Pregnant Women’s Perception of Gestational Anemia and Iron Supplements in Oman

Abstract

Background: Gestational anemia is one of the most confronted problems during gestation. Nevertheless, the number of pregnant women with gestational anemia is growing in Oman. This study aimed to explore the perception of pregnant women regarding gestational anemia and iron supplements. This study would help us to comprehend pregnant women’s perceptions, attitudes, and factors regarding gestational anemia and iron supplements, as well as to understand the factors behind iron-deficiency anemia among pregnant women. Method: This study utilized a qualitative method directed by a grounded theory (constructivist) approach. The researchers conducted semi-structured (in-depth) interviews with 36 pregnant women with gestational anemia in the North Batinah Governorate in Oman. The researchers selected three primary healthcare institutions and one secondary healthcare institution, intending to reach pregnant women with gestational anemia. Both purposive sampling and theoretical sampling were used in this study. Results: From constant comparative analysis, four categories were developed: “Knowing the Problem”, “Believing in Treatment”, “Influencing Factors”, and “Trying To Manage”. Conclusion: Understanding pregnant women’s perception of gestational anemia and iron supplements could assist the Ministry of Health in developing ways to provide proper education and service for expectant mothers in Oman.

1. Introduction

Anemia is a significant health concern for pregnant women, characterized by a decrease in the blood’s ability to carry oxygen. It becomes more severe when red blood cells’ hemoglobin concentration or cell volume reduces below the average reference interval for the individual’s age, gender, and physiological status [1]. Pregnant women with a hemoglobin level of less than 11 g/dL are considered to have gestational anemia [2]. Meanwhile, those with a hemoglobin level of 7 g/dL or less are classified as having severe anemia [2]. Gestational anemia is associated with high rates of mortality and morbidity among mothers, contributing to 40% of maternal deaths globally [3]. In Asia, the prevalence of anemia among pregnant women over 18 years old was 31% in 2019, and in Oman, the Ministry of Health (MOH) reported that anemia among pregnant women is increasing and accounts for 35% [4]. However, there is hope that awareness about gestational anemia and the importance of iron supplements will increase when encountering the issue. Iron supplements are crucial in improving pregnant women’s hemoglobin levels and survival rates.

Gestational anemia is a global issue linked to maternal and neonatal health issues and fatalities. Globally, maternal and neonatal deaths are significant contributors to mortality in developing countries, with 2.5 and 3.4 million deaths, respectively [5]. The risk of maternal death falls significantly with a 1 g/dl gain in hemoglobin level [2,5]. The World Health Organization (WHO) states that gestational anemia affects 42% of pregnancies, with the highest prevalence in Africa at 61.5%, followed by 52.5% in Southeast Asia [6]. Furthermore, 31% of gestational anemia cases are in the Middle East and Central Asia [7,8]. Half of gestational anemia cases are due to iron deficiency [9]. Iron-deficiency anemia during pregnancy carries various risks for mothers and newborns. Chronic iron-deficiency anemia can impact the overall health of mothers, leading to fatigue and reduced capability to work [9]. It is also associated with preterm delivery, low birth weight, decreased mental abilities, decreased mental growth, and, later on, poor academic performance [9,10].

In Oman, gestational anemia is considered to be a significant health issue [4]. The prevalence of gestational anemia is 35% in Oman [4]. The MOH has embraced numerous strategies to diminish the prevalence of gestational anemia, such as providing pregnant women with iron supplements and motivating healthcare professionals to recommend that pregnant women consume iron supplements [4]. A systematic review concluded that a regular iron supplement increases pregnant women’s hemoglobin levels [10]. The government of Oman also supplies some foods with iron, such as flour, bread, pasta and grain [4]. They also organize comprehensive educational programs to control anemia among pregnant women, including distributing pamphlets about preventing anemia, conducting workshops on nutrition, and providing counseling services in many health institutions [4]. It is shown that academic programs have changed the understanding and attitude of pregnant women toward iron supplements, which reduced gestation anemia prevalence [11,12,13]. According to the MOH, the prevalence of gestational anemia reduced from 38% in 2011 to 35% in 2023. However, gestational anemia remains challenging for the MOH in Oman. According to the MOH (2023), widespread gestational anemia and its complications for pregnant women and their infants in Oman is a worry [4]. To the researchers’ knowledge, little qualitative research investigations had been performed to evaluate pregnant women’s perception of gestational anemia and iron supplements. Consequently, it is crucial to investigate this issue in Oman. This study will explore the perception of pregnant women regarding gestational anemia and iron supplements. Acknowledging women’s perception of gestational anemia could provide appropriate services, such as health education, to pregnant women within healthcare organizations.

