Preconception care: nutritional risks and interventions

Altered metabolic homeostasis between vitamin D and long chain polyunsaturated fatty acids in preeclampsia

Sub-optimal maternal nutrition may result in pregnancy complications like preeclampsia. Preeclampsia is known to be of placental origin and a major cause of maternal morbidity and mortality worldwide. Our earlier studies suggest that altered metabolism of folic acid, vitamin B₁₂ and long chain polyunsaturated fatty acid (LCPUFAs) in the one carbon cycle increases homocysteine levels in preeclampsia. Recent reports indicate that vitamin D deficiency may also have a role in preeclampsia, although the mechanisms are unclear. A disturbed one carbon cycle can influence methylation patterns of various genes involved in placental development. Altered expression of cystathionine beta synthase (CBS) gene can result in hyperhomocystenemia. Higher homocysteine levels are known to increase reactive oxygen species (ROS) production which in turn leads to increased expression of phospholipase A2 (PLA2) and cyclooxygenase-2 (COX-2). Higher expression of PLA2 and COX-2 can influence the release of arachidonic acid (AA) from membrane phospholipid and result in increased conversion to thromboxane. Vitamin D [1,25(OH)₂D₃] is known to induce the CBS gene expression while it can suppress the oxidative stress-induced COX-2 up-regulation and thromboxane production. Based on this, we propose a novel hypothesis that a disturbed vitamin D and LCPUFA metabolism influence the regulation of the one carbon cycle which will trigger inflammation through oxidative stress in preeclampsia. This may lead to altered feto-placental growth and development in preeclampsia.

Maternal nutrition: opportunities in the prevention of gestational diabetes

Gestational diabetes mellitus (GDM) is currently defined as glucose intolerance that is of variable severity with onset or first recognition during pregnancy. The Hyperglycemia and Adverse Pregnancy Outcome Study, including 25 000 nondiabetic pregnant women in 15 centers across the world, reported that an average of 17.8% of pregnancies are affected by GDM and its frequency can be as high as 25.5% in some countries, based on the International Association of Diabetes and Pregnancy Study Groups criteria. Nevertheless, true global prevalence estimates of GDM are currently lacking due to the high level of heterogeneity in screening approaches, diagnostic criteria, and differences in the characteristics of the populations that were studied. The presence of systemic high blood glucose levels in pregnancy results in an adverse intrauterine environment, which has been shown to have a negative impact on short- and long-term health outcomes for both the mother and her offspring, including increased risks for the infant to develop obesity and for both mother and child to develop type 2 diabetes mellitus later in life. Epigenetic mechanisms that are directly influenced by environmental factors, including nutrition, may play a key role in shaping these future health risks and may be part of this vicious cycle. This article reviews the burden of GDM and the current evidence that supports maternal nutritional interventions as a promising strategy to break the cycle by addressing risk factors associated with GDM.

Body mass index is linked to cervical length and duration of pregnancy: An observational study in low risk pregnancy

In this prospective cohort study, one hundred participants were allocated into four groups according to their body mass indices. Vaginal ultrasound was performed at enrolment to measure cervical length. The shortest cervical measurement was recorded. Overweight and obese groups had significantly longer mean cervical length than women in the normal weight group when measured at 20-22 weeks of gestation (p < .001). Underweight women had the shortest mean cervical length. The incidence of preterm delivery was the highest in underweight women (RR; 1.5). The incidence of post-term delivery was 10% in total in overweight and obese women. Underweight women were more likely to have short cervical length and subsequent preterm delivery compared to overweight and obese women.

Impact of Preconception Micronutrient Supplementation on Anemia and Iron Status during Pregnancy and Postpartum: A Randomized Controlled Trial in Rural Vietnam

Objective

Preconception micronutrient interventions may be a promising approach to reduce anemia and iron deficiency during pregnancy, but currently we have limited data to inform policies. We evaluated whether providing additional pre-pregnancy weekly iron-folic acid (IFA) or multiple micronutrient (MM) supplements compared to only folic acid (FA) improves iron status and anemia during pregnancy and early postpartum.

