am j clin nutr 1993 schultink 135 9

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  • 7/27/2019 Am J Clin Nutr 1993 Schultink 135 9

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    Am J C /in N utr I 9 93 :57 : 1 35-9 . P rin ted in U SA . I 993 Am erican Soc ie ty fo r C lin ica l N utritio n 135

    Low com p liance w ith an iron -supp lem en ta tion p ro g ram :a s tudy am ong p regnan t w om en in Jaka rta , lndones ia13W ern er S chu /tin k, M a rian ne van d er R ee , P au l M atu le ssi, an d Ra iner G ross

    ABSTRACT The effic iency of an estab lish ed iron-supp le -m enta tion prog ram for pregn an t w om en in Jakarta, In dones iaw as investiga ted . H em oglo b in , se rum ferr i t in , an d packed ce llvo lum e (PCV ) w ere m easured a t the s ta rt o fthe s tu dy and afte r2 m o supp lem enta tio n w ith 300 m g ferrous su lph a te /d . T h ewomen (n = 45 ) w ere que stioned about comp lian ce and stoolsamp le s w ere checked fo r iron con ten t to con tro l fo r tab le t in take .Tw elve wom en dro pped ou t. P reva lence of anem ia (42% ) d idno t decrease du ring the stud y period . O f the rem ain ing 33w om en , 64% (n = 2 1) c la im ed to have tak en a ll iron tab le ts .T h is w as on ly co nfirm ed by pos itive stoo l tests in 1 2 w om en .S erum ferritin and PCV increased in wom en w ith pos itive s to o ltests (P < 0 .05 and P < 0 .01 , resp ec tive ly ) a fte r supp lem enta tion .It is conc lud ed tha t com p liance w as low and tha t th e iron doseneeds to be increased . Supp lem entation prog ram s need re liab lem onito ring and eva lua tion sys tem s. Am J C /in N utr l993;57:135-9.

    KEY WORDS Iron supp lem enta tion , com p liance , p reg-nancy , anem ia

    Introduct ionP regnan t w om en in deve lop in g coun tries su ffe r frequen tly

    from nutritio na l anem ia , particu la rly iro n-defic iency anem ia .In S ou th A sia preva lence of anem ia am ong preg nan t w om en isas h ig h as 65% (1 ). In Indon es ia estim ated prev alence of nu tri-tiona l anem ia am ong pregn an t w om en , based on sca tte red su r-veys , is be tw een 50% and 70% (2 , 3 ). It has been dem onstra tedin con tro lled f ield tria ls that iron -de ficiency an em ia can be pre -ven ted and trea ted by iron-supp lem ent d is tribu tion th rou gh apr im ary hea lth care sy stem (4-7 ).

    T here fo re , th e Indones ian gov ernm ent sta rted im plem entin gan iron -su pp lem entation pro gram 10 y ago to redu ce the h ighanem ia ra te . T he United N ations Ch ild rens F und (UN ICEF )suppo rts th e In dones ian supp lem enta tion p rogram w ithaso$500 ,0 00 (US ) per year. T h is p rogram is b ased on the expec-ta tio n th at a ll p regnan t w om en regu la rly v isit e ithe r a comm unityhea lth cen ter (Puskesm as) o r an in teg rated hea lth se rv ice pos t(P osyandu) dur in g pregnancy . H ea lth care sta ff are ins tru c tedto d is tribu te iron and fo la te tab le ts to each w om en throu ghou tthe th ird trim este r o f p regnancy free of charge .

    H ow ever, iro n-su pp lem entation program s w ithou t superv isedor con tro lled co nsum ption of tab le ts m ay lose effec tiven essth ro ugh fac to rs such as irregu la r tab le t d is tribu tion and poo rcom p liance (7 -9 ). D a ta o n the ef fic iency of estab lished iro n-

    supp lem enta tio n program s are lim ited , an d little in fo rm ationw as av ailab le on th e Ind onesian program . T he presen t s tu dya im ed to describe com pliance of prog ram partic ipan ts and theeffec tiveness of th e ongo ing iro n-supp lem enta tion program inJaka rta , Indone sia .