1.1. Research Problem

According to an MOH (2023) report, the prevalence of gestational anemia in Oman is 35% [4]. Despite the numerous studies on this issue, there is a need to explore the perception of pregnant women regarding gestational anemia and iron supplements. Furthermore, there are limited studies on women’s knowledge of gestational anemia and iron supplements, and we have not yet identified the root causes of the low hemoglobin rates among pregnant women. This significant literature gap underscores the novelty and potential contribution of our proposed study, which aims to explore women’s awareness, beliefs, attitudes, and practices of gestational anemia and iron supplements and to identify the factors behind the low rate of hemoglobin among pregnant women in Oman.

1.2. Importance of the Study

Acknowledging the perceptions of pregnant women about gestational anemia and iron supplements could help us to develop appropriate programs or healthcare facilities for pregnant women at antenatal clinics within healthcare organizations.

1.3. Research Questions

• What is pregnant women’s perception of anemia and its complications?
• What is pregnant women’s perception of iron supplements and their importance?
• What beliefs and understandings do pregnant women hold about gestational anemia and iron supplements, and how do these beliefs shape their behaviors and choices?
• How do pregnant women feel about iron supplements, and how does this affect their willingness to take them?
• What is the practice of pregnant women regarding preventing anemia during pregnancy?
• What are the factors affecting pregnant women’s iron supplementation adherence during pregnancy?

2. Materials and Methods

2.1. Study Design

This research, which used a qualitative method (grounded theory), thoroughly investigated the perceptions of pregnant women regarding gestational anemia and iron supplements. This approach was chosen because it is suitable for examining social interactions and activities, especially when few studies have influenced individuals’ perceptions. Grounded theory allows for observing individuals’ lives from their insights and involves systematically gathering and analyzing data to describe and explain social processes during interactions. The researchers interviewed pregnant women diagnosed with gestational anemia to understand their perspectives on gestational anemia and iron supplements, their diet during pregnancy, and the reasons for not adhering to iron supplement tablets.

2.2. Study Context

This study was conducted in antenatal clinics. The researchers selected three primary healthcare organizations and one secondary hospital in NBG, Oman. The aim was to reach pregnant women with gestational anemia. NBG was chosen due to its large population size. These healthcare facilities, carefully chosen for their suitability, were considered ideal for recruiting participants and gaining an understanding of women’s perception of gestational anemia.

2.3. Sampling Strategy

This study utilized purposive and theoretical sampling strategies. The researchers used purposive sampling to recruit women who met specific criteria (pregnant women diagnosed with gestational anemia and above 18 years of age). They included women of different ages, education levels, and living areas. The participants were asked about their perceptions of gestational anemia and iron supplements. The researchers were dedicated to understanding the participants’ experiences and wanted to explore their perceptions, beliefs, attitudes, and practices regarding the topic. The researchers were also determined to uncover the reasons why pregnant women do not adhere to taking iron supplements.

Theoretical sampling involves identifying participants who can provide additional data about the phenomena under study to aid theory development [14]. The sample size in grounded theory should be inductively established until saturation occurs [15,16]. Therefore, the exact sample size can only be determined after the initial data collection and analysis stage. In this study, the researchers added participants until data saturation was achieved and no new information emerged from the data [14,15]. A total of 36 women was considered sufficient to reach saturation. Women were recruited via posters by nurses unaffiliated with the investigation area. Potential participants obtained a Participant Information Sheet (PIS) from the recruiting nurses explaining the study’s objective. The nurses obtained contact information and verbal approval from interested women so the researchers could reach them. The researchers then reached the women by telephone, addressed their concerns, and arranged a suitable time and place for the interview. Written consent was acquired from the women before performing the interview.

