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Finkelstein JL, Cuthbert A, Weeks J, Venkatramanan S, Larvie DY, De-Regil LM, Garcia-Casal MN. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev 2024; 8:CD004736. [PMID: 39145520 PMCID: PMC11325660 DOI: 10.1002/14651858.cd004736.pub6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
BACKGROUND Iron and folic acid supplementation have been recommended in pregnancy for anaemia prevention, and may improve other maternal, pregnancy, and infant outcomes. OBJECTIVES To examine the effects of daily oral iron supplementation during pregnancy, either alone or in combination with folic acid or with other vitamins and minerals, as an intervention in antenatal care. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Trials Registry on 18 January 2024 (including CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO's International Clinical Trials Registry Platform, conference proceedings), and searched reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised trials that evaluated the effects of oral supplementation with daily iron, iron + folic acid, or iron + other vitamins and minerals during pregnancy were included. DATA COLLECTION AND ANALYSIS Review authors independently assessed trial eligibility, ascertained trustworthiness based on pre-defined criteria, assessed risk of bias, extracted data, and conducted checks for accuracy. We used the GRADE approach to assess the certainty of the evidence for primary outcomes. We anticipated high heterogeneity amongst trials; we pooled trial results using a random-effects model (average treatment effect). MAIN RESULTS We included 57 trials involving 48,971 women. A total of 40 trials compared the effects of daily oral supplements with iron to placebo or no iron; eight trials evaluated the effects of iron + folic acid compared to placebo or no iron + folic acid. Iron supplementation compared to placebo or no iron Maternal outcomes: Iron supplementation during pregnancy may reduce maternal anaemia (4.0% versus 7.4%; risk ratio (RR) 0.30, 95% confidence interval (CI) 0.20 to 0.47; 14 trials, 13,543 women; low-certainty evidence) and iron deficiency at term (44.0% versus 66.0%; RR 0.51, 95% CI 0.38 to 0.68; 8 trials, 2873 women; low-certainty evidence), and probably reduces maternal iron-deficiency anaemia at term (5.0% versus 18.4%; RR 0.41, 95% CI 0.26 to 0.63; 7 trials, 2704 women; moderate-certainty evidence), compared to placebo or no iron supplementation. There is probably little to no difference in maternal death (2 versus 4 events, RR 0.57, 95% CI 0.12 to 2.69; 3 trials, 14,060 women; moderate-certainty evidence). The evidence is very uncertain for adverse effects (21.6% versus 18.0%; RR 1.29, 95% CI 0.83 to 2.02; 12 trials, 2423 women; very low-certainty evidence) and severe anaemia (Hb < 70 g/L) in the second/third trimester (< 1% versus 3.6%; RR 0.22, 95% CI 0.01 to 3.20; 8 trials, 1398 women; very low-certainty evidence). No trials reported clinical malaria or infection during pregnancy. Infant outcomes: Women taking iron supplements are probably less likely to have infants with low birthweight (5.2% versus 6.1%; RR 0.84, 95% CI 0.72 to 0.99; 12 trials, 18,290 infants; moderate-certainty evidence), compared to placebo or no iron supplementation. However, the evidence is very uncertain for infant birthweight (MD 24.9 g, 95% CI -125.81 to 175.60; 16 trials, 18,554 infants; very low-certainty evidence). There is probably little to no difference in preterm birth (7.6% versus 8.2%; RR 0.93, 95% CI 0.84 to 1.02; 11 trials, 18,827 infants; moderate-certainty evidence) and there may be little to no difference in neonatal death (1.4% versus 1.5%, RR 0.98, 95% CI 0.77 to 1.24; 4 trials, 17,243 infants; low-certainty evidence) or congenital anomalies, including neural tube defects (41 versus 48 events; RR 0.88, 95% CI 0.58 to 1.33; 4 trials, 14,377 infants; low-certainty evidence). Iron + folic supplementation compared to placebo or no iron + folic acid Maternal outcomes: Daily oral supplementation with iron + folic acid probably reduces maternal anaemia at term (12.1% versus 25.5%; RR 0.44, 95% CI 0.30 to 0.64; 4 trials, 1962 women; moderate-certainty evidence), and may reduce maternal iron deficiency at term (3.6% versus 15%; RR 0.24, 95% CI 0.06 to 0.99; 1 trial, 131 women; low-certainty evidence), compared to placebo or no iron + folic acid. The evidence is very uncertain about the effects of iron + folic acid on maternal iron-deficiency anaemia (10.8% versus 25%; RR 0.43, 95% CI 0.17 to 1.09; 1 trial, 131 women; very low-certainty evidence), or maternal deaths (no events; 1 trial; very low-certainty evidence). The evidence is uncertain for adverse effects (21.0% versus 0.0%; RR 44.32, 95% CI 2.77 to 709.09; 1 trial, 456 women; low-certainty evidence), and the evidence is very uncertain for severe anaemia in the second or third trimester (< 1% versus 5.6%; RR 0.12, 95% CI 0.02 to 0.63; 4 trials, 506 women; very low-certainty evidence), compared to placebo or no iron + folic acid. Infant outcomes: There may be little to no difference in infant low birthweight (33.4% versus 40.2%; RR 1.07, 95% CI 0.31 to 3.74; 2 trials, 1311 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. Infants born to women who received iron + folic acid during pregnancy probably had higher birthweight (MD 57.73 g, 95% CI 7.66 to 107.79; 2 trials, 1365 infants; moderate-certainty evidence), compared to placebo or no iron + folic acid. There may be little to no difference in other infant outcomes, including preterm birth (19.4% versus 19.2%; RR 1.55, 95% CI 0.40 to 6.00; 3 trials, 1497 infants; low-certainty evidence), neonatal death (3.4% versus 4.2%; RR 0.81, 95% CI 0.51 to 1.30; 1 trial, 1793 infants; low-certainty evidence), or congenital anomalies (1.7% versus 2.4; RR 0.70, 95% CI 0.35 to 1.40; 1 trial, 1652 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. A total of 19 trials were conducted in malaria-endemic countries, or in settings with some malaria risk. No studies reported maternal clinical malaria; one study reported data on placental malaria. AUTHORS' CONCLUSIONS Daily oral iron supplementation during pregnancy may reduce maternal anaemia and iron deficiency at term. For other maternal and infant outcomes, there was little to no difference between groups or the evidence was uncertain. Future research is needed to examine the effects of iron supplementation on other maternal and infant health outcomes, including infant iron status, growth, and development.
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Affiliation(s)
| | - Anna Cuthbert
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Jo Weeks
- Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Doreen Y Larvie
- Division of Nutritional Sciences, Cornell University, Ithaca, New York, USA
| | - Luz Maria De-Regil
- Multisectoral Action in Food Systems Unit, World Health Organization, Geneva, Switzerland
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Brittenham GM, Moir-Meyer G, Abuga KM, Datta-Mitra A, Cerami C, Green R, Pasricha SR, Atkinson SH. Biology of Anemia: A Public Health Perspective. J Nutr 2023; 153 Suppl 1:S7-S28. [PMID: 37778889 DOI: 10.1016/j.tjnut.2023.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/04/2023] [Accepted: 07/31/2023] [Indexed: 10/03/2023] Open
Abstract
Our goal is to present recent progress in understanding the biological mechanisms underlying anemia from a public health perspective. We describe important advances in understanding common causes of anemia and their interactions, including iron deficiency (ID), lack of other micronutrients, infection, inflammation, and genetic conditions. ID develops if the iron circulating in the blood cannot provide the amounts required for red blood cell production and tissue needs. ID anemia develops as iron-limited red blood cell production fails to maintain the hemoglobin concentration above the threshold used to define anemia. Globally, absolute ID (absent or reduced body iron stores that do not meet the need for iron of an individual but may respond to iron supplementation) contributes to only a limited proportion of anemia. Functional ID (adequate or increased iron stores that cannot meet the need for iron because of the effects of infection or inflammation and does not respond to iron supplementation) is frequently responsible for anemia in low- and middle-income countries. Absolute and functional ID may coexist. We highlight continued improvement in understanding the roles of infections and inflammation in causing a large proportion of anemia. Deficiencies of nutrients other than iron are less common but important in some settings. The importance of genetic conditions as causes of anemia depends upon the specific inherited red blood cell abnormalities and their prevalence in the settings examined. From a public health perspective, each setting has a distinctive composition of components underlying the common causes of anemia. We emphasize the coincidence between regions with a high prevalence of anemia attributed to ID (both absolute and functional), those with endemic infections, and those with widespread genetic conditions affecting red blood cells, especially in sub-Saharan Africa and regions in Asia and Oceania.
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Affiliation(s)
- Gary M Brittenham
- Department of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, United States.
| | - Gemma Moir-Meyer
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia
| | - Kelvin Mokaya Abuga
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ananya Datta-Mitra
- Department of Pathology and Laboratory Medicine, University of California, Davis, CA, United States
| | - Carla Cerami
- The Medical Research Council Unit, The Gambia, London School of Hygiene and Tropical Medicine, London, UK
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis, CA, United States
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia; Department of Medical Biology, The University of Melbourne, Parkville, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital; and Clinical Haematology at the Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC Australia
| | - Sarah H Atkinson
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Research Programme, Kilifi, Kenya; Department of Paediatrics, University of Oxford, Oxford, UK
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Perumal N, Wang D, Darling AM, Liu E, Wang M, Ahmed T, Christian P, Dewey KG, Kac G, Kennedy SH, Subramoney V, Briggs B, Fawzi WW. Suboptimal gestational weight gain and neonatal outcomes in low and middle income countries: individual participant data meta-analysis. BMJ 2023; 382:e072249. [PMID: 37734757 PMCID: PMC10512803 DOI: 10.1136/bmj-2022-072249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVE To estimate the associations between gestational weight gain (GWG) during pregnancy and neonatal outcomes in low and middle income countries. DESIGN Individual participant data meta-analysis. SETTING Prospective pregnancy studies from 24 low and middle income countries. MAIN OUTCOME MEASURES Nine neonatal outcomes related to timing (preterm birth) and anthropometry (weight, length, and head circumference) at birth, stillbirths, and neonatal death. ANALYSIS METHODS A systematic search was conducted in PubMed, Embase, and Web of Science which identified 53 prospective pregnancy studies published after the year 2000 with data on GWG, timing and anthropometry at birth, and neonatal mortality. GWG adequacy was defined as the ratio of the observed maternal weight gain over the recommended weight gain based on the Institute of Medicine body mass index specific guidelines, which are derived from data in high income settings, and the INTERGROWTH-21st GWG standards. Study specific estimates, adjusted for confounders, were generated and then pooled using random effects meta-analysis models. Maternal age and body mass index before pregnancy were examined as potential modifiers of the associations between GWG adequacy and neonatal outcomes. RESULTS Overall, 55% of participants had severely inadequate (<70%) or moderately inadequate (70% to <90%) GWG, 22% had adequate GWG (90-125%), and 23% had excessive GWG (≥125%). Severely inadequate GWG was associated with a higher risk of low birthweight (adjusted relative risk 1.62, 95% confidence interval 1.51 to 1.72; 48 studies, 93 337 participants; τ2=0.006), small for gestational age (1.44, 1.36 to 1.54; 51 studies, 93 191 participants; τ2=0.016), short for gestational age (1.47, 1.29 to 1.69; 40 studies, 83 827 participants; τ2=0.074), and microcephaly (1.57, 1.31 to 1.88; 31 studies, 80 046 participants; τ2=0.145) compared with adequate GWG. Excessive GWG was associated with a higher risk of preterm birth (1.22, 1.13 to 1.31; 48 studies, 103 762 participants; τ2=0.008), large for gestational age (1.44, 1.33 to 1.57; 47 studies, 90 044 participants; τ2=0.009), and macrosomia (1.52, 1.33 to 1.73; 29 studies, 68 138 participants; τ2=0) compared with adequate GWG. The direction and magnitude of the associations between GWG adequacy and several neonatal outcomes were modified by maternal age and body mass index before pregnancy. CONCLUSIONS Inadequate and excessive GWG are associated with a higher risk of adverse neonatal outcomes across settings. Interventions to promote optimal GWG during pregnancy are likely to reduce the burden of adverse neonatal outcomes, however further research is needed to assess optimal ranges of GWG based on data from low and middle income countries.
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Affiliation(s)
- Nandita Perumal
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, SC, USA
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Dongqing Wang
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA, USA
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Biostatistics, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Tahmeed Ahmed
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Dhaka, Bangladesh
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California, Davis, CA, USA
| | - Gilberto Kac
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Stephen H Kennedy
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | | | - Brittany Briggs
- Certara USA, on behalf of the Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Wafaie W Fawzi
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Epidemiology, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
- Department of Nutrition, Harvard T H Chan School of Public Health, Harvard University, Boston, MA, USA
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Darling AM, Wang D, Perumal N, Liu E, Wang M, Ahmed T, Christian P, Dewey KG, Kac G, Kennedy SH, Subramoney V, Briggs B, Fawzi WW. Risk factors for inadequate and excessive gestational weight gain in 25 low- and middle-income countries: An individual-level participant meta-analysis. PLoS Med 2023; 20:e1004236. [PMID: 37486938 PMCID: PMC10406332 DOI: 10.1371/journal.pmed.1004236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/07/2023] [Accepted: 04/21/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Many women experience suboptimal gestational weight gain (GWG) in low- and middle-income countries (LMICs), but our understanding of risk factors associated with GWG in these settings is limited. We investigated the relationships between demographic, anthropometric, lifestyle, and clinical factors and GWG in prospectively collected data from LMICs. METHODS AND FINDINGS We conducted an individual participant-level meta-analysis of risk factors for GWG outcomes among 138,286 pregnant women with singleton pregnancies in 55 studies (27 randomized controlled trials and 28 prospective cohorts from 25 LMICs). Data sources were identified through PubMed, Embase, and Web of Science searches for articles published from January 2000 to March 2019. Titles and abstracts of articles identified in all databases were independently screened by 2 team members according to the following eligibility criteria: following inclusion criteria: (1) GWG data collection took place in an LMIC; (2) the study was a prospective cohort or randomized trial; (3) study participants were pregnant; and (4) the study was not conducted exclusively among human immunodeficiency virus (HIV)-infected women or women with other health conditions that could limit the generalizability of the results. The Institute of Medicine (IOM) body mass index (BMI)-specific guidelines were used to determine the adequacy of GWG, which we calculated as the ratio of the total observed weight gain over the mean recommended weight gain. Study outcomes included severely inadequate GWG (percent adequacy of GWG <70), inadequate GWG (percent adequacy of GWG <90, inclusive of severely inadequate), and excessive GWG (percent adequacy of GWG >125). Multivariable estimates from each study were pooled using fixed-effects meta-analysis. Study-specific regression models for each risk factor included all other demographic risk factors measured in a particular study as potential confounders, as well as BMI, maternal height, pre-pregnancy smoking, and chronic hypertension. Risk factors occurring during pregnancy were further adjusted for receipt of study intervention (if any) and 3-month calendar period. The INTERGROWTH-21st standard was used to define high and low GWG among normal weight women in a sensitivity analysis. The prevalence of inadequate GWG was 54%, while the prevalence of excessive weight gain was 22%. In multivariable models, factors that were associated with a higher risk of inadequate GWG included short maternal stature (<145 cm), tobacco smoking, and HIV infection. A mid-upper arm circumference (MUAC) of ≥28.1 cm was associated with the largest increase in risk for excessive GWG (risk ratio (RR) 3.02, 95% confidence interval (CI) [2.86, 3.19]). The estimated pooled difference in absolute risk between those with MUAC of ≥28.1 cm compared to those with a MUAC of 24 to 28.09 cm was 5.8% (95% CI 3.1% to 8.4%). Higher levels of education and age <20 years were also associated with an increased risk of excessive GWG. Results using the INTERGROWTH-21st standard among normal weight women were similar but attenuated compared to the results using the IOM guidelines among normal weight women. Limitations of the study's methodology include differences in the availability of risk factors and potential confounders measured in each individual dataset; not all risk factors or potential confounders of interest were available across datasets and data on potential confounders collected across studies. CONCLUSIONS Inadequate GWG is a significant public health concern in LMICs. We identified diverse nutritional, behavioral, and clinical risk factors for inadequate GWG, highlighting the need for integrated approaches to optimizing GWG in LMICs. The prevalence of excessive GWG suggests that attention to the emerging burden of excessive GWG in LMICs is also warranted.
