Effects and safety of periconceptional oral folate supplementation for preventing birth defects

Daily oral iron supplementation during pregnancy

BACKGROUND

Iron and folic acid supplementation have been recommended in pregnancy for anaemia prevention, and may improve other maternal, pregnancy, and infant outcomes.

OBJECTIVES

To examine the effects of daily oral iron supplementation during pregnancy, either alone or in combination with folic acid or with other vitamins and minerals, as an intervention in antenatal care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Registry on 18 January 2024 (including CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO's International Clinical Trials Registry Platform, conference proceedings), and searched reference lists of retrieved studies.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trial eligibility, ascertained trustworthiness based on pre-defined criteria, assessed risk of bias, extracted data, and conducted checks for accuracy. We used the GRADE approach to assess the certainty of the evidence for primary outcomes. We anticipated high heterogeneity amongst trials; we pooled trial results using a random-effects model (average treatment effect).

MAIN RESULTS

We included 57 trials involving 48,971 women. A total of 40 trials compared the effects of daily oral supplements with iron to placebo or no iron; eight trials evaluated the effects of iron + folic acid compared to placebo or no iron + folic acid. Iron supplementation compared to placebo or no iron Maternal outcomes: Iron supplementation during pregnancy may reduce maternal anaemia (4.0% versus 7.4%; risk ratio (RR) 0.30, 95% confidence interval (CI) 0.20 to 0.47; 14 trials, 13,543 women; low-certainty evidence) and iron deficiency at term (44.0% versus 66.0%; RR 0.51, 95% CI 0.38 to 0.68; 8 trials, 2873 women; low-certainty evidence), and probably reduces maternal iron-deficiency anaemia at term (5.0% versus 18.4%; RR 0.41, 95% CI 0.26 to 0.63; 7 trials, 2704 women; moderate-certainty evidence), compared to placebo or no iron supplementation. There is probably little to no difference in maternal death (2 versus 4 events, RR 0.57, 95% CI 0.12 to 2.69; 3 trials, 14,060 women; moderate-certainty evidence). The evidence is very uncertain for adverse effects (21.6% versus 18.0%; RR 1.29, 95% CI 0.83 to 2.02; 12 trials, 2423 women; very low-certainty evidence) and severe anaemia (Hb < 70 g/L) in the second/third trimester (< 1% versus 3.6%; RR 0.22, 95% CI 0.01 to 3.20; 8 trials, 1398 women; very low-certainty evidence). No trials reported clinical malaria or infection during pregnancy. Infant outcomes: Women taking iron supplements are probably less likely to have infants with low birthweight (5.2% versus 6.1%; RR 0.84, 95% CI 0.72 to 0.99; 12 trials, 18,290 infants; moderate-certainty evidence), compared to placebo or no iron supplementation. However, the evidence is very uncertain for infant birthweight (MD 24.9 g, 95% CI -125.81 to 175.60; 16 trials, 18,554 infants; very low-certainty evidence). There is probably little to no difference in preterm birth (7.6% versus 8.2%; RR 0.93, 95% CI 0.84 to 1.02; 11 trials, 18,827 infants; moderate-certainty evidence) and there may be little to no difference in neonatal death (1.4% versus 1.5%, RR 0.98, 95% CI 0.77 to 1.24; 4 trials, 17,243 infants; low-certainty evidence) or congenital anomalies, including neural tube defects (41 versus 48 events; RR 0.88, 95% CI 0.58 to 1.33; 4 trials, 14,377 infants; low-certainty evidence). Iron + folic supplementation compared to placebo or no iron + folic acid Maternal outcomes: Daily oral supplementation with iron + folic acid probably reduces maternal anaemia at term (12.1% versus 25.5%; RR 0.44, 95% CI 0.30 to 0.64; 4 trials, 1962 women; moderate-certainty evidence), and may reduce maternal iron deficiency at term (3.6% versus 15%; RR 0.24, 95% CI 0.06 to 0.99; 1 trial, 131 women; low-certainty evidence), compared to placebo or no iron + folic acid. The evidence is very uncertain about the effects of iron + folic acid on maternal iron-deficiency anaemia (10.8% versus 25%; RR 0.43, 95% CI 0.17 to 1.09; 1 trial, 131 women; very low-certainty evidence), or maternal deaths (no events; 1 trial; very low-certainty evidence). The evidence is uncertain for adverse effects (21.0% versus 0.0%; RR 44.32, 95% CI 2.77 to 709.09; 1 trial, 456 women; low-certainty evidence), and the evidence is very uncertain for severe anaemia in the second or third trimester (< 1% versus 5.6%; RR 0.12, 95% CI 0.02 to 0.63; 4 trials, 506 women; very low-certainty evidence), compared to placebo or no iron + folic acid. Infant outcomes: There may be little to no difference in infant low birthweight (33.4% versus 40.2%; RR 1.07, 95% CI 0.31 to 3.74; 2 trials, 1311 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. Infants born to women who received iron + folic acid during pregnancy probably had higher birthweight (MD 57.73 g, 95% CI 7.66 to 107.79; 2 trials, 1365 infants; moderate-certainty evidence), compared to placebo or no iron + folic acid. There may be little to no difference in other infant outcomes, including preterm birth (19.4% versus 19.2%; RR 1.55, 95% CI 0.40 to 6.00; 3 trials, 1497 infants; low-certainty evidence), neonatal death (3.4% versus 4.2%; RR 0.81, 95% CI 0.51 to 1.30; 1 trial, 1793 infants; low-certainty evidence), or congenital anomalies (1.7% versus 2.4; RR 0.70, 95% CI 0.35 to 1.40; 1 trial, 1652 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. A total of 19 trials were conducted in malaria-endemic countries, or in settings with some malaria risk. No studies reported maternal clinical malaria; one study reported data on placental malaria.

AUTHORS' CONCLUSIONS

Daily oral iron supplementation during pregnancy may reduce maternal anaemia and iron deficiency at term. For other maternal and infant outcomes, there was little to no difference between groups or the evidence was uncertain. Future research is needed to examine the effects of iron supplementation on other maternal and infant health outcomes, including infant iron status, growth, and development.