    Sub jects and m ethod sThe study too k p lace at an estab lish ed comm unity h ealth cen -

    te r in cen tra l Jakarta , Indonesia from Septem ber to N ovem ber199 1 . The h ealth cen te r se rves an area w ith 248 500 inhab itan tsand 1 000 pregnan t w om en attend the cen te r y early . Sub jec tsw ere 45 w om en in the second trim este r o fp regnancy . T hey w erese lec ted a t random from preg nan t w om en w ho a tten ded th eno rm al p reg nancy care pro gram at the hea lth cen te r. A s p ar t o fthe p rogram the wom en norm ally received once a m onth 30iron table ts contain ing 300 m g ferrous su lph ate (PT K im iaF arm a, B andung , Ind onesia ; one tab le t is equ iva len t to 60 m gelem enta l iron) . T he usu al iron tab le t-d istribu tion pro ced urew as no t changed for th is p rogram . T ab le ts w ere d is tribu ted inth ree sm all p las tic bags, each bag con ta in ing 10 tab lets . H ea lthcare s ta ff to ld pregn an t w om en to take one tab le t p er d ay (w itho u tspec ia l in struc tions on tim e o f inges tion ) and to re tu rn to thehea lth cen te r w hen the tab lets w ere fin ished . T he co lo r o f th etab le ts w as red and they w ere the sam e in con ten t an d appearanceas th e tab le ts n orm ally d istribu ted by th e hea lth cen te r.

    H em oglob in concen tra tion , packed ce ll vo lum e (PCV ), se rumferritin , bo dy w eigh t, and he igh t o f the sub jec ts w ere m easureda t the beg inn ing of th e s tu dy and after 2 m o. B lood w as ob tain edby sk in pun ctu re o f the lef t-h and r ing finge r by us ing an auto -m atic sk in pun ctu re d ev ice (A u to clix -L ance t B o eh ringer M ann-h eim , M annheim , G erm any). H emoglobin concentration w asd e te rm ined in dup lica te by the cyanom eth em oglob in m ethod

    t F rom South E as t A sian M in is trie s o fE ducation O rgan iza tion-T rop-ic al M edicin e (SEAM EO -TRO PM ED ) Center , In don esia , at the U ni-v ersi ty of Indon esia , Jaka rta , Indone sia : th e D ivision o f H ealth , Popu-la tio n and N utrition of the G erm an C oopera tion for T echn ica l C o llab -o ration (GTZ) E schbo rn , G e rm any : th e D epartm en t of H um anN utr itio n , W ageningen Ag ricu ltu ral U n ive rsity , W agenin gen , T heNether lands .

    2 A ddress correspond ence to iW Schultink . SEAMEO /GTZ , P0 Box3852 , 10 038 Jakarta , Indones ia .

    3 R ep rin ts no t ava ilab le.R eceiv ed M ay 15 , 1992 .A ccep ted for publicat ion A ugust 2 1 , 1992 .

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    1 1 : SD : ii =t For 12 w omen, 2 1 w omen w ere pregnant for f i rst time.

    A SD : n = 33 unl ess otherw ise noted.t Signi f i cantly greater than value at the start of the study . P < 0.01. Signi f icantl y greater than v alue at the start of the study . P = 0.05;

    n = 26.

    136 SCH U L T IN K ET A LT A B L E 1Selected characteri sti cs of the w omen at the start of the study0

    A ge (y) 24.5 4.6Gestati on time (w k) 20.8 3.5W eight (kg) 51.4 7.1H eight ( cm) 152.6 7.0Pari ty 0.6 1.0T ime since last pregnancy (mo) 46.4 29.7t

    (10) by using a Compur M ini l ab (B ay er D iagnosti c GmbH ,M Onchen, Germany). V ari ati on based on dupl i cate measure-ments w as 2% . PCV w as measured by the m icrohematocri tmethod ( 10). Serum ferri ti n w as determ ined by enzy me im-munoassay procedure ( 1 0) by using a commercial k i t (RamcoL aboratori es, H ouston, TX ). B ody w eight w as measured to thenearest 0. 1 kg on an electroni c w eighing scale (770 alpha; SECA ,H amburg, Germ any). A correcti on of0.5 kg w as made for cloth-ing. B ody height w as measured to the nearest 0. 1 cm using aM icrotoi se (CM S W eighing Equipment, L td. L ondon). W henthe subjects returned to the heal th center af ter 1 mo to recei venew iron tablets they w ere asked to bri ng a stool sample. T hesubjects w ere ask ed to bri ng a second stool sample af ter 2 mo.These stool samples w ere checked f or elemental i ron to determ inew hether the w omen took thei r i ron tablets. Presence of elementali ron in stool w as tested by using the colori ng reacti on descr ibedby A f i f i et al (9). Stool samples w ere al so checked for the presenceof hookw orm parasi tes by m icroscopic exam inati on. N one ofthe subjects had hook w orm. N o explanation w as given as to w hythey had to bri ng stool sam ples.