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Affiliation(s)
- Anne Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Dongqing Wang
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, Virginia, United States of America
| | - Nandita Perumal
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
| | - Tahmeed Ahmed
- Nutrition & Clinical Services, International Centre for Diarrheal Disease Research, Bangladesh
| | - Parul Christian
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kathryn G. Dewey
- Department of Nutrition, University of California, Davis, Davis, California, United States of America
| | - Gilberto Kac
- Nutritional Epidemiology Observatory, Josué de Castro Nutrition Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Stephen H. Kennedy
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | | | - Brittany Briggs
- Certara USA, Inc. on behalf of the Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Wafaie W. Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
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Abioye AI, Hughes MD, Sudfeld CR, Premji Z, Aboud S, Hamer DH, Roberts DJ, Duggan CP, Fawzi WW. The effect of iron supplementation on maternal iron deficiency anemia does not differ by baseline anemia type among Tanzanian pregnant women without severe iron deficiency anemia. Eur J Nutr 2023; 62:987-1001. [PMID: 36344770 PMCID: PMC9987582 DOI: 10.1007/s00394-022-03029-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE Whether anemia type modifies the risk of pregnancy and newborn outcomes and the effectiveness of iron supplementation is unclear. We examined the association of iron deficiency anemia (IDA) and non-iron deficiency anemia (NIDA) on the risks of these outcomes and the extent to which anemia type modifies the impact of prenatal iron supplementation. METHODS This was a secondary analysis of a placebo-controlled trial of iron supplementation among 1450 HIV-negative women in Tanzania. Eligibility criteria included gestational age < 27 weeks, hemoglobin > 85 g/L, and ferritin > 12 µg/L. Individuals were categorized as non-anemia, IDA or NIDA using hemoglobin, ferritin and CRP. Analyses were conducted using regression models and likelihood ratio tests. RESULTS Compared to the non-anemia group, delivery hemoglobin was lower by 15 g/L (95% CI 10.9, 19.3) in the baseline IDA group, and 7.3 g/L (95% CI 3.1, 11.5) in the baseline NIDA group. The RRs of anemia severity, iron deficiency, placental malaria, stillbirths, perinatal mortality, birthweight, and preterm birth were not different among women in the baseline NIDA group (vs. non-anemia) compared to the baseline IDA group (vs. non-anemia). The difference in the mean delivery hemoglobin for iron supplementation and placebo arms was 8 g/L (95% CI 6, 11) in the non-anemia group, 7 g/L (95% CI 2, 13) in the NIDA group, and 16 g/L (95% CI 10, 22) in the IDA group. CONCLUSION Iron supplementation is effective even among pregnant women with NIDA. TRIAL REGISTRATION NCT01119612 (May 7, 2010).
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Affiliation(s)
- Ajibola Ibraheem Abioye
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard T.H. School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.
| | - Michael D Hughes
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Christopher R Sudfeld
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard T.H. School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Davidson H Hamer
- Department of Global Health, School of Public Health, Boston University, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Drucilla J Roberts
- Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher P Duggan
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard T.H. School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - Wafaie W Fawzi
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Harvard T.H. School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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6
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Cliffer IR, Yussuf MH, Millogo O, Mwanyika-Sando M, Barry Y, Yusufu IS, Hemler EC, Sie A, Tinkasimile A, Compaoré G, Ali AS, Kouanda I, Wang D, Mosha D, Fawzi W. Scaling-up high-impact micronutrient supplementation interventions to improve adolescents' nutrition and health in Burkina Faso and Tanzania: protocol for a cluster-randomised controlled trial. BMJ Open 2023; 13:e063686. [PMID: 36792333 PMCID: PMC9933747 DOI: 10.1136/bmjopen-2022-063686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Adolescence is a critical time for growth and development, but this age group is often neglected in research and development of nutrition interventions. Despite recommendations from the WHO to provide nutrient supplements to adolescents, evidence remains scarce on the most effective supplementation strategy. This study aims to compare weekly iron and folic acid (IFA) supplementation with daily multiple micronutrient supplements (MMSs) in prevention of anaemia and improvement of school outcomes among adolescents in Burkina Faso and Tanzania. METHODS AND ANALYSIS A three-arm cluster-randomised, school-based supplementation trial will be conducted among 84 schools (42 schools per site) and roughly 4500 students aged 10-17. Schools will be matched on three characteristics: number of students, school ranking profile, distance to main road (Tanzania) or distance to city council (Burkina Faso). Each school will be randomised to receive either weekly IFA, daily MMSs or serve as a control. Supplements will be delivered to students by teachers, who will provide monitoring data to the study team. Baseline and endline surveys will be conducted prior to and after each supplementation cycle (12 weeks in Burkina Faso; 1 year in Tanzania) to assess haemoglobin, anthropometry and sociodemographic variables. The primary outcome of haemoglobin will be analysed continuously using linear regression, and anaemia status will be analysed using logistic or multinomial regression, depending on categorisation level of the outcome. Secondary analyses of school performance indicators will also be conducted with either logistic or linear regression. ETHICS AND DISSEMINATION This protocol has been approved by the Institutional Review Board of the Harvard TH Chan School of Public Health (IRB20-1108) and the Research Ethics Committees for the Ministries of Health in Tanzania (Zanzibar) and Burkina Faso. Results will be disseminated during meetings with the Ministries of Health and the participating communities as well as through peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT04657640; NCT05104554.
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Affiliation(s)
- Ilana Rachel Cliffer
- Department of Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Mashavu H Yussuf
- Africa Academy for Public Health, Dar es Salaam, United Republic of Tanzania
| | - Ourohire Millogo
- Centre de Recherche en Sante de Nouna, Nouna, Boucle du Mouhoun, Burkina Faso
| | - Mary Mwanyika-Sando
- Africa Academy for Public Health, Dar es Salaam, United Republic of Tanzania
| | | | - Innocent S Yusufu
- Africa Academy for Public Health, Dar es Salaam, United Republic of Tanzania
| | - Elena Cori Hemler
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Ali Sie
- Centre de Recherche en Sante de Nouna, Nouna, Boucle du Mouhoun, Burkina Faso
| | - Amani Tinkasimile
- Africa Academy for Public Health, Dar es Salaam, United Republic of Tanzania
| | - Guillaume Compaoré
- Centre de Recherche en Sante de Nouna, Nouna, Boucle du Mouhoun, Burkina Faso
| | - Ali Salim Ali
- Zanzibar Association for People Living with HIV/AIDS, Zanzibar, United Republic of Tanzania
| | - Idrissa Kouanda
- Centre de Recherche en Sante de Nouna, Nouna, Boucle du Mouhoun, Burkina Faso
| | - Dongqing Wang
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Global and Community Health, George Mason University, College of Health and Human Services, Fairfax, Virginia, USA
| | - Dominic Mosha
- Africa Academy for Public Health, Dar es Salaam, United Republic of Tanzania
| | - Wafaie Fawzi
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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7
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Abd Rahman R, Idris IB, Md Isa Z, Abd Rahman R. The effectiveness of a theory-based intervention program for pregnant women with anemia: A randomized control trial. PLoS One 2022; 17:e0278192. [PMID: 36473006 PMCID: PMC9725169 DOI: 10.1371/journal.pone.0278192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 11/11/2022] [Indexed: 12/12/2022] Open
Abstract
Anemia in pregnancy is a public health concern. It has been diagnosed in 27% of pregnant women in Malaysia and up to 40% of pregnant women globally. This study aimed to develop and evaluate the effectiveness of an intervention initiative based on the health belief model. The MyPinkMom program was disseminated through a mobile messaging application to pregnant women to educate them on the prevention of anemia in pregnancy. We conducted a two-arm cluster-assignment, single-blinded, randomized control trial at two government antenatal clinics in Selangor. One clinic was randomly chosen as the intervention group, and the other was chosen as the control group. Sixty pregnant women with anemia from the intervention group received the MyPinkMom intervention program in the form of six infographic video clips, and 60 pregnant women with anemia from the control group received routine counseling on anemia in pregnancy. Pregnant women who had anemia secondary to hemoglobinopathy or other chronic diseases were excluded from this study. MANOVA showed significant increases in hemoglobin, knowledge, attitude, subjective norms, and perceived behavioral control scores for adherence to iron supplements, dietary iron, and dietary vitamin C intake (p < 0.001) in the intervention group at week 6. A significant reduction also occurred in dietary tannin intake (p < 0.001) in the intervention group at week 6. The intervention group at week 6 showed a large effect on hemoglobin level increments (partial eta squared, Ƞp2 0.268), dietary iron intake (Ƞp2 0.213), knowledge of anemia in pregnancy (Ƞp2 0.622), subjective norm scores for adherence to iron supplements (Ƞp2 0.167), and reduction in dietary tannin intake (Ƞp2 0.353). Similarly, repeated measures ANOVA showed that changes in hemoglobin levels were significantly different over time (i.e., at baseline, week 6, and week 12) between the intervention and control groups (p < 0.001). Hemoglobin increased rapidly over time among participants in the intervention group but gradually in the control group. To conclude, the newly developed MyPinkMom program that was delivered through a messaging application showed effectiveness in preventing anemia during pregnancy.
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Affiliation(s)
- Raudah Abd Rahman
- Public Health Division, Kuala Lumpur and Putrajaya Health Department, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Idayu Badilla Idris
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia Jalan Yaacob Latif, Cheras, Kuala Lumpur, Malaysia
- * E-mail:
| | - Zaleha Md Isa
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia Jalan Yaacob Latif, Cheras, Kuala Lumpur, Malaysia
| | - Rahana Abd Rahman
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Konje ET, Ngaila BV, Kihunrwa A, Mugassa S, Basinda N, Dewey D. High Prevalence of Anemia and Poor Compliance with Preventive Strategies among Pregnant Women in Mwanza City, Northwest Tanzania: A Hospital-Based Cross-Sectional Study. Nutrients 2022; 14:nu14183850. [PMID: 36145226 PMCID: PMC9505096 DOI: 10.3390/nu14183850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 08/29/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Anemia in pregnancy is prevalent in Tanzania despite the implementation of existing prevention strategies. This study aims to determine the level of compliance with anemia preventive strategies among pregnant women and the factors associated with poor compliance. A cross sectional study was conducted among 768 pregnant women who attended the Bugando Medical Center, Sekou-Toure Regional Hospital, Nyamagana District Hospital, and Buzuruga Health Center in Mwanza, Northwest Tanzania. The prevalence of anemia at term was 68.8% (95% CI, 65.5–72.0%). The average hemoglobin level at term was 10.0 g/dL (95% CI, 9.8–10.1). Only 10.9% of pregnant women complied fully with anemia-preventive strategies. A decrease in mean hemoglobin level was observed across levels of compliance, with women who were non-compliant displaying a significantly lower mean hemoglobin level (8.3 g/dL) compared to women who were fully compliant (11.0 g/dL). Poor compliance was associated with no formal or primary education and initiating antenatal care in the 2nd or 3rd trimester. Anemia in pregnancy was commonly associated with lack of compliance with preventive strategies among participants. There is a need for community-based health education on the importance of complying with anemia-preventive strategies in order to reduce the burden during pregnancy and the consequences of anemia to the unborn baby.
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Affiliation(s)
- Eveline T. Konje
- Department of Biostatistics and Epidemiology, School of Public Health, Catholic University of Health and Allied Sciences—BUGANDO, Mwanza P.O. Box 1464, Tanzania
- Correspondence: or
| | - Bernadin Vicent Ngaila
- Department of Obstetrics and Gynecology, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences—BUGANDO, Mwanza P.O. Box 1464, Tanzania
| | - Albert Kihunrwa
- Department of Obstetrics and Gynecology, Weill Bugando School of Medicine, Catholic University of Health and Allied Sciences—BUGANDO, Mwanza P.O. Box 1464, Tanzania
| | - Stella Mugassa
- Department of Biostatistics and Epidemiology, School of Public Health, Catholic University of Health and Allied Sciences—BUGANDO, Mwanza P.O. Box 1464, Tanzania
| | - Namanya Basinda
- Department of Community Medicine, School of Public Health, Catholic University of Health and Allied Sciences—BUGANDO, Mwanza P.O. Box 1464, Tanzania
| | - Deborah Dewey
- Departments of Pediatrics and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Owerko Centre at the Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB T2N 1N4, Canada
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9
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Yang J, Wang M, Tobias DK, Rich-Edwards JW, Darling AM, Abioye AI, Pembe AB, Madzorera I, Fawzi WW. Gestational weight gain during the second and third trimesters and adverse pregnancy outcomes, results from a prospective pregnancy cohort in urban Tanzania. Reprod Health 2022; 19:140. [PMID: 35710384 PMCID: PMC9204988 DOI: 10.1186/s12978-022-01441-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/18/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Appropriate gestational weight gain (GWG) is important for optimal pregnancy outcomes. This study prospectively evaluated the associations between GWG during the second and third trimesters of pregnancy and adverse pregnancy outcomes in an urban Tanzanian pregnancy cohort. METHODS We used data from a randomized clinical trial conducted among pregnant women recruited by 27 weeks of gestation in Dar es Salaam, Tanzania (N = 1230). Women's gestational weight was measured at baseline and at monthly antenatal visits. Weekly GWG rate during the second and third trimesters was calculated and characterized as inadequate, adequate, or excessive, in conjunction with measured or imputed early-pregnancy BMI status according to the 2009 Institute of Medicine (IOM) GWG guidelines. We used multivariable Poisson regression with a sandwich variance estimator to calculate risk ratios (RR) for associations of GWG with low birth weight, preterm birth, small for gestational age (SGA), and large for gestational age (LGA). Degree of appropriate GWG defined using additional metrics (i.e., percentage of adequacy, z-score) and potential effect modification by maternal BMI were additionally evaluated. RESULTS According to the IOM guidelines, 517 (42.0%), 270 (22.0%), and 443 (36.0%) women were characterized as having inadequate, adequate, and excessive GWG, respectively. Overall, compared to women with adequate GWG, women with inadequate GWG had a lower risk of LGA births (RR = 0.54, 95% CI: 0.36-0.80) and a higher risk of SGA births (RR = 1.32, 95% CI: 0.95-1.81). Women with inadequate GWG as defined by percentage of GWG adequacy had a higher risk of LBW (OR = 1.93, 95% CI: 1.03-3.63). In stratified analyses by early-pregnancy BMI, excessive GWG among women with normal BMI was associated with a higher risk of preterm birth (RR = 1.59, 95% CI: 1.03-2.44). CONCLUSIONS A comparatively high percentage of excessive GWG was observed among healthy pregnant women in Tanzania. Both inadequate and excessive GWGs were associated with elevated risks of poor pregnancy outcomes. Future studies among diverse SSA populations are warranted to confirm our findings, and clinical recommendations on optimal GWG should be developed to promote healthy GWG in SSA settings. TRIAL REGISTRATION This trial was registered as "Prenatal Iron Supplements: Safety and Efficacy in Tanzania" (NCT01119612; http://clinicaltrials.gov/show/NCT01119612 ).
