early intervention.2 Furthermore, the absence of robust intersectoral coordination across health, education, and nutrition departments contributes to duplication of efforts and inefficient use of resources. Even where policies are in place, poor monitoring and weak accountability frameworks hinder program outcomes, with rural populations disproportionately affected. In contrast, most high-income countries have successfully integrated IFA distribution within routine ANC services; however, adherence gaps persist among marginalized and underserved groups. Collectively, this evidence underscores the need for stronger policy enforcement, improved system integration, and intersectoral collaboration to ensure equitable IFA coverage.
B. Effectiveness of mass supplementation campaigns
Large-scale IFA supplementation campaigns, such as India’s National Iron Plus Initiative and comparable programs in Latin America and sub-Saharan Africa, have demonstrated variable levels of success. Evidence suggests that mandatory, well-monitored programs achieve higher compliance than voluntary initiatives, largely due to stronger accountability and resource allocation. For example, Bangladesh reported significant improvements in maternal hemoglobin levels following the nationwide scale-up of IFA distribution through CHWs. However, program effectiveness is frequently undermined by systemic challenges, including inadequate training of frontline workers, stock-outs, and irregular supply chains, which disrupt continuity of supplementation. India’s National Iron Plus Initiative reflects this variability: while regions with robust monitoring and supervision mechanisms report coverage rates exceeding 60%, other areas achieve only about 35% adherence to the recommended 180-day regimen.5 These findings highlight the critical importance of supply chain stability, workforce capacity, and rigorous monitoring in ensuring the success of mass supplementation programs.
C. Public-private partnerships in IFA distribution
Public-private partnerships have emerged as promising models for enhancing access to and compliance with IFA supplementation. NGOs and private pharmaceutical companies play pivotal roles in manufacturing, distributing, and promoting supplements, particularly in hard-to-reach areas.18 In Kenya and Ethiopia, collaborative initiatives between governments, donor agencies, and private partners have successfully expanded IFA coverage through mobile health units and door-to-door delivery campaigns. Similarly, workplace supplementation programs in factories employing large numbers of women have demonstrated improvements in adherence by reducing time and access barriers. In India, partnerships leveraging NGOs for community-level distribution have helped extend program reach to underserved populations. In high-income settings, PPPs increasingly incorporate digital platforms and workplace initiatives to promote compliance, reflecting broader health system integration.19 Nonetheless, the success of PPP models depends heavily on robust regulatory oversight to ensure product quality, equitable distribution, and ethical promotion practices. Collectively, these experiences highlight the potential of PPPs as complementary strategies to strengthen existing public health systems.
IV. Strategies to improve IFA compliance across populations
A. Culturally tailored health education programs
Culturally sensitive and context-specific health education remains a cornerstone for improving IFA adherence. CHWs play a critical role in bridging knowledge gaps by providing accurate, relatable information in local languages and culturally acceptable formats. Evidence shows that counseling integrated into routine ANC, when culturally adapted, can significantly improve adherence rates. Embedding IFA awareness within existing maternal health services, school-based curricula, and village health days ensures repeated exposure to key messages, thereby reinforcing knowledge and promoting sustained behavior change. Furthermore, innovative communication methods, including storytelling, visual aids, and peer-led education, have proven particularly effective in dispelling misconceptions and reshaping social norms in South Asian and sub-Saharan African contexts. Quantitative studies suggest that culturally adapted counseling approaches, such as peer education and narrative-based communication, can increase IFA adherence by 20-25% in diverse communities.14,20 Collectively, these findings underscore the importance of localized, culturally aligned communication strategies as an essential complement to supplementation programs.
B. Behavioral interventions and counselling
Behavioral change communication (BCC) interventions have demonstrated considerable potential in addressing individual-level barriers to IFA adherence, such as forgetfulness, fear of side effects, and low perceived need for supplementation. Motivational interviewing and personalized counseling approaches help tailor information to individual concerns, thereby enhancing receptivity and compliance.21 Evidence further suggests that involving male partners, mothers-in-law, and other influential family members in counseling sessions fosters household-level support, which is particularly critical in patriarchal contexts. Group-based interventions, including women’s self-help groups and mother support clubs, have also proven effective in normalizing IFA use and promoting peer encouragement. Regular follow-up through CHWs, especially via home visits and structured counseling sessions, reinforces behavior change over time. In addition, technology-enabled approaches such as SMS reminders and partner-inclusive counseling have been associated with adherence improvements of up to 30% in LMIC settings.19,22 In high-income countries, mobile applications and digital platforms are increasingly utilized to provide reminders, track supplement intake, and deliver educational content. Collectively, these findings highlight the importance of multi-level BCC strategies that combine interpersonal, community, and technological approaches to sustain IFA adherence.