2.4. Data Collection Methods

The data collection method involved conducting semi-structured, in-depth interviews with a total of 36 pregnant women diagnosed with gestational anemia. Eight pregnant women were initially interviewed, but it was determined that more pregnant women were needed for the study, so an additional twenty-eight women were added. This study explored the participants’ perceptions of gestational anemia and iron supplements. Therefore, semi-structured interviews were chosen for their flexibility, allowing the researchers to delve into new concepts as they arose during the interviews. This approach also facilitated an in-depth exploration of the research questions and participants’ comments [17]. The goal was to gain insight into the women’s perceptions, attitudes, beliefs, practices, and factors influencing their adherence to taking iron supplements.

2.5. Data Collection Instruments and Technologies

The researchers developed an initial interview guide for pregnant women, focusing on gestational anemia and iron supplements. The guide included questions such as: What is your understanding of gestational anemia? How do you feel about taking iron supplements? Do you take your iron supplements regularly? This guide helped ensure that all relevant topics were covered. As discussions with the women progressed, it became clear that additional questions needed to be incorporated into the guide to address emerging issues. Consequently, the guide was adjusted, and questions regarding iron supplement adherence were added. All interviews were recorded utilizing a digital recorder after obtaining consent from the women. This allowed the researchers to concentrate on the conversations without the distraction of note-taking. Field notes were gathered after each interview to capture problems and facilitate reflection. The researchers also made memos in their notebooks immediately after completing the data collection. Personal information was removed from the stored data, and audio recordings were deleted after the data had been transcribed. All electronic data were securely saved on an encrypted server with password-protected access. Furthermore, the women were informed that all publications and quotations would use pseudonyms to ensure anonymity.

2.6. Data Processing and Techniques to Enhance Trustworthiness

Each interview was anonymized, and every participant was assigned a code number. The researchers carefully analyzed the transcripts for accuracy. They transcribed the collected data and recorded every word spoken by the participants. The findings were based on the data, not personal opinions. Triangulation was utilized in this study; data were collected from diverse participants with varying backgrounds, providing data variability. To ensure credibility, the researchers sought to comprehend the women’s perception of gestational anemia and their views on iron supplements. To confirm that the results could be involved in other settings, they included sufficient details about the fieldwork context for readers to assess transferability. Finally, to ensure confirmability, the researchers showed that the findings were rooted in the data, not their biases. This qualifies them to understand the participants’ perception of gestational anemia and iron supplements.

2.7. Data Analysis

Constant comparative analysis was applied during data analysis. The researchers transcribed all data from the tape recorder. With constructivist grounded theory, data collection and analysis are performed simultaneously [18]. The researchers used theoretical sampling to continuously concentrate on and compare the data [14]. The researchers categorized the gathered information using open coding, and within each category, they established many subcategories [14,15]. Coding is the primary stage of developing analytical interpretations and establishing an analytical framework for researchers to develop the analysis [15]. The researchers’ objective was to remain open to all potential theoretical directions indicated by reading data [16]. The researchers made decisions about defining the core conceptual categories [14]. They conducted line-by-line coding and systematically read the data, providing a name for each line of the collected data [19]. They also used a constant comparative approach to compare data and identify similarities and differences [16]. This phase involved comparing the data to generate conceptual categories. The second major step in coding is focused coding [16], where the researchers assemble the data in a new way to pinpoint and generate the most outstanding categories of data from earlier codes [16]. Coding allows researchers to gain a focused view of the data and obtain deeper insights into the phenomenon under study [16].

2.8. Ethical Approval

The study received approval from the MOH Research Ethical Review Approval Committee (RERAC) in Oman (RERAC 25/2022). Prior to commencing the study, the design and purpose were discussed with the Nursing and Midwifery Department in the Directorate General of Health Services in the NBG. This was done to seek permission to use the study allocation and obtain all necessary facilities for the study. This study ensured informed consent, confidentiality, and voluntary participation.

3. Results

3.1. Research Participants’ Characteristics

This research study was conducted from January to June 2023 and involved 36 pregnant women. These women were selected for data collection until a thorough understanding of the issue was accomplished. The majority of the women were married and educated, with ages ranging from 19 to 52 years. All of the women had been diagnosed with gestational anemia during pregnancy (

Table 1. Demographic data of participants.