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Affiliation(s)
- Jiaxi Yang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA.
- Global Center for Asian Women's Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Molin Wang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
| | - Deirdre K Tobias
- Department of Nutrition, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, 900 Commonwealth Avenue, Boston, MA, 02115, USA
| | - Janet W Rich-Edwards
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- Channing Division of Network Medicine, Division of Women's Health, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 900 Commonwealth Avenue, Boston, MA, 02115, USA
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
| | - Ajibola I Abioye
- Department of Nutrition, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
| | - Andrea B Pembe
- Department of Obstetrics and Gynecology, School of Medicine, Muhimbili University of Health and Allied Sciences, P. O. Box 65117, Dar es Salaam, Tanzania
| | - Isabel Madzorera
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
| | - Wafaie W Fawzi
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- Department of Nutrition, Harvard T. H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, USA
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10
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Unger HW, Bleicher A, Ome-Kaius M, Aitken EH, Rogerson SJ. Associations of maternal iron deficiency with malaria infection in a cohort of pregnant Papua New Guinean women. Malar J 2022; 21:153. [PMID: 35619134 PMCID: PMC9137066 DOI: 10.1186/s12936-022-04177-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 05/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Iron deficiency (ID) is common in malaria-endemic settings. Intermittent preventative treatment of malaria in pregnancy (IPTp) and iron supplementation are core components of antenatal care in endemic regions to prevent adverse pregnancy outcomes. ID has been associated with reduced risk of malaria infection, and correspondingly, iron supplementation with increased risk of malaria infection, in some studies. METHODS A secondary analysis was conducted amongst 1888 pregnant women enrolled in a malaria prevention trial in Papua New Guinea. Maternal ID was defined as inflammation-corrected plasma ferritin levels < 15 μg/L at antenatal enrolment. Malaria burden (Plasmodium falciparum, Plasmodium vivax) was determined by light microscopy, polymerase chain reaction, and placental histology. Multiple logistic and linear regression analyses explored the relationship of ID or ferritin levels with indicators of malaria infection. Models were fitted with interaction terms to assess for modification of iron-malaria relationships by gravidity or treatment arm. RESULTS Two-thirds (n = 1226) and 13.7% (n = 258) of women had ID and peripheral parasitaemia, respectively, at antenatal enrolment (median gestational age: 22 weeks), and 18.7% (120/1,356) had evidence of malaria infection on placental histology. Overall, ID was associated with reduced odds of peripheral parasitaemia at enrolment (adjusted odds ratio [aOR] 0.50; 95% confidence interval [95% CI] 0.38, 0.66, P < 0.001); peripheral parasitaemia at delivery (aOR 0.68, 95% CI 0.46, 1.00; P = 0.050); and past placental infection (aOR 0.35, 95% CI 0.24, 0.50; P < 0.001). Corresponding increases in the odds of infection were observed with two-fold increases in ferritin levels. There was effect modification of iron-malaria relationships by gravidity. At delivery, ID was associated with reduced odds of peripheral parasitaemia amongst primigravid (AOR 0.44, 95% CI 0.25, 0.76; P = 0.003), but not multigravid women (AOR 1.12, 95% CI 0.61, 2.05; P = 0.720). A two-fold increase in ferritin associated with increased odds of placental blood infection (1.44, 95% CI 1.06, 1.96; P = 0.019) and active placental infection on histology amongst primigravid women only (1.24, 95% CI 1.00, 1.54; P = 0.052). CONCLUSIONS Low maternal ferritin at first antenatal visit was associated with a lower risk of malaria infection during pregnancy, most notably in primigravid women. The mechanisms by which maternal iron stores influence susceptibility to infection with Plasmodium species require further investigation. TRIAL REGISTRATION
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Affiliation(s)
- Holger W Unger
- Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Darwin, NT, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Andie Bleicher
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Elizabeth H Aitken
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Stephen J Rogerson
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia.
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia.
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11
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Yang J, Wang M, Tobias DK, Rich-Edwards JW, Darling AM, Abioye AI, Noor RA, Madzorera I, Fawzi WW. Dietary diversity and diet quality with gestational weight gain and adverse birth outcomes, results from a prospective pregnancy cohort study in urban Tanzania. MATERNAL & CHILD NUTRITION 2022; 18:e13300. [PMID: 34908233 PMCID: PMC8932689 DOI: 10.1111/mcn.13300] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/25/2021] [Accepted: 11/06/2021] [Indexed: 12/15/2022]
Abstract
Healthy maternal diets during pregnancy are an important protective factor for pregnancy‐related outcomes, including gestational weight gain (GWG) and birth outcomes. We prospectively examined the associations of maternal dietary diversity and diet quality, using Minimum Dietary Diversity for Women (MDD‐W) and Prime Diet Quality Score (PDQS), with GWG and birth outcomes among women enrolled in a trial in Tanzania (n = 1190). MDD‐W and PDQS were derived from a baseline food frequency questionnaire. Women were monthly followed until delivery, during which weight was measured. GWG was classified based on the 2009 Institute of Medicine guidelines. Adverse birth outcomes were classified as low birth weight (LBW), small for gestational age, large for gestational age, and preterm birth. 46.2% participants had MDD‐W ≥ 5. Mean score of PDQS was 23.3. Maternal intakes of nuts, poultry, and eggs were low, whereas intakes of sugar‐sweetened beverages and refined grains were high. MDD‐W was not associated with GWG or birth outcomes. For PDQS, compared to the lowest tertile, women in the highest tertile had lower risk of inappropriate GWG (risk ratio [RR] = 0.93, 95% confidence interval [CI]: 0.87–1.00). Women in the middle tertile group of PDQS (RR = 0.72, 95% CI: 0.51–1.00) had lower risk of preterm birth. After excluding women with prior complications, higher PDQS was associated with lower risk of LBW (middle tertile: RR = 0.55, 95% CI: 0.31–0.99, highest tertile: RR = 0.52, 95% CI: 0.29–0.94; continuous per SD: RR = 0.77, 95% CI: 0.60–0.99). Our findings support continuing efforts to improve maternal diet quality for optimal GWG and infant outcomes among Tanzanian women. Maternal diets are a key modifiable determinant of gestational weight gain (GWG) and birth outcomes. We observed suboptimal intakes of healthy proteins and fats and high intakes of refined grains and sugar‐containing foods among well‐nourished pregnant women in urban Tanzania. This study found that higher‐quality maternal diets were associated with lower risks of inappropriate GWG, low birth weight, and preterm birth. This study supports the importance of high maternal diet quality and continuing efforts to promote well‐balanced maternal diets with avoiding both under‐ and over‐nutrition for optimal pregnancy outcomes among Tanzanian populations.
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Affiliation(s)
- Jiaxi Yang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Molin Wang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Deirdre K Tobias
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Janet W Rich-Edwards
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anne-Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ajibola I Abioye
- Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ramadhani A Noor
- United Nations Children's Fund (UNICEF), Dar es Salaam, Tanzania
| | - Isabel Madzorera
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Wafaie W Fawzi
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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12
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Saronga HP, Manji K, Liu E, Duggan CP, Menzies NA. Cost-effectiveness of Zinc Supplementation for Prevention of Childhood Diarrhoea in Tanzania. Public Health Nutr 2022; 25:1-26. [PMID: 35272738 PMCID: PMC9991691 DOI: 10.1017/s1368980022000568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To assess the cost-effectiveness of prophylactic zinc supplementation for preventing diarrhoea in young children in Tanzania. DESIGN Cost-effectiveness analysis using decision-analytic modelling. Cost-effectiveness ratios were calculated as the incremental cost (2019 USD) per disability-adjusted life year (DALY) averted, from a societal perspective, and with a 3% discount rate applied to future outcomes. Sensitivity analyses were performed to test the robustness of results to alternative assumptions. SETTING Tanzania. PARTICIPANTS A hypothetical cohort of 10,000 children ages 6 weeks to 18 months. RESULTS The intervention costs of zinc supplementation were estimated as $109,800 (95% uncertainty interval: 61,716-171,507). Zinc supplementation was estimated to avert 2,200 (776-3,737) diarrhoeal episodes, 14,080 (4,692-25,839) sick days, 1,584 (522-2,927) outpatient visits, 561 (160-1,189) inpatient bed-days, 0.51 (0.15-1.03) deaths, and 19.3 (6.1-37.5) DALYs (discounted at 3% per year). Zinc supplementation reduced diarrhoea care costs by $12, 887 (4,089-25,058). The incremental cost per DALY averted was $4,950 (1,678-17,933). Incremental cost-effectiveness ratios (ICERs) estimated from a health system perspective were similar to the results from the societal perspective. ICERs were substantially lower (more favourable) when future outcomes were not discounted, but all ICERs were above contemporary thresholds for cost-effectiveness in this setting. CONCLUSION Prophylactic zinc reduced diarrhoea incidence and associated healthcare utilization; however it did not appear to be cost-effective for prevention of childhood diarrhoea in the scenario examined in this study. Reducing intervention costs, or identifying high risk groups for intervention targeting, may be needed to improve cost-effectiveness in this setting.
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Affiliation(s)
- Happiness Pius Saronga
- Behavioural Sciences Department, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, 65001Dar-es-salaam, Tanzania
| | - Karim Manji
- Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar-es-salaam, Tanzania
| | - Enju Liu
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA, USA
| | - Christopher P Duggan
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Nutrition, Harvard T.H Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H Chan School of Public Health, Boston, MA, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T.H Chan School of Public Health, Boston, MA, USA
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Mégier C, Peoc’h K, Puy V, Cordier AG. Iron Metabolism in Normal and Pathological Pregnancies and Fetal Consequences. Metabolites 2022; 12:metabo12020129. [PMID: 35208204 PMCID: PMC8876952 DOI: 10.3390/metabo12020129] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 02/04/2023] Open
Abstract
Iron is required for energy production, DNA synthesis, and cell proliferation, mainly as a component of the prosthetic group in hemoproteins and as part of iron-sulfur clusters. Iron is also a critical component of hemoglobin and plays an important role in oxygen delivery. Imbalances in iron metabolism negatively affect these vital functions. As the crucial barrier between the fetus and the mother, the placenta plays a pivotal role in iron metabolism during pregnancy. Iron deficiency affects 1.2 billion individuals worldwide. Pregnant women are at high risk of developing or worsening iron deficiency. On the contrary, in frequent hemoglobin diseases, such as sickle-cell disease and thalassemia, iron overload is observed. Both iron deficiency and iron overload can affect neonatal development. This review aims to provide an update on our current knowledge on iron and heme metabolism in normal and pathological pregnancies. The main molecular actors in human placental iron metabolism are described, focusing on the impact of iron deficiency and hemoglobin diseases on the placenta, together with normal metabolism. Then, we discuss data concerning iron metabolism in frequent pathological pregnancies to complete the picture, focusing on the most frequent diseases.
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Affiliation(s)
- Charles Mégier
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Bicêtre, Université Paris Saclay, 94270 Le Kremlin-Bicetre, France;
| | - Katell Peoc’h
- Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie Clinique, HUPNVS, Hôpital Beaujon, Clichy and Université de Paris, UFR de Médecine Xavier Bichat, INSERM U1149, F-75018 Paris, France;
| | - Vincent Puy
- Unité de biologie de la Reproduction CECOS, Hôpital Antoine Béclère, Université Paris Saclay, 92140 Clamart, France;
- Laboratoire de Développement des Gonades, UMRE008 Stabilité Génétique Cellules Souches et Radiations, Université de Paris, Université Paris-Saclay, CEA, F-92265 Fontenay-aux-Roses, France
| | - Anne-Gaël Cordier
- INSERM, 3PHM, UMR-S1139, F-75006 Paris, France
- PremUp Foundation, F-75014 Paris, France
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie Obstétrique, Hôpital Antoine Béclère, Université Paris-Saclay, 92140 Clamart, France
- Correspondence: ; Tel.: +33-145374441; Fax: +33-45374366
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14
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Rees G, Brough L, Orsatti GM, Lodge A, Walker S. Do Micronutrient and Omega-3 Fatty Acid Supplements Affect Human Maternal Immunity during Pregnancy? A Scoping Review. Nutrients 2022; 14:367. [PMID: 35057548 PMCID: PMC8781537 DOI: 10.3390/nu14020367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/04/2022] [Accepted: 01/10/2022] [Indexed: 02/04/2023] Open
Abstract
Maternal dietary micronutrients and omega-3 fatty acids support development of the fetal and neonatal immune system. Whether supplementation is similarly beneficial for the mother during gestation has received limited attention. A scoping review of human trials was conducted looking for evidence of biochemical, genomic, and clinical effects of supplementation on the maternal immune system. The authors explored the literature on PubMed, Cochrane Library, and Web of Science databases from 2010 to the present day using PRISMA-ScR methodology. Full-length human trials in English were searched for using general terms and vitamin A, B12, C, D, and E; choline; iodine; iron; selenium; zinc; and docosahexaenoic/eicosapentaenoic acid. Of 1391 unique articles, 36 were eligible for inclusion. Diverse biochemical and epigenomic effects of supplementation were identified that may influence innate and adaptive immunity. Possible clinical benefits were encountered in malaria, HIV infections, anemia, Type 1 diabetes mellitus, and preventing preterm delivery. Only limited publications were identified that directly explored maternal immunity in pregnancy and the effects of micronutrients. None provided a holistic perspective. It is concluded that supplementation may influence biochemical aspects of the maternal immune response and some clinical outcomes, but the evidence from this review is not sufficient to justify changes to current guidelines.
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Affiliation(s)
- Gail Rees
- School of Biomedical Sciences, University of Plymouth, Drake Circus, Plymouth PL4 8AA, UK
| | - Louise Brough
- School of Food and Advanced Technology, Massey University, Palmerston North 4442, New Zealand
| | | | - Anna Lodge
- St Gilesmedical, London WC2H 8LG, UK; (A.L.); (S.W.)
| | - Steven Walker
- St Gilesmedical, London WC2H 8LG, UK; (A.L.); (S.W.)
