Antenatal care visits as a determinant of pregnant women's compliance with iron supplementation at Batalaiworu health center

*Corresponding author: Nindy Elliana Benly Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Antenatal care visits as a determinant of pregnant women’s compliance with iron supplementation at Batalaiworu health center Nindy Elliana Benly 1, *, Wa Ode Sitti Fidia Husuni 1 and Ramlah Milawati Ramli 2 1 Diploma in Midwifery, Paramata Raha Polytechnic, Raha, Indonesia, 93612 2 Diploma in Midwifery, Karya Persada Muna University, Raha, Indonesia, 93612 World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 237-243 Publication history: Received on 10 July 2025; revised on 17 August 2025; accepted on 19 August 2025 Article DOI: https://doi.org/10.30574/wjbphs.2025.23.2.0761 Abstract Background: Anemia in pregnancy remains a major maternal health problem contributing to maternal morbidity and mortality. One of the main prevention strategies is iron (Fe) supplementation. However, adherence to iron tablet consumption among pregnant women is influenced by various factors, including antenatal care (ANC) visits. Objective: This study aimed to determine the association between antenatal care visits and adherence to iron supplementation among pregnant women at Batalaiworu Health Center, Kendari City. Methods: A quantitative study with a cross-sectional design was conducted in May 2025. The population consisted of 405 pregnant women registered at Batalaiworu Health Center, with 165 respondents selected as the sample using proportional sampling. Primary data were collected through structured questionnaires and analyzed using the chisquare test with a 95% confidence level. Results: The findings revealed a significant relationship between ANC visits and adherence to iron tablet consumption. The chi-square test showed a p-value = 0.000 (p < 0.05), indicating that the more regular the ANC visits, the higher the adherence of pregnant women to iron supplementation. Conclusion: ANC visits play a crucial role in improving adherence to iron supplementation among pregnant women. Recommendations: Strengthening nutrition education and counseling during ANC visits is essential to enhance adherence and prevent anemia in pregnancy. Keywords: Antenatal Care; Adherence; Iron Supplementation; Pregnant Women; Maternal Health 1. Introduction Anemia during pregnancy remains a global public health concern and continues to pose a serious challenge for maternal and child health programs. According to the World Health Organization (WHO), approximately 35.5% of pregnant women worldwide were anemic in 2023, making anemia a leading cause of maternal and neonatal morbidity (1). The condition is particularly concerning in developing countries, where prevalence tends to be higher than in developed nations. For instance, anemia prevalence among pregnant women in Africa exceeds 50%, with most cases attributed to iron deficiency and chronic infections (2). In Southeast Asia, the prevalence remains high, as reported in Thailand at 25.5% (3). Based on the latest data from the Indonesian Nutrition Status Survey (SSGI) 2022, the prevalence of anemia among pregnant women in Indonesia was recorded at 48.9%. This indicates that nearly half of all pregnant women World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 237-243 238 experience anemia, representing a significant public health concern. This prevalence also reflects the ongoing challenges in achieving maternal and child health targets, as the rate exceeds the threshold set by the World Health Organization (WHO) for a public health problem, which is 40%. (4). At the regional level, recent reports indicate that the prevalence of anemia in Southeast Sulawesi Province reached 10.5% in 2020, with Muna Regency (40.7%) and Buton Regency (23.5%) having the highest rates (5). These data highlight that anemia during pregnancy remains a significant health challenge, including in the working area of Batalaiworu Health Center, requiring urgent and evidence-based interventions. The impact of anemia during pregnancy extends beyond clinical outcomes, affecting long-term public health. In mothers, anemia can disrupt bodily metabolism, leading to reduced physical capacity, chronic fatigue, cognitive impairment, and weakened immunity, increasing susceptibility to infections (6). Obstetrically, anemia is associated with elevated risks of preeclampsia, postpartum hemorrhage, blood transfusions, and maternal mortality (7). For the fetus, maternal anemia can result in intrauterine growth restriction, preterm birth, low birth weight, delayed cognitive development, and increased perinatal mortality risk (8). Literature also suggests that anemia in pregnancy contributes to intergenerational malnutrition cycles, whereby infants born with poor nutritional status are likely to grow into adolescents and adults with compromised health, perpetuating public health challenges (9,10). The etiology of anemia in pregnant women is multifactorial. The primary cause is iron deficiency due to increased physiological demands during pregnancy that are not met with adequate dietary intake (11,12). Additionally, chronic infections such as malaria, tuberculosis, and hookworm significantly exacerbate anemia, particularly in tropical countries. Socioeconomic factors, education, and