Abstract

Background: Compliance with iron-folic acid (IFA) supplementation is essential to prevent maternal anemia and associated adverse maternal and neonatal outcomes. Despite national policy support, adherence remains suboptimal in Afghanistan, and contextual evidence on determinants of compliance is limited. This study aimed to explore barriers and facilitators of IFA supplementation compliance among pregnant women in southern Afghanistan. Methods: This exploratory qualitative study was conducted between November and December 2025 among 24 pregnant women attending antenatal care services at four comprehensive health centers in southern Afghanistan. Participants were purposively selected to participate in two focus group discussions (n=16) and eight in-depth interviews (n=8). Data were analyzed using a hybrid deductive–inductive thematic approach informed by the Health Belief Model. Results: Four key facilitators of compliance were identified: perceived health benefits, social support (cues to action), perceived susceptibility to anemia, and self-efficacy. Seven major barriers emerged: lack of supplement availability, long waiting times, transportation and mobility constraints, unfavorable attitudes of healthcare providers, fear of side effects, forgetfulness, and myths and misconceptions. Findings indicate that compliance was shaped not only by individual beliefs but also by structural health system challenges and sociocultural norms. Conclusion: Compliance with IFA supplementation among pregnant women in southern Afghanistan is influenced by interconnected individual, health system, and community-level factors. Interventions to improve adherence should integrate behavioral strategies with efforts to strengthen health system capacity and address sociocultural barriers.