Vitamin D, Folate, Vitamin B12, and Iron Status in Pregnant/Postpartum Old Order Anabaptist Women in Southwestern Ontario

Purpose: To assess vitamin D, folate, vitamin B12, and iron status in Old Order Anabaptist (OOA) pregnant/postpartum women.Methods: Blood was analyzed for plasma 25 hydroxy vitamin D (25(OH)D), red blood cell (RBC) folate, serum vitamin B12, and iron status indicators. Dietary intakes (food and supplements) from 3-day estimated records were compared to Dietary Reference Intakes and Canada's Food Guide (2007).Results: Fifty women participated in this descriptive cross-sectional study. Concentrations of 25(OH)D were low (<50 nmol/L for 20% and < 75 nmol/L for 63%); 42% had total vitamin D intakes < estimated average requirement (EAR). All women had RBC folate above the 1360 mmol/L cut-off. Nineteen percent had folate intakes upper limit. One woman had low serum vitamin B12 (<148 pmol/L); serum vitamin B12 was high (>652 pmol/L) for 24%. None had vitamin B12 intakes  Collapse

Key Words

• Anabaptist
• anabaptiste
• femmes enceintes post-partum
• fer
• folate
• iron
• pregnant postpartum women
• vitamin B12
• vitamin D
• vitamine B12
• vitamine D

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MESH Headings Collapse

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Affiliation(s)

Janis A Randall Simpson Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON
Natalee Miller Huron Perth Public Health, Stratford, ON
Taylor Hartwig Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, ON
Jane Leach Huron Perth Public Health, Stratford, ON
Melissa Purdy Huron Perth Public Health, Stratford, ON
Emily Roth Countryside Midwifery Services, Milverton, ON
Victoria Mok Siu Department of Pediatrics, Western University, London, ON
Cynthia Soulliere Countryside Midwifery Services, Milverton, ON
Jacqui Tam Huron Perth Public Health, Stratford, ON
Ann Watt Huron Perth Public Health, Stratford, ON

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Preconception health risk factors documented in general practice electronic medical records

BACKGROUND

Documenting medical and lifestyle preconception health risk factors in electronic medical records (EMRs) could assist general practitioners (GPs) to identify those reproductive-aged women who could most benefit from preconception care (PCC). However, it is unclear to what extent PCC risk factors are identifiable in general practice records. This study aimed to determine the extent to which medical and lifestyle preconception health risk factors are documented in general practice EMRs.

METHODS

We conducted an audit of the documentation of medical and lifestyle preconception risk factors in 10 general practice EMRs in Melbourne, Australia. We retrospectively analysed the EMRs of 100 consecutive women aged 18-44 years who visited each practice between January and September 2022. Using a template informed by PCC guidelines, we extracted data from structured fields in the EMR and conducted a descriptive analysis.

RESULTS

Among the data extracted, the more commonly documented medical and lifestyle preconception health risk factors in the EMRs included smoking (79%), blood pressure (74%), alcohol consumption (63%) and body mass index (57%). Among the women audited, 14% were smokers, 24% were obese, 7% had high blood pressure, 5% had diabetes, 28% had a mental health condition, 13% had asthma, 6% had thyroid disease and 17% had been prescribed and could be using a potentially teratogenic medication.

CONCLUSIONS

Better documentation of medical and lifestyle preconception health risk factors in structured fields in EMRs may potentially assist primary care providers including GPs in identifying and providing PCC to women who could most benefit from it.

Decrease in Prevalence of Cleft lip, Alveolus and Palate After Nationwide Introduction of the Second-Trimester Anomaly Scan in the Netherlands

OBJECTIVE

Some studies have suggested that introducing a second-trimester anomaly scan (SAS) leads to increased rates of termination of pregnancy (TOP) in fetuses with orofacial clefts (OFCs). The aim of this study was to evaluate the impact of a nationwide introduction of SAS on the prevalence of live births with OFCs in the Netherlands.

DESIGN

Retrospective cohort study.

SETTING

Tertiary setting.

POPULATION

Included in the study were all patients diagnosed with OFCs as recorded in the "Dutch Association for Cleft Palate Anomalies" database between 1997 and 2019.

INTERVENTIONS

Patients were divided into three categories: cleft lip with or without alveolus (CL/A), cleft lip, alveolus and palate (CLAP) and cleft palate (CP) based on anatomical landmarks at the first consultation.

MAIN OUTCOME MEASURES

Prevalence rates of OFCs before and after the nationwide introduction of the SAS on January 1, 2007 were compared.

RESULT

Overall, 1899 patients were diagnosed with CL/A, 2586 with CLAP and 2927 with CP. The prevalence of clefts before and after introduction of the SAS did not differ (P = 0.85). The prevalence of CL/A decreased (P = 0.04), and that of CLAP decreased (P = 0.01) and that of CP increased (P = 0.02).

CONCLUSIONS

This study demonstrates a significant decrease in the prevalence of CL/A and CLAP after introduction of the SAS. However, due to an increase in CP, the prevalence of all patients born with OFCs has not changed in the Netherlands between 1997 and 2019.

Guideline for the management of conception and pregnancy in thalassaemia syndromes: A British Society for Haematology Guideline

This comprehensive guideline, developed by a representative group of UK-based medical experts specialising in haemoglobinopathies, addresses the management of conception and pregnancy in patients with thalassaemia. A systematic search of PubMed and EMBASE using specific keywords, formed the basis of the literature review. Key terms included "thalassaemia," "pregnancy," "Cooley's anaemia," "Mediterranean anaemia," and others, covering aspects such as fertility, iron burden and ultrasonography. The guideline underwent rigorous review by prominent organisations, including the Endocrine Society, the Royal College of Obstetricians and Gynaecologists (RCOG), the United Kingdom Thalassaemia Society and the British Society of Haematology (BSH) guideline writing group. Additional feedback was solicited from a sounding board of UK haematologists, ensuring a thorough and collaborative approach. The objective of the guideline is to equip healthcare professionals with precise recommendations for managing conception and pregnancy in patients with thalassaemia.