No	Age	Occupation	Education	No	Age	Occupation	Education
1	22	Housewife	Secondary	19	40	Housewife	Secondary
2	42	Private	Secondary	20	44	Private	Secondary
3	25	Housewife	Secondary	21	19	Housewife	Secondary
4	39	Government	Diploma	22	26	Private	Diploma
5	30	Government	Secondary	23	37	Housewife	Secondary
6	25	Housewife	Bachelor	24	40	Private	Bachelor
7	37	Private	Secondary	25	22	Private	Diploma
8	31	Government	Diploma	26	29	Housewife	Secondary
9	30	Housewife	Diploma	27	34	Housewife	Diploma
10	27	Government	Bachelor	28	41	Government	Master
11	23	Housewife	Secondary	29	27	Private	Secondary
12	30	Government	Secondary	30	33	Private	Secondary
13	50	Housewife	Secondary	31	28	Private	Secondary
14	36	Private	Diploma	32	34	Private	Secondary
15	27	Government	Diploma	33	45	Housewife	Secondary
16	52	Private	Secondary	34	41	Private	Secondary
17	25	Private	Diploma	35	38	Private	Secondary
18	36	Government	Bachelor	36	44	Housewife	Secondary

).

The data acquired from the interviews were repeatedly compared and analyzed, resulting in the establishment of four themes: “Understanding the Issue”, “Having Confidence in Treatment”, “Influencing Factors”, and “Attempting to Manage”. See Figure 1 for the emerging themes and sub-themes.

3.2. Knowing the Problem

Exploring pregnant women’s comprehension of gestational anemia and iron supplements was the focus of this theme. It was evident that many women in this study had some information about gestational anemia and iron supplements (

Table 2. Women’s knowledge about gestational anemia and iron supplements.

Knowledge about	Yes (n, %)	No (n, %)
Gestational Anemia	(28, 77.7%)	(8, 22.3%)
Signs and Symptoms	(14, 38.8.%)	(22, 61.2%)
Complications	(6, 16%)	(30, 83.3%)
Nutrition to Prevent Gestational Anemia	(8, 22.3%)	(28, 77.7%)
Iron Supplements	(36, 100%)	(0, 0%)
Benefits of Iron Supplements	(36, 100%)	(0, 0%)

). However, a concerning finding was that they had infrequent information about nutrition that prevents anemia. This highlights the need for better education and guidance on this crucial aspect of pregnancy. Many women stated, “I know a bit about the signs and symptoms of gestational anemia, like feeling tired”. Participant 3’s comment, “I have very little information about gestational anemia complications… anemia will be cured after pregnancy”, further underscores the need for comprehensive education. However, it is noteworthy that most women in this study (n = 28, 77.7%) were familiar with the definition of anemia, particularly gestational anemia. Some women stated that

“Gestational anemia is similar like anemia but it happen during pregnancy….anemia is lack of iron in the blood which can occur during pregnancy or before.”

(Participant 1)

“Anemia is lack of iron carrying oxygen in the blood.”

(Participant 9)

On the other hand, only a small number of women (n = 6) had good knowledge of gestational anemia complications (16%). They knew that anemia during pregnancy could influence their health if not treated in the early stage of pregnancy. These women expressed that gestation anemia caused complications such as bleeding during delivery and then the necessity of cesarean delivery. One woman reported that

“Gestational anemia can cause lots of problems during pregnancy; it affects women and their babies…anemia can cause bleeding during labor and can affect the health of baby later on or maybe during pregnancy.”

(Participant 4)

“Gestational anemia affects mothers’ and babies’ health and should be treated as early as possible…Gestational anemia can cause bleeding to the women during birth and can lead to operation if not treated.”

(Participant 30)

Another woman expressed that gestational anemia affects babies’ health. She said that gestational anemia causes stunted growth and the inability of the babies to gain weight. Also, she identified that gestational anemia leads to abortion and stillbirth if not treated in early pregnancy. Participant 14 said that

“Gestational anemia affects child’s growth and development, it can affect babies’ weight and they will not gain good weight, also abortion and babies’ death can occur if not treated at early stage of pregnancy.”

(Participant 14)

In addition, a few women (n = 8, 22.2%) knew about the nutrition or food that increases hemoglobin levels within the blood. They explained that fruits, green vegetables, eggs, and some proteins such as fish, meat, chicken, and liver helped to elevate hemoglobin levels within the blood. One of the women said

“I know what to eat if my blood reduce, I am eating green vegetables, fruits, meat, fish, liver and other protein. These types of food will increase iron in my blood.”