Methods

We conducted a double blind randomized controlled trial in which 5011 Vietnamese women were provided with weekly supplements containing either only 2800 μg FA (control group), IFA (60 mg Fe and 2800 μg FA) or MM (15 micronutrients with similar amounts of IFA). All women who became pregnant (n = 1813) in each of the 3 groups received daily IFA (60 mg Fe and 400 μg FA) through delivery. Hematological indicators were assessed at baseline (pre-pregnancy), during pregnancy, 3 months post-partum, and in cord blood. Adjusted generalized linear models were applied to examine the impact of preconception supplementation on anemia and iron stores, using both intention to treat and per protocol analyses (women consumed supplements ≥ 26 weeks before conception).

Results

At baseline, 20% of women were anemic, but only 14% had low iron stores (ferritin <30 μg/L) and 3% had iron deficiency (ferritin <12 μg/L). The groups were balanced for baseline characteristics. Anemia prevalence increased during pregnancy and post-partum but was similar among intervention groups. In intention to treat analyses, prenatal ferritin was significantly higher among women receiving MM (geometric mean (μg/L) [95% CI]: 93.6 [89.3–98.2]) and IFA (91.9 [87.6–96.3]) compared to control (85.3 [81.5–89.2]). In per protocol analyses, women receiving MM or IFA had higher ferritin 3 months postpartum (MM 118.2 [109.3–127.8]), IFA 117.8 [108.7–127.7] vs control 101.5 [94.0–109.7]) and gave birth to infants with greater iron stores (MM 184.3 [176.1–192.9]), IFA 189.9 [181.6–198.3] vs control 175.1 [167.9–182.6]).

Conclusion

Preconception supplementation with MM or IFA resulted in modest increases in maternal and infant iron stores but did not impact anemia. Further research is needed to characterize the etiology of anemia in this population and identify effective interventions for reducing prenatal anemia.

Trial Registration

ClinicalTrials.Gov NCT01665378

Preventing deaths due to the hypertensive disorders of pregnancy

In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs.

Neither Preconceptional Weekly Multiple Micronutrient nor Iron-Folic Acid Supplements Affect Birth Size and Gestational Age Compared with a Folic Acid Supplement Alone in Rural Vietnamese Women: A Randomized Controlled Trial

BACKGROUND

Maternal nutritional status before and during early pregnancy plays a critical role in fetal growth and development. The benefits of periconception folic acid (FA) supplementation in the prevention of neural tube defects is well recognized, but the evidence for preconception micronutrient interventions for improving pregnancy outcomes is limited.

OBJECTIVE

This study aimed to evaluate whether preconception supplementation with weekly iron and folic acid (IFA) or multiple micronutrients (MMs) improves birth outcomes compared with FA alone.

METHODS

We recruited 5011 women of reproductive age in a double-blind, randomized controlled trial in Vietnam and provided weekly supplements containing either 2800 μg FA, 60 mg Fe and 2800 μg FA (IFA), or the same amount of FA and iron plus other MMs until they conceived (n = 1813). All pregnant women received daily IFA through delivery, and were followed up for birth outcomes, including birth weight, gestational age, preterm delivery and small for gestational age (SGA). Group comparisons were done with the use of ANOVA or chi-square tests for both intention-to-treat (n = 1599) and per-protocol analyses (women consumed supplements ≥26 wk before conception; n = 824). Effect modification by baseline underweight or anemia status was tested with the use of generalized linear models.

RESULTS

The mean age of the women was 26 y, 30% were underweight, and <10% were nulliparous. The groups were similar for most baseline characteristics. The mean ± SD duration of the preconception intervention was 33 ± 25 wk and compliance was high (>90%). Infants born to the 3 groups of women did not differ (P ≥ 0.05) on mean ± SD birth weight (3076.8 ± 444.5 g) or gestational age (39.2 ± 2.0 wk), or prevalence of SGA (12%), low birth weight (5%) and preterm delivery (10%). There were no significant differences in women who consumed supplements ≥26 wk before conception or by baseline underweight or anemia.