Maternal serum unmetabolized folic acid concentration following multivitamin and mineral supplementation with or without folic acid after 12 weeks gestation: A randomized controlled trial

Pregnant women are advised to take folic acid (FA) supplements before conception and during the first trimester of pregnancy. Many women continue FA supplementation throughout pregnancy, and concerns have been raised about associations between excessive FA intake and adverse maternal and child health outcomes. Unmetabolized folic acid (UMFA) is found in serum after high FA intakes and is proposed as a biomarker for excessive FA intake. We aimed to determine if removing FA from prenatal micronutrient supplements after 12 weeks of pregnancy reduces serum UMFA concentrations at 36 weeks gestation. In this double-blind, randomized controlled trial conducted in South Australia, 103 women with a singleton pregnancy were randomly assigned at 12-16 weeks gestation to take a micronutrient supplement containing no FA or 800 µg/day FA from enrollment until 36 weeks gestation. Ninety women (0 µg/day FA n = 46; 800 µg/day FA n = 44) completed the study. Mean, UMFA concentration was lower in the women randomized to the 0 µg/day group compared to the 800 µg/day FA group, 0.6 ± 0.7 and 1.4 ± 2.7 nmol/L, respectively. The adjusted mean difference (95% CI) in UMFA between the groups was [-0.85 (-1.62, -0.08) nmol/L, p = 0.03]. Maternal serum and red blood cell folate concentrations were lower in the 0 µg/day FA group than in the 800 µg/day group (median 23.2 vs. 49.3 and 1335 vs. 1914 nmol/L, respectively; p < 0.001). Removing FA at 12-16 weeks gestation from prenatal micronutrient supplements reduced the concentration of UMFA at 36 weeks gestation.

Are migrants during the periconception period less likely to be supplementing with folic acid: An Australian cohort study

BACKGROUND

Folic acid (FA) supplementation before and in early pregnancy is known to improve outcomes such as reducing neural tube defects; however, little is known about groups in Australia at risk of low FA use.

AIM

To determine whether differences exist in FA supplementation rates between Australian-born women and migrant women, with a secondary aim of examining the sociodemographic characteristics of women who are not supplementing with FA in early pregnancy.

METHODS

A retrospective cohort study from January 2018-July 2022 in a high-migrant population in Western Sydney, Australia. Multivariate logistic regression analysis was conducted adjusting for confounders including place of birth, age, ethnicity, parity, history of diabetes, and type of conception.

FINDINGS

There were 48,045 women who met inclusion criteria; 65% of whom were migrants. We identified that 39.4% of the study population did not report FA supplementation by early pregnancy. Women who were migrants were more likely to report FA usage than those born in Australia (aOR 1.24; 95%CI 1.17-1.31). Women least likely to report use of FA were women < 20 years of age (aOR 0.54; 95%CI 0.44-0.67) and multiparous women (aOR 0.84; 95%CI 0.82-0.86). Women with type 1 or type 2 diabetes were more likely to report FA use (aOR 1.66; 95%CI 1.11-2.48, aOR 1.30; 95%CI 1.05-1.61).

CONCLUSION

A significant proportion of the population did not report FA supplementation before or during early pregnancy. To increase uptake of FA supplementation, clinicians and public health messaging should target at-risk groups.

Multivitamin Use Among Hispanic Women of Reproductive Age in the United States, 2013-2022

Background: The U.S. Public Health Service and the Institute of Medicine recommend that all women capable of becoming pregnant consume 400 μg of folic acid daily to help prevent neural tube defects (NTDs). Hispanic women are at higher risk of having babies with NTDs than non-Hispanic White women. This study assessed multivitamin (MV) use, a main source of folic acid, among Hispanic women of reproductive age using a survey of solely U.S. Hispanic adults. Materials and Methods: MV use was assessed as part of Porter Novelli's Estilos survey, fielded annually through the largest online U.S. Hispanic panel, Offerwise's QueOpinas. During the study period of 2013-2022, 9,999 surveys were completed; selection was weighted to match the U.S. Census American Community Survey proportions. Log-binomial regression models were applied to estimate MV use trends by age groups, acculturation levels, and pregnancy intention. Results: Among 3,700 Hispanic women of reproductive age, overall no MV use increased from 39.3% in 2013 to 54.7% in 2022 (p for trend <0.0001), especially among Hispanic women aged 18-34 years and those classified as acculturated. Among women planning to get pregnant, daily MV use was 31.1% in 2013 compared with 18.7% in 2020-2022 (p = 0.04). Conclusions: Given the increase in no MV use among Hispanic women of reproductive age, targeted interventions may help reach at-risk groups for NTDs prevention.

Optimizing perinatal wellbeing in pregnancy with obesity: a clinical trial with a multi-component nutrition intervention for prevention of gestational diabetes and infant growth and neurodevelopment impairment

Pregnancy complicated by obesity represents an increased risk of unfavorable perinatal outcomes such as gestational diabetes mellitus (GDM), hypertensive disorders in pregnancy, preterm birth, and impaired fetal growth, among others. Obesity is associated with deficiencies of micronutrients, and pregnant women with obesity may have higher needs. The intrauterine environment in pregnancies complicated with obesity is characterized by inflammation and oxidative stress, where maternal nutrition and metabolic status have significant influence and are critical in maternal health and in fetal programming of health in the offspring later in life. Comprehensive lifestyle interventions, including intensive nutrition care, are associated with a lower risk of adverse perinatal outcomes. Routine supplementation during pregnancy includes folic acid and iron; other nutrient supplementation is recommended for high-risk women or women in low-middle income countries. This study is an open label randomized clinical trial of parallel groups (UMIN Clinical Trials Registry: UMIN000052753, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000060194) to evaluate the effect of an intensive nutrition therapy and nutrient supplementation intervention (folic acid, iron, vitamin D, omega 3 fatty acids, myo-inositol and micronutrients) in pregnant women with obesity on the prevention of GDM, other perinatal outcomes, maternal and newborn nutritional status, and infant growth, adiposity, and neurodevelopment compared to usual care. Given the absence of established nutritional guidelines for managing obesity during pregnancy, there is a pressing need to develop and implement new nutritional programs to enhance perinatal outcomes.

Folate and vitamin B12 status and predicted neural tube defects risk among nonpregnant women of reproductive age from the Malawi National Micronutrient Survey, 2015-2016

BACKGROUND

Maternal folate and vitamin B12 deficiency can lead to serious adverse pregnancy outcomes. There are no nationally representative estimates on folate and vitamin B12 status among women of reproductive age (WRA) in Malawi.

OBJECTIVE

We assessed folate and vitamin B12 status among nonpregnant WRA in Malawi and predicted the risk of folate-sensitive neural tube defects (NTDs) were they to become pregnant.

METHODS

Using data from the cross-sectional, nationally representative 2015-2016 Malawi Micronutrient Survey, we calculated the proportion of folate and vitamin B12 deficiency and insufficiency by demographic characteristics among 778 nonpregnant WRA (15-49 years). We predicted NTD prevalence using red blood cell (RBC) folate distributions and a published Bayesian model of the association between RBC folate and NTD risk. Analyses accounted for complex survey design.

