Abstract
<title>Abstract</title> <p>Background Anaemia in pregnancy is a continuing public health challenge in low and middle-income country (LMIC), most importantly, India. National initiatives such as Anaemia Mukt Bharat have been implemented since 2018; nevertheless, there has always been suboptimal adherence to oral iron and folic acid supplementation (IFAS) among pregnant women. This study evaluated the adherence to IFAS and identified factors associated with compliance among pregnant women in rural central India. Methods A community-based mixed-method cross-sectional study was conducted among 97 third-trimester pregnant women registered at a randomly selected primary health centre in Wardha district, Maharashtra, India. Quantitative data were collected using a structured interviewer-administered questionnaire. Compliance was defined as consumption of ≥ 80% of prescribed IFAS tablets during the preceding 14 days. Descriptive statistics, univariable logistic regression, and multivariable logistic regression analyses were performed using R software version 4.1.2. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were estimated. Qualitative data were obtained through 12 in-depth interviews with pregnant women, caregivers, and healthcare stakeholders and analysed using Braun and Clarke’s thematic approach. Results Overall compliance with IFAS was 67.0% (65/97). The most frequently reported barriers to regular intake were forgetfulness (63.9%), busy schedules (27.8%), and fear of side effects (26.8%). Univariable analysis demonstrated significant associations between compliance and maternal education, caste, type of ration card, husband’s education, healthcare provider interaction, myths and taboos, awareness regarding iron absorption, dietary practices, and systemic illness (p < 0.05). In multivariable analysis, missing IFAS doses (AOR = 0.006; 95% CI: 0.00008–0.081; p = 0.002) and experiencing side effects (AOR = 0.10; 95% CI: 0.014–0.49; p = 0.009) remained independent predictors of non-compliance. Qualitative findings highlighted forgetfulness, gastrointestinal side effects, misconceptions, poor dietary diversity, financial constraints, and health system challenges as key barriers, while counselling, family support, and community health worker follow-up facilitated adherence. Conclusions Among rural Indian pregnant women, Compliance of IFAS was moderate and influenced by behavioural, sociocultural, dietary and health system factors. Focusing on counselling, tackling side effects, misperceptions of supplementation among beneficiaries and families along with ensuring continuous availability of supplements in the health systems may help improve adherence as well as ultimately reducing maternal anaemia.</p>