Effects of routine oral iron supplementation with or without folic acid for women during pregnancy

Review of intervention products for use in the prevention and control of anemia

Anemia remains a major public health problem, especially in low- and middle-income countries. The World Health Organization recommends several interventions to prevent and manage anemia in vulnerable population groups, including young children, menstruating adolescent girls and women, and pregnant and postpartum women. Daily iron supplementation reduces the risk of anemia in infants, children, and pregnant women, and intermittent iron supplementation reduces anemia risk in menstruating girls and women. Micronutrient powders reduce the risk of anemia in children. Fortifying wheat flour with iron reduces the risk of anemia in the overall population, whereas the effect of fortifying maize flour and rice is still uncertain. Regarding non-nutrition-related interventions, malaria treatment and deworming have been reported to decrease anemia prevalence. Promising interventions to prevent anemia include vitamin A supplementation, multiple micronutrient supplementation for pregnant women, small-quantity lipid-based supplements, and fortification of salt with iodine and iron. Future research could address the efficacy and safety of different iron supplementation formulations, identify the most bioavailable form of iron for fortification, examine adherence to supplementation regimens and fortification standards, and investigate the effectiveness of integrating micronutrient, helminth, and malaria control programs.

Spatial distribution and identifying biochemical factors affecting haemoglobin levels among women of reproductive age for each province in Indonesia: A geospatial analysis

Anaemia is still a public health problem in Indonesia. The iron supplement program, known as Tablet Tambah Darah (Blood Add Tablet) has not yet produced optimal results. This study aimed to identify the cause of anaemia and the factors that influence it. Biochemical indicator data are haemoglobin (Hb), C-reactive protein (CRP), ferritin and serum transferrin receptor (sTfR) from 9,463 women of reproduction age. Data from the Basic Health Research (Riskesdas) project of 2013 were used for the study. ANOVA as well as global and local regression approaches (classical regression and geo-weighted regression) were used to compare the mean Hb and CRP values between provinces and to determine the factors that influence Hb concentrations. The results showed that the distribution of anaemia in Indonesia is uneven and not always caused by iron deficiency. The lowest Hb mean coupled with the highest iron deficiency was found in Papua, where there are high rates of parasitic infections. In contrast, the highest mean Hb coupled with low iron deficiency, and also low infection rates, was found in North Sulawesi. The Hb concentrations were significantly associated by ferritin, CRP and sTfR and there were varying magnitudes between provinces. Although anaemia is mainly influenced by the iron concentration, CRP, ferritin and sTfR can also affect it through their association with inflammatory reactions. Identification of all causes of anaemia in each province needs to be done in the future, while blanket iron supplementation should be reviewed.

Effect of Eel Cookie Supplementation on the Hemoglobin Status of Pregnant Women with Anaemia: A Pilot Study

Background

Anaemia in pregnancy is a major global health problem. Iron and folic acid (IFAS) and animal-based supplement consumption could improve the hemoglobin status of pregnant women. This study is aimed at determining the effect of eel cookie supplementation on hemoglobin levels of pregnant women.

Methods

This pilot study with pretest–posttest design was conducted in Tamanjaya Public Health Center, Geopark Ciletuh, Sukabumi District, West Java Province, Indonesia. A total of 40 voluntary pregnant women were divided into two groups: an intervention group that received 11 pieces of eel cookies and control group that received the same number of cookies without eel. The women's hemoglobin level was analysed using t-test, Mann-Whitney, Wilcoxon, and analysis of covariance tests.

Results

After consuming the eel cookies for 1 month, there was a significantly greater increase in the hemoglobin levels in the intervention group than those in the control group, which were 1.69 and 0.69 g/dL, respectively. Improvement in percentage of mean hemoglobin was higher in the intervention group than in the control group, which was 17.21% and 6.53%, respectively.

Conclusions

Supplementation with eel cookies and IFAS for 1 month could improve the hemoglobin status in pregnant women with anaemia.

High and Low Haemoglobin Levels in Early Pregnancy Are Associated to a Higher Risk of Miscarriage: A Population-Based Cohort Study

To evaluate whether women with anaemia or high haemoglobin (Hb) in early pregnancy would be at higher risk of miscarriage, this population-based cohort study involved 9453 women whose pregnancies were monitored at primary care centres between 2007 and 2012. The computerised clinical histories were used to collect: Hb measurements (up to 14 weeks of gestation), miscarriage before or by 24 weeks of gestation, and other maternal characteristics. The relation between anaemia (Hb < 110 g/L), normal Hb (110-140 g/L, reference), and high Hb concentrations (≥140 g/L) with miscarriage were expressed as adjusted OR with 95%CI. Restricted cubic spline models were applied to evaluate the dose-response relationships. A total of 520 (5.5%) women were recorded as having a miscarriage. The rate of miscarriage in anaemia, normal Hb, and high Hb concentrations was 8.4%, 5.1%, and 10.2%, respectively. Compared with women with normal Hb at the first trimester, the multivariable-adjusted OR for miscarriage was 2.11 (95%CI, 1.38-3.21) for women with anaemia and 1.83 (95%CI, 1.29-2.58) for women with high Hb. Hb concentrations showed a U-shaped association with miscarriage, with the lowest incidence among women with Hb of 120-130 g/L. These data highlight the importance of considering anaemia and high Hb levels in early pregnancy as harmful indicators for miscarriage.

Self-reported compliance with routine prenatal medications by pregnant women in a tertiary hospital in Enugu State, Nigeria

INTRODUCTION

Compliance to routine antenatal medications increases a woman's chances of achieving a normal pregnancy and having a healthy baby. However, non-compliance is a commonly encountered problem in developing countries including Nigeria. This study investigated compliance to routine antenatal medications as reported by pregnant women receiving antenatal care in a tertiary hospital in Enugu State, Nigeria.

METHODS

A cross-sectional descriptive survey research design was adopted for the study while simple random sampling technique was used to select the 354 pregnant women at Enugu state teaching hospital. A validated structured questionnaire (α=0.72) was utilized for data collection. Analysis of data involved descriptive and inferential statistics.

RESULTS

Only 32% of pregnant women had a good compliance to their routine antenatal drugs while forgetfulness (27.2%) and vomiting as a side effect of the drug (25.7%) were the major barriers to compliance with routine drugs. Furthermore, there was a statistically significant association between respondents' compliance with antenatal drugs and number of children as well as level of income (p<0.001). No statistically significant association was found between education level and compliance.

CONCLUSIONS

Nurses and other health workers should support pregnant women to set reminders for taking their medications and prescribe alternative dosage forms or products that will not induce vomiting. In addition, antenatal education should emphasize the benefits of adherence to routine taking of medications at every stage of pregnancy and the possible negative consequences of non-compliance.

Structure, functional properties and iron bioavailability of Pneumatophorus japonicus myoglobin and its glycosylation products

Developing safe and efficient iron supplements is significant for the alleviation of iron-deficient anemia (IDA). Myoglobin (Mb) is a heme-protein rich in bioavailable iron. Pneumatophorus japonicus (P. japonicus), one important economic fish in China, contain a high Mb level in its dark meat normally discarded during processing. The present study aimed to determine the structure, physicochemical properties, and iron bioavailability of Mb extracted from P. japonicus. Meanwhile, the effects of glycosylation, a commonly applied chemical modification of proteins, on these parameters were evaluated. Using Box-Behnken design, the optimal conditions for Mb-chitosan glycosylation were obtained: 45.07 °C, pH 6.10 and Mb/chitosan mass ratio of 6.29. The structure and functional properties of the glycosylated Mb (Mb-gly) were investigated. Compared with the original Mb, Mb-gly obtained a more ordered secondary structure. The surface hydrophobicity of Mb-gly was found to be decreased together with the observations of elevated water solubility. Moreover, glycosylation enhanced the Mb antioxidant capacity, and improved its stability in enzymatic digestion system. Regarding to the iron bioavailability, the cellular uptake of Mb‑iron was significantly higher than FeSO₄, and further elevated by glycosylation. These results provided a basis for the development of Mb-based iron supplements, promoting the utilization of fish-processing industries wastes.

Anatomical and physiological alterations of pregnancy

The extensive metabolic demands of pregnancy require specific physiological and anatomical changes. These changes affect almost all organ systems, including the cardiovascular, respiratory, renal, gastrointestinal, and hematologic system. The placenta adds another layer of complexity. These changes make it challenging for clinicians to understand presenting signs and symptoms, or to interpret laboratory and radiological tests. Furthermore, these physiological alterations can affect the pharmacokinetics and pharmacodynamics of drugs. Drug safety in lactation is only supported by limited evidence. In addition, the teratogenic effects of medications are often extrapolated from animals, which further adds uncertainties. Unfortunately, pregnant women are only rarely included in clinical drug trials, while doses, regimens, and side effects are often extrapolated from studies conducted in non-pregnant populations. In this comprehensive review, we present the changes occurring in each system with its effects on the pharmacokinetic variables. Understanding these physiological changes throughout normal pregnancy helps clinicians to optimize the health of pregnant women and their fetuses. Furthermore, the information on pregnancy-related physiology is also critical to guide study design in this vulnerable 'orphan' population, and provides a framework to explore pregnancy-related pathophysiology such as pre-eclampsia.

Oral iron supplementation in iron-deficient women: How much and how often?

Iron deficiency and iron deficiency anemia (IDA) are major public health problems worldwide, especially in young women. Oral iron supplementation can be an effective strategy to treat and prevent IDA, but guidelines vary. Some experts recommend doses of 150-200 mg elemental iron per day, with the dose split through the day. However, recent studies suggest this may not be an optimal regimen. The fraction of iron absorbed from high doses of oral iron is low, and unabsorbed iron can cause gut irritation, inflammation and dysbiosis, and these reduce compliance. In recent studies using serum hepcidin profiles and stable iron isotopes to quantify iron absorption in young women, we have shown that: (a) oral iron doses ≥60 mg in iron-deficient women, and doses ≥100 mg in women with IDA, stimulate an acute increase in hepcidin that persists 24 h after the dose, but subsides by 48 h; (b) therefore, to maximize fractional iron absorption, oral doses ≥60 mg should be given on alternate days; (c) the circadian increase in plasma hepcidin is augmented by a morning iron dose; therefore, iron doses should not be given in the afternoon or evening after a morning dose. If rate of Hb response is important, a pooled analysis of our data done for this review indicates that total iron absorption is also higher if twice the target daily iron dose is given on alternate days. In summary, these studies suggest changing from daily to alternate-day schedules and from divided to morning single doses increases iron absorption and may reduce side effects. Thus, providing morning doses of 60-120 mg iron as a ferrous salt given with ascorbic acid on alternate days may be an optimal oral dosing regimen for women with iron-deficiency and mild IDA.