RESULTS

Among WRA, 8.5% (95% CI: 6.2, 11.6) and 13.3% (10.0, 17.4) had serum (<7 nmol/L) and RBC folate (<305 nmol/L) deficiency, respectively. The proportion of vitamin B12 deficiency (<148 pmol/L) and insufficiency (≤221 pmol/L) was 11.8% (8.6, 16.0) and 40.6% (34.1, 47.4), respectively. RBC folate insufficiency (<748 nmol/L, defined as the concentration associated with the threshold for elevated NTD risk: >8 cases per 10,000 births) was widespread: 81.4% (75.0, 86.4). The predicted NTD risk nationally was 24.7 cases per 10,000 live births. RBC folate insufficiency and higher predicted NTD risk were more common among WRA living in urban areas or with higher education.

CONCLUSIONS

These findings highlight the importance of nutritional and NTD surveillance in Malawi and the opportunity for improving folate and vitamin B12 nutrition among Malawian WRA.

The association of preconceptional folic acid supplementation with gestational age and preterm birth risk in twin pregnancies: a prospective cohort study in China

PURPOSE

This study aims to explore the association of maternal preconceptional folic acid (FA) supplementation with gestational age and preterm birth in twin pregnancies, and whether the association varies by chorionicity or conception mode.

METHODS

From November 2018 to December 2021, the information of FA supplementation and pregnancy outcomes were collected in twin pregnant women. The linear regression models and the logistic regression were used to test the association of preconceptional FA supplementation with gestational age at delivery and preterm birth and premature rupture of membranes (PROM).

RESULTS

A total of 416 twin pregnancies were included. Compared with no use in twins, maternal preconceptional FA use was associated with a 0.385-week longer gestational age (95% CI 0.019-0.751) and lower risk of preterm birth < 36 weeks (adjusted OR 0.519; 95% CI 0.301-0.895) and PROM (adjusted OR 0.426; 95% CI 0.215-0.845). The protective effect on preterm birth < 36 weeks and PROM is similar whether taking FA supplements alone or multivitamins. However, the associations varied by chorionicity and conception mode of twins or compliance with supplementation. The positive associations between preconceptional FA use and gestational age only remained significant among twins via assisted reproductive technology or dichorionic diamniotic twins. Significant protective effects on preterm birth < 36 weeks and PROM were only found among women who took FA at least 4 times a week before conception.

CONCLUSION

Maternal preconceptional FA supplementation was associated with longer gestation duration and lower risk of preterm birth < 36 weeks and PROM in twin pregnancies. To improve the success of their pregnancies, reproductive women should start taking FA supplements well before conception and with good compliance.

Interconception care during well-child visits by family physicians in the United States: A cross-sectional study

Background

Interconception care (ICC) by family physicians during well-child visits (WCVs) has been broadly advocated in principle but has not been widely implemented. We aimed to investigate ICC at WCVs by family physicians at our facility, focusing on four maternal risk factors, including maternal tobacco use, maternal depression, contraception, and folic acid supplementation.

Methods

Mothers who visited WCVs with children up to the age of 24 months at our university-affiliated clinic were screened for the four maternal risks. Brief interventions were provided to mothers with positive screening results. We investigated mothers at WCVs from December 1, 2020, to November 30, 2022. We performed descriptive and binary logistic regression analyses to determine the maternal demographic factors associated with positive screenings.

Results

Of 1143 WCVs, 205 mothers were evaluated. Screening was positive in the following rates: tobacco use 5.9%, depression 11.5%, contraception 73.6%, and folic acid supplementation 40.5%. Single marital status was associated with positive screening for smoking (odds ratio [OR] 8.689, p = 0.016) and maternal depression (OR 3.470, p = 0.035). Maternal education level lower than a high school diploma was associated with positive screening for folic acid intake (OR 4.975, p = 0.004).

Conclusions

ICC conducted during WCVs by family physicians offers valuable opportunities to identify maternal risk factors and address modifiable factors that can influence future birth outcomes. Single marital status and educational level less than a high school diploma were more potent risk factors for maternal behavior in ICC. More research is needed to assess the outcomes of the interventions.

Folate - a scoping review for Nordic Nutrition Recommendations 2023

Folate is an essential micronutrient for normal development and metabolic function, and folate deficiency is associated with an increased risk of cancer, cardiovascular disease, mental dysfuntion and negative pregnancy outcomes. When estimating folate requirements, one must consider different bioavailability and functionality between synthetic folic acid and dietary folate, together with increased needs of folate in women of fertile age, pregnant and lactating women, preterm and small for gestational age weight infants and individuals who are homozygote for the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene polymorphism. In order to achieve an adequate metabolic status based on the metabolic marker total homocysteine, and not merely the absence of clinical signs of folate deficiency, the recommended intake of folate differs according to age, pregnancy and lactation. According to the World Health Organization, a decision limit for folate deficiency in adults is serum folate level below 10 nmol/L, and in women of fertile age a red blood cell folate level below 906 nmol/L in order to prevent neural tube defects. Qualified systematic reviews along with identified relevant literature have been used for this scoping review prepared for the Nordic Nutrition Recommendations 2023.

Inequities in pre-pregnancy folic acid use in Central and South Auckland: secondary analysis from a postpartum contraception survey

Introduction In Aotearoa New Zealand (NZ), there is inequity in rates of neural tube defects (NTDs). Among Maaori, NTD occur in 4.58/10 000 live births, and for Pacific peoples, it is 4.09/10 000 live births; this is compared to 2.81/10 000 live births for non-Maaori, non-Pacific peoples. Aim To describe self-reported pre-pregnancy folic acid supplementation and to determine the association between pregnancy intendedness, ethnicity, parity, maternal age, care provider and pre-pregnancy folic acid supplementation. Methods Secondary analysis of postpartum survey data collected at Te Whatu Ora Te Toka Tumai and Counties Manukau birthing facilities in 2020 was conducted. Descriptive analyses explored pregnancy intendedness and self-reported folic acid use by demographic variables. Multivariable logistic regression explored independent associations between demographic variables and folic acid use among intended pregnancies. Results In total, 398 participants completed the survey. The response rate was (140/149) 94% at Counties Manukau and (258/315) 82% at Te Toka Tumai. Pre-pregnancy supplementation was reported by 182 of 398 participants (46%). Use was higher among those who intended their pregnancy (151/262, 58%) compared to those who were 'pregnancy ambivalent' (9/33, 27%) or did not intend to become pregnant (22/103, 21%). Factors independently associated with supplementation among intended pregnancies included: 'Other ethnicity' (European, Middle Eastern, Latin American, African) compared to Maaori (aOR 5.3 (95% CI 1.3, 21.8)), age ≥30 years compared to Discussion Low rates of pre-pregnancy folic acid supplementation exist in Auckland with significant ethnic disparity. Mandatory fortification of non-organic wheat is important, but supplementation is still recommended to maximally reduce risk.

