Regional variations in the trend of iron supplementation during pregnancy and its multi-level predictors in Pakistan

Iron supplementation during pregnancy is a key intervention preventing and treating iron deficiency anemia, which is associated with adverse maternal and neonatal outcomes, including severe maternal anemia, miscarriage, hemorrhage, preterm birth, and low birth weight. Despite this, a comprehensive understanding of the trends and predictors of iron supplementation across different regions and provinces in Pakistan remains limited. This study aims to assess both the temporal trends in iron supplementation among pregnant women and its multi-level determinants. This research utilizes repeated cross-sectional study design using secondary data from four waves of the Pakistan Demographic and Health Survey (PDHS; 2006-07 to 2019) to analyze the regional variations on the trend of iron supplementation. Participants included ever married women of reproductive age who have responded to the question of "uptake of iron supplementation during last pregnancy". Various individual, community and institutional level factors from the data set of PDHS 2019 were used as independent factors to study the predictors of iron supplementation among women during pregnancy. For studying the trends, rate differences, rate ratios, changes in percentages and differences in percentages of iron supplementation during pregnancy were calculated, while for analyzing the predictors of iron supplementation, binary logistic regression models were used. There has been a 44.1% increase in iron supplementation among pregnant women nationwide, with regional increases of 61.7% in rural areas and 19.9% in urban areas, leading to a current national supplementation rate of 65.4%. Factors such as older age, rural residency, living in Sindh or Baluchistan, smoking history, higher number of pregnancies and losses, and more children born or deceased were associated with lower odds of iron supplementation(p < 0.005). Conversely, higher education, residency in Gilgit Baltistan, Azad Jammu and Kashmi, as well as Khyber Pakhtunkhwa, and lady health worker's advice regarding antenatal care were the significant factors with antenatal care utilization as the strongest predictor of supplementation in both unadjusted (OR = 30.07; 95% CI: 23.55-38.40) and adjusted models (AOR = 31.29; 95% CI: 14.37-68.11). Although over half of pregnant women in the study population take iron supplements, the rate is still lower compared to many other countries. Significant regional disparities suggest the need for targeted efforts to increase supplementation rates and improve maternal health outcomes, such as increasing healthcare access in underperforming regions, expanding educational campaigns, and strengthening community-based programs to improve supplementation adherence.