(Participant 11)

A question was asked about iron supplements, including if the women knew about them and their benefits. All women knew that iron supplement was a treatment for gestational anemia. They also learned the benefits of iron supplements to raise hemoglobin within their blood. However, most women (n = 32, 88.8%) identified that they did not adhere to iron supplementation. Some of the women stated

“I know that iron supplements is a tablet to treat anemia and it is good to increase blood but I do not take this medication.”

(Participant 25)

“Iron supplements is good medication to treat anemia but I cannot take this medication during pregnancy.”

(Participant 15)

The data revealed that many women (n = 28, 77.7%) knew the definition of gestational anemia. However, 22 (61.2%) did not know gestational anemia’s warning signs and symptoms. On the other hand, only a small number of women (n = 6, 16%) had good knowledge about the potential complications of gestational anemia for themselves and their babies. Also, few women (n = 8, 22.2%) knew about the nutrition or food that increases hemoglobin levels within the blood. In addition, all women knew iron supplements were a treatment for gestational anemia and knew their benefits were raising hemoglobin within their blood. However, most women identified that they did not adhere to iron supplementation. The reason for not adhering to the treatment is discussed in detail in Section 3.4. Influencing Factors.

3.3. Believing on Treatment

This theme explores women’s beliefs about iron supplements and what they think about their importance. All pregnant women believed in the importance of iron supplements and their benefits in raising the hemoglobin level within the blood. This indicates that they had a positive attitude toward iron supplements.

“Yes, iron supplements are important and good to increase the iron level in the blood.”

(Participant 17)

However, most women who believed in the importance of iron supplements did not adhere to the treatment (n = 32, 88.8%). According to the women, they were not taking the iron supplement during pregnancy. The reasons for not adhering to the treatment are discussed in detail in theme 3.

“I know that iron supplements are good and benefits for me to increase my blood but I cannot eat it, it is difficult to take this medication during pregnancy.”

(Participant 34)

The data indicated that all pregnant woman acknowledged the significance of iron supplements and their effectiveness in increasing the hemoglobin level in the blood. This suggests that they had a positive attitude toward iron supplements. However, most women identified that they did not adhere to iron supplementation. The reason for not adhering to the treatment is discussed in Section 3.4. Influencing Factors.

3.4. Influencing Factors

This theme explores pregnant women’s views about the factors influencing anemia prevention. This means why the women were unable to control gestational anemia. Lack of knowledge about nutrition or food that enhances hemoglobin is considered to be one of the factors that influence anemia prevention among pregnant women. Moreover, 28 pregnant women (77.7%) identified that they did not have information about foods that increase hemoglobin within their blood, as mentioned in the first theme (Knowing the Problem).

In addition, many women (n = 25, 69.4%) drank tea immediately after food as a habit within their family. All their family members drank tea immediately after eating, and they joined them and shared the same habit. Participant 2 stated that

“I was drinking tea after food, this practice is not new, usually I am doing that because all of my family doing the same…every day we drink tea immediately after food and this is our family habit since my childhood.”

(Participant 2)

A question was asked regarding if they knew that drinking tea immediately after food affects hemoglobin, and the answer was

“No, I don’t know I thought it is okay because we don’t drink lots of tea, it is only one or two small cups.”

(Participant 2)

Insufficient support from healthcare professionals has also been found to impact pregnant women’s ability to prevent gestational anemia. According to the pregnant women (n = 24, 66.7%), when they followed up in the antenatal clinics, the midwives did not provide information about gestational anemia and the ways to prevent it during pregnancy. The healthcare professionals also had contradicting information about the timing of iron supplement intake. According to the women, some midwives informed them to take iron supplements two hours after food, and others told the pregnant women to take iron tablets two hours before food. The pregnant women felt confused, which resulted in taking medication on time or not taking it at all.

“When I opened the green card or visited antenatal clinic for follow up of care, none of the midwives toke to me about gestational anemia or how to prevent it.”

(Participant 19)

“Actually, I am confused and I don’t know when to take iron supplements, some midwives said to take tablets two hours after food and others said two hours before food.”

(Participant 33)

A question was asked of the same woman (Participant 33) about the timing of iron supplement intake. She stated

“Actually, I am confused and know what to do because of the information from the midwives so, I am taking the tables any time I wanted and for the last two months I did not take the tables at all.”