Recommendation and intake of dietary supplements periconceptional and during pregnancy: results of a nationwide survey of gynaecologists

BACKGROUND

Micronutrient supplementation during pregnancy is a controversial issue. For some micronutrients, for example folic acid or iodine, the evidence regarding supplementation is clear, whereas for others, such as zinc or vitamin E, it is not. Studies show that a large number of pregnant women have deficient levels of folic acid and iodine. However, especially with folic acid, starting supplementation during the preconception period is crucial. It is, therefore, important that gynaecologists explain this to their pregnant or preconceptional patients. Our goal was to find out how gynaecologists make their recommendations on this topic, how they assess the compliance of their patients and which micronutrients they consider to be important before/during pregnancy and during breastfeeding. METHOD AND RESULTS: We sent about 12,000 questionnaires to all registered resident gynaecologists in Germany, with a response rate of 12.2%. Regarding which micronutrients gynaecologists  consider to be particularly important during pregnancy, there was a broad agreement for both folic acid and iodine (> 88% answered yes). According to the questionnaire, doctors rate other micronutrients, such as vitamin D and omega-3 fatty acids, as less essential. The controversial evidence level for many micronutrients certainly plays a role here. Overall, the intake rate, especially for preconceptional women, is classified as rather low (< 60%). The most widely valued reason is the high price of dietary supplements. It was also noticeable that doctors consider certain micronutrients to be particularly important but then do not include them in the products they recommend.

CONCLUSION

Overall, there seems to be uncertainty about micronutrients in pregnancy and their supplementation. The study situation is often ambiguous and there are no official guidelines, leading to ambiguous recommendations from doctors and therefore low intake rates for pregnant or preconceptional women.

The roles of JAK2/STAT3 signaling in fusion of the secondary palate

Cleft palate has a multifactorial etiology. In palatal fusion, the contacting medial edge epithelium (MEE) forms the epithelial seam, which is subsequently removed with the reduction of p63. Failure in this process results in a cleft palate. We herein report the involvement of janus kinase 2 (JAK2)/signal transducer and activator of transcription 3 (STAT3) signaling in palatal fusion and that folic acid rescues the fusing defect by reactivating JAK2/STAT3. In closure of bilateral palatal shelves, STAT3 phosphorylation was activated at the fusing MEE and mesenchyme underlying the MEE. JAK2 inhibition by AG490 inhibited STAT3 phosphorylation and resulted in palatal fusion failure without removal of the epithelial seam, in which p63 and keratin 17 (K17) periderm markers were retained. Folic acid application restored STAT3 phosphorylation in AG490-treated palatal explants and rescued the fusion defect, in which the p63- and K17-positive epithelial seam were removed. The AG490-induced palatal defect was also rescued in p63 haploinsufficient explants. These findings suggest that JAK2/STAT3 signaling is involved in palatal fusion by suppressing p63 expression in MEE and that folate restores the fusion defect by reactivating JAK2/STAT3.

Investigating the pathways from preconception care to preventing maternal, perinatal and child mortality: A scoping review and causal loop diagram

In recent years, there has been a growing recognition that developing preconception care provides an opportunity to significantly reduce maternal and child mortality and morbidity. This involves targeting multiple risk factors through a large array of medical, behavioural and social interventions. In this study, we created a Causal Loop Diagram (CLD) to describe several pathways by which a set of preconception interventions may lead to women's improved health and better pregnancy outcomes. The CLD was informed by a scoping review of meta-analyses. It summarises evidence on the outcomes and interventions related to eight preconception risk factors. The authors reviewed literature from two databases (PubMed and Embase) and used the framework developed by Arksey and O'Malley. The CLD includes 29 constructs categorised into five different levels (mortality, causes of death, preconception risk factors, intermediate factors, interventions or policies). The model indicates interconnections between five sub-systems and highlights the role of preventing early and rapidly repeated pregnancies, as well as optimising women's nutritional status in the preconception period. It also shows the prevention of preterm birth as a privileged route for lowering child mortality and morbidity. The CLD demonstrates the potential benefits of strategies that address multiple preconception risk factors simultaneously and can be used as a tool to promote the integration of preconception care into efforts to prevent maternal and child mortality. With further improvements, this model could serve as a basis for future research on the costs and benefits of preconception care.

Improving the provision of preconception care in Australian general practice through task-sharing with practice nurses

Preconception care (PCC) is effective in reducing modifiable risk factors and optimising maternal health. Primary care services such as general practices in Australia are an appropriate setting to provide PCC. However, PCC is not routinely provided in most of these settings, and many reproductive-aged women and men are not aware of the need for PCC. In this forum article, we discuss the factors that hinder PCC provision in Australian general practices and make recommendations on how access to PCC services can be broadened in Australia, including the potential opportunity for general practice nurses to contribute to the provision of PCC.

DNMT1 involved in the analgesic effect of folic acid on gastric hypersensitivity through downregulating ASIC1 in adult offspring rats with prenatal maternal stress

AIMS

Gastric hypersensitivity (GHS) is a characteristic pathogenesis of functional dyspepsia (FD). DNA methyltransferase 1 (DNMT1) and acid-sensing ion channel 1 (ASIC1) are associated with GHS induced by prenatal maternal stress (PMS). The aim of this study was to investigate the mechanism of DNMT1 mediating the analgesic effect of folic acid (FA) on PMS-induced GHS.

METHODS

GHS was quantified by electromyogram recordings. The expression of DNMT1, DNMT3a, DNMT3b, and ASIC1 were detected by western blot, RT-PCR, and double-immunofluorescence. Neuronal excitability and proton-elicited currents of dorsal root ganglion (DRG) neurons were determined by whole-cell patch clamp recordings.