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Abdallah F, John SE, Hancy A, Paulo HA, Sanga A, Noor R, Lankoande F, Chimanya K, Masumo RM, Leyna GH. Prevalence and factors associated with anaemia among pregnant women attending reproductive and child health clinics in Mbeya region, Tanzania. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000280. [PMID: 36962486 PMCID: PMC10021601 DOI: 10.1371/journal.pgph.0000280] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 09/12/2022] [Indexed: 03/26/2023]
Abstract
Anaemia is a global public health issue, disproportionately affecting vulnerable populations such as pregnant women. The aim of this study was to assess the prevalence of anaemia and to identify factors associated with the condition among pregnant women attending antenatal clinics in the Mbeya Region of Tanzania. A cross sectional study was conducted with 420 pregnant women (<28 weeks of gestation) attending antenatal visits in the 7 districts of the Mbeya Region. A structured questionnaire was used to collect demographic information and eating habits using a 24hours dietary recall. A blood sample was collected and tested for hemoglobin content using the HemoCue 201+. Multivariate analysis was performed using standard logistic regression to explore the association between anaemia status with socio-demographic, reproductive and nutritional factors. Overall prevalence of anaemia in pregnant women was 25.5%. Out of 107 pregnant women diagnosed with anaemia and, sixty six had mild anaemia. In a multivariate logistical regression analysis anaemic women was associated with pregnant women coming from lower socio-economic status [adjusted OR = 2.40, 95%CI (1.05, 5.48)]. Moreover, anaemia was less associated with pregnant women who were living in Mbeya district council [adjusted OR = 0.28, 95%CI (0.11, 0.72)], consume at least once a day dark green leafy vegetables [adjusted OR = 0.53, 95% CI (0.30, 0.94)], and vegetable liquid cooking oil [adjusted OR = 0.56, 95% CI (0.34, 0.98)]. The prevalence of anaemia among the pregnant women falls in the category of moderate public health problem according to the WHO classification. Low socio-economic status, consumption of green leafy vegetables and vegetable liquid cooking oil were significantly and independently associated with anaemia during pregnancy. Thus, special attention should be given to pregnant women who are in lower socio-economic status and those not consuming vegetables. Interventions that integrate health and nutrition education in reproductive and child health clinics are needed to combat anaemia.
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Affiliation(s)
- Fatma Abdallah
- Tanzania Food and Nutrition Centre, Dar es Salaam, Tanzania
| | - Sauli E John
- Tanzania Food and Nutrition Centre, Dar es Salaam, Tanzania
| | - Adam Hancy
- Tanzania Food and Nutrition Centre, Dar es Salaam, Tanzania
| | - Heavenlight A Paulo
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, MUHAS, Dar es Salaam, Tanzania
| | - Abraham Sanga
- The United Nations Children's Fund (UNICEF) Tanzania, Dar es Salaam, Tanzania
| | - Ramadhan Noor
- The United Nations Children's Fund (UNICEF) Tanzania, Dar es Salaam, Tanzania
| | - Fatoumata Lankoande
- The United Nations Children's Fund (UNICEF) Tanzania, Dar es Salaam, Tanzania
| | - Kudakwashe Chimanya
- The United Nations Children's Fund (UNICEF) Tanzania, Dar es Salaam, Tanzania
| | - Ray M Masumo
- Tanzania Food and Nutrition Centre, Dar es Salaam, Tanzania
| | - Germana H Leyna
- Tanzania Food and Nutrition Centre, Dar es Salaam, Tanzania
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, MUHAS, Dar es Salaam, Tanzania
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Unger HW, Laurita Longo V, Bleicher A, Ome-Kaius M, Karl S, Simpson JA, Karahalios A, Aitken EH, Rogerson SJ. The relationship between markers of antenatal iron stores and birth outcomes differs by malaria prevention regimen-a prospective cohort study. BMC Med 2021; 19:236. [PMID: 34607575 PMCID: PMC8491429 DOI: 10.1186/s12916-021-02114-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/31/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Iron deficiency (ID) has been associated with adverse pregnancy outcomes, maternal anaemia, and altered susceptibility to infection. In Papua New Guinea (PNG), monthly treatment with sulphadoxine-pyrimethamine plus azithromycin (SPAZ) prevented low birthweight (LBW; <2500 g) through a combination of anti-malarial and non-malarial effects when compared to a single treatment with SP plus chloroquine (SPCQ) at first antenatal visit. We assessed the relationship between ID and adverse birth outcomes in women receiving SPAZ or SPCQ, and the mediating effects of malaria infection and haemoglobin levels during pregnancy. METHODS Plasma ferritin levels measured at antenatal enrolment in a cohort of 1892 women were adjusted for concomitant inflammation using C-reactive protein and α-1-acid glycoprotein. Associations of ID (defined as ferritin <15 μg/L) or ferritin levels with birth outcomes (birthweight, LBW, preterm birth, small-for-gestational-age birthweight [SGA]) were determined using linear or logistic regression analysis, as appropriate. Mediation analysis assessed the degree of mediation of ID-birth outcome relationships by malaria infection or haemoglobin levels. RESULTS At first antenatal visit (median gestational age, 22 weeks), 1256 women (66.4%) had ID. Overall, ID or ferritin levels at first antenatal visit were not associated with birth outcomes. There was effect modification by treatment arm. Amongst SPCQ recipients, ID was associated with a 81-g higher mean birthweight (95% confidence interval [CI] 10, 152; P = 0.025), and a twofold increase in ferritin levels was associated with increased odds of SGA (adjusted odds ratio [aOR] 1.25; 95% CI 1.06, 1.46; P = 0.007). By contrast, amongst SPAZ recipients, a twofold increase in ferritin was associated with reduced odds of LBW (aOR 0.80; 95% CI 0.67, 0.94; P = 0.009). Mediation analyses suggested that malaria infection or haemoglobin levels during pregnancy do not substantially mediate the association of ID with birth outcomes amongst SPCQ recipients. CONCLUSIONS Improved antenatal iron stores do not confer a benefit for the prevention of adverse birth outcomes in the context of malaria chemoprevention strategies that lack the non-malarial properties of monthly SPAZ. Research to determine the mechanisms by which ID protects from suboptimal foetal growth is needed to guide the design of new malaria prevention strategies and to inform iron supplementation policy in malaria-endemic settings. TRIAL REGISTRATION ClinicalTrials.gov NCT01136850 .
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Affiliation(s)
- Holger W Unger
- Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Darwin, Northern Territory, Australia.,Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Valentina Laurita Longo
- Catholic University of Sacred Heart, Rome, Italy.,Department of Obstetrics and Gynaecology, San Pietro-Fatebenefratelli Hospital, Rome, Italy
| | - Andie Bleicher
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Stephan Karl
- Australian Institute of Tropical Health & Medicine, James Cook University, Cairns, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth H Aitken
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen J Rogerson
- Department of Medicine (RMH), Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia. .,Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia.
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17
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Sunguya BF, Ge Y, Mlunde L, Mpembeni R, Leyna G, Huang J. High burden of anemia among pregnant women in Tanzania: a call to address its determinants. Nutr J 2021; 20:65. [PMID: 34238307 PMCID: PMC8268339 DOI: 10.1186/s12937-021-00726-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/03/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Anemia in pregnancy is behind a significant burden of maternal mortality and poor birth outcomes globally. Efforts to address it need evidence on trends and its pertinent factors as they vary from one area to another. METHODS We pooled data of 23,203 women of reproductive age whose hemoglobin levels were measured from two Tanzania Demographic and Health Surveys (TDHS). Of them, 2,194 women were pregnant. Analyses employed descriptive analyses to determine the burden of anemia, its characteristics, and severity; GIS mapping to determine the regional changes of anemia between 2005 and 2015; and logistic regression to determine the remaining determinants of anemia among pregnant women using Stata 15. RESULTS The burden of anemia among pregnant women in Tanzania has remained unprecedently high, and varies between regions. There was no significant decline of anemia in general between the two periods after adjusting for individual, households, reproductive, and child characteristics [AOR = 0.964, 95% CI = 0.774-1.202, p = 0.747). Anemia is currently prevalent in 57% of pregnant women in Tanzania. The prevalence is more likely to be higher among women aged 15-19 years than those aged between 20-34 years. It is more likely to be prevalent among those within large families, with no formal education, food insecurity, lack of health insurance, had no antimalaria during pregnancy, and had low frequency of ANC attendance. On the other hand, delivery in a health facility may be potentially protective against anemia. CONCLUSIONS Anemia in pregnancy remained persistently high and prevalent among 57% of pregnant women in Tanzania. Efforts to address anemia are crucial and need to be focused in regions with increasing burden of anemia among pregnant women. It is imperative to address important risk factors such as food insecurity, strengthening universal health coverage, empowering women of reproductive age with education and especially nutritional knowledge and advocating for early antenatal booking, attendance, and facility delivery.
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Affiliation(s)
- Bruno F Sunguya
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Yue Ge
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China
- Key Laboratory of Health Technology Assessment, National Health Commission, Shanghai, China
| | - Linda Mlunde
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Implementation Science Tanzania, Dar es Salaam, Tanzania
| | - Rose Mpembeni
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Germana Leyna
- Tanzania Food and Nutrition Center, Dar es Salaam, Tanzania
| | - Jiayan Huang
- Global Health Institute, School of Public Health, Fudan University, Shanghai, China.
- Key Laboratory of Health Technology Assessment, National Health Commission, Shanghai, China.
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18
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Ilboudo B, Savadogo LGB, Traoré I, Meda CZ, Kinda M, Sombié I, Dramaix-Wilmet M, Donnen P. Effect of Personalized Support at Home on the Prevalence of Anemia in Pregnancy in Burkina Faso: A Cluster Randomized Trial. Am J Trop Med Hyg 2021; 105:207-216. [PMID: 34097646 DOI: 10.4269/ajtmh.20-1043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 03/01/2021] [Indexed: 11/07/2022] Open
Abstract
Burkina Faso has high prevalence of anemia in pregnancy (hemoglobin < 11 g/dL), despite the implementation of the WHO recommended guidelines. This study aimed to test the effects of personalized support for pregnant women at home on the trend of anemia prevalence in pregnancy. A cluster randomized trial was conducted from January 2015 to August 2016 at Sindou health district in Burkina Faso. Data were collected from 617 women in their first or second trimester of pregnancy, including 440 and 177 women in the intervention and control groups, respectively. The intervention consisted of a monthly home-based visit to the pregnant woman, focusing on nutritional counseling and pregnancy management, alongside an improvement antenatal visit quality. Compared with the prevalence of anemia in pregnancy in the control group [64.0% (95% confidence interval [CI]: 52.1-74.4%)], that of the intervention group was significantly lower from the fifth home visit onward [36.8% (95% CI: 32.1-41.8%)] (P < 0.001). The adjusted difference-in-differences in anemia prevalence between the two groups was -19.8% (95% CI: -30.2% to -9.4%) for women who received more than four home visits (P < 0.001). The corresponding difference in hemoglobin levels was 0.644 g/dL (95% CI: 0.309-0.167; P < 0.001). Personalized support for pregnant women at home, combined with appropriate antenatal care, can significantly reduce anemia prevalence during pregnancy in rural Burkina Faso.
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Affiliation(s)
- Bernard Ilboudo
- 1Centre Muraz, Institut National de Santé Publique, Bobo-Dioulasso, Burkina Faso.,3Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
| | - Léon G B Savadogo
- 2Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Isidore Traoré
- 1Centre Muraz, Institut National de Santé Publique, Bobo-Dioulasso, Burkina Faso.,2Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Clément Z Meda
- 2Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Maurice Kinda
- 2Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | - Issiaka Sombié
- 2Institut Supérieur des Sciences de la Santé, Université Nazi Boni, Bobo-Dioulasso, Burkina Faso
| | | | - Philippe Donnen
- 3Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
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Keats EC, Oh C, Chau T, Khalifa DS, Imdad A, Bhutta ZA. Effects of vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: A systematic review. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1127. [PMID: 37051178 PMCID: PMC8356361 DOI: 10.1002/cl2.1127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Almost two billion people who are deficient in vitamins and minerals are women and children in low- and middle-income countries (LMIC). These deficiencies are worsened during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child. To reduce micronutrient deficiencies, several strategies have been implemented, including diet diversification, large-scale and targeted fortification, staple crop bio-fortification and micronutrient supplementation. Objectives To evaluate and summarize the available evidence on the effects of micronutrient supplementation during pregnancy in LMIC on maternal, fetal, child health and child development outcomes. This review will assess the impact of single micronutrient supplementation (calcium, vitamin A, iron, vitamin D, iodine, zinc, vitamin B12), iron-folic acid (IFA) supplementation, multiple micronutrient (MMN) supplementation, and lipid-based nutrient supplementation (LNS) during pregnancy. Search Methods We searched papers published from 1995 to 31 October 2019 (related programmes and good quality studies pre-1995 were limited) in CAB Abstracts, CINAHL, Cochrane Central Register of Controlled Trials, Embase, International Initiative for Impact Evaluations, LILACS, Medline, POPLINE, Web of Science, WHOLIS, ProQuest Dissertations & Theses Global, R4D, WHO International Clinical Trials Registry Platform. Non-indexed grey literature searches were conducted using Google, Google Scholar, and web pages of key international nutrition agencies. Selection Criteria We included randomized controlled trials (individual and cluster-randomized) and quasi-experimental studies that evaluated micronutrient supplementation in healthy, pregnant women of any age and parity living in a LMIC. LMIC were defined by the World Bank Group at the time of the search for this review. While the aim was to include healthy pregnant women, it is likely that these populations had one or more micronutrient deficiencies at baseline; women were not excluded on this basis. Data Collection and Analysis Two authors independently assessed studies for inclusion and risk of bias, and conducted data extraction. Data were matched to check for accuracy. Quality of evidence was assessed using the GRADE approach. Main Results A total of 314 papers across 72 studies (451,723 women) were eligible for inclusion, of which 64 studies (439,649 women) contributed to meta-analyses. Seven studies assessed iron-folic acid (IFA) supplementation versus folic acid; 34 studies assessed MMN vs. IFA; 4 studies assessed LNS vs. MMN; 13 evaluated iron; 13 assessed zinc; 9 evaluated vitamin A; 11 assessed vitamin D; and 6 assessed calcium. Several studies were eligible for inclusion in multiple types of supplementation. IFA compared to folic acid showed a large and significant (48%) reduction in the risk of maternal anaemia (average risk ratio (RR) 0.52, 95% CI 0.41 to 0.66; studies = 5; participants = 15,540; moderate-quality evidence). As well, IFA supplementation demonstrated a smaller but significant, 12% reduction in risk of low birthweight (LBW) babies (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). MMN supplementation was defined as any supplement that contained at least 3 micronutrients. Post-hoc analyses were conducted, where possible, comparing the differences in effect of MMN with 4+ components and MMN with 3 or 4 components. When compared to iron with or without FA, MMN supplementation reduced the risk of LBW by 15% (average RR 0.85, 95% CI 0.77 to 0.93; studies = 28; participants = 79,972); this effect was greater in MMN with >4 micronutrients (average RR 0.79, 95% CI 0.71 to 0.88; studies = 19; participants = 68,138 versus average RR 1.01, 95% CI 0.92 to 1.11; studies = 9; participants = 11,834). There was a small and significant reduction in the risk of stillbirths (average RR 0.91; 95% CI 0.86 to 0.98; studies = 22; participants = 96,772) and a small and significant effect on the risk of small-for-gestational age (SGA) (average RR 0.93; 95% CI 0.88 to 0.98; studies = 19; participants = 52,965). For stillbirths and SGA, the effects were greater among those provided MMN with 4+ micronutrients. Children whose mothers had been supplemented with MMN, compared to IFA, demonstrated a 16% reduced risk of diarrhea (average RR 0.84; 95% CI 0.76 to 0.92; studies = 4; participants = 3,142). LNS supplementation, compared to MMN, made no difference to any outcome; however, the evidence is limited. Iron supplementation, when compared to no iron or placebo, showed a large and significant effect on maternal anaemia, a reduction of 47% (average RR 0.53, 95% CI 0.43 to 0.65; studies = 6; participants = 15,737; moderate-quality evidence) and a small and significant effect on LBW (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). Zinc and vitamin A supplementation, each both compared to placebo, had no impact on any outcome examined with the exception of potentially improving serum/plasma zinc (mean difference (MD) 0.43 umol/L; 95% CI -0.04 to 0.89; studies = 5; participants = 1,202) and serum/plasma retinol (MD 0.13 umol/L; 95% CI -0.03 to 0.30; studies = 6; participants = 1,654), respectively. When compared to placebo, vitamin D supplementation may have reduced the risk of preterm births (average RR 0.64; 95% CI 0.40 to 1.04; studies = 7; participants = 1,262), though the upper CI just crosses the line of no effect. Similarly, calcium supplementation versus placebo may have improved rates of pre-eclampsia/eclampsia (average RR 0.45; 95% CI 0.19 to 1.06; studies = 4; participants = 9,616), though the upper CI just crosses 1. Authors' Conclusions The findings suggest that MMN and vitamin supplementation improve maternal and child health outcomes, including maternal anaemia, LBW, preterm birth, SGA, stillbirths, micronutrient deficiencies, and morbidities, including pre-eclampsia/eclampsia and diarrhea among children. MMN supplementation demonstrated a beneficial impact on the most number of outcomes. In addition, MMN with >4 micronutrients appeared to be more impactful than MMN with only 3 or 4 micronutrients included in the tablet. Very few studies conducted longitudinal analysis on longer-term health outcomes for the child, such as anthropometric measures and developmental outcomes; this may be an important area for future research. This review may provide some basis to guide continual discourse around replacing IFA supplementation with MMN along with the use of single micronutrient supplementation programs for specific outcomes.