The Influence of Antenatal Oral Iron and Folic Acid Side Effects on Supplementation Duration in Low-Resource Rural Kenya: A Cross-Sectional Study

Background

Undesirable effects of a daily regimen of iron and folic acid ingested jointly (iron-folate) are potential disincentives to optimal antenatal supplementation. We intended to profile antenatal iron-folate side effects and elucidate their influence on supplementation duration in low-resource rural Kenya.

Methods

This was a cross-sectional descriptive study of randomly selected postnatal mothers of under-five-year-old children. Using a modified WHO Safe Motherhood Assessment standard questionnaire, they recalled the total number of days of antenatal iron-folate intake and the attendant supplement-attributed undesirable experiences. The analyses considered only participants who ingested the supplements in their immediate last pregnancies (n = 277).

Results

About half of the study participants reported at least a side effect and a mean of 2.4 (SD 1.5) effects per person in the entire pregnancy period. Most common reported effects were chest pains (31.8%), constipation (28.5%), severe stomach pains (11.6%), and diarrhoea (11.6%). Mothers who reported at least a side effect ingested the supplements for ten days less compared to those who did not experience any effect (p = 0.03); and a greater proportion of the former were primigravida (p = 0.02) and used combined form of iron and folic acid (p = 0.003). In a multivariate analysis, significant correlations with supplementation compliance (ingestion for 90+ days) were found only for nausea and severe stomach pain experiences (r = -0.1, p = 0.04; r = 0.2, p = 0.01, resp.).

Conclusions

The commonness of undesirable experiences attributed to daily ingestion of 60 mg iron and 0.4 mg folic acid and their deterrence to longer supplementation durations suggest the need for considering a weekly intermittent regimen for some antenatal women in such set-ups. Our study demonstrated that potentially, more counselling on nausea as a side effect might be critical in advancing iron-folate supplementation compliance.

Effectiveness of Sulfadoxine-Pyrimethamine for Intermittent Preventive Treatment of Malaria and Adverse Birth Outcomes in Pregnant Women

Effectiveness of intermittent preventive treatment in pregnancy with sulfadoxine–pyrimethamine (IPTp-SP) for prevention of malaria and adverse birth outcomes can be compromised by parasites-resistance to sulfadoxine–pyrimethamine. This study prospectively evaluated the effectiveness of IPTp-SP in Southeast Tanzania. From January 2017 to May 2019, HIV-negative and malaria-negative (mRDT) pregnant women attending their first antenatal-care visit in the second or third trimester (n = 500) were enrolled to receive monthly IPTp-SP and followed the protocol till delivery. The primary outcome was the prevalence of histopathological placental malaria. Secondary outcomes were anemia, malaria parasites detected during pregnancy and at delivery, adverse birth outcomes (low-birth-weight [LBW], premature birth, fetal anemia, still birth, and spontaneous abortion). Rates of histopathological placental malaria, any parasitemia at delivery (placental, cord or maternal), and any adverse birth outcome were 9.4%, 20.9%, and 26.5%, respectively. Rates of symptomatic malaria and parasitemia during pregnancy were 2.8% and 16%, respectively. Histopathological placental malaria significantly increased the odds of any adverse birth outcomes, particularly LBW. IPTp-SP with more than or equal to three doses significantly improved birth weight and reduced the risk of LBW by 56% compared to <3 SP doses (p = 0.009). IPTp-SP with more than or equal to three doses is still effective in improving birth weight. However, the detection of histopathological placental-malaria in one-tenth and parasitemia in one-fifth of pregnant women reflects the need to optimize the prevention of malaria during pregnancy.

Power of partnerships

Purpose

Many low- and middle-income countries (LMICs) are struggling to reduce maternal mortality rates, despite increased efforts by the United Nations through the implementation of their Millennium Development Goals program. Industrialized nations, such as Canada, have a collaborative role to play in raising the global maternal health standards. The purpose of this paper is to propose policy approaches for Canadians and other Organization of Economic Cooperation and Development (OECD) nations who wish to assist in reducing maternal mortality rates.

Design/methodology/approach

Ten Canadian health experts with experience in global maternal health were interviewed. Using qualitative analytical methods, the authors coded and themed their responses and paired them with peer-reviewed literature in this area to establish a model for improving global maternal health and survival rates.

Findings

Findings from this study indicated that maternal health may be improved by establishing a collaborative approach between interdisciplinary teams of health professionals (e.g. midwives, family physicians, OB/GYNs and nurses), literacy teachers, agriculturalists and community development professionals (e.g. humanitarians with diverse linguistic and cultural backgrounds). From this, a conceptual approach was devised for elevating the standard of maternal health. This approach includes specifications by which maternal health may be improved, such as gender justice, women’s literacy, freedom from violence against women, food and water security and healthcare accessibility. This model is based on community health center (CHC) models that integrate upstream changes with downstream services may be utilized by Canada and other OECD nations in efforts to enhance maternal health at home and abroad.

Research limitations/implications

Maternal mortality may be reduced by the adoption of a CHC model, an approach well suited for all nations regardless of economic status. Establishing such a model in LMICs would ideally establish long-term relationships between countries, such as Canada and the LMICs, where teams from supporting nations would collaborate with local Ministries of Health, non-government organizations as well as traditional birth attendants and healthcare professionals to reduce maternal mortality.

Practical implications

All OECD Nations ought to donate 0.7 percent of their GDP toward international community development. These funds should break the tradition of “tied aid”, thereby removing profit motives, and genuinely contribute to the wellbeing of people in LMICs, particularly women, children and others who are vulnerable. The power of partnerships between people whose aims are genuinely focused on caring is truly transformative.

Social implications

Canada is not a driver of global maternal mortality reduction work but has a responsibility to work in partnership with countries or regions in a humble and supportive role. Applying a comprehensive and interdisciplinary approach to reducing maternal mortality in the Global South includes adopting a CHC model: a community development approach to address social determinants of health and integrating various systems of evidence-informed healthcare with a commitment to social justice. Interdisciplinary teams would include literacy professionals, researchers, midwives, nurses, family physicians, OB/GYNs and community development professionals who specialize in anti-poverty work, mediation/dialogue and education campaigns that emphasize the value of all people regardless of their gender, ethnicity, religion and income. Diasporic Canadians are invaluable members of these teams due to their linguistic and cultural knowledge as well as their enthusiasm for working with their countries of origin. Establishment of long-term partnerships of 5–10 years between a Canadian team and a region or nation in the Global South that is dedicated to reducing maternal mortality and improving women’s health are valuable. Canada’s midwifery education programs are rated as world leaders so connecting midwives from Canada with those of the Global South will facilitate essential transfer of knowledge such as using birth plans and other evidence-based practices. Skilled attendants at the birth place will save women’s lives; in most cases, trained midwives are the most appropriate attendants. Video link to a primer about this paper by Dr Farah Shroff: https://maa.med.ubc.ca/videos-and-media/.

Originality/value

There are virtually no retrievable articles that document why OECD nations ought to work with nations in the LMICs to improve maternal health. This paper outlines the reasons why it is important and explains how to do it well.

Effectiveness of Workplace Nutrition Programs on Anemia Status among Female Readymade Garment Workers in Bangladesh: A Program Evaluation

Eight in ten female readymade garment (RMG) workers in Bangladesh suffer from anemia, a condition which damages both health and productivity. This study evaluated the effectiveness of a workplace nutrition program on anemia reduction in female RMG workers of Bangladesh. A quasi-experimental mixed method study was conducted on 1310 non-pregnant female RMG workers from four factories. Two types of intervention packages (A and C) were tested against their respective controls (B and D) over a 10-month period. Among factories that already provided lunch to workers with regular behavior change counseling (BCC), one intervention (A) and one control (B) factory were selected, and among factories that did not provide lunches to their workers but provided regular BCC, one intervention (C) and one control (D) factory were selected: (A) Lunch meal intervention package: daily nutritionally-enhanced (with fortified rice) hot lunch, once weekly iron-folic acid (IFA) supplement and monthly enhanced (with nutrition module) behavior change counseling (BCC) versus (B) Lunch meal control package: regular lunch and BCC; and (C) Non-meal intervention package: twice-weekly IFA and enhanced BCC versus (D) Non-meal control package: BCC alone. Body weight and capillary hemoglobin were measured. Changes in anemia prevalence were estimated by difference-in-difference (DID) method. Thematic analysis of qualitative in-depth interviews with RMG workers was performed and findings were triangulated. Anemia was reduced significantly in both lunch meal and non-meal intervention (A and C) group (DID: 32 and 12 percentage points, p: <0.001 and <0.05 respectively). The mean hemoglobin concentration also significantly increased by 1 gm/dL and 0.4 gm/dL in both A and C group (p: <0.001 respectively). Weight did not change in the intervention groups (A and C) but significantly increased by more than 1.5 kg in the comparison groups (B and D). The knowledge of different vitamin and mineral containing foods and their benefits was increased significantly among all participants. Workplace nutrition programs can reduce anemia in female RMG workers, with the greatest benefits observed when both nutritionally enhanced lunches and IFA supplements are provided.

Counselling and knowledge on iron and folic acid supplementation (IFAS) among pregnant women in Kiambu County, Kenya: a cross-sectional study

Background: The increased demand for iron and folic acid during pregnancy is not met through diet due to insufficiency or reduced bioavailability of nutrients among women from low income countries. Thus, iron and folic acid supplementation (IFAS) is a promising interventional strategy for control of anaemia during pregnancy. Kenya adopted the global IFAS intervention with a target of 80% coverage by 2017, however, the compliance remains low. Increasing awareness, counselling, communication and community education on IFAS have improved compliance among pregnant women. Thus, we aimed to determine: IFAS knowledge, availability, practices, and content of IFAS counselling among pregnant women attending health facilities in Kiambu County, Kenya.

Methods: A cross-sectional study involving 364 pregnant women aged 15-49 years. A two stage cluster sampling, including one sub-county and five public health facilities were used. A pre-tested, structured questionnaire consisting of socio-demographic data, maternal knowledge and counselling on IFAS was used. An observation checklist was used to observe practices and content of antenatal counselling session in each facility. Data was analysed using STATA in which descriptive and inferential statistics were computed.

Results: Of 364 respondents, less than half (40.9%) scored high on knowledge on IFAS. Women who were counselled on duration of IFAS intake, side effects, and their mitigation were more likely (p <0.005) to have high IFAS knowledge. Although all the health facilities had varied IFAS posters displayed, none had key IFAS counselling documents.

Conclusion: Less than half of the pregnant women had high IFAS knowledge, IFAS documents were scarce in health facilities, IFAS counselling information in different health facilities was limited and varied, and content of counselling was associated with levels of knowledge on IFAS. This underscores the need to strengthen focused and targeted IFAS counselling for pregnant women and standardization of counselling messages to improve compliance and pregnancy outcomes.