    A f ter 2 m o the w om en w ere interv iew ed about thei r compl i -ance w ith the supplementati on program and about factors in-f luencing compl i ance. T hi s interv iew at the end of the studytook place in subject s homes w ithout the presence of heal thcenter staf f . W omen w ere asked how many tablets they had re-cei ved f rom heal th center staf f : w hether they had tak en al l thei rtablets: about possible side ef f ects they experienced l ik e nausea,v om i ti ng, constipati on: and w hether they knew the purpose oftak ing the tablets.

    Changes in blood v alues w i thin subjects betw een the start andthe end of the study w ere tested w i th paired t t est s. D i ff er en cesbetw een subgroups of subjects w ere tested w i th unpai red t tests.W here values w ere not normal l y di stri buted, as w i th serum fer-r i t i n, di f f erences w ere tested by using W il cox on s matched-pai rssigned-ranks test (1 1). T he study protocol w as approv ed by theethi cal rev iew commi ttee of the SEA M EO-T ROPM ED Centerat the U niversi ty of I ndonesia, Jakarta.

    O f the ini tial group of45 w omen, a blood sample w as obtainedf rom 33 w omen af ter 2 mo. T w elve w omen could not be sur-v ey ed at the end of the study for reasons such as mov ing, pre-mature del i very , and i l l ness. D ata w i l l be presented for the 33w omen f rom w hom blood samples w ere obtained at the startand at the end of the study . A verage income of the w omen shouseholds w as sa$80/mo (U S). T w o w omen of 33 w ere i l l i t-erate: al l w omen w ere M usl im . Selected character isti cs of the33 w omen are presented in T able I .

    Re s u l t s

    Prevalence of anem ia, def i ned as hemoglobin concentration< 1 1 0 g/L , w as 42% (n = 14) at the start of the study . A t theend of the study , af ter 2-mo supplementati on program, theprevalence ofanem ia w as also 42% . Of the 14 w omen w ho w ereanem ic at the start of the study , I 1 sti l l had low hemoglobinconcentrati ons af ter 2 mo. A mong the ini ti al group of45 w omen4 1 % of the w omen w ere anem ic. H emoglobin concentrati on,PCV , serum ferri ti n, and w eight of the subjects at the start andat the end of the study are presented in T able 2. T here w as nosigni f i cant change in hemoglobin v alue. PCV at the end of thestudy w as 1 .8 3. 1 L /L higher (P < 0.05) than at the startof the study . Serum ferri ti n i ncreased by 1 1.8 28.2 g/L(P = 0.05).

    W hen asked during the interv iew at the end of the study i fthey had taken the i ron tablets gi ven to them by heal th centerstaf f , 2 1 w omen responded posi ti vel y : 16 of them claimed tohave tak en 30 tablets per month, 4 claimed to have taken 20tablets per month, and 1 w omen said that she took 10 tabletsper month. T he f i ve w omen w ho took 20 tablets stated thatthey had not receiv ed more tablets at the heal th center. Fi f teenof the 2 1 w omen w ho claimed to have tak en the tablets statedthat they knew the purpose of tak ing the tablets: I 3 said that i tserv ed to increase the amount ofblood, one w oman said that i tw ould improve the condi ti on of the fetus, one thought the tabletscontained v i tam ins. Si x w omen w ho said that they had takenthe tablets did not know the purpose. O f the 12 w omen w hosaid that they had not taken the i ron tablets onl y tw o complainedabout side ef f ects l ik e nausea and vom i ting. T he most importantreason f or not tak ing the tablets w as that they just f orgot, w i thoutf urther ex planati on. Four of these 12 w omen knew the purposeof tak ing i ron tablets.