CONCLUSION

Weekly supplementation with MMs or IFA before conception did not affect birth outcomes compared with FA in rural Vietnamese women. The trial was registered at clinicaltrials.gov as NCT01665378.

Preconceptional Nutrition Interventions for Adolescent Girls and Adult Women: Global Guidelines and Gaps in Evidence and Policy with Emphasis on Micronutrients

Much of the global nutrition efforts in recent years have been focused on improving the nutritional status of children during the window of the first 1000 d of life, from conception to 2 y of age. However, as the world transitions from the Millennium Development Goals to the Sustainable Development Goals, women's and adolescent girls' overall health and well-being are being placed at the center of the global agenda. It is also increasingly recognized that a woman's nutritional status before pregnancy affects maternal and child outcomes and thus needs to be improved to ensure optimal outcomes. This article reviews the global picture of preconception nutrition in women and girls, including some of the key factors that influence women's outcomes, as well as their children's outcomes, if they do become pregnant. This article describes the current global guidelines on preconceptional nutrition interventions for girls and women; highlights related gaps in evidence, guidelines, and policy; and discusses research to forward the agenda of improving women's and girls' preconceptional nutrition.

Intimate Partner Victimization and Health Risk Behaviors Among Pregnant Adolescents

OBJECTIVES

To provide lifetime estimates of intimate partner victimization among pregnant adolescents and examine associations between victimization and health risk behaviors identified by the Centers for Disease Control and Prevention as leading causes of adolescent morbidity and mortality.

METHODS

Participants (n = 1233) were predominantly Latina (58%) and non-Latina Black (34%) pregnant adolescents (aged 14-21 years) enrolled in a randomized controlled trial of group prenatal care in 14 clinical sites in New York City (2008-2012). They completed surveys to assess interpersonal victimization and risk behaviors: substance use, risky sexual behaviors, injuries or violence, unhealthy dietary behavior, and inadequate physical activity.

RESULTS

Fifty-two percent reported intimate partner victimization, which was associated with nearly all health risk behaviors.

CONCLUSIONS

Pregnant adolescents who experienced intimate partner victimization were significantly more likely to engage in health risk behaviors, which can have adverse health consequences. Expanded prevention programs tailored to specific needs of pregnant adolescents are needed. Health care providers and others who work with pregnant adolescents should consistently screen for and intervene in intimate partner victimization.

Pregnancy Requires Major Changes in the Quality of the Diet for Nutritional Adequacy: Simulations in the French and the United States Populations

BACKGROUND

Maternal nutrition is critical to the health of both mother and offspring, but there is a paucity of data on the nutritional adequacy of diets during pregnancy.

OBJECTIVE

Our objective was to identify to what extent pregnancy reduces the nutritional adequacy of the expecting mother's diet and if this nutritional gap can be resolved by simple quantitative or qualitative changes in the diet.

MATERIALS AND METHODS

We evaluated the observed overall nutritional adequacy of diets of French and American women of childbearing age participating in ENNS (n = 344) and NHANES (n = 563) using the probabilistic approach of the PANDiet system, resulting in a 100-point score. Then, we simulated the changes in the PANDiet scores of women of childbearing age who would remain on their diet during pregnancy. Finally, by either increasing the quantity of consumed foods or using eleven snacks recommended during pregnancy, we simulated the effect of a 150-kcal increase in the energy intake of French women.

RESULTS

Observed PANDiet scores were equal to 59.3 ± 7.0 and 58.8 ± 9.3 points respectively in France and in the US. Simulation of pregnancy for women of childbearing age led to a decrease in nutritional adequacy for key nutrients during pregnancy and resulted in reducing PANDiet scores by 3.3 ± 0.1 and 3.7 ± 0.1 points in France and in the US. Simulated 150-kcal increases in energy intake proved to be only partially effective in filling the gap both when the quantity of food consumed was increased and when recommended snacks were used.