RESULTS

The expression of DNMT1, but not DNMT3a or DNMT3b, was decreased in DRGs of PMS rats. FA alleviated PMS-induced GHS and hyperexcitability of DRG neurons. FA also increased DNMT1 and decreased ASIC1 expression and sensitivity. Intrathecal injection of DNMT1 inhibitor DC-517 attenuated the effect of FA on GHS alleviation and ASIC1 downregulation. Overexpression of DNMT1 with lentivirus not only rescued ASIC1 upregulation and hypersensitivity, but also alleviated GHS and hyperexcitability of DRG neurons induced by PMS.

CONCLUSIONS

These results indicate that increased DNMT1 contributes to the analgesic effect of FA on PMS-induced GHS by reducing ASIC1 expression and sensitivity.

Congenital malformations among offspring of women with type 1 diabetes who use insulin pumps: a prospective cohort study

AIMS/HYPOTHESIS

Continuous subcutaneous insulin infusion by insulin pump is often superior in improving glycaemic control compared with conventional multiple daily insulin injection (MDI). However, whether pump treatment leads to improved pregnancy outcomes in terms of congenital malformations and perinatal death remains unknown. The present aim was to evaluate the risk of malformations and perinatal and neonatal death in pregnant women with type 1 diabetes treated with pump or MDI.

METHODS

We performed a secondary analysis of a prospective multinational cohort of 2088 pregnant women with type 1 diabetes in a real-world setting who were treated by pump (n=750) or MDI (n=1338). ORs for offspring with congenital malformations or perinatal or neonatal death were calculated using crude data and by logistic regression on propensity score-matched data.

RESULTS

At enrolment (gestational week 8; 95% CI 4, 14), pump users had a higher educational level (university degree: 37.3% vs 25.1%; p<0.001) and better glycaemic control (mean HbA1c: 51±10 mmol/mol [6.8±0.9%] vs 54±14 mmol/mol [7.1±1.3%], p<0.001) compared with MDI users. Moreover, a greater proportion of pump users had an HbA1c level below 75 mmol/mol (9%) (97.6% vs 91.9%, p<0.001), and more often reported taking folic acid supplementation (86.3% vs 74.8%; p<0.001) compared with MDI users. All clinically important potential confounders were balanced after propensity score matching, and HbA1c remained lower in pump users. The proportion of fetuses with at least one malformation was 13.5% in pump users vs 11.2% in MDI users (crude OR 1.23; 95% CI 0.94, 1.61; p=0.13; propensity score-matched (adjusted) OR 1.11; 95% CI 0.81, 1.52; p=0.52). The proportion of fetuses with at least one major malformation was 2.8% in pump users vs 3.1% in MDI users (crude OR 0.89; 95% CI 0.52, 1.51; p=0.66; adjusted OR 0.78; 95% CI 0.42, 1.45; p=0.43), and the proportions of fetuses carrying one or more minor malformations (but no major malformations) were 10.7% vs 8.1% (crude OR 1.36; 95% CI 1.00, 1.84; p=0.05; adjusted OR 1.23; 95% CI 0.87, 1.75; p=0.25). The proportions of perinatal and neonatal death were 1.6% vs 1.3% (crude OR 1.23; 95% CI 0.57, 2.67; p=0.59; adjusted OR 2.02; 95% CI 0.69, 5.93; p=0.20) and 0.3% vs 0.3% (n=2 vs n=4, p=not applicable), respectively.

CONCLUSIONS/INTERPRETATIONS

Insulin pump treatment was not associated with a lower risk of congenital malformations, despite better glycaemic control in early pregnancy compared with MDI. Further studies exploring the efficacy and safety of pump treatment during pregnancy are needed.

Maternal and fetal outcomes in pregnant women with rheumatoid arthritis: a systematic review and meta-analysis

OBJECTIVE

Rheumatoid arthritis (RA) is a common chronic systemic autoimmune disease affecting women of childbearing age. We aimed to conduct a meta-analysis of published observational studies to systematically evaluate the association between RA and adverse pregnancy outcomes.

METHODS

Medline (PubMed), EMBASE, and Web of Science were searched for keywords from the date of inception to December 28, 2021, to identify relevant studies reporting adverse maternal and/or fetal outcomes in RA pregnancies. Data from individual studies were pooled using random-effects models and presented as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

Eighteen studies with a total number of over 50 million participants were eligible for inclusion. This current analysis showed that in pregnant women with RA, there was a significantly increased risk of adverse maternal outcomes, including caesarean section (OR, 1.39; 95% CI 1.24-1.55), pre-eclampsia (OR, 1.48; 95% CI 1.19-1.83), gestational hypertension (OR, 1.34; 95% CI 1.07-1.68) and spontaneous abortion (OR, 1.16; 95% CI 1.04-1.29). Similarly, maternal RA during pregnancy was also associated with a significantly increased risk of adverse fetal outcomes, including preterm birth (OR, 1.58; 95% CI 1.44-1.74), small for gestational age (OR, 1.49; 95% CI 1.22-1.82), low birth weight (OR, 1.45; 95% CI 1.30-1.63), congenital anomalies (OR, 1.36; 95% CI 1.01-1.83) and stillborn (OR, 1.38; 95% CI 1.09-1.74).

CONCLUSION

Maternal RA is significantly associated with an increased risk of adverse maternal and fetal outcomes. Close monitoring of the clinical status of RA patients before and during pregnancy is essential in clinical practice. Key Points • Pregnant women with rheumatoid arthritis (RA) are at significantly increased risk for adverse maternal and fetal outcomes. • The increased risk of adverse pregnancy outcomes in women with RA may be closely related to medication use and disease activity. • Close monitoring of the clinical status of RA patients before and during pregnancy is essential in clinical practice.

Advances in Fetal Surgical Repair of Open Spina Bifida

Spina bifida remains a common congenital anomaly of the central nervous system despite national fortification of foods with folic acid, with a prevalence of 2-4 per 10,000 live births. Prenatal screening for the early detection of this condition provides patients with the opportunity to consider various management options during pregnancy. Prenatal repair of open spina bifida, traditionally performed by the open maternal-fetal surgical approach through hysterotomy, has been shown to improve outcomes for the child, including decreased need for cerebrospinal fluid diversion surgery and improved lower neuromotor function. However, the open maternal-fetal surgical approach is associated with relatively increased risk for the patient and the overall pregnancy, as well as future pregnancies. Recent advances in minimally invasive prenatal repair of open spina bifida through fetoscopy have shown similar benefits for the child but relatively improved outcomes for the pregnant patient and future childbearing.