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Affiliation(s)
- Emily C. Keats
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Christina Oh
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Tamara Chau
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Dina S. Khalifa
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - Aamer Imdad
- PediatricsUpstate Medical University, SyracuseNew YorkUSA
| | - Zulfiqar A. Bhutta
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
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20
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Yang J, Wang D, Darling AM, Liu E, Perumal N, Fawzi WW, Wang M. Methodological approaches to imputing early-pregnancy weight based on weight measures collected during pregnancy. BMC Med Res Methodol 2021; 21:24. [PMID: 33546607 PMCID: PMC7863454 DOI: 10.1186/s12874-021-01210-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022] Open
Abstract
Background Early pregnancy weights are needed to quantify gestational weight gain accurately. Different methods have been used in previous studies to impute early-pregnancy weights. However, no studies have systematically compared imputed weight accuracy across different imputation techniques. This study aimed to compare four methodological approaches to imputing early-pregnancy weight, using repeated measures of pregnancy weights collected from two pregnancy cohorts in Tanzania. Methods The mean gestational ages at enrollment were 17.8 weeks for Study I and 10.0 weeks for Study II. Given the gestational age distributions at enrollment, early-pregnancy weights were extrapolated for Study I and interpolated for Study II. The four imputation approaches included: (i) simple imputation based on the nearest measure, (ii) simple arithmetic imputation based on the nearest two measures, (iii) mixed-effects models, and (iv) marginal models with generalized estimating equations. For the mixed-effects model and the marginal model with generalized estimating equation methods, imputation accuracy was further compared across varying degrees of model flexibility by fitting splines and polynomial terms. Additional analyses included dropping third-trimester weights, adding covariate to the models, and log-transforming weight before imputation. Mean absolute error was used to quantify imputation accuracy. Results Study I included 1472 women with 6272 weight measures; Study II included 2131 individuals with 11,775 weight measures. Among the four imputation approaches, mixed-effects models had the highest accuracy (smallest mean absolute error: 1.99 kg and 1.60 kg for Studies I and II, respectively), while the other three approaches showed similar degrees of accuracy. Depending on the underlying data structure, allowing appropriate degree of model flexibility and dropping remote pregnancy weight measures may further improve the imputation performance. Conclusions Mixed-effects models had superior performance in imputing early-pregnancy weight compared to other commonly used strategies. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01210-3.
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Affiliation(s)
- Jiaxi Yang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02215, USA
| | - Dongqing Wang
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Nandita Perumal
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Wafaie W Fawzi
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02215, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Nutrition, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Molin Wang
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02215, USA. .,Department of Biostatistics, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02215, USA. .,Channing Division of Network Medicine, Harvard Medical School and Brigham and Women's Hosptial, Boston, MA, USA.
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21
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Abioye AI, Aboud S, Premji Z, Etheredge AJ, Gunaratna NS, Sudfeld CR, Noor RA, Hertzmark E, Spiegelman D, Duggan C, Fawzi W. Hemoglobin and hepcidin have good validity and utility for diagnosing iron deficiency anemia among pregnant women. Eur J Clin Nutr 2020; 74:708-719. [PMID: 31624364 PMCID: PMC7162716 DOI: 10.1038/s41430-019-0512-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND/OBJECTIVES Screening and diagnosis of iron deficiency anemia (IDA) is cumbersome as it may require testing for hemoglobin, ferritin, and an inflammatory biomarker. The aim of this study was to compare the diagnostic capacity of hematologic biomarkers to detect IDA among pregnant women in Tanzania. SUBJECTS/METHODS We pooled data from an iron supplementation trial of 1500 iron-replete pregnant woman and a prospective cohort of 600 iron-deficient pregnant women. Receiver operating characteristic curves (ROC) for hematologic biomarkers were used to assess the sensitivity, specificity, and area under the curve (AUC) for iron deficiency (ID) and iron deficiency anemia (IDA), crude, or corrected for inflammation. Regression models assessed the relationship of baseline biomarker categories (gestational age <27 weeks) and IDA at delivery. RESULTS Hemoglobin had the largest AUC for crude ID (0.96), while hepcidin had the largest AUC for corrected ID (0.80). The optimal hepcidin cutoff for the diagnosis of corrected IDA based on maximal sensitivity and specificity was ≤1.6 µg/L. An hepcidin cutoff of <4.3 µg/L had a sensitivity of 95% for regression-corrected ID. Among iron-replete women who did not receive iron, the association of baseline hemoglobin >110 g/L with IDA at delivery (RR = 0.73; 95% CI: 0.47, 1.13) was attenuated. Baseline hepcidin >1.6 µg/L was associated with reduced risk of anemia at delivery by 49% (95% CI: 27%, 45%). CONCLUSIONS Ascertaining hemoglobin and hepcidin levels may improve the targeting of iron supplementation programs in resource-limited countries, though hepcidin's high costs may limit its use.
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Affiliation(s)
- Ajibola I Abioye
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Said Aboud
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Zulfiqarali Premji
- Department of Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Analee J Etheredge
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ramadhani A Noor
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Center on Methods for Implementation and Prevention Science, Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Christopher Duggan
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Wafaie Fawzi
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Mikomangwa WP, Minzi O, Mutagonda R, Baraka V, Mlugu EM, Aklillu E, Kamuhabwa AAR. Effect of sulfadoxine-pyrimethamine doses for prevention of malaria during pregnancy in hypoendemic area in Tanzania. Malar J 2020; 19:160. [PMID: 32306955 PMCID: PMC7168863 DOI: 10.1186/s12936-020-03234-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria in pregnancy increases the risk of deleterious maternal and birth outcomes. The use of ≥ 3 doses of sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria (IPTp-SP) is recommended for preventing the consequences of malaria during pregnancy. This study assessed the effect of IPTp-SP for prevention of malaria during pregnancy in low transmission settings. METHODS A cross-sectional study that involved consecutively selected 1161 pregnant women was conducted at Mwananyamala regional referral hospital in Dar es Salaam. Assessment of the uptake of IPTp-SP was done by extracting information from antenatal clinic cards. Maternal venous blood, cord blood, placental blood and placental biopsy were collected for assessment of anaemia and malaria. High performance liquid chromatography with ultraviolet detection (HPLC-UV) was used to detect and quantify sulfadoxine (SDX). Dried blood spots (DBS) of placental blood were collected for determination of sub-microscopic malaria using polymerase chain reaction (PCR). RESULTS In total, 397 (34.2%) pregnant women reported to have used sub-optimal doses (≤ 2) while 764 (65.8%) used optimal doses (≥ 3) of IPTp-SP at the time of delivery. The prevalence of placental malaria as determined by histology was 3.6%. Submicroscopic placental malaria was detected in 1.4% of the study participants. Women with peripheral malaria had six times risk of maternal anaemia than those who were malaria negative (aOR, 5.83; 95% CI 1.10-30.92; p = 0.04). The geometric mean plasma SDX concentration was 10.76 ± 2.51 μg/mL. Sub-optimal IPTp-SP dose was not associated with placental malaria, premature delivery and fetal anaemia. The use of ≤ 2 doses of IPTp-SP increased the risk of maternal anaemia by 1.36-fold compared to ≥ 3 doses (aOR, 1.36; 95% CI 1.04-1.79; p = 0.02). CONCLUSION The use of < 2 doses of IPTp-SP increased the risk of maternal anaemia. However, sub-optimal doses (≤ 2 doses) were not associated with increased the risk of malaria parasitaemia, fetal anaemia and preterm delivery among pregnant women in low malaria transmission setting. The use of optimal doses (≥ 3 doses) of IPTp-SP and complementary interventions should continue even in areas with low malaria transmission.
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Affiliation(s)
- Wigilya P Mikomangwa
- Clinical Pharmacy and Pharmacology Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania.
| | - Omary Minzi
- Clinical Pharmacy and Pharmacology Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Ritah Mutagonda
- Clinical Pharmacy and Pharmacology Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Vito Baraka
- National Institute for Medical Research, Tanga Centre, Tanga, United Republic of Tanzania
| | - Eulambius M Mlugu
- Pharmaceutics and Pharmacy Practice Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital-Huddinge C1:68, 141 86, Stockholm, Sweden
| | - Appolinary A R Kamuhabwa
- Clinical Pharmacy and Pharmacology Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
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Passarelli S, Bromage S, Darling AM, Wang J, Aboud S, Mugusi F, Griffiths JK, Fawzi W. Aflatoxin exposure in utero and birth and growth outcomes in Tanzania. MATERNAL & CHILD NUTRITION 2020; 16:e12917. [PMID: 31823516 PMCID: PMC7083471 DOI: 10.1111/mcn.12917] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/03/2019] [Accepted: 10/31/2019] [Indexed: 01/09/2023]
Abstract
Some evidence suggests that aflatoxin may contribute to the high prevalence of stunting observed in low-income countries. Whereas several studies have been conducted in West Africa, fewer exist in East Africa and even fewer in nonagricultural contexts. We analyzed serum samples from 400 iron-replete, nonanemic pregnant women from a cohort in Dar es Salaam, Tanzania to determine the extent and magnitude of exposure to aflatoxin and to study the relationship between levels of aflatoxin exposure in utero and infant birth and growth outcomes. Ninety-nine percent of women had detectable concentrations of aflatoxin B1-lysine (AFB1-lysine), with a median level of 1.4-pg/mg albumin, indicating a much lower level compared to studies of rural populations in sub-Saharan Africa. Our results do not show a statistically significant relationship between AFB1-lysine levels and birth weight, small for gestational age, or prematurity. We observe a small statistically significant reduction in gestational age at delivery (0.47 weeks; 95% CI: -0.86, -0.07) as the natural log of AFB1-lysine levels increases by 1 unit of pg/mg of albumin, after controlling for potential confounders. Among a nonrandom set of infants who had measurements for placental weight, haemoglobin at delivery, and follow-up z-score measurements, we find no association between aflatoxin plasma concentrations and these variables. These findings suggest a high prevalence of chronic low-level exposure to aflatoxin, though its effect on birth outcomes in this population remains unclear. Our research adds to a growing body of literature finding mixed associations between aflatoxins on pregnancy outcomes and child growth.
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Affiliation(s)
- Simone Passarelli
- Department of NutritionHarvard T.H. Chan School of Public HealthBostonMassachusetts
| | - Sabri Bromage
- Department of NutritionHarvard T.H. Chan School of Public HealthBostonMassachusetts
| | - Anne Marie Darling
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusetts
| | - Jia‐Sheng Wang
- Department of Environmental Health ScienceUniversity of GeorgiaAthensGeorgia
| | - Said Aboud
- Department of Microbiology and ImmunologyMuhimbili University of Health and Allied SciencesSalaamTanzania
| | - Ferdinand Mugusi
- Department of Internal MedicineMuhimbili University of Health and Allied SciencesSalaamTanzania
| | - Jeffrey K. Griffiths
- Department of Public Health and Community MedicineTufts University School of MedicineBostonMassachusetts
| | - Wafaie Fawzi
- Department of NutritionHarvard T.H. Chan School of Public HealthBostonMassachusetts
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusetts
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusetts
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24
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Oh C, Keats EC, Bhutta ZA. Vitamin and Mineral Supplementation During Pregnancy on Maternal, Birth, Child Health and Development Outcomes in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis. Nutrients 2020; 12:E491. [PMID: 32075071 PMCID: PMC7071347 DOI: 10.3390/nu12020491] [Citation(s) in RCA: 93] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/29/2020] [Accepted: 02/05/2020] [Indexed: 12/14/2022] Open
Abstract
Almost two billion people are deficient in key vitamins and minerals, mostly women and children in low- and middle-income countries (LMICs). Deficiencies worsen during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child, but could be mitigated by interventions like micronutrient supplementation. To our knowledge, this is the first systematic review that aimed to compile evidence from both efficacy and effectiveness trials, evaluating different supplementation interventions on maternal, birth, child health, and developmental outcomes. We evaluated randomized controlled trials and quasi-experimental studies published since 1995 in peer-reviewed and grey literature that assessed the effects of calcium, vitamin A, iron, vitamin D, and zinc supplementation compared to placebo/no treatment; iron-folic (IFA) supplementation compared to folic acid only; multiple micronutrient (MMN) supplementation compared to IFA; and lipid-based nutrient supplementation (LNS) compared to MMN supplementation. Seventy-two studies, which collectively involved 314 papers (451,723 women), were included. Meta-analyses showed improvement in several key birth outcomes, such as preterm birth, small-for-gestational age (SGA) and low birthweight with MMN supplementation, compared to IFA. MMN also improved child outcomes, including diarrhea incidence and retinol concentration, which are findings not previously reported. Across all comparisons, micronutrient supplementation had little to no effect on mortality (maternal, neonatal, perinatal, and infant) outcomes, which is consistent with other systematic reviews. IFA supplementation showed notable improvement in maternal anemia and the reduction in low birthweight, whereas LNS supplementation had no apparent effect on outcomes; further research that compares LNS and MMN supplementation could help understand differences with these commodities. For single micronutrient supplementation, improvements were noted in only a few outcomes, mainly pre-eclampsia/eclampsia (calcium), maternal anemia (iron), preterm births (vitamin D), and maternal serum zinc concentration (zinc). These findings highlight that micronutrient-specific supplementation should be tailored to specific groups or needs for maximum benefit. In addition, they further contribute to the ongoing discourse of choosing antenatal MMN over IFA as the standard of care in LMICs.
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Affiliation(s)
- Christina Oh
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (C.O.); (E.C.K.)
| | - Emily C. Keats
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (C.O.); (E.C.K.)
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 0A4, Canada; (C.O.); (E.C.K.)