C. Innovative approaches to supplementation
Recent innovations in the formulation and delivery of iron supplements present promising solutions to longstanding compliance challenges. Food fortification strategies, such as iron-enriched cereals, rice, and salt, offer non-pill alternatives that bypass pill fatigue and gastrointestinal side effects, thereby improving acceptability among diverse populations. Similarly, lipid-based nutrient supplements and multiple micronutrient powders have demonstrated superior tolerability and adherence compared to traditional IFA tablets, with trials reporting improvements in hemoglobin levels of 15-25% in low-adherence populations.22 Parallel advances in digital health interventions have further enhanced supplement uptake. SMS reminders, mobile health (mHealth) applications, and telephonic follow-ups have proven effective in supporting consistent adherence, particularly among younger and tech-literate groups. Evidence from India shows that mobile-based health alerts increased IFA consumption by more than 30% in a randomized controlled trial. Collectively, these technological and nutritional innovations highlight the potential for diversified approaches that move beyond tablet distribution, offering scalable strategies to improve compliance in both LMIC and high-income contexts.23
D. Policy recommendations for sustainable change
Sustainable improvement in IFA compliance ultimately depends on strong policy commitment and system-wide reforms. Strengthening supply chain management through digital stock-tracking, improved forecasting, and decentralized procurement has been shown to reduce stock-outs and ensure uninterrupted supplement availability.6 Evidence also supports the use of incentive-based approaches, such as linking IFA adherence to conditional cash transfers, food rations, or transport vouchers, which have demonstrated positive effects on supplement uptake in several LMIC contexts. Equally important are robust monitoring and evaluation mechanisms: integrating adherence and coverage indicators into national health information systems allows governments to track progress and identify gaps in program implementation.24 Beyond the health sector, multi-sectoral collaboration involving education, agriculture, and labor ministries can help embed IFA supplementation within broader nutrition and maternal health strategies, thereby promoting long-term sustainability. Collectively, these measures highlight the critical role of policy-level action in addressing structural barriers and ensuring equitable access to IFA supplementation.
CONCLUSION
IFA supplementation remains a cornerstone strategy in the global fight against maternal anemia and associated adverse pregnancy outcomes. Despite strong evidence supporting its efficacy, compliance with IFA supplementation is hindered by a complex interplay of socioeconomic and cultural factors. Financial limitations, inadequate health infrastructure, and low health literacy levels consistently emerge as significant socioeconomic barriers. Simultaneously, cultural beliefs, traditional practices, and social influences profoundly shape individual and community perceptions of supplementation.
Despite these challenges, emerging evidence highlights a spectrum of effective solutions. Culturally appropriate education, BCC, and family-inclusive counseling have been shown to enhance awareness and adherence. Community-based interventions, peer support groups, and workplace supplementation models improve access and continuity. Technological innovations, ranging from SMS reminders and mobile health applications to digital stock-tracking, offer scalable opportunities to strengthen both individual compliance and health system performance. Likewise, fortified foods and micronutrient powders provide viable alternatives for populations with poor pill tolerance.
Future research should focus on evaluating the long-term impact of integrated interventions, particularly those that harness technology and social support mechanisms. Additionally, global and national policy frameworks must prioritize IFA adherence not only as a medical issue but as a developmental priority tied to women’s empowerment, education, and socioeconomic equity. A coordinated global effort, informed by both qualitative and quantitative evidence, is essential to overcome the persistent barriers to IFA compliance and realize the full potential of this life-saving intervention.
In conclusion, addressing maternal anemia through IFA supplementation demands both systemic reform and community-driven innovation. By uniting cultural sensitivity, behavioral strategies, technological tools, and strong political commitment, global health systems can overcome persistent barriers and ensure healthier futures for mothers and their children.
Acknowledgment
I sincerely acknowledge the guidance and support of my mentors and faculty throughout the development of this review. I extend my gratitude to the institution for providing access to resources essential for this work. Finally, I thank my peers and family for their constant encouragement and motivation.
Author Contibution
RB: Conceptualization, data curation, formal analysis, investigation, development or design of methodology, project administration, writing-original draft with review and editing. correspondence with publishing journal; NS: Data curation, formal analysis, supervision, writing - review and editing. RV: Data curation, formal analysis, supervision, writing - review & editing.
Ethical approval
The research/study approved by the Institutional Review Board at All India Institute of Medical sciences, Bhopal, number IHEC/SR/2024/09, dated 1st February 2024.
Declaration of patient consent
Patient’s consent not required as patients identity is not disclosed or compromised.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of Artificial Intelligence (AI)-Assisted Technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
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