    T he w omen w ere asked to bri ng stool samples af ter 1 and 2m o. One-month samples w ere obtained f rom 23 w omen. Fiv eof these samples contained i ron, i ndi cati ng recent i ntake of i rontablets. A fter 2 m o samples w ere obtained f rom 33 w omen andeight of these samples contained iron. A total of 1 3 posi ti vesamples came f rom 12 di f f erent w omen, hence the stool of onl yone w oman contained iron at both times ofstool col l ecti on. T hetw o i l l i terate w omen had negati ve stool tests. T he relati onshipbetw een i ron-tablet i ntake as claimed during the interv iew andposi ti ve stool samples in the second month i s show n in T a b l e3. Sensi tiv i ty and speci f i ci ty of the interv iew method compared

    T A B L E 2H emoglobin concentrati on, packed cel l volume (PCV ), serum ferri ti n,and body w eight at the star t of the study and af ter 2-mosupplementation0

    Start of study A f ter 2 moH emoglobin (gI L ) 1 1 1 10PCV (L /L ) 31.2 2.9Serum ferri ti n (g/L ) 15.4 12.7We i ght ( k g ) 5 1 . 4 7 . 1

    1 12 I 133.0 3. lt27.3 26. l5 5 . 4 7 . 4 t

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    IR O N S U PPL EM EN T A T IO N IN PR EG N A N C Y 13 7T A B L E 3R e lationsh ip b etw een po sitiv e s to o l te st and w om ans c laim to hav etak en all tab le ts

    I ron in s to o l sam ple

    Y es N o T o talW om ans claim

    Y esNo

    71

    141 1

    211 2

    T o tal 8 25 33

    w ith the check o f s too l sam p les is 0 .88 (7 /8 ) and 0 .44 ( 1 1 /25 ) ,re spec t ive ly .

    C h an ges in b lood m easurem en ts and body w e igh t f o r w om enw ith at leas t o ne positiv e stoo l te st com pared w ith w om en w itha negativ e stoo l te st are g iv en in T ab le 4 . H em og lo b in concen -tration and serum f erritin o f w om en w ith a pos itiv e stoo l te s ti n c r e a s e d b y 4 9 g / L ( P = 0 . 1 6 ) a n d 1 7 . 0 2 3 . 5 z g / L ( P= 0.05), re sp ec tiv e ly , be tw een th e s tart an d the end o f the stud y .S erum f em tin o f the w om en w ith a negativ e s to o l te s t in c reasedby 8 .6 3 1 . 1 g/L (P = 0 .43 ), w hereas hem og lob in stay ed atth e sam e con cen tration . In Figure 1 th e re latio nsh ip be tw eenthe in itial hem og lo b in concen tration and the ch an ge in hem o-g lo b in concen tration is dep ic ted . A sign if ican t corre lation ex is ted(r = 0 .8 1 : P < 0 .0 1 ) be tw een in itial h em og lob in co ncen trationand the change in hem og lob in be tw een s tart an d en d o f thes tudy f o r w om en w ith at leas t on e pos itiv e stoo l te s t (ii = 12 ) .For th e w ho le grou p o fw om en n o s ign if ican t corre lation ex istedbe tw een in itial hem og lob in con cen tration and the chan ge inhem og lo bin concen tration .

    D iscussion

    T he presen t s tudy took p lace in a health cen te r situated in alow er-soc ioeconom ic -c lass area o f Jak arta. Prev alence o f anem ia(hem og lob in concen tratio n < 1 10 g /L ) am ong the pregnan tw om en w as 42% , w h ich is sligh tly low er th an the repo rted 4 9%prev alence am ong pregn an t Jav anese w om en in B o gor D is tric t(3 ) . A nem ia prev alence am ong poor rural n onpreg nan t w om enin E ast Jav a w as 2 5% ( 1 2 ). R ep orte d prev alence rate s am ongpregnan t w om en in o ther parts o f th e S o u theast A s ian reg ionsuch as northeas te rn T hailand and B urm a are ev en h ig her, at70% and 5 8-80% , respec tiv ely (7 ) . Prev alence o f anem ia am ongthe Jak arta w om en af te r jo in in g the es tab lished sup p lem en tationprog ram fo r 2 m o w as at th e sam e lev e l as at the s tart o f thestud y . T he resu lts o f the presen t stud y d if f e r f rom a sim ilar s tudyam ong pregn an t w om en f rom T hailand (7 ). T he T h ai w om enp artic ipated in a lO -w k iro n -su pp lem en tation prog ram at 18 -22 w k g es tation and prev alence o f anem ia decreased m ark ed ly .