CONCLUSIONS

The decrease in nutritional adequacy induced by pregnancy cannot be addressed by simply following generic dietary guidelines.

Stillbirths: ending preventable deaths by 2030

Efforts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2.6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for women's and children's health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure effect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.

Validation of a Metallomics Analysis of Placenta Tissue by Inductively-Coupled Plasma Mass Spectrometry

Trace elements can play an important role in maternal health and fetal development, and deficiencies in some essential minerals including zinc and copper have been correlated in some individuals to the development of birth defects and adverse health outcomes later in life. The exact etiology of conditions like preeclampsia and the effects of fetal exposure to toxic metals has not been determined, making the assessment of trace element levels crucial to the elucidation of the causes of conditions like preeclampsia. Previous studies analyzing serum and placenta tissue have produced conflicting findings, suggesting the need for a robust, validated sample preparation and analysis method for the determination of trace elements in placenta. In this report, an acid digestion method and analysis by ICP-MS for a broad metallomics/mineralomics panel of trace elements is developed and validated over three experimental days for inter- and intraday precision and accuracy, linear range, matrix impact, and dilution verification. Spike recovery experiments were performed for the essential elements chromium (Cr), iron (Fe), cobalt (Co), nickel (Ni), copper (Cu), and zinc (Zn), and the toxic elements arsenic (As), cadmium (Cd), and lead (Pb) at levels equal to and in excess of native concentrations in control placenta tissue. The validated method will be essential for the development of scientific studies of maternal health and toxic metal exposure effects in childhood.

Folic acid supplementation, preconception body mass index, and preterm delivery: findings from the preconception cohort data in a Chinese rural population

BACKGROUND

Folic acid (FA) supplementation before and during the first trimester can reduce the risk of occurrence of preterm delivery (PTD). Preconception body mass index (BMI) is also associated with PTD. This study aimed to investigate the combined effect of FA supplements and preconception BMI on the risk of PTD.

METHODS

The data of a cohort from 2010-2011 that was obtained through a preconception care service in China was used (including 172,206 women). A multivariable regression model was used to investigate the association between maternal preconception conditions and the risk of PTD. The interaction of preconception BMI and FA supplementation was measured by a logistic regression model.

RESULTS

Taking FA supplements in the preconception period or in the first trimester reduced the risk of PTD (odds ratio [OR] = 0.58 and OR = 0.61, respectively). Women with an abnormal BMI had an increased risk of PTD (OR = 1.09, OR = 1.10, and OR = 1.17 for underweight, overweight, and obese, respectively). Preconception BMI showed an interaction with the protective effect of FA supplementation for PTD. With regard to the interaction of FA supplementation, the adjusted odds ratio (aOR) was 0.57 (95% CI: 0.51, 0.64) in underweight women, 0.85 (95% CI: 0.73, 0.98) in overweight women, and 0.77 (95% CI, 0.65, 0.91) in obese women. Preconception BMI also showed an interaction with the time of FA supplementation. Women with a normal BMI who began to take FA supplements in the preconception period had the lowest risk of PTD (aORs: 0.58 vs. 0.65 beginning in the first trimester). The aORs at preconception and the first trimester in the underweight group were 0.56 vs. 0.60. The aORs at preconception and the first trimester were 0.94 vs. 0.65 and 1.15 vs. 0.60 in the overweight and obesity groups, respectively.

CONCLUSIONS

In our study, FA supplements reduced the risk of PTD, while abnormal BMI raised the risk of PTD, although higher BMI categories did not have this higher risk once adjusted analysis was conducted. The protective effect of FA supplementation for PTD was reduced in women with overweight or obesity. To get better protection of FA supplementation, women with normal BMI or underweight should begin to use in preconception, while women with overweight or obesity should begin to use after conception.