Counselling and knowledge on iron and folic acid supplementation (IFAS) among pregnant women in Kiambu County, Kenya: a cross-sectional study

Background: The increased demand for iron and folic acid during pregnancy is not met through diet due to insufficiency or reduced bioavailability of nutrients among women from low income countries. Thus, iron and folic acid supplementation (IFAS) is a promising interventional strategy for control of anaemia during pregnancy. Kenya adopted the global IFAS intervention with a target of 80% coverage by 2017, however, the compliance remains low. Increasing awareness, counselling, communication and community education on IFAS have improved compliance among pregnant women. Thus, we aimed to determine: IFAS knowledge, availability, practices, and content of IFAS counselling among pregnant women attending health facilities in Kiambu County, Kenya. Methods: A cross-sectional study involving 364 pregnant women aged 15-49 years. A two stage cluster sampling, including one sub-county and five public health facilities were used. A pre-tested structured questionnaire consisting of socio-demographic data, maternal knowledge and counselling on IFAS was used. An observation checklist was used to observe practices and content of antenatal counselling session in each facility. Data was analysed using STATA in which descriptive and inferential statistics were computed. Results: Of 364 respondents, less than half (40.9%) scored high on knowledge on IFAS. Women who were counselled on duration of IFAS intake, side effects, and their mitigation were more likely (p <0.005) to have high IFAS knowledge. Although all the health facilities had varied IFAS posters displayed, none had key IFAS counselling documents. Conclusion: Less than half of the pregnant women had high IFAS knowledge, IFAS documents were scarce in health facilities, IFAS counselling information in different health facilities was limited and varied and content of counselling was associated with levels of knowledge on IFAS. This underscores the need to strengthen focused and targeted IFAS counselling for pregnant women and standardization of counselling messages to improve compliance and pregnancy outcomes.

Time to start and adherence to iron-folate supplement for pregnant women in antenatal care follow up; Northern Ethiopia

BACKGROUND

Iron folate supplementation is a cost-effective way of reducing iron deficiency anemia, low birth weight, and neural tube defects in resource-limited countries like Ethiopia. Late to start and poor adherence to iron-folate supplement has restricted its effectiveness. The aim of this study was to determine the time to start and adherence level of iron-folate supplementation to pregnant women attending at the Ayder Comprehensive Specialized Hospital.

METHODS

Two hundred pregnant women were recruited in cross-sectional study design between February and April 2018.

RESULTS

From the total participant pregnant women the urban dweller constituted the major proportion of 182 (91%). Seventy-eight (39%) of the participants had two antenatal care visits, whereas only, 21 (10.5%) of them had an antenatal care visit three and above. One hundred fifty-five (77.5%) participants women had knowledge about the cause of anemia in pregnancy. In this study, 143 (71.5%) of the pregnant women started their iron folate supplement in the second and third trimester. The adherence of iron folate intake was 10.5%. Healthcare education and counseling about iron-folate supplementation (AOR =4.55, 95% CI =[1.534, 13.512]), number of pregnancies (AOR =6.941, 95% CI =[1.511, 31.09]), and number of antenatal visit (AOR =0.242, 95% CI =[0.069, 0.852]) were significantly associated with adherence to iron-folate supplementation.

CONCLUSION

Time to start iron folate supplement in the first trimester was low and the adherence level was also very poor, which can be attributed by the number of antenatal care visits, frequency of pregnancy and healthcare education and counseling about iron folate supplement.

Counselling on iron and folic acid supplementation (IFAS) is associated with improved knowledge among pregnant women in a rural county of Kenya: a cross-sectional study

Background:The demand for iron and folic acid, is greatly increased during pregnancy. The high demand is not met through diet due to insufficiency or reduced bioavailability of nutrients among women from low income countries. Thus, iron and folic acid supplementation (IFAS) is a promising interventional strategy for control of anaemia during pregnancy. Kenya adopted the global IFAS intervention with a target of 80% coverage by 2017, however, the compliance remains low. Increasing awareness, counselling, communication and community education on IFAS have improved compliance among pregnant women. Thus, we aimed to determine: availability, practices, and content of IFAS counselling on knowledge of antenatal mothers attending health facilities in Kiambu County, Kenya.Methods:A cross-sectional study involving 364 pregnant women aged 15-49 years attending antenatal clinic. A two stage cluster sampling, including one sub-county and five public primary health facilities were used. A pre-tested structured questionnaire consisting of socio-demographic data, maternal knowledge and counselling on IFAS was used. An observation checklist was used to observe practices and content of antenatal counselling session in each facility. Data was analysed using STATA in which descriptive and inferential statistics were computed.Results:Of 364 respondents, less than half (40.9%) scored high on knowledge on IFAS. Women who were counselled on duration of IFAS intake, side effects, and their mitigation were more likely (p <0.005) to have high IFAS knowledge. Although all the health facilities had varied IFAS posters displayed, none had key IFAS counselling documents.Conclusion:Content of counselling substantially contributed to high level of knowledge on IFAS among pregnant women. Counselling information on the duration of IFAS supplementation, IFAS side effects, and their management are the predictors of IFAS knowledge among pregnant women. This underscores the need to strengthen focused and targeted IFAS counselling for pregnant women to improve compliance and pregnancy outcomes.

Compliance with Iron and folic acid supplementation (IFAS) and associated factors among pregnant women: results from a cross-sectional study in Kiambu County, Kenya

BACKGROUND

Macro and micronutrients including iron and folic acid deficiencies are prevalent in Kenya, particularly during pregnancy resulting in anaemia. Despite efforts to control anaemia in pregnancy by adopting Iron and Folic Acid Supplementation (IFAS), this public health problem has persisted contributing to significant morbidity and mortality. The problem notwithstanding, there is poor IFAS compliance, whose reasons remain poorly understood, calling for their investigations. We sought to determine compliance status with IFAS and associated factors among pregnant women.

METHODS

This was a cross-sectional study involving 364 pregnant women aged 15-49 years. Using two stage cluster sampling, one Sub-County and five public health facilities in Kiambu County were selected. All pregnant women attending antenatal clinics who met inclusion criteria and consented to participate in the study were recruited. Compliance with IFAS was defined as taking supplements at least 5 out of 7 days per week. A structured interviewer-administered questionnaire consisting of sociodemographic data, IFAS maternal knowledge and compliance practices was pretested and administered. Descriptive and inferential statistics were computed using STATA.

RESULTS

Of the 364 respondents interviewed, 32.7% were IFAS compliant and 40.9% scored high on its knowledge. Of those with high IFAS knowledge, 48.3% were compliant compared to those with low knowledge (21.4%, n = 46, PR = 2.25;95%CI = 1.59-3.17, p < 0.001). Women who were multigravid (30.4%) were less likely to comply compared to primigravid (37.2%, n = 45, PR = 0.68;95%CI = 0.47-0.99, p = 0.004). Multivariate analysis revealed that respondents counselled on management of IFAS side effects (100%, n = 4) were more compliant (76.2%, n = 112, aPR = 1.31;95%CI = 1.19-1.44, p < 0.001).

CONCLUSION

Few pregnant women were compliant with IFAS regimen, associated with: knowledgeability on IFAS, primi-gravidity, and IFAS counselling especially on management of its side effects. These underscore the need for approaches to scale up health awareness on the benefits of IFAS, mitigation measures for the side effects, as well as targeted counselling.

Prophylactic Iron Supplementation in Pregnancy: A Controversial Issue

In our world today, iron deficiency (ID) is the most frequent nutritional deficiency and it is being considered as an epidemic public health crisis. Women of reproductive age and infants are at particular risk of ID, especially in underdeveloped countries. During pregnancy, iron deficiency anemia is a specific risk factor associated with negative maternal and perinatal outcomes. Many countries have iron supplementation (IS) programs-as recommended by the World Health Organization-during pregnancy; however, IS clinical benefits and risks are unclear. This review aims to discuss the threats and benefits of routine IS on maternal and infant outcomes.

Identification of a Hemolysis Threshold That Increases Plasma and Serum Zinc Concentration

Background: Plasma or serum zinc concentration (PZC or SZC) is the primary measure of zinc status, but accurate sampling requires controlling for hemolysis to prevent leakage of zinc from erythrocytes. It is not established how much hemolysis can occur without changing PZC/SZC concentrations.Objective: This study determines a guideline for the level of hemolysis that can significantly elevate PZC/SZC.Methods: The effect of hemolysis on PZC/SZC was estimated by using standard hematologic variables and mineral content. The calculated hemolysis threshold was then compared with results from an in vitro study and a population survey. Hemolysis was assessed by hemoglobin and iron concentrations, direct spectrophotometry, and visual assessment of the plasma or serum. Zinc and iron concentrations were determined by inductively coupled plasma spectrometry.Results: A 5% increase in PZC/SZC was calculated to result from the lysis of 1.15% of the erythrocytes in whole blood, corresponding to ∼1 g hemoglobin/L added into the plasma or serum. Similarly, the addition of simulated hemolysate to control plasma in vitro caused a 5% increase in PZC when hemoglobin concentrations reached 1.18 ± 0.10 g/L. In addition, serum samples from a population nutritional survey were scored for hemolysis and analyzed for changes in SZC; samples with hemolysis in the range of 1-2.5 g hemoglobin/L showed an estimated increase in SZC of 6% compared with nonhemolyzed samples. Each approach indicated that a 5% increase in PZC/SZC occurs at ∼1 g hemoglobin/L in plasma or serum. This concentration of hemoglobin can be readily identified directly by chemical hemoglobin assays or indirectly by direct spectrophotometry or matching to a color scale.Conclusions: A threshold of 1 g hemoglobin/L is recommended for PZC/SZC measurements to avoid increases in zinc caused by hemolysis. The use of this threshold may improve zinc assessment for monitoring zinc status and nutritional interventions.

Intermittent oral iron supplementation during pregnancy

BACKGROUND

Anaemia is a frequent condition during pregnancy, particularly among women in low- and middle-income countries. Traditionally, gestational anaemia has been prevented with daily iron supplements throughout pregnancy, but adherence to this regimen due to side effects, interrupted supply of the supplements, and concerns about safety among women with an adequate iron intake, have limited the use of this intervention. Intermittent (i.e. two or three times a week on non-consecutive days) supplementation has been proposed as an alternative to daily supplementation.

OBJECTIVES

To assess the benefits and harms of intermittent supplementation with iron alone or in combination with folic acid or other vitamins and minerals to pregnant women on neonatal and pregnancy outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2015), the WHO International Clinical Trials Registry Platform (ICTRP) (31 July 2015) and contacted relevant organisations for the identification of ongoing and unpublished studies (31 July 2015).