- Centre of Excellence in Women and Child’s Health, Aga Khan University, Karachi 74800, Pakistan
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25
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Noor RA, Abioye AI, Darling AM, Hertzmark E, Aboud S, Premji Z, Mugusi FM, Duggan C, Sudfeld CR, Spiegelman D, Fawzi W. Prenatal Zinc and Vitamin A Reduce the Benefit of Iron on Maternal Hematologic and Micronutrient Status at Delivery in Tanzania. J Nutr 2020; 150:240-248. [PMID: 31618430 PMCID: PMC7373818 DOI: 10.1093/jn/nxz242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/28/2019] [Accepted: 09/11/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Zinc and vitamin A supplementation have both been shown to affect iron status, hemoglobin (Hb) concentration, and anemia in animal and human studies. However, evidence on their combined use in pregnancy, in the context of iron-folic acid (IFA) supplementation, remains limited. OBJECTIVE This study determined the effects of prenatal zinc, vitamin A, and iron supplementation on maternal hematologic and micronutrient status at delivery in Tanzania. METHODS We analyzed 2 large randomized controlled trials, using generalized estimating equations, and examined the effect of daily zinc (25 mg) and vitamin A (2500 IU) supplementation starting in the first trimester of pregnancy compared with placebo (n = 2500), and separately evaluated the safety and efficacy of daily iron (60 mg) supplementation among iron-replete pregnant women (n = 1500). Blood samples from baseline and delivery were tested for Hb, serum ferritin, soluble transferrin receptor, plasma zinc, and zinc protoporphyrin. RESULTS Zinc and vitamin A supplementation were associated with lower Hb concentrations at delivery of -0.26 g/dL (95% CI: -0.50, -0.02 g/dL) and -0.25 g/dL (95% CI: -0.49, -0.01 g/dL), respectively. Vitamin A increased mean ferritin concentrations at delivery (14.3 μg/L, 95% CI: 1.84, 29.11 μg/L), but was associated with increased risk of severe anemia (RR: 1.41; 95% CI: 1.06, 1.88). Among women who were iron replete at baseline, iron supplementation reduced the risk of iron depletion at delivery by 47% (RR: 0.53; 95% CI: 0.43, 0.65). There was no effect of zinc or iron supplements on plasma zinc concentrations. CONCLUSIONS Our findings support existing WHO guidelines on prenatal iron, vitamin A, and zinc supplementation among pregnant women. In this setting, scaling uptake of prenatal iron supplements is warranted, but prenatal zinc and vitamin A supplementation did not benefit maternal hematologic status at delivery. In settings where vitamin A deficiency is endemic, the efficacy and safety of the WHO recommended prenatal vitamin A supplementation require further evaluation.
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Affiliation(s)
- Ramadhani A Noor
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ajibola I Abioye
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Anne Marie Darling
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Said Aboud
- Department of Microbiology and Immunology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Zulfiqarali Premji
- Department of Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Ferdinand M Mugusi
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher Duggan
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Donna Spiegelman
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Wafaie Fawzi
- Department of Nutrition, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
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26
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Gies S, Diallo S, Roberts SA, Kazienga A, Powney M, Brabin L, Ouedraogo S, Swinkels DW, Geurts-Moespot AJ, Claeys Y, D'Alessandro U, Tinto H, Faragher B, Brabin B. Effects of Weekly Iron and Folic Acid Supplements on Malaria Risk in Nulliparous Women in Burkina Faso: A Periconceptional, Double-Blind, Randomized Controlled Noninferiority Trial. J Infect Dis 2019; 218:1099-1109. [PMID: 29733403 PMCID: PMC6107738 DOI: 10.1093/infdis/jiy257] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/02/2018] [Indexed: 01/10/2023] Open
Abstract
Background The safety of iron supplementation for young women is uncertain in malaria-endemic settings. Methods This was a double-blind, randomized controlled noninferiority trial in rural Burkina Faso. Results A total of 1959 nulliparae were assigned to weekly supplementation (60 mg iron and 2.8 mg folic acid) (n = 980) or 2.8 mg folic acid (n = 979) until first antenatal visit (ANC1), or 18 months if remaining nonpregnant. Three hundred fifteen women attended ANC1, and 916 remained nonpregnant. There was no difference at ANC1 in parasitemia prevalence (iron, 53.4% [95% confidence interval {CI}, 45.7%–61.0%]; control, 55.3% [95% CI, 47.3%–62.9%]; prevalence ratio, 0.97 [95% CI, .79–1.18]; P = .82), anemia (adjusted effect, 0.96 [95% CI, .83–1.10]; P = .52), iron deficiency (adjusted risk ratio [aRR], 0.84 [95% CI, .46–1.54]; P = .58), or plasma iron biomarkers. Outcomes in nonpregnant women were parasitemia (iron, 42.9% [95% CI, 38.3%–47.5%]; control, 39.2% [95% CI, 34.9%–43.7%]; prevalence ratio, 1.09 [95% CI, .93–1.28]; P = .282); anemia (aRR, 0.90 [95% CI, .78–1.05]; P = .17), and iron deficiency (aRR, 0.99 [95% CI, .77–1.28]; P = .96), with no iron biomarker differences. Conclusions Weekly iron supplementation did not increase malaria risk, improve iron status, or reduce anemia in young, mostly adolescent menstruating women, nor in early pregnancy. World Health Organization Guidelines for universal supplementation for young nulliparous women may need reassessment. Clinical Trials Registration NCT01210040.
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Affiliation(s)
- Sabine Gies
- Department of Biomedical Sciences, Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium.,Medical Mission Institute, Würzburg, Germany
| | - Salou Diallo
- Institute for Research in Health Sciences, Clinical Research Unit of Nanoro, Burkina Faso
| | - Stephen A Roberts
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre (MAHSC), United Kingdom
| | - Adama Kazienga
- Institute for Research in Health Sciences, Clinical Research Unit of Nanoro, Burkina Faso
| | - Matthew Powney
- Clinical Division, Liverpool School of Tropical Medicine, University of Manchester, MAHSC, United Kingdom
| | - Loretta Brabin
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, MAHSC, United Kingdom
| | - Sayouba Ouedraogo
- Institute for Research in Health Sciences, Clinical Research Unit of Nanoro, Burkina Faso
| | - Dorine W Swinkels
- Department of Laboratory Medicine, Radboud University Nijmegen Medical Center, and HepcidinAnalysis.com, The Netherlands
| | - Anneke J Geurts-Moespot
- Department of Laboratory Medicine, Radboud University Nijmegen Medical Center, and HepcidinAnalysis.com, The Netherlands
| | - Yves Claeys
- Clinical Trials Unit, Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium
| | - Umberto D'Alessandro
- Medical Research Council Unit, Banjul, The Gambia.,London School of Hygiene and Tropical Medicine, University of Liverpool, United Kingdom
| | - Halidou Tinto
- Institute for Research in Health Sciences, Clinical Research Unit of Nanoro, Burkina Faso
| | - Brian Faragher
- Clinical Division, Liverpool School of Tropical Medicine, University of Manchester, MAHSC, United Kingdom
| | - Bernard Brabin
- Clinical Division, Liverpool School of Tropical Medicine, University of Manchester, MAHSC, United Kingdom.,Institute of Infection and Global Health, University of Liverpool, United Kingdom.,Global Child Health Group, Academic Medical Centre, University of Amsterdam, The Netherlands
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27
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Symington EA, Baumgartner J, Malan L, Wise AJ, Ricci C, Zandberg L, Smuts CM. Maternal iron-deficiency is associated with premature birth and higher birth weight despite routine antenatal iron supplementation in an urban South African setting: The NuPED prospective study. PLoS One 2019; 14:e0221299. [PMID: 31479449 PMCID: PMC6719862 DOI: 10.1371/journal.pone.0221299] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/02/2019] [Indexed: 02/06/2023] Open
Abstract
Background Recent studies are suggesting a U-shaped relationship between antenatal iron exposure and birth outcomes. Little is known about the iron status and associated birth outcomes of pregnant women in South Africa. Our aim was to assess iron status at early, mid- and late pregnancy, and to determine associations with gestational age and birth weight in women in Johannesburg, South Africa. Methods In this prospective study of 250 pregnant women, we measured haemoglobin, biomarkers of iron status and inflammation at <18, 22 and 36 weeks of gestation, plus birth weight and gestational age at delivery. Associations of anaemia and iron status with birth outcomes were determined using regression models adjusted for confounders. Results At enrolment, the prevalence of anaemia, iron depletion (ID) and iron deficiency erythropoiesis (IDE) was 29%, 15% and 15%, respectively, and increased significantly with pregnancy progression. Anaemia and ID at 22 weeks, as well as IDE at 36 weeks were associated with higher birth weight (β = 135.4; 95% CI: 4.8, 266.1 and β = 205.4; 95% CI: 45.6, 365.1 and β = 178.0; 95% CI: 47.3, 308.7, respectively). Women in the lowest ferritin quartile at 22 weeks gave birth to babies weighing 312 g (95% CI: 94.8, 528.8) more than those in the highest quartile. In contrast, IDE at 22 weeks was associated with a higher risk for premature birth (OR: 3.57, 95% CI: 1.24, 10.34) and women in lower haemoglobin quartiles at <18 weeks had a shorter gestation by 7 days (β = -6.9, 95% CI: -13.3, -0.6) compared to those in the highest quartile. Conclusion Anaemia, ID and IDE prevalence increased during pregnancy despite routine iron supplementation. ID and anaemia at mid-pregnancy were associated with higher birth weight, while IDE was associated with premature birth. These results suggest that current antenatal screening and supplementation practices in South Africa need to be revisited.
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Affiliation(s)
- Elizabeth A. Symington
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
- Department of Life and Consumer Sciences, University of South Africa, Johannesburg, South Africa
- * E-mail:
| | - Jeannine Baumgartner
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
- Human Nutrition Laboratory, Institute of Food, Nutrition and Health, ETH Zürich, Switzerland
| | - Linda Malan
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Amy J. Wise
- Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa
- Empilweni Services and Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Cristian Ricci
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Lizelle Zandberg
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Cornelius M. Smuts
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
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Mkhize PZ, Naicker T, Onyangunga OA, Moodley J. Adherence to iron prophylactic therapy during pregnancy in an urban regional hospital in South Africa. S Afr Fam Pract (2004) 2019. [DOI: 10.1080/20786190.2019.1654705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Princess Z Mkhize
- Women’s Health and HIV Research Group, Department of Obstetrics and Gynaecology
| | - T Naicker
- Optics and Imaging Centre, University of KwaZulu-Natal, South Africa
| | - OA Onyangunga
- Optics and Imaging Centre, University of KwaZulu-Natal, South Africa
| | - J Moodley
- Women’s Health and HIV Research Group, Department of Obstetrics and Gynaecology
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Abstract
This review focuses on pre- and post-natal iron supplementation in malaria endemic settings. Although iron supplementation can reduce iron deficiency, malaria infection may counteract this effect by the increase of hepcidin, and iron supplementation may further worsen malaria infection by providing additional iron for the parasites. However, most iron supplementation intervention studies in pregnant women with malaria have not shown a negative impact, although malaria treatment with iron supplementation may be beneficial in terms of improving birth outcomes. In infants and young children in malaria endemic settings, the adverse effects of iron supplementation has been well documented and malaria prevention and treatment with iron supplementation is recommended. Besides fostering the growth of malaria parasites, iron may also promote potential pathogens in the gut and cause an inflammatory response in young children. Overall, iron supplementation is beneficial for treating iron deficiency, but needs to be considered in the context of malaria prevention and treatment in pregnant women, infants and young children for safety and effectiveness.
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MESH Headings
- Adult
- Anemia, Iron-Deficiency/prevention & control
- Child, Preschool
- Dietary Supplements/adverse effects
- Endemic Diseases
- Female
- Guidelines as Topic
- Hepcidins/blood
- Humans
- Infant
- Infant, Newborn
- Iron, Dietary/administration & dosage
- Iron, Dietary/adverse effects
- Iron, Dietary/therapeutic use
- Malaria/blood
- Malaria/drug therapy
- Male
- Maternal Health
- Maternal Nutritional Physiological Phenomena
- Pregnancy
- Pregnancy Complications, Infectious/blood
- Pregnancy Complications, Infectious/drug therapy
- Pregnancy Complications, Parasitic/blood
- Pregnancy Complications, Parasitic/drug therapy
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Affiliation(s)
- Minghua Tang
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, 12700 E 19th Avenue Box C225, Aurora, CO 80045, United States
| | - Nancy F Krebs
- Department of Pediatrics, Section of Nutrition, University of Colorado School of Medicine, 12700 E 19th Avenue Box C225, Aurora, CO 80045, United States.
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30
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Mikomangwa WP, OMS M, Aklillu E, Kamuhabwa AAR. Adverse birth outcomes among mothers who received intermittent preventive treatment with Sulphadoxine-Pyrimethamine in the low malaria transmission region. BMC Pregnancy Childbirth 2019; 19:236. [PMID: 31286878 PMCID: PMC6615266 DOI: 10.1186/s12884-019-2397-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 07/03/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Malaria in pregnancy increases the risk of adverse birth outcomes such as low birth weight (LBW), maternal and foetal anemia. In Tanzania, some areas have attained low malaria transmission. However, data on the burden of preterm delivery, LBW, maternal and foetal anemia following substantial reduction of malaria transmission in recent years is still scarce in these settings. METHODS A study involving 631 pregnant women was conducted at Mwananyamala referral hospital in Dar es Salaam from April to August, 2018. Study enrollment was done prior to delivery. Structured interview and antenatal clinic cards were used to obtain data including the use of intermittent preventive therapy in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). Infants birth weights were recorded, maternal venous and cord blood were taken for testing of malaria and determination of haemoglobin (Hb) levels. Chi-square test and regression analysis were done to identify risk factors for preterm delivery, LBW, maternal and foetal anemia. RESULTS The prevalence of malaria among mothers who used at least one dose of IPTp-SP was 0.6% (4/631). Fourteen mothers (2.2%) did not use IPTp-SP and had no malaria infection. The prevalence of maternal anemia, LBW, foetal anemia and preterm delivery was 40.6, 6.5, 5.9 and 9.2% respectively. Participants who were malaria positive had 11 times more risk of LBW compared to those who were negative (AOR, 11; 95%, CI 1.07-132.2; p = 0.04). The risk of delivering babies with LBW was 1.12 times high among mothers who were ≤ 36 weeks of gestation (AOR, 1.12; 95% CI, 0.06-0.25; p = < 0.001). The use of ≥3 doses of IPTp-SP was associated with 83% decrease in risk of LBW compared to those who did not use any dose of IPTp-SP (AOR, 0.17; 95% CI, 0.03-0.88; p = 0.05). Severe anaemia at delivery was associated with seven times increased risk of preterm delivery compared to non-anemic participants (AOR, 6.5; 95% CI, 1.49-28.16; p = 0.013). CONCLUSION Despite the reduced malaria transmission and use of IPTp-SP, prevalence of preterm delivery, maternal anemia, LBW and foetal anemia is still high in Tanzania. The recommended ≥3 doses of IPTp-SP should continue be provided even in areas with substantial reduction of malaria.
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Affiliation(s)
- Wigilya P. Mikomangwa
- Clinical Pharmacy and Pharmacology Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Minzi OMS
- Clinical Pharmacy and Pharmacology Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital-Huddinge C1:68, SE-141 86 Stockholm, Sweden
| | - Appolinary A. R. Kamuhabwa
- Clinical Pharmacy and Pharmacology Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Georgieff MK, Krebs NF, Cusick SE. The Benefits and Risks of Iron Supplementation in Pregnancy and Childhood. Annu Rev Nutr 2019; 39:121-146. [PMID: 31091416 DOI: 10.1146/annurev-nutr-082018-124213] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Iron deficiency is the most common micronutrient deficiency in the world and disproportionately affects pregnant women and young children. Iron deficiency has negative effects on pregnancy outcomes in women and on immune function and neurodevelopment in children. Iron supplementation programs have been successful in reducing this health burden. However, iron supplementation of iron-sufficient individuals is likely not necessary and may carry health risks for iron-sufficient and potentially some iron-deficient populations. This review considers the physiology of iron as a nutrient and how this physiology informs decision-making about weighing the benefits and risks of iron supplementation in iron-deficient, iron-sufficient, and iron-overloaded pregnant women and children.