    T hree f ac to rs m ay ex p lain w hy p rev alen ce o f anem ia d id no tdec lin e. T h e f irst is that th e pregnan t w om en d id n o t tak e the irtab le ts. I t can be conc luded that com p liance rate w as low becauseabou t one -th ird o f the w om en adm itted that they had no t tak enall the tab le ts g iv en to them . In add ition , although 64% of thew om en c laim ed to h av e tak en all iro n tab le ts, th is cou ld o n lyb e con f irm ed in 3 6% of th e gro up w ith at least on e pos itiv e stoo lte s t. T he stoo l te st has prov en to be f airly re liab le in de tec tin g

    recen t in tak e o f iron supp lem en ts in sev eral o th er stud ie s . U nd ercon tro lled co nd itions the tes t g av e pos itiv e resu lts in 98% (9 ),92% (13 ), an d 7 7% (1 4 ) o f su b jects w ho had tak en iro n supp le -m en ts . T h e re liab ility o f the stoo l te s ts is also sug gested by thef ac t that hem og lob in concen tratio n show ed a pos itiv e tren d andserum f erritin concen tratio n increased s ign if ican tly in w om enw ith a pos itiv e stoo l te s t w hereas no sim ilar in creases occurredin w om en w ith negativ e s too l te s ts . H em og lob in con cen trationo f 7 o f 2 1 w om en w ho h ad negativ e s too l tes ts d id in crease (Fig1 ). T hese sev en w om en m ay hav e tak en at leas t som e o f thetab le ts (bu t no t on the day s be f o re s to o l sam p lin g ) or th ey m ayh av e in creased in tak e o f iro n -rich f ood stu f f s . A ltho ugh 64% ofth e w om en c laim ed to hav e tak en all iron tab le ts , th e ac tualp ercen tage o fw om en w ho took all tab le ts is m os t p rob ab ly m uchlow er. S tud ie s am ong p regnan t E ng lish w om en w hose iron -tab le tin tak e w as check ed w ith stoo l sam p les reported that 7 0% ofth e w om en w ere tak ing the tab le ts af te r 2 m o (8 , 9 ). N oncom -p liance rate am ong these pregn an t w om en o f Jak arta w as alm osttw ice as h igh .

    T he second f ac to r that m ay hav e red uced im p rov em en ts inth e iron s tatu s o f the preg nan t w om en is that the daily am oun to f iro n prov ided by the supp lem en ts is n o t eno ugh . T he W orldH ealth O rgan iz ation (W HO ) (4 ) recom m ends a daily iron in tak eo f 1 20 m g f or preg nan t w om en , w h ich is tw ice as h igh as th edose prov ided by the health cen te rs in Jak arta. E f f ic ien cy o f ironabsorp tion increases if hem og lob in co ncen tration is low . O f th ew om en w ith a p ositiv e s to o l te s t o n ly w om en w ho w ere anem ic(h em og lob in co ncen tration < 1 10 g /L ) at the s tart o f the s tu dyshow ed a m ark ed increase in h em og lob in co ncen tration . T h ism ay ind icate th at the do se that the w om en rece iv ed w as no th igh eno ugh to in crease hem og lob in if the in itial hem og lob incon cen tration w as > 1 1 0 g/L . T h e dose w as, how ev er, h igheno ugh to increase serum f erritin con cen tration . A dd itio nally .inh ib ito rs o f iron absorp tion in f oo d m ay hav e p lay ed a ro le .E f f ic iency o f iron absorp tion decreases w hen tab le ts are tak en

    T A B L E 4H em og lob in co ncen tration , pack ed ce ll v o lum e (PC V ). serum f erritin .and bo dy w e igh t o fw om en acco rd ing to s too l te s t at the startand at th e en d o f the s tudy (2 m o)0

