We identified three main themes around the acceptability of IV iron: perceived comparative advantages of IV iron over oral therapy; existing infrastructure in the health facility which could be leveraged and strengthened to sustainably provide IV iron; and existing high-level of trust between pregnant women and HCPs which can avert potential misconceptions about IV iron therapy. Eight sub-themes described factors associated with the acceptability of IV iron therapy (Table 3). These themes and sub-themes were mapped to all domains of TFA.

Table 3 Illustrating identified themes and sub-themes mapped into seven constructs of the TFAPerceived comparative advantages of IV iron are critical for acceptability

All stakeholder groups identified some advantages of IV iron therapy over oral treatment, which are critical for its acceptance by both users and the HCPs providing IV iron. These are the advantages IV iron has over oral iron and blood transfusion, including its capacity to reduce workload among HCPs.

For iron supplements, anything is better than taking pills

Considering the challenges with oral iron therapy, such as intolerance, the burden of daily use throughout pregnancy until the postpartum period and gastrointestinal side effects, pregnant women, HCPs, and domestic decision-makers believed that any other iron formulation was better than ‘pills’ to treat IDA. When discussing alternatives to oral iron therapy, they perceived IV iron as a ‘perfect’ treatment. They described several advantages, including prompt response to treatment, being a good fit for patients with oral iron intolerance and those irritated by the taste and or smell of oral iron, and overall, improving treatment adherence. A pregnant woman who had experience with taking oral in previous pregnancy for IDA and hardly tolerated food from excessive vomiting stated her preference for IV iron therapy.

“If IV iron is available, I will receive it because I used to have complications like excessive vomiting. I also do not tolerate food during pregnancy and usually have low blood levels. So, anything that will help me to get better, I will look for it, honestly.” 32-year-old, Multigravida, Kano (KII-04)

The opinion above was acknowledged by HCPs, who explained that excessive vomiting in pregnancy, including intolerance to oral iron—whether tablet or suspension—was not only of concern to pregnant women but also to the HCPs who provide care to them and feel IV iron was a suitable alternative. To further emphasise this point, one of the HCPs, a specialist trained in obstetrics and gynaecology who had previously administered IV iron to a severely ill patient described the “immediate improvement in health.” He also felt that “not repeatedly coming to the facility for more doses was a big advantage compared to oral iron.”

Furthermore, pregnant women, HCPs and domestic decision-makers highlighted that they believed IV iron could solve the issues of adherence to oral iron. “Lack of will, forgetfulness and the burden of daily use of oral pills throughout pregnancy and after delivery” were highlighted by pregnant women as the cause of poor adherence. Therefore, these pregnant women will “choose IV iron therapy over the oral formulation because it will improve adherence to the treatment of IDA, more importantly, because of its one-time use throughout pregnancy.” This opinion was also reflected in the response of a male partner from Kano who stated that “if I do not get involved with the routine use of oral iron for my wife, she will never take it,” hence his preference for IV iron. For the HCPs, being an HCP-dependent intervention makes IV iron a superior choice which comes with the assurance of its adherence, unlike the oral route. However, from the perspective of a pregnant woman who had received IV iron previously, to receive this therapy meant coming to the facility, which is an additional effort compared to the oral route.

“Anyway, the thing with IV iron is that it works, but l have to come in, and this is different from the pills that can be taken at home. l have to be monitored... and it could take an hour or two for the whole process”. 35-year-old, Multigravida with anaemia, Lagos (KII- 02)

Reduction of anaemia -related complications will ease HCP workload

According to the HCPs, even though administering IV iron means increased workload as time spent caring for patients increases, it is an excellent option to yield immediate response to treatment, treat IDA, and reduce the risk of anaemia-related complications. Some HCPs also believed that IV iron would reduce the rate of feto-maternal complications. According to some other HCPs, it will ultimately reduce the overflow of the workload associated with the high prevalence of IDA.

