Concerns of iodized salt and its effects for women seeking antenatal care in Pakistan

Background and Objective: Pregnant women are the most susceptible group for Iodine deficiency disorder (IDD) whose neonate are at the risk of brain impairment, if they are iodine deficient in utero. The study was carried out to analyze the concerns and effects regarding iodized salt and IDD in women seeking antenatal care in Pakistan Methods: A descriptive cross-sectional study was conducted in Obstetrics OPD at Civil Hospital Karachi from April 2017 to January 2018. In this study, antenatal care seeking women (n=360) visiting obstetric outpatient department (OPD) at public sector tertiary care hospital of Karachi were interviewed face to face using a structured questionnaire. Systematic random sampling method was employed. Kruskal Wallis test was applied to assess the significance among study variables. Results: Sixty-three (63.6%) of pregnant women heard about iodized salt. Approximately 40.6% of them received iodized salt related information through mass media. Ninety (90.6%) were ignorant that their unborn child needs iodine for brain development. A statistically significant association was found between the educational status (p<0.001), household income (p<0.001), age (p=0.016), ethnicity (p=0.018), trimester (p=0.005) with the knowledge of study participants regarding iodized salt and IDD. Conclusion: There is an immense need to address the present concerns of women seeking antenatal care by advocacy and health education on individual and at mass level regarding the use of iodized salt among women seeking antenatal care. Advocacy can be done by governmental initiatives, medical personnel and through mass media in all tertiary care hospitals of Pakistan.


INTRODUCTION
IDDs during pregnancy and infancy are the leading cause of a preventable cognitive impairment and intellectual disabilities which irreversibly hinders development of brain and growth in children. 1 Iodine is a trace element essential for the synthesis of thyroid hormone by the thyroid gland. Pregnant women are the most susceptible group for IDD whose neonate are at the risk of brain impairment, if they are iodine deficient in utero. Globally about 241 million (29.8%) of school age children are estimated to have inadequate iodine intake. Among 241 million children, 76 million belong to the WHO South East Asia region and 58 million children belong to African region. 2 IDD due to insufficient thyroid hormone production has numerous adverse effects on health. 3 Globally two billion individuals have an inadequate iodine intake. The regions which are particularly affected with iodine deficiency are South Asia and Sub-Saharan Africa. 4 Mild iodine deficiency is also affecting approximately 50% Continental Europe. 5 According to National Nutrition Survey (NNS) of Pakistan, prevalence of low Urinary Iodine excretion among women of reproductive age (i.e., 17.5%) is higher in countryside as compared to metropolitan areas. 6 In 1993, Universal Salt Iodization (USI) has been recommended as the main strategy to achieve elimination of IDD. It was introduced in Pakistan in 1994 7 as a widely used cost effective strategy According to NNS, the reported consumption of iodized salt at household level in Pakistan is 79.6% 8 which is less than the WHO benchmark of > 90% household coverage of iodized salt to achieve the goal of USI. 9 Pakistan is moving forward towards attaining USI, the program focus has now been shifted for sustaining USI. 8 Therefore, The study was carried out to analyze the concerns and effects regarding iodized salt and IDD in women seeking antenatal care in Pakistan.

METHODS
A descriptive cross-sectional study was carried out in Obstetrics OPD at Civil Hospital Karachi. The study population included pregnant women aged 16-45 years seeking routine antenatal care and who were willing to participate in the study. Those who were having chronic diseases, taking chronic medications and who did not give consent to participate in the study were excluded. A Systematic random sampling method was employed in which every 5 th pregnant woman who were enrolled in the OPD register were included and interviewed after taking informed consent. Sample size was estimated using the software OpenEpi. Sample size estimation was based on proportion of inadequate iodine intake (37.4%) with 5% level of significance and 95% CI. The proportion of people with inadequate iodine intake for EMRO was taken from WHO global database i.e., 37.4%. 10 Using the above mentioned values, the calculated sample size was found to be 360. Data was collected from April 2017 to January 2018. Pilot testing of a questionnaire was performed on 10% of respondents i.e., 36 pregnant women. After this final survey was implemented. Data collection tool included a validated structured questionnaire administered on 360 study participants through face to face interview.
There were two main sections in the questionnaire that included sociodemographic characteristics, assessment of level of knowledge of antenatal women regarding iodized salt. Study participants were asked regarding the iodized salt, sources of iodized salt related information, adverse effects of iodine deficiency and importance of iodized salt in pregnant women.

DISCUSSION
Our study findings revealed lack of concern about IDD, its consequences, benefits of iodine and importance of iodized salt in antenatal women. Ninety percent of respondents had no knowledge that iodine deficiency results in mental retardation and goitre. Despite the introduction of a National IDD Control Program in 1994, approximately half of population of Pakistan is afflicted with IDD. Since the guidelines of National USI program do not include the measures for the utilization of iodized salt in processed foods which is affecting program sustainability .However adequately iodized salt is not available and acceptable by several regions    of community. 10 Therefore the availability and fortification of iodine in processed foods may contribute for increasing iodine nutrition. 11,12 The findings of present study are supported by studies conducted. [13][14][15] In present study and Addis Ababa city, monthly household income and educational status of participants were associated with knowledge related to iodized salt. 15 17 In the present study the educational status of participants is quite low and 87.2% belong to low socio-economic status.
In contrast to another study which was carried out in Bangladesh, 19 a significant correlation was found between knowledge level and educational status (p < 0.05) of participants. 19 In another study conducted in Somali Ethiopia 20 which reported that most of the respondents were well aware about iodized salt and acknowledged mass media (31.3%) and health worker (8%) as a source of information. This difference could be because of their higher educational status. 20 While in a study conducted in Norway 21 which reported that 16.6% received information about iodine from their health professional, less than 17% of pregnant women replied that intake of iodine is important for normal fetal development. The difference could be due to difference in level of education, dietary habits and geographical location. 21 The researcher through this study revealed lack of concern related to benefits of iodized salt and effects of IDD in antenatal women.

Limitations of the study:
As this study carried out in a single tertiary care hospital, therefore the results cannot be generalized at population level. Limitation in retrieving information was observed among the study participants while conducting interview because of memory lapse.

CONCLUSION
Pregnant women are the most vulnerable population which are lacking knowledge regarding the importance of iodized salt. There is an immense need to address the present concerns of women seeking antenatal care by advocacy and health education on individual and at mass level. Advocacy can be done by governmental initiatives, medical personnel and through mass media in all tertiary care hospitals of Pakistan regarding the use of iodized salt by women seeking antenatal care.