    S tart o f s tudy A f te r 2 m oA t leas t one p ositiv e s too l tes t

    (11 = 12 )He mo gl o b i n ( g / L) 1 1 0 12 1 14 7PC V (L /L ) 31 .0 3. 5 33 .7 2.2 tS erum f em tin (jtg /L ) 1 1 .3 7 .6 28 .3 21 .5 jW eigh t (k g ) 52 .1 4.4 56 .3 5 .4 t

    N o pos itiv e stoo l te st( n = 21)

    Hemog l o b i n ( g / L ) I ll 8 111 13PC V (L /L ) 31 .2 2 .6 32 .6 3. 5S erum f erritin (z g/L ) 18 .0 15.1 26 .6 29 .2We i g h t ( k g ) 5 1 . 0 8 . 3 5 4 . 9 8 . 4 t

    0. S D :n= 33 .t S ign if ican tly g reate r than v alue at th e s tart o f the s tu dy , P < 0.01.j: S ign if ican tly g reate r than v alue at the s tart o f the s tu dy . P < 0.05:

    n = 10.11= 16 .

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    13 8 S C H U L T IN K ET A L

    0811 )

    08.0I.5

    C0808

    .0I-J

    08C08

    C -).0I

    0))0

    200

    1 0 00 0

    00C 0 00

    0

    0 9 0 fl - 1 0 W 0

    -2 0 0

    70 80 90 100 110 1 20 130 140 70 8 0 9 0 100 110 120 130 140

    11# { 1 4 9 } 8

    I

    C

    11

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    .CC- ).0I -20

    H b a t s t a r t o f s t u d y (g /L )FIG I. R e latio nsh ip be tw een hem og lob in concen tratio n (H b ).at start o f study and the chang e in H b af te r 2 -m o

    supp lem en tatio n . 0 , no iron in s too l, n = 21, r - 0 .09 : U , iron in s to o l, n = 12, r = 0.81 (P < 0 .0 01 ), v = 72.8- 0 .63 .v .

    w ith f oods that co n tain inh ib ito rs o f iro n ab sorp tion . T he in f lu -ence o f these inh ib ito rs w ou ld b e re lativ e ly larg er w hen th e d ailysupp lem en t dose is low .

    T he th ird possib le f ac to r h indering im prov em en t o f iron statu sam ong th e w om en m ay be low serum re tino l con cen trations insom e o f the w om en . In preg nan t w om en a pos itiv e assoc iationhas been f ound be tw een hem og lob in and serum re tino l con cen -tratio ns (3 ) . S im ilar re su lts are repo rted f o r anem ic ch ild renw hose h em og lob in con cen tration increased af ter v itam in A sup -p lem en tation (1 5 ) . In the presen t s tu dy , how ev er, no in f o rm ationis av ailab le on th is p oss ib le in te raction .

    It is conc luded on the basis o f these f ind in gs th at an im p ortan tf ac to r cau sing a f ailu re to decrease anem ia prev alence am ongpregn an t w om en in Jak arta w as the lack o f com p liance . Im -portan t f ac to rs in f lu en cing iron -tab le t in tak e rep orted by o thersare negativ e side e f f ec ts , e ithe r f rom the iron tab le t d irec tly o rf rom the e f f ec ts o f the pregnancy itse lf (7 , 16 ). In add ition a lacko f u nders tand in g abou t anem ia and the need to tak e iron tab le tsm ay hav e in f luenced com pliance ( 1 7 ). In the presen t study on lytw o w om en com p lain ed abo u t nausea and v om iting . T h is m ayhav e b een caused b y the re lativ e ly low dose o f 6 0 m g elem en taliron . M os t w om en stated that they o f ten ju s t f o rg o t to tak e th e irdaily tab le t, w h ich m ay in d icate a lack o f m o tiv ation and un -ders tan d ing . H ow ev er, ev en w om en (n = 4) w ho k new th e pur-pose o f tak ing iro n tab le ts (to increase the am oun t o f b lood ) d idno t tak e th em .