The Prevalence of Nutritional Anaemia in Brazilian Pregnant Women: A Systematic Review and Meta-Analysis

Despite the global tendency of maternal anaemia to decline, the persistence of anaemia in Brazil is an important health problem given its vulnerability to deficiencies and the significant increase in nutritional requirements during pregnancy. The aim of this study was to estimate the prevalence of anaemia in Brazilian pregnant women through a systematic literature review and meta-analysis. The systematic review was carried out according to Systematic Reviews and Meta-Analyses PRISMA checklist recommendations and using the following electronic databases: Medline, Scopus, Embase, Web of Science, Lilacs, Scielo, Google Scholar, and CAPES Catalog of Theses and Dissertations. Studies that presented a prevalence of anaemia data in Brazilian pregnant women, considering all gestational trimesters, were included. The total sample included 12,792 pregnant women covering all gestational trimesters. The pooled prevalence of anaemia in Brazilian pregnant women was 23% (95% CI: 20-27), with the highest prevalence in the Northeast Region at 26% (95% CI 23-29), while the lowest prevalence was observed in the North Region with 17% (95% CI 14-20). Among the subgroups, no statistical difference was observed. The prevalence of anaemia status in Brazil is still classified as a moderate public health problem according to the World Health Organization maternal anaemia classification.

Public Engagement in Digital Recommendations for Promoting Healthy Parental Behaviours from Preconception through the First 1000 Days

Web-based digital interventions may play a central role for health promoting strategies in the first "1000 days", from conception through the first 2 years of life. We developed a web platform providing evidence-based recommendations in the first 1000 days through short videos, and we studied engagement by users from preconception through parenthood in the second year of life. We described the access to videos by topic and used a multilevel model to explore the user characteristics associated with access to the video recommendations. Overall, breastfeeding, physical activity and nutrition were the most popular topics (normalized views: 89.2%, 87.2% and 86.4% respectively), while content on paternal health and smoking and alcohol was less engaging (37.3% and 42.0%). Nutrition content was the most viewed in the preconception period and during the first two trimesters of pregnancy. Nutrition and breastfeeding were also the most popular topics for users with children less than 2 years old. Higher levels of health literacy were associated only with child health content. The study findings indicate that digital strategies should be adapted according to the time period in the first 1000 days. Alternative digital promotion strategies for the less engaging topics should be considered.

Risk of major malformations in infants after first-trimester exposure to benzodiazepines: Results from the Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications

BACKGROUND

Perinatal anxiety affects 20% of women, and untreated maternal mental illness can cause deleterious effects for women and their children. Benzodiazepines are commonly used to treat anxiety disorders. The reported risk of congenital malformations after in utero benzodiazepine exposure has been inconsistent.

METHODS

The Massachusetts General Hospital National Pregnancy Registry for Psychiatric Medications prospectively enrolls pregnant women with psychiatric illness who take one or more psychiatric medications. Participants are interviewed twice during pregnancy and at 12 weeks postpartum. Women taking any benzodiazepine during the first trimester of pregnancy were compared with a group of women taking psychiatric medication(s) other than benzodiazepines during pregnancy.

RESULTS

A total of 1053 women were eligible for this analysis; N = 151 women who had taken a benzodiazepine during the first trimester, and the comparison group was N = 902 women. There were 5 (3.21%) major malformations in the exposure group and 32 (3.46%) in the comparison group (odds ratio 0.92; 95% confidence interval 0.35-2.41).

CONCLUSION

This ongoing pregnancy registry offers reassurance that benzodiazepines do not appear to have major teratogenic effects. The precision of relative risk estimate will improve as the number of participants increases. This and other pregnancy registries will better inform the reproductive safety of benzodiazepines.

Empirical evidence of study design biases in nutrition randomised controlled trials: a meta-epidemiological study

BACKGROUND

Instruments to critically appraise randomised controlled trials (RCTs) are based on evidence from meta-epidemiological studies. We aim to conduct a meta-epidemiological study on the average bias associated with reported methodological trial characteristics such as random sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting, and compliance of RCTs in nutrition research.

METHODS

We searched the Cochrane Database of Systematic Reviews, for systematic reviews of RCTs, published between 01 January 2010 and 31 December 2019. We combined the estimates of the average bias (e.g. ratio of risk ratios [RRR] or differences in standardised mean differences) in meta-analyses using the random-effects model. Subgroup analyses were conducted to investigate the potential differences among the RCTs with low versus high/unclear risk of bias with respect to the different types of interventions (e.g. micronutrients, fatty acids, dietary approach), outcomes (e.g. mortality, pregnancy outcomes), and type of outcome (objective, subjective). Heterogeneity was assessed through I² and τ², and prediction intervals were calculated.

RESULTS

We included 27 Cochrane nutrition reviews with 77 meta-analyses (n = 927 RCTs). The available evidence suggests that intervention effect estimates may not be exaggerated in RCTs with high/unclear risk of bias (versus low) judgement for sequence generation (RRR 0.97, 95% CI 0.93 to 1.02; I² = 28%; τ² = 0.002), allocation concealment (RRR 1.00, 95% CI 0.96 to 1.04; I² = 27%; τ² = 0.001), blinding of participants and personnel (RRR 0.95, 95% CI 0.91 to 1.00; I² = 23%; τ² = 0), selective reporting (RRR 0.97, 95% CI 0.92 to 1.02; I² = 24%; τ² = 0), and compliance (RRR 0.95, 95% CI 0.89 to 1.02; I² = 0%; τ² = 0). Intervention effect estimates seemed to be exaggerated in RCTs with a high/unclear risk of bias judgement for blinding of outcome assessment (RRR 0.81, 95% CI 0.70 to 0.94; I² = 26%; τ² = 0.03), which was predominately driven by subjective outcomes, and incomplete outcome data (RRR 0.92, 95% CI 0.88 to 0.97; I² = 22%; τ² = 0.001). For continuous outcomes, no differences were observed, except for selective reporting.

CONCLUSIONS

On average, most characteristics of nutrition RCTs may not exaggerate intervention effect estimates, but the average bias appears to be greatest in trials of subjective outcomes. Replication of this study is suggested in this field to keep this conclusion updated.