SELECTION CRITERIA

Randomised or quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of trials using standard Cochrane criteria. Two review authors independently assessed trial eligibility, extracted data and conducted checks for accuracy.

MAIN RESULTS

This review includes 27 trials from 15 countries, but only 21 trials (with 5490 women) contributed data to the review. All studies compared daily versus intermittent iron supplementation. The methodological quality of included studies was mixed and most had high levels of attrition.The overall assessment of the quality of the evidence for primary infant outcomes was low and for maternal outcomes very low.Of the 21 trials contributing data, three studies provided intermittent iron alone, 14 intermittent iron + folic acid and four intermittent iron plus multiple vitamins and minerals in comparison with the same composition of supplements provided in a daily regimen.Overall, for women receiving any intermittent iron regimen (with or without other vitamins and minerals) compared with a daily regimen there was no clear evidence of differences between groups for any infant primary outcomes: low birthweight (average risk ratio (RR) 0.82; 95% confidence interval (CI) 0.55 to 1.22; participants = 1898; studies = eight; low quality evidence), infant birthweight (mean difference (MD) 5.13 g; 95% CI -29.46 to 39.72; participants = 1939; studies = nine; low quality evidence), premature birth (average RR 1.03; 95% CI 0.76 to 1.39; participants = 1177; studies = five; low quality evidence), or neonatal death (average RR 0.49; 95% CI 0.04 to 5.42; participants = 795; studies = one; very low quality). None of the studies reported congenital anomalies.For maternal outcomes, there was no clear evidence of differences between groups for anaemia at term (average RR 1.22; 95% CI 0.84 to 1.80; participants = 676; studies = four; I² = 10%; very low quality). Women receiving intermittent supplementation had fewer side effects (average RR 0.56; 95% CI 0.37 to 0.84; participants = 1777; studies = 11; I² = 87%; very low quality) and were at lower risk of having high haemoglobin (Hb) concentrations (greater than 130 g/L) during the second or third trimester of pregnancy (average RR 0.53; 95% CI 0.38 to 0.74; participants = 2616; studies = 15; I² = 52%; (this was not a primary outcome)) compared with women receiving daily supplements. There were no significant differences in iron-deficiency anaemia at term between women receiving intermittent or daily iron + folic acid supplementation (average RR 0.71; 95% CI 0.08 to 6.63; participants = 156; studies = one). There were no maternal deaths (six studies) or women with severe anaemia in pregnancy (six studies). None of the studies reported on iron deficiency at term or infections during pregnancy.Most of the studies included in the review (14/21 contributing data) compared intermittent oral iron + folic acid supplementation compared with daily oral iron + folic acid supplementation (4653 women) and findings for this comparison broadly reflect findings for the main comparison (any intermittent versus any daily regimen).Three studies with 464 women examined supplementation with intermittent oral iron alone compared with daily oral iron alone. There were no clear differences between groups for mean birthweight, preterm birth, maternal anaemia or maternal side effects. Other primary outcomes were not reported.Four studies with a combined sample size of 412 women compared intermittent oral iron + vitamins and minerals supplementation with daily oral iron + vitamins and minerals supplementation. Results were not reported for any of the review's infant primary outcomes. One study reported fewer maternal side effects in the intermittent iron group, and two studies that more women were anaemic at term compared with those receiving daily supplementation.Where sufficient data were available for primary outcomes, we set up subgroups to look for possible differences between studies in terms of earlier or later supplementation; women's anaemia status at the start of supplementation; higher and lower weekly doses of iron; and the malarial status of the region in which the trials were conducted. There was no clear effect of these variables on results.

AUTHORS' CONCLUSIONS

This review is the most comprehensive summary of the evidence assessing the benefits and harms of intermittent iron supplementation in pregnant women on haematological and pregnancy outcomes. Findings suggest that intermittent regimens produced similar maternal and infant outcomes as daily supplementation but were associated with fewer side effects and reduced the risk of high levels of Hb in mid and late pregnancy, although the risk of mild anaemia near term was increased. While the quality of the evidence was assessed as low or very low, intermittent may be a feasible alternative to daily iron supplementation among those pregnant women who are not anaemic and have adequate antenatal care.

Markers of iron status are associated with stage of pregnancy and acute-phase response, but not with parity among pregnant women in Guinea-Bissau

While prenatal Fe supplementation prevents maternal Fe deficiency and anaemia, it is uncertain whether it improves infant health outcomes, at least when taken by Fe-replete women. Inflammation as well as physiological changes complicates the assessment of Fe status during pregnancy. In the present study, we measured the concentrations of serum ferritin and soluble transferrin receptors (sTfR), Hb and the acute-phase proteins C-reactive protein (CRP) and α1-antichymotrypsin (ACT) in a cross-sectional study among 738 pregnant women attending antenatal care in Guinea-Bissau, West Africa. Multiple linear regression analysis was used to identify the predictors of Fe status markers. The mean gestational age was 23 (sd7) weeks. Serum ferritin values were lower with progressing gestation, from 27 % lower during weeks 16–20 of gestation up to 59 % lower after 29 weeks of gestation compared with early pregnancy. Using cut-off values for Fe deficiency as established in non-pregnant individuals, 52 % of the women had sTfR levels >2·3 mg/l, while only 25 % had serum ferritin levels < 12 μg/l. Serum ferritin but also sTfR levels were elevated at increased serum CRP and ACT levels. The proportion of sTfR >2·3 mg/l decreased to 47 % after adjustment for elevated serum CRP and ACT levels. On the contrary, the proportion of serum ferritin < 12 μg/l increased to 33 % after adjustment for ACT and CRP. The high proportion of elevated serum sTfR calls for pregnancy-specific cut-offs since increased erythropoiesis is expected in response to increased plasma volume of pregnancy. The present study further underlines the need to adjust for inflammation when serum sTfR and serum ferritin are used to assess Fe status in pregnancy.

Prenatal Iron Supplementation Reduces Maternal Anemia, Iron Deficiency, and Iron Deficiency Anemia in a Randomized Clinical Trial in Rural China, but Iron Deficiency Remains Widespread in Mothers and Neonates

BACKGROUND

Previous trials of prenatal iron supplementation had limited measures of maternal or neonatal iron status.

OBJECTIVE

The purpose was to assess effects of prenatal iron-folate supplementation on maternal and neonatal iron status.

METHODS

Enrollment occurred June 2009 through December 2011 in Hebei, China. Women with uncomplicated singleton pregnancies at ≤20 wk gestation, aged ≥18 y, and with hemoglobin ≥100 g/L were randomly assigned 1:1 to receive daily iron (300 mg ferrous sulfate) or placebo + 0.40 mg folate from enrollment to birth. Iron status was assessed in maternal venous blood (at enrollment and at or near term) and cord blood. Primary outcomes were as follows: 1) maternal iron deficiency (ID) defined in 2 ways as serum ferritin (SF) <15 μg/L and body iron (BI) <0 mg/kg; 2) maternal ID anemia [ID + anemia (IDA); hemoglobin <110 g/L]; and 3) neonatal ID (cord blood ferritin <75 μg/L or zinc protoporphyrin/heme >118 μmol/mol).

RESULTS

A total of 2371 women were randomly assigned, with outcomes for 1632 women or neonates (809 placebo/folate, 823 iron/folate; 1579 mother-newborn pairs, 37 mothers, 16 neonates). Most infants (97%) were born at term. At or near term, maternal hemoglobin was significantly higher (+5.56 g/L) for iron vs. placebo groups. Anemia risk was reduced (RR: 0.53; 95% CI: 0.43, 0.66), as were risks of ID (RR: 0.74; 95% CI: 0.69, 0.79 by SF; RR: 0.65; 95% CI: 0.59, 0.71 by BI) and IDA (RR: 0.49; 95% CI: 0.38, 0.62 by SF; RR: 0.51; 95% CI: 0.40, 0.65 by BI). Most women still had ID (66.8% by SF, 54.7% by BI). Adverse effects, all minor, were similar by group. There were no differences in cord blood iron measures; >45% of neonates in each group had ID. However, dose-response analyses showed higher cord SF with more maternal iron capsules reported being consumed (β per 10 capsules = 2.60, P < 0.05).

CONCLUSIONS

Prenatal iron supplementation reduced anemia, ID, and IDA in pregnant women in rural China, but most women and >45% of neonates had ID, regardless of supplementation. This trial was registered at clinicaltrials.gov as NCT02221752.

Daily oral iron supplementation during pregnancy

BACKGROUND

Iron and folic acid supplementation has been the preferred intervention to improve iron stores and prevent anaemia among pregnant women, and it is thought to improve other maternal and birth outcomes.

OBJECTIVES

To assess the effects of daily oral iron supplements for pregnant women, either alone or in conjunction with folic acid, or with other vitamins and minerals as a public health intervention in antenatal care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2015). We also searched the WHO International Clinical Trials Registry Platform (ICTRP) (26 February 2015) and contacted relevant organisations for the identification of ongoing and unpublished studies (26 February 2015) .

SELECTION CRITERIA

Randomised or quasi-randomised trials evaluating the effects of oral preventive supplementation with daily iron, iron + folic acid or iron + other vitamins and minerals during pregnancy.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of trials using standard Cochrane criteria. Two review authors independently assessed trial eligibility, extracted data and conducted checks for accuracy. We used the GRADE approach to assess the quality of the evidence for primary outcomes.We anticipated high heterogeneity among trials and we pooled trial results using a random-effects model and were cautious in our interpretation of the pooled results: the random-effects model gives the average treatment effect.