Effects of Exercise During Pregnancy on Maternal Heart Rate and Heart Rate Variability

BACKGROUND

Pregnancy is associated with an increased sympathetic state, which can be exacerbated by gestational conditions. Research has shown that exercise during pregnancy lowers heart rate (HR) and can attenuate the symptoms of gestational conditions associated with increased sympathetic control. However, changes in maternal heart autonomic function in response to exercise have not been reported across multiple time points during pregnancy. This analysis is designed to address this gap.

OBJECTIVE

To determine if exercise throughout gestation improves maternal cardiac autonomic nervous system functioning, as evidenced by decreased HR and increased heart rate variability (HRV) indices.

DESIGN

Case control study.

SETTING

Academic medical institution.

PARTICIPANTS

A total of 56 women with healthy, singleton, low-risk pregnancies.

METHODS

Participants were asked to complete 3 resting 18-minute HRV recordings at 28, 32, and 36 weeks' gestation, along with a physical activity questionnaire.

MAIN OUTCOME MEASURES

HRV indices were calculated for time (R peak to R peak interval standard deviation and root mean squared of successive differences) and frequency (very low, low, and high frequency) domain measures. The differences between groups were compared for HRV indices at 28, 32, and 36 weeks.

RESULTS

Resting HR was significantly lower in the exercise group at 28 weeks (P < .01) compared with the control group. The exercise group had significantly (P < .05) increased measures of resting HRV time domain measures at 28, 32, and 36 weeks' gestation compared with the control group. Resting HRV power was significantly increased (P < .05) in all frequency domain measures at 32 weeks in the exercise group relative to the control group. No differences occurred in sympathovagal balance (low frequency/high frequency ratio) between groups.

CONCLUSION

Exercise throughout pregnancy can significantly improve cardiac autonomic control. More research is needed to determine if this adaptation to exercise may reduce the risk of adverse outcomes associated with gestational conditions with poor autonomic control, such as diabetes, hypertension, pre-eclampsia, and excessive weight gain.

The effect of folate supplementation and genotype on cardiovascular and epigenetic measures in schizophrenia subjects

Background:

Metabolic syndrome may be related to folate’s pharmacogenetically regulated metabolism and atypical antipsychotic (AAP) exposure.

Aims:

We examined folate supplementation on metabolic measures, endothelial functioning (Reactive Hyperemia Index (RHI)), and global methylation in AAP-treated schizophrenia subjects meeting NCEP-ATP-III-a metabolic syndrome criteria.

Methods:

Subjects were given 5 mg/day open label folate for 3 months. Baseline and end point measurements included RHI, body mass index, fasting metabolic laboratory measures, C-reactive protein, homocysteine, IL-6, and leptin. Subjects were genotyped for methylenetetrahydrofolate reductase (MTHFR) 677C/T and catechol-O-methyltransferase (COMT) 158 Val/Met, as well as global DNA methylation using the LUminometric Methylation Assay (LUMA).

Results:

Thirty-five subjects (mean age 50±9 years and 70% Caucasian) were included. At end point, RHI improved by 20% (P=0.02), homocysteine decreased 14% (P=0.006), and IL-6 decreased 13% (P=0.09). At baseline, 61% met endothelial dysfunction criteria (RHI<1.67), which decreased to 27% (P=0.0006) at end point. The MTHFR 677C/C+COMT 158Met/Met group also showed significant reduction in those meeting endothelial dysfunction (83% baseline and 16% end point (P=0.001)). Global methylation levels increased after supplementation (4.3%, P<0.0001), with subjects receiving olanzapine or clozapine experiencing greater methylation changes after folate supplementation. Folate may reduce AAP-associated metabolic risks.

Conclusions:

We report significant reductions in the number of subjects meeting endothelial dysfunction. Given that all subjects met metabolic syndrome criteria, this may prove as a useful avenue to reducing cardiovascular disease risk. MTHFR and COMT genotypes may affect response and underlying changes in DNA methylation may help to explain the mechanistic underpinnings of these findings.