access to healthcare services also play crucial roles in determining maternal anemia status (13). One of the main strategies to prevent and manage anemia during pregnancy is iron and folic acid supplementation. The Indonesian government recommends providing at least 90 iron tablets during pregnancy, distributed free of charge through primary healthcare facilitiesn (14). However, various studies indicate that adherence to iron tablet consumption remains low, mainly due to side effects (nausea, constipation), limited understanding of the benefits, weak family support, and insufficient healthcare supervision (15,16). A key factor influencing adherence to iron supplementation is antenatal care (ANC) visits. Each ANC visit provides an opportunity for healthcare providers to conduct maternal examinations, deliver nutrition education, and provide counseling regarding the importance of iron tablet intake. Previous studies show that pregnant women who attend ANC according to WHO standards (at least four visits during pregnancy, now recommended eight) have higher adherence to iron supplementation compared to those with fewer visits (17). Nevertheless, research in Indonesia has tended to focus on sociodemographic factors such as education, occupation, and parity, while the direct role of ANC visits as a determinant of iron tablet adherence remains underexplored. Therefore, a research gap exists in the literature, particularly at the primary healthcare level such as Puskesmas. This study aims to fill this gap by examining the relationship between ANC visits and adherence to iron supplementation among pregnant women at Batalaiworu Health Center. The novelty of this research lies in its empirical approach, focusing on the frequency of ANC visits as a determinant of adherence rather than merely as a supporting variable. The findings are expected to provide practical contributions for developing Puskesmas-based intervention programs to improve iron supplementation adherence, as well as theoretical contributions to enrich the literature on determinants of supplementation compliance in pregnant women in Indonesia. Consequently, this study is not only locally relevant but may also serve as a reference in a global context, particularly for developing countries with similar maternal health challenges. 2. Material and methods 2.1. Study Design This study employed an analytical survey with a cross-sectional design, which enabled the simultaneous measurement of the independent variable (antenatal care visits) and the dependent variable (adherence to iron supplementation) at a single point in time. This design was chosen because it is appropriate for identifying associations between exposure and outcome without requiring follow-up. 2.2. Research Site The study was conducted at Puskesmas Batalaiworu, Muna Regency, Southeast Sulawesi, Indonesia, a primary healthcare facility that provides maternal and child health services. The research site was selected due to the high World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 237-243 239 prevalence of anemia among pregnant women and its strategic role as the first-level healthcare facility serving the community. Data collection was carried out in May 2025. 2.3. Population, Sample, and Sampling Procedure The target population consisted of all pregnant women registered in the working area of Puskesmas Batalaiworu in 2024, totaling 405 individuals. The study sample was determined using a purposive sampling technique, focusing on third-trimester pregnant women who had received iron tablets (Fe) through antenatal care services. The final sample included 83 respondents. Inclusion criteria were: (1) pregnant women attending antenatal care at Puskesmas Batalaiworu, (2) women in the third trimester of pregnancy, and (3) women who had received iron supplementation. 2.4. Data Analysis Primary data were collected using a structured questionnaire that had been previously validated and adapted from Nurana (2023) and Dara (2019). Data processing included coding, editing, scoring, and tabulation prior to statistical analysis. Univariate analysis was performed to describe the frequency distribution of both independent and dependent variables. Bivariate analysis was conducted using the Chi-Square test to examine the association between antenatal care visits and adherence to iron supplementation, with a significance level of α = 0.05. When the assumption of expected cell counts was not met (i.e., more than 20% of cells with an expected frequency <5), Fisher’s Exact Test was applied. 2.5. Ethical Considerations This study adhered to ethical standards for research involving human participants. Prior to participation, all respondents were informed about the objectives, procedures, potential risks, and benefits of the study, and their participation was voluntary. Each participant signed a written informed consent form before data collection. Confidentiality and anonymity were strictly maintained throughout the research process. 