(Participant 33)

The working women (n = 23, 63.8%) mentioned that their occupation affected their ability to control anemia during the gestational period and after delivery. According to them, they were exhausted when they returned from work; thus, they did not consider good nutrition, such as fruits, green vegetables, and proteins, which enhance hemoglobin levels. Others expressed that after delivery, they did not have enough days to care for their diet and to improve their hemoglobin levels. They took only 50–60 days, and during these days, they concentrated on caring for the new baby and other children.

“I am working in private sector, I have to work for 9 h and this is too tiring…when I arrived house, I don’t feel to eat and I wanted to sleep, taking care of other kids and do some house activities, after that I sleep so next day I have to go to my duty. The same on the next day and so on.”

(Participant 20)

“After delivery, I take 50 days maternal leave and some days from my annual leave to take care of my new baby, I feel this is not enough because I feel still I did not relax and all my time had spent on taking care of my new baby or other kids, I need time to take care of myself because of that the level of iron was not increasing.”

(Participant 28)

In addition, a few women (n = 5, 13,8%) revealed that they did not use birth spacing and were having children yearly. According to them, they did not believe in family planning due to its disadvantages, such as bleeding, infection, and weight gain. They knew that they could not control anemia because of pregnancy every year, but still, they did not want to use the birth spacing method.

“I have four kinds and now I am pregnant, I don’t want to use birth spacing because it cause bleeding, infection and it will increase my weight….I have gestational anemia and I know that this is not got more me, I know that I have to be healthy but I will not take any thing (birth spacing), I will try to manage by eating good food.”

(Participant 11)

Moreover, many women (n = 19, 52,8%) identified that sickness, especially at the early stage of pregnancy due to nausea and vomiting, prevented them from controlling anemia. The reason was that women could not eat food during the first trimester. One of the women said

“I was not eating well during the first three or four months of pregnancy, I was vomiting too much and I had nausea for four months…This was a reason of anemia …later on when I started eating, I was in need for time to increase the level of iron in the blood.”

(Participant 31)

The majority of women (n = 32, 88,8%) were not able to control anemia during pregnancy due to complications of iron supplements, which led to a lack of adherence to the treatment (

Table 3. Participants’ adherence to treatment.

NO	Adhere RX	Reason Not Adherence	NO	Adhere RX	Reason Not Adherence
1	No	Complication	19	No	Complication
2	No	Complication	20	No	Complication
3	No	Complication	21	No	Complication
4	No	Complication	22	No	Complication
5	No	Complication	23	No	Complication
6	No	Complication	24	No	Complication
7	No	Complication	25	No	Complication
8	No	Complication	26	No	Complication
9	Yes	-----	27	No	Complication
10	No	Complication	28	No	Complication
11	No	Complication	29	No	Complication
12	No	Complication	30	Yes	-----
13	No	Complication	31	No	Complication
14	Yes	-----	32	No	Complication
15	No	Complication	33	No	Complication
16	No	Complication	34	No	Complication
17	Yes	-----	35	No	Complication
18	No	Complication	36	No	Complication

). The women stated that iron supplements caused lots of side effects during pregnancy, such as constipation, nausea, vomiting, heartburn burn, and abdominal cramps. One of the women said that

“I had anemia and I was on treatment from the beginning of my pregnancy… I was suffering from this tablets and I develop constipation, nausea and vomiting… I could not tolerate this tablets and now I had heart burn and pain in my abdomen, I stopped taking this medication.”

(Participant 8)

Only four pregnant women (11, 11%) adhered to treatment and took iron supplements. These women stated that they were taking iron supplements from private health institutions because iron supplements provided by governmental healthcare institutions caused lots of complications and side effects, unlike tablets from private pharmacies.

“Yes, I was taking iron supplements from private pharmacy because the tablets from health center caused constipation for my and other problems.”

(Participant 14)

Another question was posed to women who did not adhere to treatment concerning why they did not buy iron supplements from private pharmacies. Many women (n = 17, 47%) said that

“I am not able to buy iron supplements from private pharmacy, it is expensive.”

(Participant 23)

In sum, many factors influence pregnant women’s ability to prevent anemia. These factors are lack of knowledge, lack of support, women’s occupation, not using birth spacing methods, sickness at early pregnancy, and complications of iron supplements.

3.5. Trying to Manage

This theme explored pregnant women’s management of their problem with gestational anemia. The data indicated that 15 women (41.7%) sought medical treatment only when they were severely anemic. They were trying to manage their health issue by seeking information, support, and treatment from healthcare professionals and other family members.

