**Background:** Anemia affects 38.2% of pregnant women globally, with the highest prevalence in Africa (46.3%) and South East Asia (48.7%). In Ethiopia, anemia prevalence increased from 22% in 2011 to 29% in 2016. The WHO recommends daily iron (30–60 mg) and folic acid (400 µg) supplementation for 6 months during pregnancy to reduce maternal anemia, low birth weight, and neural tube defects. Despite national guidelines in Ethiopia, adherence to iron and folate supplementation (IFAS) remains low. Previous studies in Ethiopia reported adherence rates ranging from 10.5% to 76%, with most using only quantitative methods. This study aimed to assess adherence to IFAS and associated factors among pregnant women attending antenatal care (ANC) in public health facilities in Dire Dawa, Ethiopia, using a mixed-methods approach.
**Methods:** A facility-based cross-sectional study supplemented by a phenomenological qualitative design was conducted from October 20 to November 19, 2020, in nine randomly selected public health facilities in Dire Dawa. The sample size was calculated using a single population proportion formula assuming 76% adherence (from a prior local study), yielding 308 participants after adding 10% for non-response. Systematic random sampling was used with a sampling interval of 3 (k=3). For the qualitative component, 12 participants (4 ANC focal persons, 4 health professionals, and 4 pregnant women not in the quantitative study) were purposively selected for in-depth interviews. Data were collected via face-to-face interviewer-administered questionnaires and semi-structured guides. Adherence was defined as taking ≥4 IFAS tablets per week in the month preceding the survey. Awareness of anemia (25 items), birth defects (12 items), and IFAS (9 items) was assessed using composite scores. Data were entered in Epi Data version 7.2.2.6 and analyzed using SPSS version 25. Bivariate and multivariate logistic regression were performed; variables with p≤0.25 in bivariate analysis were entered into the multivariable model. Statistical significance was set at p<0.05. The Hosmer-Lemeshow test was used to assess model fit.
**Key Results:** All 308 participants responded (100% response rate). Mean age was 27.08 years (±5.59 SD). Most were married (100%), Muslim (65.3%), urban residents (71.1%), and housewives (64.3%). 45.8% had no formal education. Mean gestational age at current visit was 30.63 weeks (SD 5.91); 77.3% were in the third trimester. 41.6% registered for ANC at ≤16 weeks gestation. 31.5% were anemic at the time of the study. 79.9% had fewer than 4 ANC visits. Overall self-reported adherence to IFAS was 56.5% (95% CI: 51%–62.2%). Among adherent women, 54% cited counseling from care providers as the reason, 44.8% feared consequences of stopping, and 33.3% believed supplements increased blood volume. The main barriers to adherence were side effects (58.2%), forgetfulness (44%), supplement shortage (32%), concern about harm from too many pills (26.1%), and lack of awareness of supplement importance (21%). Among those reporting side effects, 79.5% had gastric upset, 61.5% heartburn, and 44.9% nausea/vomiting. In the multivariable analysis, five factors were independently associated with adherence: maternal primary education (AOR=0.38, 95% CI: 0.17–0.83) compared to secondary and above; urban residence (AOR=4.61, 95% CI: 2.19–9.65); ≥4 ANC visits (AOR=3.05, 95% CI: 1.22–7.58); early ANC registration (AOR=4.01, 95% CI: 1.66–9.69); and good awareness of birth defects (AOR=5.66, 95% CI: 1.85–17.27). Qualitative findings corroborated these results, with reports of supplement shortages lasting up to six months at some facilities and women being sent to purchase supplements from private pharmacies.
**Clinical Implications:** The adherence rate of 56.5% is lower than previous estimates in Dire Dawa (76% in 2018) and falls short of WHO targets. The COVID-19 pandemic may have contributed to reduced ANC attendance due to fear of infection. Supplement shortages at health facilities, particularly at Dil Chora Hospital where stock-outs lasted over six months, represent a critical health system failure. The strong association between early and frequent ANC visits and adherence suggests that interventions to promote early registration and continued follow-up could significantly improve supplementation. The finding that good awareness of birth defects was the strongest predictor (5.66 times higher adherence) underscores the importance of health education, particularly about folic acid's role in preventing neural tube defects. Urban–rural disparities (4.61 times higher adherence in urban areas) highlight the need for targeted outreach to rural populations. Side effects, especially gastric upset and heartburn, were the most commonly cited barrier, indicating a need for counseling on side effect management. The study's limitations include reliance on self-reported adherence (susceptible to recall and social desirability bias) and the absence of gold-standard adherence measures. Nonetheless, the mixed-methods design provides valuable insights into both the prevalence and the lived experiences of barriers to IFAS adherence in this setting.