Iron-Folic Acid Supplementation

Iron deficiency is caused by inadequate iron intake to meet normal requirements or increased requirements due to excessive blood loss and reproduction. Anemia is a good predictor of iron deficiency when iron deficiency is the main cause of anemia. There are specific tests to measure iron deficiency such as serum ferritin but these tests are not described here because they are not available in most developing countries. In addition, the interpretation of some of the tests will differ based on presence of infection in a population. Click here for more information on tests for iron deficiency.

Giving iron and folic acid (IFA) supplements to pregnant women to prevent and treat anemia is a policy in most developing countries. All pregnant women need iron because a woman will become iron deficient with or without anemia by the end of her pregnancy, if she does not take iron supplements (Lynch, 2000). IFA supplementation should be integrated with other effective anemia control interventions in pregnancy such as IPTp, ITNs, and deworming (visit the sub-tabs on helminths, malaria and program guidance for more information). Giving iron supplementation to children younger than five years of age is not a policy in all countries, a few countries are continuing the practice of supplementing with iron and have taken it to scale. Premature and low-birth-weight infants need additional iron starting at two months of age.

The Impact of Giving Iron-Folic Acid (IFA) Supplements


Giving IFA is effective in increasing hemoglobin values and reducing anemia prevalence (Peña-Rosa, et al., 2012). Recent studies have shown that antenatal iron and folic acid given during pregnancy reduces rates of low birth weight and preterm birth, and anemia which is associated with increased risk of perinatal and maternal mortality. Emerging evidence finds that iron and folic acid supplementation during pregnancy significantly reduces the risk of early neonatal death and child mortality in Indonesia. 


Giving Iron-Folic Acid (IFA) Supplements to Children in Malaria-Endemic Areas


The World Health Organization recommends giving iron-folic acid supplements to young children in areas of high malaria transmission along with malaria programs and surveillance. Click here for information about giving IFA to children in malaria endemic areas.


The Dose of Iron-Folic Acid (IFA) Supplements


WHO recommends both preventive and treatment doses of IFA. Click here to view IFA preventive and treatment doses and duration.


Some women will not be able to take all 180 IFA supplements during pregnancy, either because supplies are not available or women do not visit ANC early or frequently enough to receive all their IFA supplements. These women should continue to take IFA after delivery until they have taken 180 IFA supplements. In countries, where anemia prevalence is less than 20%, non-anemic pregnant women can be offered a weekly dose of iron (WHO, 2011). Other groups that can be offered a weekly dose are school-age children, adolescent girls or all reproductive age women, the elderly, and men who are exposed to helminths or engage in heavy labor. The cost of providing weekly doses of IFA to many different groups should be considered when additional funding is available. Pregnant women and children younger than two years of age should continue to receive the highest priority.


In most countries, a combined iron-folic acid supplement is given to pregnant women containing 60 mg of iron and 400 mcg of folic acid. This dose of folic acid helps meet the requirement of the mother for additonal folic acid during pregnancy. However, in some countries large doses of 5 mg of folic acid are given as a separate supplement.  These large doses of folic acid are not needed and interfere with the treatment of malaria using sulphadoxine-pyrimethamine (SP). The World Health Organization recommends giving folic acid at a dose of less than 5 mg (WHO, 2012).


Coverage of Iron-Folic Acid (IFA) Supplementation


IFA supplementation programs for pregnant women and young children have not reached public health coverage as defined by 80% of the target population receiving the recommended doseof IFA. The coverage of IFA supplements for pregnant women is higher than coverage for children. Click here to view the IFA coverage for pregnant women for USAID priority countries. No country has achieved 80% coverage, and only two (Nepal and Senegal) have achieved coverage of greater than 50% of women receiving IFA supplements during pregnancy.


Types of Supplements


In most countries, IFA is given as one tablet to pregnant women, although iron syrups also may be given. Some countries have not transitioned to a combined IFA supplement and give iron and folic acid supplements separately and may give other micronutrients such as the B-vitamins separately as well. Some countries recommend giving children iron drops or syrup, but many countries are piloting micronutrient powders that contain iron and can be sprinkled on the child’s porridge. There is no evidence that giving iron to pregnant women in the form of micronutrient powders has a comparative advantage over IFA supplements. As a result, the World Health organization does not recommend multi-micronutrient powders during pregnancy (WHO, 2011). Click Program Guidance for information about the types of IFA supplements women prefer.


Giving Multi-Micronutrient (MMN) Supplements Instead of Iron-Folic Acid (IFA)


WHO’s policy still supports giving women IFA supplements during pregnancy. Replacing IFA with multi-micronutrient (MMN) supplements will need to be balanced with the benefits of MMN over IFA and the costs. MMN supplements are three times more expensive than IFA supplements. See the Questions and Answers section for more information on giving MMN supplements instead of IFA.

Visit the UNICEF Supply Catalogue to view the costs of all commodities including IFA and MMN. Click on “Pharmaceuticals” on the left to access cost information for both IFA and MMN. For IFA click on “affecting blood” and then “antianaemias.” For MMN click on “minerals and vitamins.”

Click here for information on how to improve IFA supplementation programs and integrate with other components of the integrated package to address anemia.