3. Results This study was conducted at Batalaiworu Health Center, a primary healthcare facility located in Batalaiworu Subdistrict, Muna Regency, Southeast Sulawesi. The health center provides maternal and child healthcare services, including antenatal care (ANC), iron supplementation, nutrition counseling, immunization, and management of infectious diseases. It is also actively engaged in community health promotion programs such as the Healthy Community Movement (Germas). The catchment area of the health center covers several villages with a diverse population in terms of age, education, and socioeconomic status. Most of the area is rural with limited transportation access, making the health center the main source of healthcare services. The pregnant population in this area is relatively high, with a significant prevalence of anemia influenced by nutritional status, education, health awareness, and access to services. The health center staff, consisting of midwives, nurses, and administrative personnel, actively provide ANC services, distribute iron tablets, deliver nutrition counseling, and monitor pregnant women both at the facility and through home visits. The characteristics of the area, the high prevalence of anemia, and the strategic role of the health center make it a relevant site for studying the relationship between ANC visits and adherence to iron supplementation among pregnant women. 3.1. Sub heading 2 Copy and paste here the content of the article. Copy and paste here the content of the article. Copy and paste here the content of the article. Copy and paste here the content of the article. Copy and paste here the content of the article. Copy and paste here the content of the article. Copy and paste here the content of the article. Copy and paste here the content of the article. Copy and paste here the content of the article. Copy and paste here the content of the article. Copy and paste here the content of the article. 3.1.1 General Overview of Respondents This study involved pregnant women registered at Batalaiworu Health Center, Batalaiworu Subdistrict, Muna Regency, Southeast Sulawesi. The respondents varied in age, education, and occupation, reflecting the diversity of the community. Most participants were of reproductive age, with a notable prevalence of anemia. The respondents regularly received antenatal care (ANC), iron (Fe) supplementation, and nutrition counseling provided by midwives and nurses at the health center as well as through home visits. This population is representative for examining the relationship between ANC visits and pregnant women’s adherence to iron tablet consumption. Complete details are presented in Table 1. World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 237-243 240 Table 1 General Overview of Respondents Variable Category Frequency (n) Percentage (%) Maternal Age < 20 years 16 19.3 20–35 years 41 49.4 > 35 years 26 31.3 Total 83 100 Education Elementary School (SD) 9 10.8 Junior High School (SMP) 18 21.7 Senior High School (SMA) 46 55.4 Higher Education (PT) 10 12.0 Total 83 100 Occupation Housewife 66 79.5 Civil Servant (PNS) 3 3.6 Private Sector 14 16.9 Total 83 100 ANC Visits ≥ 4 visits 51 61.4 < 4 visits 32 38.6 Total 83 100 Adherence to Fe Tablet Compliant 47 56.6 Non-Compliant 36 43.4 Total 83 100 Based on descriptive analysis of the 83 respondents in the working area of Batalaiworu Health Center, Kendari City, in 2025, the majority of participants were aged 20–35 years (49.4%), with the highest education level being senior high school (SMA) at 55.4%, and most were housewives (79.5%). Regarding antenatal care (ANC) visits, 61.4% of respondents attended at least four visits, while 38.6% did not meet this standard. In terms of adherence to iron (Fe) tablet consumption, 56.6% of respondents were compliant, whereas 43.4% were non-compliant. These findings indicate that although awareness and attendance of ANC are relatively good, adherence to iron supplementation still requires improvement to prevent the risk of anemia among pregnant women. 3.1.2 The Relationship Between Antenatal Care Visits and Adherence to Iron Tablet (Fe) Consumption Table 2 The Relationship Between Antenatal Care Visits and Adherence to Iron Tablet (Fe) Consumption at Batalaiworu Health Center Adherence to Fe Tablets Antenatal Care Visits Total ρ Value ≥ 4 Visits < 4 Visits Compliant 38 (45.8%) 9 (10.8%) 47 (56.6%) Non-Compliant 13 (15.7%) 23 (27.7%) 36 (43.4%) Total 51 (61.4%) 32 (38.6%) 83 (100%) Table 2 illustrates the association between antenatal care (ANC) visits and pregnant women’s adherence to iron tablet (Fe) consumption at Puskesmas Batalaiworu. Among the 47 respondents who adhered to Fe supplementation, the majority (38 respondents; 45.8%) attended ANC at least four times, while 9 respondents (10.8%) had fewer than four World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 237-243 241 visits. Conversely, of the 36 respondents who did not comply with Fe consumption, 13 (15.7%) completed four ANC visits, whereas 23 (27.7%) attended fewer than four visits. The Chi-Square analysis yielded a p-value of 0.000, which is less than the significance threshold of α = 0.05. This indicates that the null hypothesis (H₀) is rejected, and the alternative hypothesis (Hₐ) is accepted, confirming a statistically significant relationship between the frequency of ANC visits and adherence to iron supplementation. Scientifically, these findings suggest that regular ANC attendance plays a critical role in promoting compliance with iron supplementation among pregnant women. Frequent ANC visits provide opportunities for healthcare providers to deliver nutritional counseling, monitor maternal health, and reinforce the importance of iron tablet intake. The higher adherence observed among women attending at least four ANC visits underscores the effectiveness of structured prenatal care in improving maternal nutritional behavior and preventing anemia during pregnancy. These results are consistent with previous studies highlighting ANC visits as a key determinant of maternal adherence to micronutrient supplementation programs. 