“So, this intravenous iron will reduce the number of patients with anaemia and all its complications, so it is very effective or useful for healthcare workers.” Apex HCP, Male, Kano (FGD P6)

Furthermore, according to the HCPs, IV iron could generate a positive outcome for both the mother and the baby and achieve the desired outcome of all HCPs, which is to reduce the rate of maternal and perinatal morbidity and mortality associated with IDA.

Preferred alternative to blood transfusion

The HCPs felt that IV iron could help avert blood transfusions needed to treat complicated IDA during and after birth, which had many significant benefits. According to them, IV iron administered on an outpatient basis in 15 to 20 min could promptly treat IDA and reduce the need for a blood transfusion that can take several hours or days. In addition, they believed that IV iron was more cost-effective compared to blood transfusion. For some HCPs, “IV iron can avert the cost of screening for blood-borne transmitted infections, consumables, and admission for blood”. According to some other HCPs, it can also avert problems associated with blood transfusion such as challenges of getting donors to donate blood, and the lack of compatible blood in hospitals. Most HCPs also felt that IV iron is a suitable alternative to blood transfusions before its need arises for specific individuals based on their beliefs and values. They gave examples of some pregnant women who delay or refuse to receive blood transfusions based on their personal or religious beliefs, thereby increasing their risk of morbidity or mortality.

Existing infrastructure in the health facility could be leveraged and strengthened to sustainably provide IV iron

Participants in each stakeholder group agreed that the maternal healthcare system has an existing infrastructure that could be leveraged to guarantee the acceptability of IV iron and strengthened for sustenance. While it is not yet designed to effectively deliver IV iron therapy, these participants stated that the existing processes of care provision could integrate information on IV iron into ANC health talks, train HCPs and ensure constant resources and supplies.

Existing processes of care provision to integrate information on IV iron therapy into ANC health talk sessions

As reported by all stakeholder groups, there are existing well-functioning processes in place to provide care, which include information sharing and education for pregnant women in the form of group health talks during all ANC visits. According to them, information on IV iron can be integrated into the existing ANC services and modified to promote it as an option for managing IDA. For example, one of the participants who had received IV iron outside of Nigeria during her previous pregnancy attributed adequate counselling to her positive perception and, ultimately, acceptance of the therapy. Furthermore, she believed pregnant women would accept IV iron if HCPs could build on the existing ANC health talks to include discussions on the importance of adequate treatment of IDA in pregnancy with IV iron.

“Pregnant women will accept it if it is explained to them; you know if the difference is explained to them. They will ask you why you are bringing an IV [iron] since they already have the oral, so if the health care workers explain that this IV [iron] increases, makes it easy and even improves the anaemia drastically, it will make a difference. l feel anything that will protect the health of women and prevent death, they will accept it. You know we already have our health talk, which has helped educate our women, so we should use this to educate them on the importance of IV iron when talking to them in the antenatal clinic.” 35-year-old, Multigravida with anaemia, Lagos (KII- 02)

Another pregnant woman whose baby died during birth from complications of IDA stated that the HCPs should include IV iron as a treatment option in their health talks to warn pregnant women about the dangers of untreated IDA. The importance of this was further elucidated by the HCPs, who stated that the demand for treating IDA with IV iron would increase if the focus were on how IV iron works, the process of administration, and its health benefit to the individual and the baby. Furthermore, according to them, it could facilitate a deeper understanding and knowledge of pregnant women and enhance decision-making.

HCPs lack confidence but are optimistic to safely administer IV iron with further training

The HCPs stated that IV iron administration needs to be monitored closely, given the risk of adverse effects, thus necessitating the need for training before it is provided routinely. In addition, some HCPs lacked the confidence to respond promptly and accurately in the event of severe reactions. This concern was expressed by some HCPs from primary healthcare facilities where only basic healthcare services are typically performed. To them, IV iron is indicated in severe anaemic cases and should be referred for administration in a secondary health facility with the capacity for rapid response and immediate treatment. Generally, there was consensus among the HCPs with eagerness and readiness to administer IV iron therapy, however, they highlighted the need for specialised training and a protocol to facilitate safe administration and identification of reaction symptoms.