“When my blood reduced too much, which may have reached 5.5, I asked the nurse what to do and how to solve this problem. She told me to take tablets and to eat healthy food, and then the doctor transferred me to a hospital for a blood transfusion.”

(Participant 15)

“When the midwife told me about my low hemoglobin around 9, immediately I told my husband, and he took me to private hospital… the doctor in private hospital gave me good tablets to increase hemoglobin, and it was perfect…now my hemoglobin is 10.5.”

(Participant 17)

In sum, health-seeking behavior was a problem for many pregnant women in this study. Many women were seeking information, support, and treatment when they had severe anemia.

4. Discussion

This study identified pregnant women’s perceptions of gestational anemia and iron supplements. The data exhibited that women did not understand gestational anemia, including signs, symptoms, complications, and dietary measures to prevent it. This study’s results agree with other studies in which the women lacked knowledge about gestational anemia and iron supplementation [20,21,22]. In addition, many women in this study considered anemia to be an issue that would disappear after pregnancy. These findings mirror those of a study conducted in India, where women described anemia during pregnancy as “normal” because they believed that their fatigue would not impact their unborn child [20]. Furthermore, women in this study did not know about nutrition, which enhances hemoglobin; thus, they did not concentrate on their nutrition during pregnancy. This result does not align with a study conducted in Thailand [23]. The women pointed out that they were concerned about their general foods to increase their hemoglobin level [23].

On the other hand, most women in this study knew about iron supplements and their importance and had positive attitudes toward them. This finding is not reflected in a study conducted by Klankhajhon and colleagues in 2021, where the women indicated they were interested in consuming foods rather than iron supplements. The women hesitated to take iron supplements during pregnancy, reflecting a low attitude toward iron supplements [23]. Low knowledge and misunderstanding about gestational anemia could affect women’s attitudes and behavior during pregnancy [24,25]. This indicates the necessity of creating an educational program to raise awareness about gestational anemia among expectant mothers.

Additionally, data revealed that pregnant women needed support, especially from healthcare professionals. The women were seeking information, support, and treatment once they had severe anemia. This outcome is constant with other studies that illustrated the importance of community support for women with gestational anemia so women would be able to control anemia at an early stage of pregnancy [20,25,26]. Pregnant women with gestational anemia need to have informational and emotional support as facilitators during pregnancy so they can control or prevent gestational anemia [26].

The findings also illustrated women’s occupation as a barrier to controlling anemia during pregnancy. Many women were not taking care of themselves after work and needed a balanced diet because they were overwhelmed with household activities and children’s responsibilities. This result is in line with numerous studies, which have indicated that the dual responsibility of women in both work and household tasks, stemming from low income, has led to an increase in the prevalence of anemia among women [27,28]. This indicates the necessity of having a flexible working time for pregnant women, especially those with pregnancy complications such as gestational anemia.

Adherence to iron supplementation is essential to prevent pregnancy anemia. Health services have made significant efforts to enhance maternal adherence through health promotion initiatives, but unfortunately, non-adherence rates persist at unacceptably high levels [29]. This study showed that adherence to the treatment was one of the elements that impacted women’s ability to control anemia, and many women could not use iron supplements due to their side effects, such as constipation. This study reveals that gastrointestinal side effects, such as nausea and constipation, have a significant impact on women’s adherence to iron supplementation [29,30]. Most women in this study reported non-compliance due to these side effects. This conclusion is consistent with a study performed in Indonesia, and it was mentioned that women who experience side effects of iron supplements, such as constipation and nausea, indicate a diminished commitment to iron tablets [31].

5. Conclusions

Constant comparative analysis revealed four key themes: “Knowing the Problem”, “Believing in Treatment”, “Influencing Factors”, and “Trying to Manage”. Women needed more knowledge and support about gestational anemia. However, they have a positive attitude toward iron supplements. There were many factors affecting women’s ability to control anemia, such as insufficient knowledge, insufficient support, occupation, pregnancy sickness, and complications of iron supplements. Most women in the study reported non-compliance to iron supplements due to gastrointestinal side effects. Therefore, they tried to manage this problem by seeking information, support, and treatment. It could benefit the MOH to understand the experiences of pregnant women with gestational anemia and iron supplements. This understanding could help the MOH provide effective health education and improved health facilities for pregnant women with gestational anemia in Oman.