4. Discussion This study demonstrated a significant association between the frequency of antenatal care (ANC) visits and pregnant women’s adherence to iron (Fe) supplementation at Batalaiworu Health Center. The Chi-Square test revealed a p-value of 0.000 (<0.05), indicating a statistically significant relationship. Among the 47 women who adhered to Fe supplementation, the majority (38 respondents; 45.8%) attended at least four ANC visits, while 9 respondents (10.8%) attended fewer than four visits. Conversely, of the 36 non-adherent respondents, 23 (27.7%) had fewer than four ANC visits. These findings highlight that regular ANC attendance is closely linked to higher compliance with iron supplementation. The results underscore the critical role of ANC visits in promoting adherence to iron supplementation. Regular ANC provides opportunities for healthcare providers to deliver nutritional education, conduct routine health monitoring, and reinforce the importance of Fe intake. Pregnant women who attend ANC consistently receive repeated reinforcement regarding the benefits of iron supplementation, risks of anemia, and proper consumption practices, thereby enhancing adherence. In contrast, limited ANC attendance reduces opportunities for education and monitoring, increasing the likelihood of non-compliance. This emphasizes the necessity of integrating nutrition counseling and adherence monitoring into routine ANC services. These findings are consistent with prior research demonstrating that ANC frequency is a key determinant of maternal compliance with iron supplementation (18,19). The observed behavior aligns with the Health Belief Model (HBM), which posits that perceived susceptibility to anemia, perceived benefits of Fe supplementation, and cues to action provided through ANC visits influence compliance behavior (20,21). Structured primary healthcare services, such as ANC, thus serve as effective mechanisms to positively modify maternal health behavior and reduce anemia prevalence during pregnancy (22,23). The study has important implications for maternal health practice and policy. First, enhancing the frequency and quality of ANC visits can serve as a strategic intervention to improve adherence to iron supplementation and reduce anemia prevalence. Second, the findings provide empirical support for healthcare providers to strengthen nutrition counseling, adherence monitoring, and home-visit interventions at Puskesmas. Third, for policymakers, the study offers evidence that reinforcing ANC programs and integrating maternal nutrition education into primary healthcare is essential for improving maternal and neonatal health outcomes. The strength of this study lies in its empirical focus on the direct relationship between ANC visits and iron supplementation adherence at the primary healthcare level, providing practical insights for local interventions. However, limitations include the relatively small sample size (n = 83), cross-sectional design limiting causal inference, and potential self-reporting bias regarding Fe intake. Future research should employ longitudinal designs to assess the long-term impact of ANC attendance on adherence and anemia outcomes. Additionally, incorporating sociodemographic factors, family support, and maternal health perceptions can yield more comprehensive predictive models. Evaluating the effectiveness of educational and home-visit interventions across diverse Puskesmas populations is also recommended to develop tailored, evidence-based strategies. World Journal of Biology Pharmacy and Health Sciences, 2025, 23(02), 237-243 242 5. Conclusion The study concluded that the frequency of antenatal care (ANC) visits is significantly associated with pregnant women’s adherence to iron (Fe) supplementation at Batalaiworu Health Center. Pregnant women who attended at least four ANC visits demonstrated higher compliance with Fe intake compared to those with fewer visits. This finding emphasizes the pivotal role of regular and structured ANC in promoting maternal nutritional behavior, preventing anemia, and improving overall maternal and neonatal health outcomes. The study highlights that optimizing ANC services, including routine education, counseling, and monitoring, is crucial for enhancing adherence to iron supplementation Compliance with ethical standards Acknowledgments The author would like to express gratitude to the Head of Puskesmas Batalaiworu and all healthcare workers who granted permission and provided support during the implementation of this research. Appreciation is also extended to all respondents who generously gave their time and shared information to ensure the smooth progress of the study. Disclosure of conflict of interest. The author declares that there is no conflict of interest in the conduct of this research or in the writing of this article. 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