MAIN RESULTS

We included 61 trials. Forty-four trials, involving 43,274 women, contributed data and compared the effects of daily oral supplements containing iron versus no iron or placebo.Preventive iron supplementation reduced maternal anaemia at term by 70% (risk ratio (RR) 0.30; 95% confidence interval (CI) 0.19 to 0.46, 14 trials, 2199 women, low quality evidence), iron-deficiency anaemia at term (RR 0.33; 95% CI 0.16 to 0.69, six trials, 1088 women), and iron deficiency at term by 57% (RR 0.43; 95% CI 0.27 to 0.66, seven trials, 1256 women, low quality evidence). There were no clear differences between groups for severe anaemia in the second or third trimester, or maternal infection during pregnancy (RR 0.22; 95% CI 0.01 to 3.20, nine trials, 2125 women, very low quality evidence; and, RR 1.21; 95% CI 0.33 to 4.46; one trial, 727 women, low quality evidence, respectively), or maternal mortality (RR 0.33; 95% CI 0.01 to 8.19, two trials, 12,560 women, very low quality evidence), or reporting of side effects (RR 1.29; 95% CI 0.83 to 2.02, 11 trials, 2423 women, very low quality evidence). Women receiving iron were on average more likely to have higher haemoglobin (Hb) concentrations at term and in the postpartum period, but were at increased risk of Hb concentrations greater than 130 g/L during pregnancy, and at term.Compared with controls, women taking iron supplements less frequently had low birthweight newborns (8.4% versus 10.3%, average RR 0.84; 95% CI 0.69 to 1.03, 11 trials, 17,613 women, low quality evidence), and preterm babies (RR 0.93; 95% CI 0.84 to 1.03, 13 trials, 19,286 women, moderate quality evidence). They appeared to also deliver slightly heavier babies (mean difference (MD) 23.75; 95% CI -3.02 to 50.51, 15 trials, 18,590 women, moderate quality evidence). None of these results were statistically significant. There were no clear differences between groups for neonatal death (RR 0.91; 95% CI 0.71 to 1.18, four trials, 16,603 infants, low quality evidence), or congenital anomalies (RR 0.88, 95% CI 0.58 to 1.33, four trials, 14,636 infants, low quality evidence).Twenty-three studies were conducted in countries that in 2011 had some malaria risk in parts of the country. In some of these countries/territories, malaria is present only in certain areas or up to a particular altitude. Only two of these studies reported malaria outcomes. There is no evidence that iron supplementation increases placental malaria. For some outcomes heterogeneity was higher than 50%.

AUTHORS' CONCLUSIONS

Supplementation reduces the risk of maternal anaemia and iron deficiency in pregnancy but the positive effect on other maternal and infant outcomes is less clear. Implementation of iron supplementation recommendations may produce heterogeneous results depending on the populations' background risk for low birthweight and anaemia, as well as the level of adherence to the intervention.

Evaluation of dietary habits during pregnancy

Objective:

Pregnancy is a special period of increased nutritional needs during which conscious nutritional support is required. Insufficient and imbalanced nutrition in this period of life causes serious conditions that affect both child and mother. This study aimed to evaluate the relationship between pregnancy and nutrition/nutritional habits during pregnancy.

Materials and Methods:

In this descriptive study, a questionnaire was conducted on a voluntary basis to pregnant women who were admitted to the Pregnancy Outpatient Clinic of Obstetrics and Gynecology Department at Ankara Numune Training and Research Hospital. Questions about general information, pregnancy-related information, thoughts and knowledge about breastfeeding, nutritional habits, and meal frequency were asked to pregnant women. Three hundred fourteen questionnaires were assessed in the study. SPSS for Windows Version 16.0 and MS-Excel 2007 were used for statistical evaluations. P<0.05 was accepted as statistical significance.

Results:

There was a statistically significant relationship between pre-pregnancy body mass index (BMI) and number of pregnancies; level of education and income levels; number of children and history of caesarian section as an additional problem within previous pregnancies. The change of nutritional habits during pregnancy was examined; we found that consumption of fruits (51%) and vegetables (40.8%) increased the most, while intake of tea (26.1%) and redmeat (21%) mainly decreased during pregnancy. It was found that during pregnancy 20.4% of pregnant women had never consumed fish, 13.1% abstained from red meat, and 12.4% excluded white meat from their diet.

Conclusions:

We believe that this study will help to raise awareness about adequate and balanced nutrition during pregnancy and to define special nutritional recommendations.

Zinc supplementation for improving pregnancy and infant outcome

BACKGROUND

It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy such as prolonged labour, atonic postpartum haemorrhage, pregnancy-induced hypertension, preterm labour and post-term pregnancies, although many of these associations have not yet been established.

OBJECTIVES

To assess the effects of zinc supplementation in pregnancy on maternal, fetal, neonatal and infant outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2014) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of zinc supplementation in pregnancy. We excluded quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information. The quality of the evidence was assessed using GRADE.

MAIN RESULTS

We included 21 randomised controlled trials (RCTs) reported in 54 papers involving over 17,000 women and their babies. One trial did not contribute data. Trials were generally at low risk of bias. Zinc supplementation resulted in a small reduction in preterm birth (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.76 to 0.97 in 16 RCTs; 16 trials of 7637 women). This was not accompanied by a similar reduction in numbers of babies with low birthweight (RR 0.93, 95% CI 0.78 to 1.12; 14 trials of 5643 women). No clear differences were seen between the zinc and no zinc groups for any of the other primary maternal or neonatal outcomes, except for induction of labour in a single trial. No differing patterns were evident in the subgroups of women with low versus normal zinc and nutrition levels or in women who complied with their treatment versus those who did not. The GRADE quality of the evidence was moderate for preterm birth, small-for-gestational age, and low birthweight, and low for stillbirth or neonatal death and birthweight.

AUTHORS' CONCLUSIONS

The evidence for a 14% relative reduction in preterm birth for zinc compared with placebo was primarily represented by trials involving women of low income and this has some relevance in areas of high perinatal mortality. There was no convincing evidence that zinc supplementation during pregnancy results in other useful and important benefits. Since the preterm association could well reflect poor nutrition, studies to address ways of improving the overall nutritional status of populations in impoverished areas, rather than focusing on micronutrient and or zinc supplementation in isolation, should be an urgent priority.

Nutritional knowledge as a determinant of vitamin and mineral supplementation during pregnancy

BACKGROUND

Pregnancy is a critical period for both woman and baby from a nutritional perspective. Nutritional education is considered an important tool for promoting a healthy lifestyle, but has not been studied as a determinant for maternal use of supplements during pregnancy, especially in Romania, where evidence about pregnancy and nutrition is scarce. This study aimed to evaluate the relationship between nutritional knowledge and the use of folic acid, iron and multivitamin supplements during pregnancy and to assess the influence of socio-demographic factors and prenatal care.

METHODS

We conducted a cross-sectional study on a sample of 400 pregnant women admitted to the Cuza-Vodă Obstetrics and Gynaecology Clinical Hospital in Iaşi, Romania, during August-September 2010. We collected self-reported data regarding socio-demographic characteristics, number of prenatal check-ups and the use of folic acid, iron and multivitamin supplements during pregnancy. We assessed nutritional knowledge using a standardized questionnaire divided into three sections: general nutritional recommendations for pregnant women; the roles of nutrients; and sources of nutrients. We used logistic regression to analyse the associations between these factors.

RESULTS

The prevalence of the use of supplements during pregnancy was 48% for folic acid, 45.3% for iron and 68% for multivitamins. Above-average nutritional knowledge was independently associated with the use of folic acid (aOR, 4.7; 95% CI, 1.6-13.8), iron (aOR, 2.6; 95% CI, 1.2-5.7) and multivitamins (aOR, 2.8; 95% CI, 1.2-6.8). The use of folic acid was independently associated with a higher level of formal education (aOR, 5.2; 95% CI, 2.1-12.8) and an early start in prenatal care (aOR, 3.4; 95% CI, 1.0-11.1). Women with a higher education (aOR, 2.3; 95% CI, 1.1-4.9), more than 10 prenatal visits (aOR, 7.2; 95% CI, 3.4-15.0) and those who received advice on breastfeeding (aOR, 2.0; 95% CI, 1.1-3.5) were more likely to use iron during pregnancy. Similar results were found when analysing the contributing factors for the use of multivitamins: more than 12 years of schooling (aOR, 3.4; 95% CI, 1.4-7.9) and appropriate prenatal care (aOR, 9.4; 95% CI, 4.5-19.5).

CONCLUSIONS

Level of nutritional knowledge has a strong independent association with the use of supplements during pregnancy.

Folic acid supplementation during pregnancy for maternal health and pregnancy outcomes

BACKGROUND

During pregnancy, fetal growth causes an increase in the total number of rapidly dividing cells, which leads to increased requirements for folate. Inadequate folate intake leads to a decrease in serum folate concentration, resulting in a decrease in erythrocyte folate concentration, a rise in homocysteine concentration, and megaloblastic changes in the bone marrow and other tissues with rapidly dividing cells

OBJECTIVES

To assess the effectiveness of oral folic acid supplementation alone or with other micronutrients versus no folic acid (placebo or same micronutrients but no folic acid) during pregnancy on haematological and biochemical parameters during pregnancy and on pregnancy outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2012) and we contacted major organisations working in micronutrient supplementation, including UNICEF Nutrition Section, World Health Organization (WHO) Maternal and Reproductive Health, WHO Nutrition Division, and National Center on Birth defects and Developmnetal Disabilities, US Centers for Disease Control and Prevention (CDC).

SELECTION CRITERIA

All randomised, cluster-randomised and cross-over controlled trials evaluating supplementation of folic acid alone or with other micronutrients versus no folic acid (placebo or same micronutrients but no folic acid) in pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy.

MAIN RESULTS

Thirty-one trials involving 17,771 women are included in this review. This review found that folic acid supplementation has no impact on pregnancy outcomes such as preterm birth (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.73 to 1.38; three studies, 2959 participants), and stillbirths/neonatal deaths (RR 1.33, 95% CI 0.96 to 1.85; three studies, 3110 participants). However, improvements were seen in the mean birthweight (mean difference (MD) 135.75, 95% CI 47.85 to 223.68). On the other hand, the review found no impact on improving pre-delivery anaemia (average RR 0.62, 95% CI 0.35 to 1.10; eight studies, 4149 participants; random-effects), mean pre-delivery haemoglobin level (MD -0.03, 95% CI -0.25 to 0.19; 12 studies, 1806 participants), mean pre-delivery serum folate levels (standardised mean difference (SMD) 2.03, 95% CI 0.80 to 3.27; eight studies, 1250 participants; random-effects), and mean pre-delivery red cell folate levels (SMD 1.59, 95% CI -0.07 to 3.26; four studies, 427 participants; random-effects). However, a significant reduction was seen in the incidence of megaloblastic anaemia (RR 0.21, 95% CI 0.11 to 0.38, four studies, 3839 participants).

AUTHORS' CONCLUSIONS

We found no conclusive evidence of benefit of folic acid supplementation during pregnancy on pregnancy outcomes.

Daily oral iron supplementation during pregnancy

BACKGROUND

Iron and folic acid supplementation has been the preferred intervention to improve iron stores and prevent anaemia among pregnant women, and it may also improve other maternal and birth outcomes.

OBJECTIVES

To assess the effects of daily oral iron supplements for pregnant women, either alone or in conjunction with folic acid, or with other vitamins and minerals as a public health intervention.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (2 July 2012). We also searched the WHO International Clinical Trials Registry Platform (ICTRP) (2 July 2012) and contacted relevant organisations for the identification of ongoing and unpublished studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials evaluating the effects of oral preventive supplementation with daily iron, iron + folic acid or iron + other vitamins and minerals during pregnancy.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of trials using standard Cochrane criteria. Two review authors independently assessed trial eligibility, extracted data and conducted checks for accuracy.

