What are the Indian guidelines for Iron and Folic Acid (IFA) supplementation in pregnancy?

IFA Supplementation in Pregnancy: Indian Guidelines

Core Recommendation

All pregnant women in India should receive daily iron-folic acid (IFA) supplementation throughout pregnancy, starting as early as possible at first antenatal contact, with 60 mg elemental iron and 0.4 mg (400 mcg) folic acid daily, continuing through delivery. 1

Standard Dosing Protocol

Iron Supplementation

• 60 mg elemental iron daily is the standard dose for all pregnant women 1
• Women with adjustable gastric banding may use lower doses (>18 mg) but still require monitoring 1
• Low-dose iron (30 mg/day) is sometimes recommended during second and third trimesters, though 60 mg remains standard 1
• Iron supplementation prevents iron deficiency anemia, which affects approximately 50.3% of pregnant women in India 2, 3

Folic Acid Supplementation

• 0.4 mg (400 mcg) folic acid daily for all pregnant women 1
• Higher dose of 4-5 mg folic acid daily for women with BMI >30 kg/m² or diabetes during periconception period and throughout first trimester 1
• Folic acid should be started preconceptionally when possible and continued throughout pregnancy 4, 1

Timing of Initiation

Begin IFA supplementation at the first antenatal contact, regardless of gestational age, and continue until delivery. 1 This approach:

• Aligns with iron supplementation recommendations to start as early as possible 4
• Maximizes compliance by establishing a routine early 4
• Addresses the practical reality that many women present late for antenatal care 4

Additional Essential Supplements

Calcium

• 1200-1500 mg daily in divided doses (including dietary intake) 1
• Particularly important in populations with low dietary calcium intake to prevent preeclampsia 4, 1
• Doses should not exceed 500 mg elemental calcium per administration for optimal absorption 4

Vitamin D

• ≥1000 IU (40 mcg) daily to maintain serum 25-hydroxyvitamin D levels above 50 nmol/L 1

Other Micronutrients

• Thiamine >12 mg daily 1
• Copper 2 mg daily 1
• Zinc 8-15 mg per 1 mg copper 1
• Selenium 50 μg daily 1
• Vitamin E 15 mg daily 1
• Vitamin A 5000 IU daily (beta-carotene form only, not retinol) 1
• Vitamin K 90-120 μg daily 1

Monitoring Schedule

Check the following at least once per trimester: 1

• Full blood count
• Serum ferritin and iron studies (including transferrin saturation)
• Serum folate or red blood cell folate
• Serum vitamin B12
• Serum vitamin D with calcium, phosphate, magnesium, and parathyroid hormone
• Serum vitamin A

Addressing Compliance Challenges

Common Barriers in Indian Context

The major reasons for non-compliance identified in Indian studies include: 2, 3, 5

• Forgetfulness (63%) - the most common reason 2
• Side effects (49.5%) - both perceived and experienced 2, 5
• Not registering at antenatal clinic 3
• Not receiving tablets from health workers 3
• Perceived lack of need 3
• Supply chain issues - 14 out of 52 villages in one study had no access to IFA tablets 3

Strategies to Improve Compliance

• Directly observed therapy: Weekly supervised first dose by ASHA workers improves compliance by 9% and increases hemoglobin by 0.52 g/dL 6
• Ensure constant supply at village/sub-center level where frontline workers can promote uptake 3
• Single daily dosing improves compliance compared to multiple doses 5
• Address side effects proactively through counseling 2, 5
• Target older pregnant women and those with lower hemoglobin who show better compliance 2

Critical Pitfalls to Avoid

Timing and Interaction Issues

• Do NOT counsel that calcium and IFA must be taken separately - while calcium can inhibit iron absorption acutely, long-term clinical effects are minimal due to adaptive responses 4, 1
• To simplify regimen and improve adherence, allow women to take IFA with one calcium dose 4
• Separating doses would require ≥4 daily administrations, significantly reducing compliance 4

Vitamin A Safety

• Use only beta-carotene form of vitamin A during pregnancy, NEVER retinol form due to teratogenicity risk 1, 7

Dosing Errors

• Do not discontinue supplementation immediately postpartum - nutritional demands remain elevated, especially during breastfeeding 8
• Do not use hypocaloric diets (<1,200 calories/day) as they can cause ketonemia and ketonuria affecting fetal development 1

Special Populations

Post-Bariatric Surgery

• Require more intensive monitoring and higher supplementation doses due to malabsorption 1
• Monthly ultrasound monitoring of fetal growth recommended 1
• More frequent nutritional screening each trimester 1
• Women advised to avoid pregnancy for 12-18 months post-surgery 1

High-Risk Women

• Women with obesity (BMI >30) or diabetes need 4-5 mg folic acid daily 1
• Those with history of neural tube defects may benefit from higher folic acid doses 1

Evidence Quality Note

The Indian context presents unique challenges with compliance rates of approximately 64.7-77.1% 2, 5, significantly impacted by supply chain issues and healthcare access 3. The directly observed therapy model shows promise in the Indian setting, with demonstrated improvements in both compliance and hemoglobin status 6.