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Affiliation(s)
- Michael K Georgieff
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota 55454, USA; ,
| | - Nancy F Krebs
- Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado 80045, USA;
| | - Sarah E Cusick
- Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis, Minnesota 55454, USA; ,
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32
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DeLoughery TG. Safety of Oral and Intravenous Iron. Acta Haematol 2019; 142:8-12. [PMID: 30970354 DOI: 10.1159/000496966] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/16/2019] [Indexed: 12/13/2022]
Abstract
As the adverse effects of iron deficiency are better recognized, the use of oral and intravenous iron has increased dramatically. Oral iron is often poorly tolerated, with up to 70% or more of patients noting gastrointestinal issues; this may affect adherence to therapy. In addition, many patients will not respond to oral iron due to their underlying illness. Intravenous iron is being used more frequently to replete iron stores. True anaphylaxis is very rare, but complement-mediated infusion reactions may be seen in up to 1 in every 200 patients. Previous concerns about intravenous iron increasing the risk of infection or cardiovascular disease are unfounded.
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Affiliation(s)
- Thomas G DeLoughery
- Division of Hematology/Medical Oncology, Department of Pathology and Pediatrics, Oregon Health and Science University, Portland, Oregon, USA,
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33
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Pike V, Zlotkin S. Excess micronutrient intake: defining toxic effects and upper limits in vulnerable populations. Ann N Y Acad Sci 2018; 1446:21-43. [PMID: 30569544 DOI: 10.1111/nyas.13993] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/21/2018] [Accepted: 11/06/2018] [Indexed: 12/17/2022]
Abstract
Excessive micronutrient intake causes a variety of adverse health effects, depending on dose and duration. The risk of excess intake carries significant implications for micronutrient delivery interventions, particularly when such programs are overlapping. To minimize risk and provide public health guidance, several countries and the Food and Agriculture Organization of the United Nations/World Health Organization have set upper intake levels (ULs) for various life-stage populations using the risk assessment framework. However, there is a lack of international consensus on the actual ULs due to variability in application of this framework and a scarcity of evidence from which to draw upon, especially for children. Often ULs for children are established through a downward weight-based extrapolation from adult ULs, which is not always appropriate. The published ULs of nine organizations are compared, recent population nutrient intake evidence is presented, and the toxic effects of key minerals and vitamins are reviewed. Finally, the evidence for toxicity and setting of ULs for each nutrient is discussed including a comment on our degree of confidence in the strength of existing individual ULs. Challenges with risk assessment and opportunities for strengthening the definition of ULs are discussed.
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Affiliation(s)
- Vanessa Pike
- The Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Stanley Zlotkin
- The Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.,The Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,The Munk School of Global Affairs and Public Policy, University of Toronto, Toronto, Ontario, Canada
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Iron deficiency during pregnancy is associated with a reduced risk of adverse birth outcomes in a malaria-endemic area in a longitudinal cohort study. BMC Med 2018; 16:156. [PMID: 30231938 PMCID: PMC6149228 DOI: 10.1186/s12916-018-1146-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/03/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Low birth weight (LBW) and preterm birth (PTB) are major contributors to infant mortality and chronic childhood morbidity. Understanding factors that contribute to or protect against these adverse birth outcomes is an important global health priority. Anaemia and iron deficiency are common in malaria-endemic regions, but there are concerns regarding the value of iron supplementation among pregnant women in malaria-endemic areas due to reports that iron supplementation may increase the risk of malaria. There is a lack of evidence on the impact of iron deficiency on pregnancy outcomes in malaria-endemic regions. METHODS We determined iron deficiency in a cohort of 279 pregnant women in a malaria-endemic area of Papua New Guinea. Associations with birth weight, LBW and PTB were estimated using linear and logistic regression. A causal model using sequential mediation analyses was constructed to assess the association between iron deficiency and LBW, either independently or mediated through malaria and/or anaemia. RESULTS Iron deficiency in pregnant women was common (71% at enrolment) and associated with higher mean birth weights (230 g; 95% confidence interval, CI 118, 514; p < 0.001), and reduced odds of LBW (adjusted odds ratio, aOR = 0.32; 95% CI 0.16, 0.64; p = 0.001) and PTB (aOR = 0.57; 95% CI 0.30, 1.09; p = 0.089). Magnitudes of effect were greatest in primigravidae (birth weight 351 g; 95% CI 188, 514; p < 0.001; LBW aOR 0.26; 95% CI 0.10, 0.66; p = 0.005; PTB aOR = 0.39, 95% CI 0.16, 0.97; p = 0.042). Sequential mediation analyses indicated that the protective association of iron deficiency on LBW was mainly mediated through mechanisms independent of malaria or anaemia. CONCLUSIONS Iron deficiency was associated with substantially reduced odds of LBW predominantly through malaria-independent protective mechanisms, which has substantial implications for understanding risks for poor pregnancy outcomes and evaluating the benefit of iron supplementation in pregnancy. This study is the first longitudinal study to demonstrate a temporal relationship between antenatal iron deficiency and improved birth outcomes. These findings suggest that iron supplementation needs to be integrated with other strategies to prevent or treat infections and undernutrition in pregnancy to achieve substantial improvements in birth outcomes.
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Abioye AI, Park S, Ripp K, McDonald EA, Kurtis JD, Wu H, Pond-Tor S, Sharma S, Ernerudh J, Baltazar P, Acosta LP, Olveda RM, Tallo V, Friedman JF. Anemia of Inflammation during Human Pregnancy Does Not Affect Newborn Iron Endowment. J Nutr 2018; 148:427-436. [PMID: 29546300 PMCID: PMC6454452 DOI: 10.1093/jn/nxx052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/27/2017] [Indexed: 12/20/2022] Open
Abstract
Background To our knowledge, no studies have addressed whether maternal anemia of inflammation (AI) affects newborn iron status, and few have addressed risk factors for specific etiologies of maternal anemia. Objectives The study aims were to evaluate 1) the contribution of AI and iron deficiency anemia (IDA) to newborn iron endowment, 2) hepcidin as a biomarker to distinguish AI from IDA among pregnant women, and 3) risk factors for specific etiologies of maternal anemia. Methods We measured hematologic biomarkers in maternal blood at 12 and 32 wk of gestation and in cord blood from a randomized trial of praziquantel in 358 pregnant women with Schistosoma japonicum in The Philippines. IDA was defined as anemia with serum ferritin <30 ng/mL and non-IDA (NIDA), largely due to AI, as anemia with ferritin ≥30 ng/mL. We identified cutoffs for biomarkers to distinguish IDA from NIDA by using area under the curve (AUC) analyses and examined the impact of different causes of anemia on newborn iron status (primary outcome) by using multivariate regression modeling. Results Of the 358 mothers, 38% (n = 136) had IDA and 9% (n = 32) had NIDA at 32 wk of gestation. At 32 wk of gestation, serum hepcidin performed better than soluble transferrin receptor (sTfR) in identifying women with NIDA compared with the rest of the cohort (AUCs: 0.75 and 0.70, respectively) and in identifying women with NIDA among women with anemia (0.73 and 0.72, respectively). The cutoff that optimally distinguished women with NIDA from women with IDA in our cohort was 6.1 µg/L. Maternal IDA, but not NIDA, was associated with significantly lower newborn ferritin (114.4 ng/mL compared with 148.4 µg/L; P = 0.042). Conclusions Hepcidin performed better than sTfR in identifying pregnant women with NIDA, but its cost may limit its use. Maternal IDA, but not NIDA, is associated with decreased newborn iron stores, emphasizing the need to identify this cause and provide iron therapy. This trial was registered at www.clinicaltrials.gov as NCT00486863.
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Affiliation(s)
- Ajibola I Abioye
- The Warren Alpert Medical School of Brown University, Providence, RI,Department of Pediatrics, Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI,Department of Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI
| | - Sangshin Park
- The Warren Alpert Medical School of Brown University, Providence, RI,Department of Pediatrics, Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI,Department of Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI,Address correspondence to SP (e-mail: or )
| | - Kelsey Ripp
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Emily A McDonald
- The Warren Alpert Medical School of Brown University, Providence, RI,Department of Pediatrics, Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI,Department of Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI
| | - Jonathan D Kurtis
- The Warren Alpert Medical School of Brown University, Providence, RI,Department of Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI,Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI
| | - Hannah Wu
- The Warren Alpert Medical School of Brown University, Providence, RI,Department of Pediatrics, Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI,Department of Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI
| | - Sunthorn Pond-Tor
- Department of Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI
| | - Surendra Sharma
- The Warren Alpert Medical School of Brown University, Providence, RI,Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI
| | - Jan Ernerudh
- Departments of Clinical Immunology and Transfusion Medicine and Clinical and Experimental Medicine, Linkoping University, Linkoping, Sweden,Departments of Clinical and Experimental Medicine, Linkoping University, Linkoping, Sweden
| | - Palmera Baltazar
- Research Institute for Tropical Medicine, Manila, Philippines,Remedios Trinidad Romualdez Hospital, Tacloban City, Leyte, Philippines
| | - Luz P Acosta
- Research Institute for Tropical Medicine, Manila, Philippines
| | | | - Veronica Tallo
- Research Institute for Tropical Medicine, Manila, Philippines
| | - Jennifer F Friedman
- The Warren Alpert Medical School of Brown University, Providence, RI,Department of Pediatrics, Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI,Department of Center for International Health Research, and Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Providence, RI
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36
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Rogerson SJ, Desai M, Mayor A, Sicuri E, Taylor SM, van Eijk AM. Burden, pathology, and costs of malaria in pregnancy: new developments for an old problem. THE LANCET. INFECTIOUS DISEASES 2018; 18:e107-e118. [PMID: 29396010 DOI: 10.1016/s1473-3099(18)30066-5] [Citation(s) in RCA: 174] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 08/07/2017] [Accepted: 10/09/2017] [Indexed: 12/17/2022]
Abstract
Over the past 10 years, knowledge of the burden, economic costs, and consequences of malaria in pregnancy has improved, and the prevalence of malaria caused by Plasmodium falciparum has declined substantially in some geographical areas. In particular, studies outside of Africa have increased the evidence base of Plasmodium vivax in pregnancy. Rapid diagnostic tests have been poor at detecting malaria in pregnant women, while PCR has shown a high prevalence of low density infection, the clinical importance of which is unknown. Erythrocytes infected with P falciparum that express the surface protein VAR2CSA accumulate in the placenta, and VAR2CSA is an important target of protective immunity. Clinical trials for a VAR2CSA vaccine are ongoing, but sequence variation needs to be carefully studied. Health system and household costs still limit access to prevention and treatment services. Within the context of malaria elimination, pregnant women could be used to monitor malaria transmission. This Series paper summarises recent progress and highlights unresolved issues related to the burden of malaria in pregnancy.
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Affiliation(s)
- Stephen J Rogerson
- Department of Medicine at the Doherty Institute, University of Melbourne, Melbourne, Victoria, Australia.
| | - Meghna Desai
- Malaria Branch, Division of Parasitic Diseases and Malaria, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Alfredo Mayor
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique
| | - Elisa Sicuri
- ISGlobal, Barcelona Centre for International Health Research (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Health Economics Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College, London, UK
| | - Steve M Taylor
- Division of Infectious Diseases and Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
| | - Anna M van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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37
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Mwangi MN, Prentice AM, Verhoef H. Safety and benefits of antenatal oral iron supplementation in low-income countries: a review. Br J Haematol 2017; 177:884-895. [PMID: 28272734 PMCID: PMC5485170 DOI: 10.1111/bjh.14584] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The World Health Organization recommends universal iron supplementation of 30-60 mg/day in pregnancy but coverage is low in most countries. Its efficacy is uncertain, however, and there has been a vigorous debate in the last decade about its safety, particularly in areas with a high burden of malaria and other infectious diseases. We reviewed the evidence on the safety and efficacy of antenatal iron supplementation in low-income countries. We found no evidence that daily supplementation at a dose of 60 mg leads to increased maternal Plasmodium infection risk. On the other hand, recent meta-analyses found that antenatal iron supplementation provides benefits for maternal health (severe anaemia at postpartum, blood transfusion). For neonates, there was a reduced prematurity risk, and only a small or no effect on birth weight. A recent trial showed, however, that benefits of antenatal iron supplementation on maternal and neonatal health vary by maternal iron status, with substantial benefits in iron-deficient women. The benefits of universal iron supplementation are likely to vary with the prevalence of iron deficiency. As a consequence, the balance between benefits and risks is probably more favourable in low-income countries than in high-income countries despite the higher exposure to infectious pathogens.
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Affiliation(s)
- Martin N Mwangi
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
- Nutrition and Health Department, School of Public Health and Community Development, Maseno University, Maseno, Kenya
| | - Andrew M Prentice
- MRC Unit The Gambia, Banjul, The Gambia
- MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Hans Verhoef
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
- MRC International Nutrition Group, London School of Hygiene and Tropical Medicine, London, UK
- Cell Biology and Immunology Group, Wageningen University, Wageningen, The Netherlands
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38
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Wylie BJ, Matechi E, Kishashu Y, Fawzi W, Premji Z, Coull BA, Hauser R, Ezzati M, Roberts DJ. Placental Pathology Associated with Household Air Pollution in a Cohort of Pregnant Women from Dar es Salaam, Tanzania. ENVIRONMENTAL HEALTH PERSPECTIVES 2017; 125:134-140. [PMID: 27286442 PMCID: PMC5226703 DOI: 10.1289/ehp256] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 03/28/2016] [Accepted: 05/20/2016] [Indexed: 05/05/2023]
Abstract
BACKGROUND Smoke from the burning of biomass fuels has been linked with adverse pregnancy outcomes such as low birth weight, stillbirth, and prematurity. OBJECTIVE To identify potential underlying mechanisms of adverse perinatal outcomes, we explored the association of placental pathology with household air pollution in pregnant women from urban/periurban Tanzania who cook predominantly with charcoal. METHODS Between 2011 and 2013, we measured personal exposures to fine particulate matter (PM2.5) and carbon monoxide (CO) over 72 hr among a cohort of Tanzanian pregnant women. Placentas were collected after delivery for examination. Placental pathologies of inflammatory, hypoxic, ischemic/hypertensive, infectious and thrombotic etiologies were diagnosed, blinded to exposure levels. Using multiple logistic regression, we explored the association of PM2.5 and CO exposure with placental pathology. RESULTS One hundred sixteen women had personal air exposure measurements and placental histopathology available for analysis. PM2.5 and CO exposures were moderate [geometric means (GSD) were 40.5 μg/m3 (17.3) and 2.21 ppm (1.47) respectively]; 88.6% of PM2.5 measurements exceeded World Health Organization air quality guidelines. We observed an increase in the odds (per 1-unit increase in exposure on the ln-scale) of fetal thrombotic vasculopathy (FTV) both with increasing PM2.5 [adjusted odds ratio (aOR) = 5.5; 95% CI: 1.1, 26.8] and CO measurements (aOR = 2.5; 95% CI: 1.0, 6.4) in adjusted models only. FTV also was more common among pregnancies complicated by stillbirth or low birth weight. CONCLUSIONS Fetal thrombosis may contribute to the adverse outcomes associated with household air pollution from cook stoves during pregnancy. Larger studies are necessary for confirmation. Citation: Wylie BJ, Matechi E, Kishashu Y, Fawzi W, Premji Z, Coull BA, Hauser R, Ezzati M, Roberts D. 2017. Placental pathology associated with household air pollution in a cohort of pregnant women from Dar es Salaam, Tanzania. Environ Health Perspect 125:134-140; http://dx.doi.org/10.1289/EHP256.