The relative influence of maternal nutritional status before and during pregnancy on birth outcomes in Vietnam

OBJECTIVE

This study aimed to: (1) examine the role of multiple measures of prepregnancy nutritional status (weight, height, body composition) on birth outcomes (low birth weight (LBW), small for gestational age (SGA), preterm, birth weight, birth length, infant head circumference and mid-upper arm circumference (MUAC)); (2) assess relative influence of maternal nutritional status before and during (gestational weight gain) pregnancy on birth outcomes.

STUDY DESIGN

We used prospective data on maternal body size and composition collected from women who participated in a randomized controlled trial evaluating the impact of preconceptional micronutrient supplements (PRECONCEPT) on birth outcomes in Thai Nguyen province, Vietnam (n=1436). Anthropometric measurements were obtained before conception through delivery by trained health workers. The relationship between prepregnancy nutritional status indicators, gestational weight gain (GWG) and birth outcomes were examined using generalized linear models, adjusting for potential confounding factors.

RESULTS

Maternal prepregnancy weight (PPW) was the strongest anthropometric indicator predicting infant birth size. A 1 standard deviation (SD) increase in PPW (5.4kg) was associated with a 283g (95%CI: 279-286) increase in birthweight. A similar and independent association was observed with birthweight for an increase of 1 SD in gestational weight gain (4kg) (250g; 95% CI: 245-255). Women with a PPW <43kg or who gained <8kg during their pregnancy were more likely to give birth to a SGA (OR 2.9: 95%CI 1.9-4.5, OR 3.3: 95%CI 2.2-5.1) or LBW infant (OR 3.1: 95%CI 1.5-6.2, OR 3.4: 95%CI 1.6-7.2), respectively.

CONCLUSIONS

These findings indicate that clinical care and programs aimed at improving birth outcomes will have the greatest impact if they address maternal nutrition both before and during pregnancy. Women with a PPW <43kg or a GWG <8kg are at greatest risk for poor birth outcomes in this setting. Preconception counseling and clinical care to obtain a healthy weight prior to pregnancy along with routine obstetric care on gestational weight gain is critical to improve birth outcomes.

TRIAL REGISTRATION

NCT01665378 (https://clinicaltrials.gov/show/NCT01665378).

Healthy Diet and Nutrition Education Program among Women of Reproductive Age: A Necessity of Multilevel Strategies or Community Responsibility

BACKGROUND

Reproductive years represent a major proportion of women‟s life. This review focuses on recommended nutritional considerations, physical activity pattern as well as the effect of nutrition education (NE) on behavior modification and health outcomes of women of reproductive age using either single-level, multiple-level or community-level interventions.

METHODS

For this narrative review, numerous searches were conducted on databases of PubMed, Science Direct and Google Scholar search engine using the keywords women, reproductive age, NE, interventions, community-based.

RESULTS

Even though single intervention is effective, multiple intervention programmes in addition to behavior modification components are even more successful in terms of modified behaviors and health outcomes. Moreover, community based interventions using multilevel strategies are further useful for improved health outcomes and behavior modification.

CONCLUSION

NE programmes have been effective in positive behavior modification measured in terms of eating pattern and health quality. Thus, it is recommended that health professionals use multiple intervention strategies at community level to ensure improved outcomes. Political support is also required to create culturally sensitive methods of delivering nutritional programmes. Finally, as policy is dependent on program cost, nutritional programmes need to combine methods of cost analysis to show cost effectiveness of supplying adequate nutrition for women throughout the lifecycle.