    Fie ld trials in T hailand , B urm a, and Ind ia (6 , 7 ) dem ons tratedthat iron -supp lem en tation program s in teg rated in to prim aryhealth care sy s tem s m ay be ab le to decrease the prev alence o fanem ia am ong pregnan t w om en q u ite e f f ec tiv e ly . H ow ev er, thee f f ic ien cy o f on go ing es tab lished supp lem en tation pro gram s m ayno t be that h igh as is dem on strated b y the presen t study . T o

    increase the e f f ec tiv eness o f the supp lem en tation prog ram inJak arta the f o llow in g th ree p o in ts m ay be cons id ered .

    First, inc rease the daily iron d ose to 1 20 m g o f e lem en tal ironas recom m en ded by W H O (4). T he dose w e u sed does no t seemto be su f f icien t to in crease av erage h em og lob in concen trationand because there w ere alm os t no com p lain ts abou t s ide e f f ec tsit se em s w o rth w hile to in crease the iron dose. A s an alte rnativ eto co nv en tional tab le ts a gas tric d e liv e ry sy s tem (G D S ) f o r ironcou ld be used . I t is repo rted that absorp tion f rom G D S ironcom pared w ith f e rrous su lphate is th ree to f ou r tim es h igh er an dis w itho u t s id e e f f ec ts (1 8 ).

    S eco nd , the m o tiv ation and aw areness lev e l o f th e pregn an tw om en an d o f the health cen te r s taf f has to be im prov ed th roughnu trition edu cation , f o r ex am p le . T he im portance o f th is f ac thas already been s tre ssed by o ther au th ors (7 , 1 7 ). E f f ec tiv e nu -tritio n educatio n b ecom es ev en m ore im portan t w hen the d ailyiron do se is increased because o f the e lev ated costs o f th is h igherdo se , ev en thoug h in general the co sts f o r iro n treatm en t arere lativ e ly low . Im pro v ing th e m o tiv ation and aw areness lev e l o fhealth cen te r s taf f m ay prev en t s ituations in w h ich w om en dono t rece iv e su f f ic ien t iron tab le ts, as apparen tly occu rred in thepresen t stud y .T h ird , the resu lts o f th is study dem ons trate the im po rtan ceo f a re liab le m on ito ring and ev alu ation sy stem . It is c learly no teno ugh to reg iste r the num b er o f d is trib u ted iron tab le ts o r thenum b er o f health cen te rs in v o lv ed in the pro gram in o rder torecord p erf o rm ance . It is also no t enoug h to ju s t ask w om enw he ther they tak e the ir iron tab le ts regu larly , as w as sh ow n b ythe presen t study . M os t su itab le seem s to be a com b ination o frandom iz ed m easurem en ts o f hem og lob in co ncen tration an dde te rm ination o f iron in s too l. H em og lo b in m easurem en t tode tec t iron -de f ic iency an em ia is su itab le in f ie ld c ircum s tances

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    IR O N S U PPL EM EN T A T IO N IN PR EG N A N C Y 13 9w here o ther ad d itio nal m e thod s are le ss su itab le and m ak e an aly siscom p lex . Furtherm o re , hem og lob in m easurem en ts g iv e a satis-f ac to ry es tim ate o f the p rev alen ce o f iron de f ic ien cy w h en prey -alence is h ig h (19 ). C ons idering that- the im pac t o f ex perim en tals tud ie s m ay no t be the sam e as the im pac t o f e s tab lished in te r-v en tion pro gram s, m ore o peration al research is necessary . B

    T he en co urag ing su pport o f S S astroam id jo jo , d irec to r o f S EA MEO -T R O PM ED C en ter Indon es ia, is g rate f u lly ack now led ged . W e th an k PH endraw an , d irec to r o f T ebe t com m un ity h ealth cen te r, f o r her co op -eration . T he v aluab le recom m endations o f U G ross, JG A J H au tv ast, GS ev enhu y sen , an d R K orte are h igh ly app reciated .

    References1 . U nited N ation s A dm in istrativ e C om m ittee o n C oord ination /S ub -

    com m ittee on N utrition . Firs t report on the w orld nu trition situation .A C C /S C N , G enev a: W HO , 19 87 .

    2 . H usain i M A , H usain i Y K , S iag ian U L , S u harno D . S tudy o n nu -t ri ti on al an em i a: an assessm en t o f in f o rm atio n . C om pilatio n f o rsupp ortin g and f o rm ulating national po licy and p rogram . Jak arta:D irec to rate o f C om m un ity N u tritio n and N u trition R esearch andD ev e lo pm en t C en te r, M in istry o fH ealth , and W HO , 1989 .