MAIN RESULTS

We included 60 trials. Forty-three trials, involving more than 27,402 women, contributed data and compared the effects of daily oral supplements containing iron versus no iron or placebo.Overall, women taking iron supplements were less likely to have low birthweight newborns (below 2500 g) compared with controls (8.4% versus 10.2%, average risk ratio (RR) 0.81; 95% confidence interval (CI) 0.68 to 0.97, 11 trials, 8480 women) and mean birthweight was 30.81 g greater for those infants whose mothers received iron during pregnancy (average mean difference (MD) 30.81; 95% CI 5.94 to 55.68, 14 trials, 9385 women). Preventive iron supplementation reduced the risk of maternal anaemia at term by 70% (RR 0.30; 95% CI 0.19 to 0.46, 14 trials, 2199 women) and iron deficiency at term by 57% (RR 0.43; 95% CI 0.27 to 0.66, seven trials, 1256 women). Although the difference between groups did not reach statistical significance, women who received iron supplements were more likely than controls to report side effects (25.3% versus 9.91%) (RR 2.36; 95% CI 0.96 to 5.82, 11 trials, 4418 women), particularly at doses 60 mg of elemental iron or higher. Women receiving iron were on average more likely to have higher haemoglobin (Hb) concentrations at term and in the postpartum period, but were at increased risk of Hb concentrations greater than 130g/L during pregnancy and at term. Twenty-three studies were conducted in countries that in 2011 had some malaria risk in parts of the country. In some of these countries/territories, malaria is present only in certain areas or up to a particular altitude. Only two of these reported malaria outcomes. There is no evidence that iron supplementation increases placental malaria. For some outcomes heterogeneity was higher than 50%.

AUTHORS' CONCLUSIONS

Prenatal supplementation with daily iron are effective to reduce the risk of low birthweight, and to prevent maternal anaemia and iron deficiency in pregnancy. Associated maternal side effects and particularly high Hb concentrations during pregnancy at currently used doses suggest the need to update recommendations on doses and regimens for routine iron supplementation.

Antenatal iron/folic acid supplements, but not postnatal care, prevents neonatal deaths in Indonesia: analysis of Indonesia Demographic and Health Surveys 2002/2003-2007 (a retrospective cohort study)

OBJECTIVE

This study aimed to assess the contribution of postnatal services to the risk of neonatal mortality, and the relative contributions of antenatal iron/folic acid supplements and postnatal care in preventing neonatal mortality in Indonesia.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Data used in this study were the 2002-2007 Indonesia Demographic and Health Surveys, nationally representative surveys. The pooled data provided survival information of 26 591 most recent live-born infants within the 5-years prior to each interview.

PRIMARY OUTCOMES

Primary outcomes were early neonatal mortality, that is, deaths in the first week, and all neonatal mortality, that is, deaths in the first month of life. Exposures were antenatal iron/folic acid supplementation and postnatal care from days 1 to 7. Potential confounders were community, socio-economic status and birthing characteristics and perinatal healthcare. Cox regression was used to assess the association between study factors and neonatal mortality.

RESULTS

Postnatal care services were not associated with newborn survival. Postnatal care on days 1-7 after birth did not reduce neonatal death (HR=1.00, 95% CI 0.55 to 1.83, p=1.00) and early postnatal care on day 1 was associated with an increased risk of early neonatal death (HR=1.27, 95% CI 0.69 to 2.32, p=0.44) possibly reflecting referral of ill newborns. Early postnatal care on day 1 was not protective for neonatal deaths on days 2-7 whether provided by doctors (HR 3.61, 95% CI 1.54 to 8.45, p<0.01), or by midwives or nurses (HR 1.38, 95% CI 0.53 to 3.57, p=0.512). In mothers who took iron/folic acid supplements during pregnancy, the risk of early neonatal death was reduced by 51% (HR=0.49, 95% CI 0.30 to 0.79, p<0.01).

CONCLUSIONS

We found no protective effect of postnatal care against neonatal deaths in Indonesia. However, important reductions in the risk of neonatal death were found for women who reported use of antenatal iron/folic acid supplements during pregnancy.

Zinc supplementation for improving pregnancy and infant outcome

BACKGROUND

It has been suggested that low serum zinc levels may be associated with suboptimal outcomes of pregnancy such as prolonged labour, atonic postpartum haemorrhage, pregnancy-induced hypertension, preterm labour and post-term pregnancies, although many of these associations have not yet been established.

OBJECTIVES

To assess the effects of zinc supplementation in pregnancy on maternal, fetal, neonatal and infant outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of zinc supplementation in pregnancy. We excluded quasi-randomised controlled trials.

DATA COLLECTION AND ANALYSIS

Three review authors applied the study selection criteria, assessed trial quality and extracted data. When necessary, we contacted study authors for additional information.

MAIN RESULTS

We included 20 randomised controlled trials (RCTs) reported in 51 papers involving over 15,000 women and their babies. Trials were generally at low risk of bias. Zinc supplementation resulted in a small but significant reduction in preterm birth (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.76 to 0.97 in 16 RCTs; 16 trials of 7637 women). This was not accompanied by a similar reduction in numbers of babies with low birthweight (RR 0.93, 95% CI 0.78 to 1.12; 14 trials of 5643 women). No significant differences were seen between the zinc and no zinc groups for any of the other primary maternal or neonatal outcomes, except for induction of labour in a single trial. No differing patterns were evident in the subgroups of women with low versus normal zinc and nutrition levels or in women who complied with their treatment versus those who did not.

AUTHORS' CONCLUSIONS

The evidence for a 14% relative reduction in preterm birth for zinc compared with placebo was primarily represented by trials involving women of low income and this has some relevance in areas of high perinatal mortality. There was no convincing evidence that zinc supplementation during pregnancy results in other useful and important benefits. Since the preterm association could well reflect poor nutrition, studies to address ways of improving the overall nutritional status of populations in impoverished areas, rather than focusing on micronutrient and or zinc supplementation in isolation, should be an urgent priority.

Intermittent oral iron supplementation during pregnancy

BACKGROUND

Anaemia is a frequent condition during pregnancy, particularly among women from developing countries who have insufficient iron intake to meet increased iron needs of both the mother and the fetus.Traditionally, gestational anaemia has been prevented with the provision of daily iron supplements throughout pregnancy, but adherence to this regimen due to side effects, interrupted supply of the supplements, and concerns about safety among women with an adequate iron intake, have limited the use of this intervention. Intermittent (i.e. one, two or three times a week on non-consecutive days) supplementation with iron alone or in combination with folic acid or other vitamins and minerals has recently been proposed as an alternative to daily supplementation.

OBJECTIVES

To assess the benefits and harms of intermittent supplementation with iron alone or in combination with folic acid or other vitamins and minerals to pregnant women on neonatal and pregnancy outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 March 2012). We also searched the WHO International Clinical Trials Registry Platform (ICTRP) for ongoing studies and contacted relevant organisations for the identification of ongoing and unpublished studies (23 March 2012).

SELECTION CRITERIA

Randomised or quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of trials using standard Cochrane criteria. Two review authors independently assessed trial eligibility, extracted data and conducted checks for accuracy.

MAIN RESULTS

This review includes 21 trials from 13 different countries, but only 18 trials (with 4072 women) reported on our outcomes of interest and contributed data to the review. All of these studies compared daily versus intermittent iron supplementation.Three studies provided iron alone, 12 iron+folic acid and three more iron plus multiple vitamins and minerals. Their methodological quality was mixed and most had high levels of attrition. Overall, there was no clear evidence of differences between groups for infant primary outcomes: low birthweight (average risk ratio (RR) 0.96; 95% confidence interval (CI) 0.61 to 1.52, seven studies), infant birthweight (mean difference MD -8.62 g; 95% CI -52.76 g to 35.52 g, eight studies), premature birth (average RR 1.82; 95% CI 0.75 to 4.40, four studies). None of the studies reported neonatal deaths or congenital anomalies.For maternal outcomes, there was no clear evidence of differences between groups for anaemia at term (average RR 1.22; 95% CI 0.84 to 1.80, four studies) and women receiving intermittent supplementation had less side effects (average RR 0.56; 95% CI 0.37 to 0.84, 11 studies) than those receiving daily supplements. Women receiving intermittent supplements were also at lower risk of having high haemoglobin (Hb) concentrations (greater than 130 g/L) during the second or third trimester of pregnancy (average RR 0.48; 95% CI 0.35 to 0.67, 13 studies). There were no significant differences in iron-deficiency anaemia between women receiving intermittent or daily iron+folic acid supplementation (average RR 0.71; 95% CI 0.08 to 6.63, 1 study). There were no maternal deaths (six studies) or women with severe anaemia in pregnancy (six studies). None of the studies reported on iron deficiency at term or infections during pregnancy.Where sufficient data were available for primary outcomes, we set up subgroups to look for possible differences between studies in terms of earlier or later supplementation; women's anaemia status at the start of supplementation; higher and lower weekly doses of iron; and the malarial status of the region in which the trials were conducted. There was no clear effect of these variables on the results of the review.

AUTHORS' CONCLUSIONS

The present systematic review is the most comprehensive summary of the evidence assessing the benefits and harms of intermittent iron supplementation regimens in pregnant women on haematological and pregnancy outcomes. The findings suggest that intermittent iron+folic acid regimens produce similar maternal and infant outcomes at birth as daily supplementation but are associated with fewer side effects. Women receiving daily supplements had increased risk of developing high levels of Hb in mid and late pregnancy but were less likely to present mild anaemia near term. Although the evidence is limited and the quality of the trials was low or very low, intermittent may be a feasible alternative to daily iron supplementation among those pregnant women who are not anaemic and have adequate antenatal care.

Preventive treatments of iron deficiency anaemia in pregnancy: a review of their effectiveness and implications for health system strengthening

Objectives. We conducted a review of effectiveness of preventive treatments of iron deficiency anaemia in pregnancy in developing countries and highlighted their constraints as well as interventions required to strengthen the health services. Methods. Literature from Pubmed (MEDLINE), AJOL, Google Scholar, and Cochrane database was reviewed. Results. Evidence-based preventive treatment options for iron deficiency anaemia in pregnancy include prophylaxis iron supplements and food fortification with iron. Evidence abounds on their effectiveness in reducing the prevalence of iron deficiency anaemia in pregnancy. However, these prospects are threatened by side effects of iron supplements, low utilization of maternal health service in developing countries, partial implementation of preventive treatments, and weak infrastructure and political commitment to implement mass fortification of local staple foods by national governments. Conclusion. Sustainability of effectiveness of preventive treatments of iron deficiency anaemia in pregnancy could be achieved if the identified threats are adequately addressed.