“Training is crucial…. For IV iron, we need to be able to give it with confidence. Because with training on how to give safely, we become more confident and more efficient. So, health workers’ training is important.” Apex HCP, Male, Lagos (KII-08)

To pregnant women and domestic decision-makers, it would be reassuring if IV iron were administered by personnel and teams trained to give it.

Local health system infrastructure, resources and supplies are insufficient.

Challenges such as inadequate physical space, limited human resources, and poor supply chain were reported by HCPs and facility managers as having significant potential to affect the acceptability of IV iron. According to these respondents, inadequate availability of space, especially in facilities with many patients and in primary health care facilities, is of concern. In addition, as a new treatment requiring close patient observation, they believed that dedicated spaces should be allocated explicitly for IV iron to facilitate a smooth administration process for the HCPs and pregnant women. For some HCPs, adequate space to administer IV iron would be the only foreseen challenge they identified in their facility.

In addition, HCPs stated that the lack of human resources is a challenge affecting the existing maternal care in most facilities in the country, considering the high volume of patients and workload in general. For example, one of the nurses explained that IV iron administration would be an additional burden to HCPs if there were no provision for adequate human resources to assist with this intervention. In addition, many questioned the feasibility of administering IV iron as they expressed their fears based on the volume of work and patients they see daily. According to a HCPs in a KII, “IV iron is a personnel-dependent form of care compared to the oral iron formulation, which entails close monitoring to prevent, identify and promptly respond to any allergic reactions”. And hence, it “makes it more challenging for IV iron to be readily acceptable among HCPs”.

Given their experience with frequent essential medicine and supply stockouts in the public sector, HCPs were concerned that they could not consistently offer this service if such issues also affected IV iron. In an FGD, one of the HCPs stated:

“The challenge we could have as health workers is the availability of medications because sometimes when we introduce a medication, we will get the supply for some time but later go out of stock. Then we are not able to get it anymore. So, the biggest challenge we will have is the irregular supply of this IV drug.” HCP, Female, Lagos (FGD P12)

Additionally, the availability of essential equipment and commodities, as stated by some of the HCPs, is necessary to provide quality maternal care, including when receiving IV iron. Therefore, the HCPs suggested creating a package where all the required commodities are in one place to facilitate easy access.

“We need to create a pack for it just like a pack for TIVA (Total intravenous anaesthesia), which contains everything, including the cost. So, the process will be to create the pack for this intervention and take it to where it is needed… We must remember that it is a result-oriented medical therapy compared to some of the other options.” HCP, Male, Lagos (FGD P1)

High out-of-pocket costs might make IV iron out of reach for the most vulnerable and socio-economically disadvantaged women

Due to the high prevalence of poverty in the country, most participants felt the cost of IV iron therapy could significantly impact the perception and use from the women’s and providers’ perspectives. This became more evident when participants compared IV to oral iron. They stated that while oral iron is potentially less effective, it is typically dispensed free of charge or given at a subsided cost. According to pregnant women, if IV iron is not available at a comparably low-cost, oral iron will be preferred. For most male partners, even though they will support and encourage their partners to take IV iron if it is available, they “hope God will provide” for them to afford it.

The HCPs voiced their concern regarding the type of pregnant women more likely to have anaemia, which are more likely to be women from low socioeconomic classes who reside mostly in rural areas. According to them, these women cannot even afford to register for routine ANC services, buy essential drugs or pay for routine tests. If IV iron is not heavily subsidised or free, poor women who are most likely affected by IDA will be unable to use it. The cost of IV iron will be the predominant acceptability factor for women and their households.

“One thing you did not tell us that may serve as a hindrance is whether it will be given free or they will pay for it. The price will determine its acceptance because, as you know, we are in an economic crisis…Let us be realistic, its acceptance will depend on the price. Because the husbands are usually poor sometimes, they cannot even afford to buy common drugs. Some of them find it hard to even pay for the initial investigations… Not every man can afford that.” HCP, Female, Kano (FGD P1)

According to the HCPs, beyond the cost of the IV iron itself are the additional costs of administering it (consumables, intravenous fluids etc.) which need to be considered. Therefore, in their opinion, most pregnant women affected by IDA will likely be financially constrained to utilise this effective treatment.