    3. S uh arno D , W est C E , M uh ilal, e t al. C ross sec tional s tudy on theiron and v itam in A s tatu s o f p regnan t w om en in W est Jav a, Indo -nes ia. A m i C lin N u tr 199 2 (in press ).

    4 . D eM ay er EM , D allm an P. G urn ey JM , H allberg L , S o od 5K , S ri-k an tia 5K . Prev en tin g and co n tro llin g iron de f ic iency anem ia th roug hprim ary health care . G enev a: W HO , 19 89 .

    5 . Iy eng ar L , A pte S V . Proph y lax is o f anem ia in p regnancy . A m I C linN ut r 1 9 70 :2 3: 72 5- 30 .

    6. S ood 5K , R am achandran K , K am li R an i, e t al. W HO spon soredco llaborativ e s tud ie s on n u tritio nal anem ia in Ind ia. T h e e f f ec t o fparen te ral iron adm in is tration in the co n tro l o f anem ia in pregn ancy .B rJ N u tr 1 97 0:4 2:3 99 -4 06 .

    7 . C haro en larp P. D hanam itta 5 , K aew v ich it R , e t al. A W HOorativ e s tudy o n iron supp lem en tation in B u rm a an d in T hailand .A m J C lin N utr 198 8 :47 :280 -97 .

    8. B onn ar J, G oldberg A , Sm i t h JA . D o preg nan t w om en tak e the iriro n? L an ce t 1 96 9:1 :4 57 -8 .

    9. A f if i A M , B anw e ll G S , B enn iso n R i, e t al. S im ple te st f o r inges tediro n in h osp ital and dom oc ily p rac tice. B r M ed I l9 66 ;l:1 02 l-2 .

    10 . In te rnatio nal N utritio nal A nem ia C onsu ltativ e G roup . M easure -m en ts o f iron s tatu s . R eport o f the In te rnatio nal N utritional A nem iaC on su ltativ e G roup . W ash ing ton D C : IN A C G , 1985 .

    1 1. S n ed eco r G W , C o ch ran W G. S tatis tical m e thod s. 7 th ed . A mes, IA :Iow a S tate U n iv ers ity Press , 19 80 .

    1 2 . K us in JA , K ard jati 5 , S ury o hudoy o P. D e W ith C. A n em ia andhy pov itam inos is A am ong ru ral w om en in Eas t Jav a, Ind onesia.T rop G eogr M ed 198 0 ;32 :30 -9 .

    1 3 . M acD ougall L G . A sim p le te st f o r th e de tection o f iron in stoo ls . JP ed ia tr 1 9 70 :7 6:7 6 4- 5.

    14 . Piz arro F, A m ar M , S tek e l A . D e term in ation o f iron in s to o ls as am etho d to m on ito r consum ption o f iron - f o rtif ied produ cts in in f an ts .A m I C lin N utr 1987 :4 5 :484 -7 .

    15. M ejia L A , C hew F. H em ato log ical e f f ec t o f sup p lem en ting anem icch ild ren w ith v itam in A alone and in com b ination w ith iron . A mI C lin N u tr 1 98 8:4 8:5 95 -6 00 .

    16 . K uiz on M D . Iron sup p lem en tation us ing d if f e ren t dose lev e ls inpregnan t Filip inos . N utr R es 1 983 ;3 :257 -64 .

    1 7 . N y az em a N Z . T ow ard s be tte r patien t d rug com p lian ce and com -prehens io n : a ch allenge to m ed ical an d pharm aceu tical se rv ice s inZ im babw e. S oc S ci M ed 19 84 :18 :55 1 -4 .

    18 . C oo k ID , C arriaga M . K ah n 5G . S chalch W , S k ik ne B S . G astricde liv e ry sy stem f o r iron supp lem en tation . L ancet 1990 :335 :1136-9 .

    19 . Fre ire W B . H em og lob in as a pred ic to r o f re sp onse to iron therapyan d its u se in screen ing and prev alen ce estim ates . A m I C lin N u tr1 989 ;50 : 144 2-9 .