Should we screen for iron deficiency anaemia? A review of the evidence and recent recommendations

Worldwide, over 1.6 billion people are anaemic. The prevalence of anaemia and contribution of iron deficiency to this burden is heterogeneous between different populations. Iron deficiency anaemia (IDA) is associated with impaired development in children, adverse effects on cognitive and physical performance in adults, and poorer maternal and infant outcomes in pregnancy. Causes of anaemia other than iron deficiency are important in developed countries and where malaria, thalassaemia or haemoglobinopathy are prevalent. Haemoglobin is the most commonly used screening test for iron deficiency, but may have inadequate sensitivity and specificity to determine iron status in many settings. Screening for anaemia during pregnancy is widely recommended. In children, studies evaluating screening programs have found problems with implementation, acceptability and follow-up of testing, and most international authorities do not support this practice. Nevertheless, certain groups with a particularly high pre-test probability of IDA may benefit from testing following clinical evaluation. Further research is required to define the role of screening and improve available tests for IDA in both developed and developing settings. In this review, the rationale, evidence, experience and expert guidelines regarding screening for IDA, especially among pregnant and paediatric populations, will be evaluated.

Association between maternal prenatal vitamin use and congenital abnormalities of the genitourinary tract in a developing country

OBJECTIVE

To determine the association between prenatal multivitamin supplementation and congenital genitourinary tract anomalies in a group of Colombian newborn babies included in the Latin-American surveillance program (ECLAMC).

STUDY DESIGN

We included all neonates born between January 2004 and August 2007 registered in the ECLAMC database. Maternal prenatal multivitamin use was assessed for 122 newborns with congenital genitourinary tract anomalies and then compared to 271 non-malformed controls.

RESULTS

46,850 births were registered and 122 (26/10,000) of them were identified to have a genitourinary tract anomaly. Prenatal multivitamin supplementation during the first, second, and third trimesters of pregnancy was associated with a reduction in the risk of these anomalies: OR 0.16 (0.08-0.31), OR 0.31 (0.19-0.52), and OR 0.38 (0.23-0.63) respectively.

CONCLUSIONS

Maternal prenatal multivitamins may reduce the risk of congenital genitourinary tract anomalies, not only during the first 8 weeks of gestation but also later in pregnancy, in developing countries.

An integrated scientific framework for child survival and early childhood development

Building a strong foundation for healthy development in the early years of life is a prerequisite for individual well-being, economic productivity, and harmonious societies around the world. Growing scientific evidence also demonstrates that social and physical environments that threaten human development (because of scarcity, stress, or instability) can lead to short-term physiologic and psychological adjustments that are necessary for immediate survival and adaptation, but which may come at a significant cost to long-term outcomes in learning, behavior, health, and longevity. Generally speaking, ministries of health prioritize child survival and physical well-being, ministries of education focus on schooling, ministries of finance promote economic development, and ministries of welfare address breakdowns across multiple domains of function. Advances in the biological and social sciences offer a unifying framework for generating significant societal benefits by catalyzing greater synergy across these policy sectors. This synergy could inform more effective and efficient investments both to increase the survival of children born under adverse circumstances and to improve life outcomes for those who live beyond the early childhood period yet face high risks for diminished life prospects.

Social determinants of iron supplementation among women of reproductive age: a systematic review of qualitative data

Iron supplementation for women of reproductive age is a main part of an interdisciplinary strategy recommended for the control and prevention of iron deficiency and the treatment of mild-to-moderate iron-deficiency anaemia. This systematic review reports the findings from a meta-synthesis of qualitative data concerning the experiences and perceptions of iron supplementation among women of reproductive age and health service providers worldwide. Qualitative systematic review methods were used to conduct a search of published literature, define inclusion and exclusion criteria, appraise quality of studies and extract data on the use of iron supplementation among women of reproductive age. Coding, thematic analysis, reciprocal translation and line of argument synthesis were used to synthesize data. Twelve studies spanning 17 countries met inclusion criteria and were included in the analysis. Seven domains emerged from the review: cultural norms and societal values including explanatory models and medical pluralism; political and socio-economic circumstances; education and communication; social organization and social relationships; health care access and supplement supply; food and nutrition availability; and adherence. In addition, 16 sub-domains are highlighted. Connecting review findings to a conceptual framework of social determinants of health highlights salient issues that policy makers must consider when adapting global iron supplementation recommendations to the local context.

Role of iron supplementation in promoting maternal and fetal outcome

Background

The data comparing daily versus intermittent iron supplementation during pregnancy remain controversial. This study was undertaken to compare the efficacy of daily versus two different intermittent iron supplementation regimes on hematologic markers and birth outcomes in nonanemic pregnant women.

Methods

Two hundred and ten women with singleton pregnancies, no known disease, and hemoglobin levels >11.0 g/dL were randomly assigned to one of three groups, ie, Group A consuming two iron supplementation tablets once weekly (100 mg iron per week, n = 70), Group B consuming one tablet twice weekly (100 mg iron per week, n = 70) and Group C, consuming one tablet daily (50 mg iron per day, n = 70). No additional micronutrients were supplied. Hemoglobin and serum ferritin levels were measured at 20, 28, and 38 weeks. Pregnancy and birth outcomes (pregnancy termination, method of delivery, birth weight, stillbirth) were analyzed.

Results

In total, 201 women completed the protocol. There was a significant difference in mean hemoglobin and ferritin levels in Group B at 38 weeks (P = 0.018 and P = 0.035, respectively) but this difference was not clinically significant (hemoglobin >12 g/dL, ferritin >19 μg/L). There was a significant increase in ferritin in Group C (P = 0.03) at 28 weeks. No significant difference was observed with respect to pregnancy or birth outcome across the groups. All regimens prevented the occurrence of hemoglobin <10.5 g/dL, but weekly supplementation was associated with development of a hemoglobin level <11.0 g/dL (risk ratio 0.044).

Conclusion

Twice-weekly supplementation is as effective as daily supplementation, and may represent an acceptable compromise in iron supplementation regimens for nonanemic pregnant women.

Optimal management of iron deficiency anemia due to poor dietary intake

Iron is necessary for the normal development of multiple vital processes. Iron deficiency (ID) may be caused by several diseases, even by physiological situations that increase requirements for this mineral. One of its possible causes is a poor dietary iron intake, which is infrequent in developed countries, but quite common in developing areas. In these countries, dietary ID is highly prevalent and comprises a real public health problem and a challenge for health authorities. ID, with or without anemia, can cause important symptoms that are not only physical, but can also include a decreased intellectual performance. All this, together with a high prevalence, can even have negative implications for a community’s economic and social development. Treatment consists of iron supplements. Prevention of ID obviously lies in increasing the dietary intake of iron, which can be difficult in developing countries. In these regions, foods with greater iron content are scarce, and attempts are made to compensate this by fortifying staple foods with iron. The effectiveness of this strategy is endorsed by multiple studies. On the other hand, in developed countries, ID with or without anemia is nearly always associated with diseases that trigger a negative balance between iron absorption and loss. Its management will be based on the treatment of underlying diseases, as well as on oral iron supplements, although these latter are limited by their tolerance and low potency, which on occasions may compel a change to intravenous administration. Iron deficiency has a series of peculiarities in pediatric patients, in the elderly, in pregnant women, and in patients with dietary restrictions, such as celiac disease.

Treatment with anthelminthics during pregnancy: what gains and what risks for the mother and child?

In 1994 and 2002, respectively, the World Health Organisation proposed that treatment for hookworm and schistosomiasis could be provided during pregnancy. It was hoped that this might have benefits for maternal anaemia, fetal growth and perinatal mortality; a beneficial effect on the infant response to immunisation was also hypothesised. Three trials have now been conducted. Two have examined the effects of benzimidazoles; one (the Entebbe Mother and Baby Study) the effects of albendazole and praziquantel. All three were conducted in settings of high prevalence but low intensity helminth infection. Results suggest that, in such settings and given adequate provision of haematinics, the benefit of routine anthelminthics during pregnancy for maternal anaemia may be small; none of the other expected benefits has yet been demonstrated. The Entebbe Mother and Baby Study found a significant adverse effect of albendazole on the incidence of infantile eczema in the whole study population, and of praziquantel on the incidence of eczema among infants of mothers with Schistosoma mansoni. Further studies are required in settings that differ in helminth species and infection intensities. Further research is required to determine whether increased rates of infantile eczema translate to long-term susceptibility to allergy, and to explore the underlying mechanisms of these effects. The risks and benefits of routine anthelminthic treatment in antenatal clinics may need to be reconsidered.

Comparative effectiveness of a prenatal medical food to prenatal vitamins on hemoglobin levels and adverse outcomes: a retrospective analysis

BACKGROUND

The role of folate in pregnancy is well established, with most prenatal vitamins (PNVs) on the market containing at least 800 μg of folic acid. Folic acid must be converted in the body to L-methylfolate, the natural and biologically active form of folate. The role of vitamin B(12) in pregnancy is less characterized, and most PNV formulations contain only 0 to 12 μg. The present study was undertaken to evaluate whether taking a prenatal medical food containing L-methylfolate and much higher doses of vitamin B(12) results in higher hemoglobin levels and thus, a lower incidence of anemia during pregnancy.

OBJECTIVE

The objective of this exploratory study was to evaluate the effects of the prenatal medical food versus standard PNVs on hemoglobin levels and adverse outcomes throughout pregnancy.

METHODS

For this retrospective analysis, we reviewed the charts of female patients taking either a prenatal medical food or standard PNV during pregnancy. Hemoglobin levels measured at initiation of prenatal care, end of second trimester, and delivery were recorded. Patients who had received additional iron supplementation, beyond that contained in the prenatal medical food or PNV they were taking and before anemia screening at the end of the second trimester, were excluded from the study. Fisher exact test, χ(2) test, student t test, and ANOVA were used to evaluate differences between the treatment groups.

RESULTS

Data were analyzed from 112 charts: 58 patients (51.8%) were taking the prenatal medical food; 54 patients (48.2%) were taking standard PNVs. Mean (SD) age at first prenatal visit was 27 (4.6) years in the medical food group and 28.8 (3.5) years in the PNV group (P = 0.024). Mean (SD) body mass indices were 29.1 (6.5) and 31.7 (8.9) in the medical food and PNV groups, respectively (P = NS). In the medical food group, 35 women (60.3%) were white/Caucasian, 17 (29.3%) were African American, and 6 (10.4%) were of other races. In the PNV group, 24 women (44.4%) were white/Caucasian, 25 (46.3%) were African American, and 5 (9.3%) were of other races. However, race was not significantly different between the two groups. At end of second trimester and at delivery, mean (SD) hemoglobin levels were higher in the prenatal medical food group (11.8 [1.1] g/dL and 11.8 [1.3] g/dL, respectively) than in the PNV group (11.3 [1.2] g/dL and 10.7 [1.2] g/dL, respectively) (P = 0.011 and P = 0.001, respectively). Significantly fewer cases of anemia were reported at end of second trimester in the prenatal medical food group than in the PNV group (39.7% vs 74.1%; P = 0.001).