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Affiliation(s)
- Blair J. Wylie
- Department of Obstetrics/Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Address correspondence to B.J. Wylie, Founders 4, 55 Fruit Street, Boston, MA, 02114, USA. Telephone: 617-643-4331. E-mail:
| | | | - Yahya Kishashu
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Zul Premji
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Brent A. Coull
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Biostatistics, and
| | - Russ Hauser
- Department of Obstetrics/Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Majid Ezzati
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Drucilla J. Roberts
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Unger HW, Ashorn P, Cates JE, Dewey KG, Rogerson SJ. Undernutrition and malaria in pregnancy - a dangerous dyad? BMC Med 2016; 14:142. [PMID: 27645498 PMCID: PMC5029041 DOI: 10.1186/s12916-016-0695-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In low-resource settings, malaria and macronutrient undernutrition are major health problems in pregnancy, contributing significantly to adverse pregnancy outcomes such as preterm birth and fetal growth restriction. Affected pregnancies may result in stillbirth and neonatal death, and surviving children are at risk of poor growth and infection in infancy, and of non-communicable diseases in adulthood. Populations exposed to macronutrient undernutrition frequently reside in malaria-endemic areas, and seasonal peaks of low food supply and malaria transmission tend to coincide. Despite these geographic and temporal overlaps, integrated approaches to these twin challenges are infrequent. DISCUSSION This opinion article examines the current evidence for malaria-macronutrition interactions and discusses possible mechanisms whereby macronutrient undernutrition and malaria may interact to worsen pregnancy outcomes. Macronutrient undernutrition dysregulates the immune response. In pregnant women, undernutrition may worsen the already increased susceptibility to malarial infection and could impair development of protective immunity to malaria, and is likely to exacerbate the impact of placental malaria on fetal growth. Malarial infection, in turn, can drive nutritional depletion; poor gestational weight gain and weight loss in pregnancy increases the risk of adverse pregnancy outcomes. Despite a commendable number of studies and trials that, in isolation, attempt to address the challenges of malaria and undernutrition in pregnancy, few dare to venture beyond the 'single disease - single solution' paradigm. We believe that this may be a lost opportunity: researching malaria-nutrition interactions, and designing and implementing integrated interventions to prevent and treat these commonly co-existing and intertwining conditions, may markedly reduce the high burden of preterm birth and fetal growth restriction in affected areas. CONCLUSION We call for more collaboration between researchers studying malaria and nutrition in pregnancy, and propose a research agenda to address this important twin health problem.
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Affiliation(s)
- Holger W. Unger
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Victoria Australia
- Simpson Centre for Reproductive Health, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Per Ashorn
- Department of Paediatrics, University of Tampere School of Medicine, Tampere, Finland
- Department for International Health, University of Tampere School of Medicine, Tampere, Finland
- Department of Paediatrics, Tampere University Hospital, Tampere, Finland
| | - Jordan E. Cates
- Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, NC USA
| | - Kathryn G. Dewey
- Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA USA
| | - Stephen J. Rogerson
- Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Victoria Australia
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Hodgins S, Tielsch J, Rankin K, Robinson A, Kearns A, Caglia J. A New Look at Care in Pregnancy: Simple, Effective Interventions for Neglected Populations. PLoS One 2016; 11:e0160562. [PMID: 27537281 PMCID: PMC4990268 DOI: 10.1371/journal.pone.0160562] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Although this is beginning to change, the content of antenatal care has been relatively neglected in safe-motherhood program efforts. This appears in part to be due to an unwarranted belief that interventions over this period have far less impact than those provided around the time of birth. In this par, we review available evidence for 21 interventions potentially deliverable during pregnancy at high coverage to neglected populations in low income countries, with regard to effectiveness in reducing risk of: maternal mortality, newborn mortality, stillbirth, prematurity and intrauterine growth restriction. Selection was restricted to interventions that can be provided by non-professional health auxiliaries and not requiring laboratory support. METHODS In this narrative review, we included relevant Cochrane and other systematic reviews and did comprehensive bibliographic searches. Inclusion criteria varied by intervention; where available randomized controlled trial evidence was insufficient, observational study evidence was considered. For each intervention we focused on overall contribution to our outcomes of interest, across varying epidemiologies. RESULTS In the aggregate, achieving high effective coverage for this set of interventions would very substantially reduce risk for our outcomes of interest and reduce outcome inequities. Certain specific interventions, if pushed to high coverage have significant potential impact across many settings. For example, reliable detection of pre-eclampsia followed by timely delivery could prevent up to ¼ of newborn and stillbirth deaths and over 90% of maternal eclampsia/pre-eclampsia deaths. Other interventions have potent effects in specific settings: in areas of high P falciparum burden, systematic use of insecticide-treated nets and/or intermittent presumptive therapy in pregnancy could reduce maternal mortality by up to 10%, newborn mortality by up to 20%, and stillbirths by up to 25-30%. Behavioral interventions targeting practices at birth and in the hours that follow can have substantial impact in settings where many births happen at home: in such circumstances early initiation of breastfeeding can reduce risk of newborn death by up to 20%; good thermal care practices can reduce mortality risk by a similar order of magnitude. CONCLUSIONS Simple interventions delivered during pregnancy have considerable potential impact on important mortality outcomes. More programmatic effort is warranted to ensure high effective coverage.
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Affiliation(s)
- Stephen Hodgins
- Saving Newborn Lives, Save the Children/ US, Washington, D.C., United States of America
| | - James Tielsch
- Milken Institute School of Public Health, George Washington University, Washington, D.C., United States of America
| | - Kristen Rankin
- Saving Newborn Lives, Save the Children/ US, Washington, D.C., United States of America
| | - Amber Robinson
- Department of Life Sciences, Brunel University London, London, United Kingdom
| | - Annie Kearns
- Human Care Systems, Boston, Massachusetts, United States of America
| | - Jacquelyn Caglia
- T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, United States of America
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Hemminki E, Nwaru BI, Salomé G, Parkkali S, Abacassamo F, Augusto O, Cliff J, Regushevskaya E, Dgedge M, Sousa C, Chilundo B. Is selective prenatal iron prophylaxis better than routine prophylaxis: final results of a trial (PROFEG) in Maputo, Mozambique. BMJ Open 2016; 6:e011280. [PMID: 27297013 PMCID: PMC4916582 DOI: 10.1136/bmjopen-2016-011280] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To compare routine versus selective (ie, screening and treatment for anaemia) prenatal iron prophylaxis in a malaria-endemic and HIV-prevalent setting, an extended analysis including previously missing data. DESIGN A pragmatic randomised controlled clinical trial. SETTING 2 health centres in Maputo, Mozambique. PARTICIPANTS Pregnant women (≥18 years old; non-high-risk pregnancy) were randomly allocated to routine iron (n=2184) and selective iron (n=2142) groups. INTERVENTIONS In the routine group, women received 60 mg ferrous sulfate plus 400 μg folic acid daily. In the selective group, women received 1 mg of folic acid daily and haemoglobin (Hb) screening at each visit; with low Hb (cut-off 9 g/dL) treatment (120 mg+800 μg of folic acid daily) for a month. PRIMARY OUTCOMES preterm birth, low birth weight; secondary outcomes: self-reported malaria, labour complications, caesarean section, perinatal death, woman's death. Nurses collected pregnancy data. Birth data were abstracted from hospital records for 52% of women and traced using various methods and linked with probabilistic matching for 24%. Women's deaths were collected from death registers. RESULTS Birth data were available for 3301 (76%) of the women. Outcomes were similar in the two groups: preterm births (27.1% in the selective vs 25.3% in the routine group), low birthweight infants (11.0% vs 11.7%), perinatal deaths (2.4% vs 2.4%) and caesarean sections (4.0% vs 4.5%). Women's deaths during pregnancy or <42 days postpartum were more common in the selective group (0.8% among the two best matched women) than in the routine group (0.4%). Extra deaths could not be explained by the cause of death, Hb level or HIV status at recruitment. CONCLUSIONS Birth outcomes were similar in the two iron groups. There might have been more women's deaths in the selective iron group, but it is unclear whether this was due to the intervention, other factors or chance finding. TRIAL REGISTRATION NUMBER NCT00488579.
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Affiliation(s)
- Elina Hemminki
- Health Services and Policy Research, National Institute for Health and Welfare, Helsinki, Finland
| | - Bright I Nwaru
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, UK
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Graca Salomé
- Medical Faculty, Department of Physiological Sciences, Eduardo Mondlane University, Maputo, Mozambique
| | - Saara Parkkali
- Health Services and Policy Research, National Institute for Health and Welfare, Helsinki, Finland
| | - Fatima Abacassamo
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Orvalho Augusto
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Julie Cliff
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Elena Regushevskaya
- Health Services and Policy Research, National Institute for Health and Welfare, Helsinki, Finland
| | | | - Cesar Sousa
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
| | - Baltazar Chilundo
- Medical Faculty, Department of Community Health, Eduardo Mondlane University, Maputo, Mozambique
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Abioye AI, Aboud S, Premji Z, Etheredge AJ, Gunaratna NS, Sudfeld CR, Mongi R, Meloney L, Darling AM, Noor RA, Spiegelman D, Duggan C, Fawzi W. Iron Supplementation Affects Hematologic Biomarker Concentrations and Pregnancy Outcomes among Iron-Deficient Tanzanian Women. J Nutr 2016; 146:1162-71. [PMID: 27121530 PMCID: PMC4877628 DOI: 10.3945/jn.115.225482] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 03/15/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Iron deficiency is a highly prevalent micronutrient abnormality and the most common cause of anemia globally, worsening the burden of adverse pregnancy and child outcomes. OBJECTIVE We sought to evaluate the response of hematologic biomarkers to iron supplementation and to examine the predictors of the response to iron supplementation among iron-deficient pregnant women. METHODS We identified 600 iron-deficient (serum ferritin ≤12 μg/L) pregnant women, aged 18-45 y, presenting to 2 antenatal clinics in Dar es Salaam, Tanzania using rapid ferritin screening tests, and prospectively followed them through delivery and postpartum. All women received 60 mg Fe and 0.25 mg folate daily from enrollment until delivery. Proportions meeting the thresholds representing deficient hematologic status including hemoglobin <110 g/L, ferritin ≤12 μg/L, serum soluble transferrin receptor (sTfR) >4.4 mg/L, zinc protoporphyrin (ZPP) >70 mmol/L, or hepcidin ≤13.3 μg/L at baseline and delivery were assessed. The prospective change in biomarker concentration and the influence of baseline hematologic status on the change in biomarker concentrations were assessed. Regression models were estimated to assess the relation of change in biomarker concentrations and pregnancy outcomes. RESULTS There was significant improvement in maternal biomarker concentrations between baseline and delivery, with increases in the concentrations of hemoglobin (mean difference: 15.2 g/L; 95% CI: 13.2, 17.2 g/L), serum ferritin (51.6 μg/L; 95% CI: 49.5, 58.8 μg/L), and serum hepcidin (14.0 μg/L; 95% CI: 12.4, 15.6 μg/L) and decreases in sTfR (-1.7 mg/L; 95% CI: -2.0, -1.3 mg/L) and ZPP (-17.8 mmol/L; 95% CI: -32.1, 3.5 mmol/L). The proportions of participants with low hemoglobin, ferritin, and hepcidin were 73%, 93%, and 99%, respectively, at baseline and 34%, 12%, and 46%, respectively, at delivery. The improvements in biomarker concentrations were significantly greater among participants with poor hematologic status at baseline - up to 12.1 g/L and 14.5 μg/L for hemoglobin and ferritin concentrations, respectively. For every 10-g/L increase in hemoglobin concentration, there was a 24% reduced risk of perinatal mortality (RR = 0.76; 95% CI: 0.59, 0.99) and a 23% reduced risk of early infant mortality (RR = 0.77; 95% CI: 0.60, 0.99). The risk of anemia at delivery despite supplementation was predicted by baseline anemia (RR = 2.11; 95% CI: 1.39, 3.18) and improvements in ferritin concentration were more likely to be observed in participants who took iron supplements for up to 90 d (RR = 1.41; 95% CI: 1.13, 1.76). CONCLUSION Iron supplementation decreases the risk of maternal anemia and increases the likelihood of infant survival among iron-deficient Tanzanian pregnant women. Interventions to promote increased duration and adherence to iron supplements may also provide greater health benefits.
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Affiliation(s)
| | - Said Aboud
- Departments of Microbiology and Immunology and
| | - Zulfiqar Premji
- Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; and
| | - Analee J Etheredge
- Departments of Global Health and Population,,Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | | | | | - Robert Mongi
- Parasitology/Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; and
| | | | | | | | - Donna Spiegelman
- Nutrition,,Epidemiology, and,Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Christopher Duggan
- Departments of Global Health and Population,,Nutrition,,Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Wafaie Fawzi
- Departments of Global Health and Population,,Nutrition,,Epidemiology, and
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43
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Abstracts for issue YHEM 21 : S1. ACTA ACUST UNITED AC 2016; 21:1-65. [PMID: 30384818 DOI: 10.1080/10245332.2016.1166729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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44
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Daru J, Cooper NAM, Khan KS. Systematic review of randomized trials of the effect of iron supplementation on iron stores and oxygen carrying capacity in pregnancy. Acta Obstet Gynecol Scand 2015; 95:270-9. [PMID: 26509354 DOI: 10.1111/aogs.12812] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/18/2015] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Anemia in pregnancy affects 25% of all pregnancies in Europe with iron deficiency affecting even more. Despite supplementation, iron deficiency persists. This review will assess the effect on serum ferritin (iron stores) and hemoglobin (oxygen-carrying capacity) following iron supplementation in pregnant women with anemic and non-anemic iron deficiency. MATERIAL AND METHODS A systemic search of electronic databases and trial registers was conducted from inception to January 2014. Randomized controlled trials of iron supplementation that measured serum ferritin and hemoglobin levels before and after supplementation were selected. Two independent reviewers selected studies, extracted data and assessed quality. Descriptive analyses were carried out. RESULTS The review included 23 randomized controlled trials (3525 women). In iron deficiency anemia, more studies described statistically significant increases in serum ferritin levels than in hemoglobin levels following intravenous iron supplementation. In non-anemic iron deficiency there were more statistically significant increases in serum ferritin levels than in hemoglobin levels following oral supplementation. There were no studies reporting maternal quality of life outcomes. CONCLUSIONS Serum ferritin appears to change more than hemoglobin following iron supplementation. The clinical effects of this need further investigation.
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Affiliation(s)
- Jahnavi Daru
- Women's Health Research Unit, Barts and the London School of Medicine, Queen Mary University of London, London, UK.,Barts Health NHS Trust, London, UK
| | - Natalie A M Cooper
- Women's Health Research Unit, Barts and the London School of Medicine, Queen Mary University of London, London, UK.,Barts Health NHS Trust, London, UK
| | - Khalid S Khan
- Women's Health Research Unit, Barts and the London School of Medicine, Queen Mary University of London, London, UK.,Barts Health NHS Trust, London, UK
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Brodwall K. Gir jerntilskudd økt risiko for malaria hos gravide? TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2015. [DOI: 10.4045/tidsskr.15.0889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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