“l think having a subsidy on this is not out of place because if you look at the health insurance scheme at the moment is not yet robust. We are talking about anaemia…it is one of the contributors to maternal mortality. So now, if you want to wait until the national health insurance scheme is very effective to take care of it without subsidy, what happens to that woman in [urban slum] selling fish or the woman in [slum settlement in Lagos] selling water? Then there will be a challenge. These are the people that come down with anaemia during pregnancy.” HCP, Male, Lagos (FGD P5)

Some HCPs noted that when calculating the price of IV iron, the benefits of avoiding complications of untreated IDA in pregnancy should be considered. This includes the potential ability to avert high fees for hospital admission, preterm delivery and complications of prematurity and postpartum haemorrhage, the cost of which is borne by the health system, women and families, and the whole of society. Although this may be a long-term effect as the benefits of being treated with IV iron, they stated that it should be considered if found to be cost-effective.

Existing trust between pregnant women and HCPs can avert misconceptions of IV iron therapy

According to all stakeholder groups, the high existing levels of trust between pregnant women and HCPs can avert misconceptions about IV iron therapy.

Pregnant women trust HCPs, but vulnerable to misconceptions

Pregnant women felt their trust towards the HCPs was strong and facilitated their belief and acceptance of any form of information or intervention shared by these HCPs. Furthermore, health talks in the antenatal clinic have been and continue to be an effective opportunity to educate pregnant women on health, including the benefits of IV iron therapy.

“During antenatal, they will have to talk about it to us pregnant women. So, you know, we quickly believe our nurses when they tell us things. So, if you ask them to include the importance of this treatment in the health talk and when they tell us, we will believe that this thing will work, and people will go for it (IV iron).” 37-year-old, Multigravida, Lagos (KII-04)

The HCP also echoed the above opinions of pregnant women by emphasising the importance of building on this trust when educating them on the importance of IV iron to their health. Furthermore, they stated that the environment should be friendly to gain more trust, enhance assurance and allay fears.

Some pregnant women, HCPs, and domestic decision-makers identified some factors that would prevent pregnant women from receiving IV iron. For example, fear of needles and pain was a significant deterrent for some. However, according to a pregnant woman with anaemia, she “overcame the fear of needles with the help of a nurse and would be willing to take IV iron”. The existing relationship with the nurse allowed the woman to understand its importance to her and her baby.

Fear of adverse events (e.g., fever, pruritus, weakness, dizziness, hypotension, myalgia) related to IV iron was another factor that could impede acceptability and use mentioned by pregnant women and HCPs. Generally, respondents had concerns about the potential risks of allergy and adverse events. They felt that adequate information on IV iron, its benefits and the likely adverse events that could occur during its administration would help minimise these concerns. However, according to them, this can only work based on the existing trust.

When probed further, the pregnant women, HCPs, and the domestic decision-makers stated that IV iron is vulnerable to misconceptions, despite the existing trust. According to a male partner in an FGD, who described religion, cultural or traditional beliefs as a strong influence on attitude to health care services stated that “some people have this belief that herbs and leaves are the best, and there is nothing anyone can say about orthodox medicine that will change their mind…”. Additionally, for some HCPs, suspicion can be from ignorance. According to them, “even with this family planning method-Jadelle and Implanon (inserted surgically under the skin), we had many challenges with its uptake within the community”. To these respondents, these factors could enhance the reluctance and resistance of people to try new treatments, such as IV iron therapy. Furthermore, when sharing their experiences, they likened the vulnerability of IV iron to the misconception people had about the Corona virus disease (COVID-19) vaccine. In an FGD with the HCPs, one of them stated:

“Our main challenge will be from the current rollout of the COVID-19 vaccine. People will be asking why this iron injection was not introduced until now that they are rejecting the Corona vaccine. They will think we only devised a way of forcing the vaccine on them. And they will say, "we were never given an iron injection before, but now that we are rejecting this vaccine, they now brought it in another way claiming to be for treatment of anaemia so that they will be killing our babies”.” HCP, Female, Kano (FGD P7)