CONCLUSIONS

In the present study, supplementation with a prenatal medical food containing L-methylfolate and high-dose vitamin B(12) may maintain hemoglobin levels and decrease rates of anemia in pregnancy more effectively than standard prenatal vitamins; however, prospective, controlled studies are warranted. ClinicalTrials.gov identifier: NCT01193192.

Lifestyle, nutrient intake, iron status, and pregnancy outcome in pregnant women of advanced maternal age

The purpose of this study was to investigate how advanced maternal age influences lifestyle, nutrient intake, iron status, and pregnancy outcomes in pregnant women. The subjects of this study were 112 pregnant women who were receiving prenatal care at gynecologists located in Seoul. The subjects were divided into two groups according to their ages: those over age 35 were the advanced age group of pregnant women (AP) and those under age 35 were the young age group of pregnant women (YP). General factors, nutrient intakes, iron status, and pregnancy outcomes of the two groups were then compared. It was found that 72.5% of the YP group and 51.2% of the AP group had pre-pregnancy alcohol drinking experience; indicating that the YP group had more pre-pregnancy alcohol consumption than the AP group (P < 0.05). The only difference found in nutrient intake between the two groups was their niacin intakes which were 16.83 ± 8.20 mg/day and 13.76 ± 5.28 mg/day, respectively. When gestational age was shorter than 38.7 weeks, the average infant birth weight was 2.95 ± 0.08 kg, and when gestational age was longer than 40 weeks, it averaged at about 3.42 ± 0.08 kg. In other words, as gestational age increased, infant birth weight increased (P < 0.0001), and when maternal weight increased more than 15 kg, the infant birth weight increased significantly (P < 0.05). In conclusion, in order to secure healthy human resources, with respect to advanced aged women, it is necessary to intervene by promoting daily habits that consist of strategic increases in folate and calcium intake along with appropriate amounts of exercise.

Nutritional deficiencies in the developing world: current status and opportunities for intervention

Several contributory factors such as poverty, lack of purchasing power, household food insecurity, and limited general knowledge about appropriate nutritional practices increase the risk of undernutrition in developing countries. The synergistic interaction between inadequate dietary intake and disease burden leads to a vicious cycle that accounts for much of the high morbidity and mortality in these countries. Three groups of underlying factors contribute to inadequate dietary intake and infectious disease: inadequate maternal and child care, household food insecurity, and poor health services in an unhealthy environment.

Linkages among reproductive health, maternal health, and perinatal outcomes

Some interventions in women before and during pregnancy may reduce perinatal and neonatal deaths, and recent research has established linkages of reproductive health with maternal, perinatal, and early neonatal health outcomes. In this review, we attempted to analyze the impact of biological, clinical, and epidemiologic aspects of reproductive and maternal health interventions on perinatal and neonatal outcomes through an elucidation of a biological framework for linking reproductive, maternal and newborn health (RHMNH); care strategies and interventions for improved perinatal and neonatal health outcomes; public health implications of these linkages and implementation strategies; and evidence gaps for scaling up such strategies. Approximately 1000 studies (up to June 15, 2010) were reviewed that have addressed an impact of reproductive and maternal health interventions on perinatal and neonatal outcomes. These include systematic reviews, meta-analyses, and stand-alone experimental and observational studies. Evidences were also drawn from recent work undertaken by the Child Health Epidemiology Reference Group (CHERG), the interconnections between maternal and newborn health reviews identified by the Global Alliance for Prevention of Prematurity and Stillbirth (GAPPS), as well as relevant work by the Partnership for Maternal, Newborn and Child Health. Our review amply demonstrates that opportunities for assessing outcomes for both mothers and newborns have been poorly realized and documented. Most of the interventions reviewed will require more greater-quality evidence before solid programmatic recommendations can be made. However, on the basis of our review, birth spacing, prevention of indoor air pollution, prevention of intimate partner violence before and during pregnancy, antenatal care during pregnancy, Doppler ultrasound monitoring during pregnancy, insecticide-treated mosquito nets, birth and newborn care preparedness via community-based intervention packages, emergency obstetrical care, elective induction for postterm delivery, Cesarean delivery for breech presentation, and prophylactic corticosteroids in preterm labor reduce perinatal mortality; and early initiation of breastfeeding and birth and newborn care preparedness through community-based intervention packages reduce neonatal mortality. This review demonstrates that RHMNH are inextricably linked, and that, therefore, health policies and programs should link them together. Such potential integration of strategies would not only help improve outcomes for millions of mothers and newborns but would also save scant resources. This would also allow for greater efficiency in training, monitoring, and supervision of health care workers and would also help families and communities to access and use services easily.

Iron and folic acid supplements and reduced early neonatal deaths in Indonesia

OBJECTIVE

To examine the relationship between antenatal care, iron and folic acid supplementation and tetanus toxoid vaccination during pregnancy in Indonesia and the risk of early neonatal death (death in days 0-6 of life).

METHODS

We analysed pooled data on neonatal survival in singleton infants born in the 5 years before each of the Indonesian demographic and health surveys of 1994, 1997 and 2002-2003. Only the most recently born infant of each mother was included. Multivariate Cox proportional hazards models were used to identify factors linked to early neonatal death.

FINDINGS

Of the 40 576 infants included, 442 experienced early neonatal death. After adjustment, the risk of early neonatal death was significantly reduced for infants of mothers who received either any form of antenatal care (hazard ratio, HR: 0.48; 95% confidence interval, CI: 0.31-0.73), any quantity of iron and folic acid (HR: 0.53; 95% CI: 0.36-0.77) or >or= 2 tetanus toxoid injections (HR: 0.66; 95% CI: 0.48-0.92). When we analysed different combinations of these measures, iron and folic acid supplementation provided the main protective effect: early neonatal deaths were still significantly reduced among infants whose mothers received iron and folic acid supplements but no other form of antenatal care (HR: 0.10; 95% CI: 0.01-0.67), or the supplements but < 2 tetanus toxoid injections (HR: 0.46; 95% CI: 0.29-0.73). Subsequent analysis showed that 20% of early neonatal deaths in Indonesia could be attributed to a lack of iron and folic acid supplementation during pregnancy.

CONCLUSION

Iron and folic acid supplementation during pregnancy in Indonesia significantly reduced the risk of early neonatal death and could also do so in other low- and middle-income countries.

[Obstetric bleeding: an update]

Massive bleeding in obstetrics still ranks among the most frequent causes of maternal morbidity and mortality worldwide. The most frequent type is primary postpartum hemorrhage, which is usually the result of an atonic uterus. The clinical priorities are to assure hemodynamic stability and to correct coagulation abnormalities. If pharmacologic treatment cannot achieve these goals, invasive methods such as interventional vascular radiology or artery ligation must be used. Hysterectomy is the last resort when the previous methods fail. For the best prognosis, in terms of preventing death, maintaining maternal fertility and minimizing morbidity, every maternity ward should have a well-defined multidisciplinary protocol that facilitates diagnosis and immediate treatment.

Evidence for perinatal and child health care guidelines in crisis settings: can Cochrane help?

BACKGROUND

It is important that healthcare provided in crisis settings is based on the best available research evidence. We reviewed guidelines for child and perinatal health care in crisis situations to determine whether they were based on research evidence, whether Cochrane systematic reviews were available in the clinical areas addressed by these guidelines and whether summaries of these reviews were provided in Evidence Aid.

METHODS

Broad internet searches were undertaken to identify relevant guidelines. Guidelines were appraised using AGREE and the clinical areas that were relevant to perinatal or child health were extracted. We searched The Cochrane Database of Systematic Reviews to identify potentially relevant reviews. For each review we determined how many trials were included, and how many were conducted in resource-limited settings.

RESULTS

Six guidelines met selection criteria. None of the included guidelines were clearly based on research evidence. 198 Cochrane reviews were potentially relevant to the guidelines. These reviews predominantly addressed nutrient supplementation, breastfeeding, malaria, maternal hypertension, premature labour and prevention of HIV transmission. Most reviews included studies from developing settings. However for large portions of the guidelines, particularly health services delivery, there were no relevant reviews. Only 18 (9.1%) reviews have summaries in Evidence Aid.

CONCLUSIONS

We did not identify any evidence-based guidelines for perinatal and child health care in disaster settings. We found many Cochrane reviews that could contribute to the evidence-base supporting future guidelines. However there are important issues to be addressed in terms of the relevance of the available reviews and increasing the number of reviews addressing health care delivery.

Global report on preterm birth and stillbirth (3 of 7): evidence for effectiveness of interventions

INTRODUCTION

Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).

METHODS

Approximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria.

RESULTS

Most interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs: Two interventions prevent preterm births--smoking cessation and progesterone. Eight interventions prevent stillbirths--balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery. Eleven interventions improve survival of preterm newborns--prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome

CONCLUSION

The research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions.

The effects of oral iron supplementation on cognition in older children and adults: a systematic review and meta-analysis

BACKGROUND

In observational studies anaemia and iron deficiency are associated with cognitive deficits, suggesting that iron supplementation may improve cognitive function. However, due to the potential for confounding by socio-economic status in observational studies, this needs to be verified in data from randomised controlled trials (RCTs).

AIM

To assess whether iron supplementation improved cognitive domains: concentration, intelligence, memory, psychomotor skills and scholastic achievement.

METHODOLOGY

Searches included MEDLINE, EMBASE, PsychINFO, Cochrane CENTRAL and bibliographies (to November 2008). Inclusion, data extraction and validity assessment were duplicated, and the meta-analysis used the standardised mean difference (SMD). Subgrouping, sensitivity analysis, assessment of publication bias and heterogeneity were employed.

RESULTS

Fourteen RCTs of children aged 6+, adolescents and women were included; no RCTs in men or older people were found. Iron supplementation improved attention and concentration irrespective of baseline iron status (SMD 0.59, 95% CI 0.29 to 0.90) without heterogeneity. In anaemic groups supplementation improved intelligence quotient (IQ) by 2.5 points (95% CI 1.24 to 3.76), but had no effect on non-anaemic participants, or on memory, psychomotor skills or scholastic achievement. However, the funnel plot suggested modest publication bias. The limited number of included studies were generally small, short and methodologically weak.

CONCLUSIONS

There was some evidence that iron supplementation improved attention, concentration and IQ, but this requires confirmation with well-powered, blinded, independently funded RCTs of at least one year's duration in different age groups including children, adolescents, adults and older people, and across all levels of baseline iron status.