Maternal micronutrient deficiencies and related adverse neonatal outcomes after bariatric surgery: a systematic review

Pregnant and postpartum women with a history of bariatric surgery are at risk of micronutrient deficiencies as a result of the combination of physiologic changes related to pregnancy and iatrogenic postoperative alterations in the absorption and metabolism of crucial nutrients. This systematic review investigates micronutrient deficiencies and related adverse clinical outcomes in pregnant and postpartum women after bariatric surgery. A systematic approach involving critical appraisal was conducted independently by 2 researchers to examine deficiencies of phylloquinone, folate, iron, calcium, zinc, magnesium, iodide, copper, and vitamins A, D, and B-12 in pregnant and postpartum women after bariatric surgery, together with subsequent outcomes in the neonates. The search identified 29 relevant cases and 8 cohort studies. The quality of reporting among the case reports was weak according to the criteria based on the CARE (CAse REporting) guidelines as was that for the cohort studies based on the criteria from the Cohort Study Quality Assessment list of the Dutch Cochrane Center. The most common adverse neonatal outcomes related to maternal micronutrient deficiencies include visual complications (vitamin A), intracranial hemorrhage (phylloquinone), neurological and developmental impairment (vitamin B-12), and neural tube defects (folate). On the basis of the systematically collected information, we conclude that the evidence on micronutrient deficiencies in pregnant and postpartum women after bariatric surgery and subsequent adverse neonatal outcomes remains weak and inconclusive.

Sirenomelia: two cases in Cali, Colombia

We report two cases of sirenomelia, a rare congenital defect with a prevalence rate of 1:100 000 births; both cases were observed in Cali, Colombia. Both pregnant women were referred from Buenaventura, Colombia. The expecting mothers shared multiple adverse sociodemographic factors. Their homes were located in a city where the entire population is of low socioeconomic status living under conditions of extreme poverty. They were uneducated, with nutritional deficiencies and no access to drinking water most of the time. Both were exposed to water and fish from a nearby river contaminated with leachate from a poorly managed landfill. A similar relation was previously reported in Cali in 2005 between environmental factors and sirenomelia. We suggest that there is a common aetiological factor of environmental origin between these two sirenomelia cases and propose that exposure to derivatives from landfills should be included among the factors for this rare defect of multifactorial aetiological origin.

Preconception care: it's never too early

The preconception window has been recognized as one of the earliest sensitive windows of human development, and interventions that focus on this period have the potential to affect not only pregnancy but long term outcomes as well. The journal Reproductive Health has published a supplement entitled 'Preconception Interventions' which includes a series of systematic reviews regarding the impact of public health interventions during the preconception period on maternal and child health. These articles describe the role that poor preconception health plays in creating health disparities across the globe. The reviews highlight our current understanding (or lack thereof) regarding how both maternal and paternal preconception health and knowledge shapes the long-term health of not only children, but of families, communities, and nations. Researchers and healthcare workers should take particular note of these interventions, as the preconception time period may be as important as the pregnancy and post-pregnancy periods, and is critical in terms of bridging the gap in the continuum of care, particularly for adolescents.

Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health

INTRODUCTION

Preconception care includes any intervention to optimize a woman's health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.

CONCLUSION

Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.

Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health

INTRODUCTION

Preconception care includes any intervention to optimize a woman's health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.

CONCLUSION

Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.

Preconception care: delivery strategies and packages for care

The notion of preconception care aims to target the existing risks before pregnancy, whereby resources may be used to improve reproductive health and optimize knowledge before conceiving. The preconception period provides an opportunity to intervene earlier to optimize the health of potential mothers (and fathers) and to prevent harmful exposures from affecting the developing fetus. These interventions include birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimization of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions. Given existing interventions and the need to organize services to optimize delivery of care in a logical and effective manner, interventions are frequently co-packaged or bundled together. This paper highlights packages of preconception interventions that can be combined and co-delivered to women through various delivery channels and provides a logical framework for development of such packages in varying contexts.

Preconception care: closing the gap in the continuum of care to accelerate improvements in maternal, newborn and child health

INTRODUCTION

Preconception care includes any intervention to optimize a woman's health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs.

METHODS

A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.

RESULTS

Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality.

CONCLUSION

Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.