[Preventive activities in women. PAPPS update 2022]

In the 2022 PAPPS update we present those specific preventive activities for women's health, except those related to cancer prevention (which are included in another document) and those aspects related to differential gender morbidity, a cross-cutting aspect for all working groups. Contraception is an essential preventive activity, considering basic the right to decide both the number of children and the time to have them. We must inform about the possible contraceptive methods, guaranteeing the monitoring of their safety, efficacy and effectiveness (tables are included on changing from one method to another to preserve contraceptive protection). We must inform about emergency contraception and propose it in the event of unprotected intercourse. All this will be done through opportunistic screening without requiring screening for thrombophilia or dyslipidemia, but for arterial hypertension. Pregnancy is an important life experience and the family doctor should not remain oblivious. We must be competent both in the preconception consultation (recommending the intake of folic acid, avoiding exposure to occupational and environmental risks, screening for certain pathologies and assessing the intake of drugs not indicated during pregnancy) and in the monitoring of pregnancy. Whether or not we monitor the pregnancy, we must not disregard its control, taking advantage of this period to promote healthy lifestyles and participating in the intercurrent processes that may occur. Menopause in general and osteoporosis in particular exemplify the strategy of medicalization of vital processes that has been followed from different instances and organizations. In our update we address the prevention and treatment of symptoms secondary to estrogen deprivation. We also propose the prevention of osteoporosis, including carrying out densitometry based on the risk of fracture in the next 10 years, and therefore densitometric screening is not recommended in women under 60 years of age. In risk assessment we recommend the use of the frax tool or better, the calibration of the risk of hip fracture with prevalence data from our setting. We linked the indication for treatment with the Z-Score (bone mineral density compared with women of the same age), as it is a condition associated with aging.

Preconception and periconception interventions to prevent low birth weight, small for gestational age and preterm birth: a systematic review and meta-analysis

Background

Low birth weight (LBW), including preterm birth (PTB) and small for gestational age (SGA), contributes a significant global health burden. We aimed to summarise current evidence on the effect of preconception and periconception interventions on LBW, SGA and PTB.

Methods

In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library and WHO Global Index Medicus for randomised controlled trials and quasi-experimental studies published by 28 November 2020, which assessed interventions delivered in preconception and periconception or preconception and pregnancy. Primary outcomes were LBW, SGA and PTB. Studies were categorised by intervention type and delivery during preconception and periconception or during preconception and pregnancy. Estimates were pooled using fixed-effects or random-effects restricted maximum likelihood method meta-analyses. Quality of evidence for primary outcomes was assessed using the Grades of Recommendations, Assessment, Development and Evaluation approach.

Results

We included 58 studies. Twenty-eight studies examined nutrition interventions (primarily micronutrient or food supplementation). Thirty studies (including one reporting a nutrition intervention) provided health interventions (general preconception health, early adverse pregnancy outcome prevention, non-communicable disease and infectious disease prevention and management). One study assessed a social intervention (reproductive planning). Studies varied in terms of specific interventions, including delivery across preconception or pregnancy, resulting in few studies for any single comparison. Overall, the evidence was generally very uncertain regarding the impact of any intervention on LBW, SGA and PTB. Additionally, preconception and periconception nutritional supplementation containing folic acid was associated with reduced risk of birth defects (10 studies, N=3 13 312, risk ratio: 0.37 (95% CI: 0.24 to 0.55), I²: 74.33%).

Conclusion

We found a paucity of evidence regarding the impact of preconception and periconception interventions on LBW, SGA and PTB. Further research on a wider range of interventions is required to clearly ascertain their potential effectiveness.

Trial registration number

This review was prospectively registered with PROSPERO (CRD42020220915).

Profile of Folate in Breast Milk from Chinese Women over 1-400 Days Postpartum

Folate is an essential nutrient for growth in early life. This study aimed to determine the levels and compositions of folate in Chinese breast milk samples. This study was part of the Maternal Nutrition and Infant Investigation (MUAI) study. A total of 205 healthy mothers were randomly recruited in Chengdu over 1−400 days postpartum. Five different species of folate, including tetrahydrofolate (THF), 5-methyl-THF, 5,10-methenyl-THF,5-formyl-THF and unmetabolized folic acid (UMFA), were measured for liquid chromatography−tandem mass spectrometry (LC-MS). The median levels of total folate ranged from 12.86 to 56.77 ng/mL in the breast milk of mothers at 1−400 days postpartum, gradually increasing throughout the lactating periods. The median levels of 5-methyl-THF, minor reduced folate (the sum of THF, 5,10-methenyl-THF and 5-formyl-THF) and UMFA were in the ranges of 8.52−40.65 ng/mL, 3.48−16.15 ng/mL and 0.00−1.24 ng/mL during 1−400 days postpartum, respectively. 5-Methyl-THF accounted for more than 65% of the total folate in all breast milk samples. The levels of UMFA in mature breast milk samples were higher in supplement users than nonusers, but not for colostrum and transitional milk samples (p < 0.05). In conclusion, the level of total folate in the breast milk changed along with the prolonged lactating periods, but 5-methyl-THF remains the dominant species of folate in the breast milk of Chinese populations across all entire lactating periods.

Effectiveness of micronutrient supplementation for pregnant and lactating women on maternal and infant nutritional status in low- and middle-income countries: protocol for a systematic review and meta-analysis (Preprint)

Background

Objective

Methods

Results

Conclusions

Trial Registration

International Registered Report Identifier (IRRID)

Dietary Supplementation Before, During and After Pregnancy: Results of the Cluster-Randomized GeliS Study

Introduction The nutritional status of women before, during, and after pregnancy plays an important role in the health of mother and child. In addition to a balanced mixed diet, the increased need for folic acid and iodine should be met and ensured with supplements. The aim of this study was to assess dietary supplementation in the context of pregnancy and to investigate the effect of targeted counselling on supplementation behavior during and after pregnancy.

Methods In the context of the “Gesund leben in der Schwangerschaft” (GeliS; “Healthy living in pregnancy”) trial, women in the intervention group (IG) received four structured lifestyle counselling sessions during pregnancy as well as postpartum, during which they were informed about appropriate dietary supplementation. The women in the control group (CG) received routine prenatal care. The intake of dietary supplements was recorded at different points using a questionnaire.

Results In total, 2099 women were included in the analysis. Prior to conception, 31.3% of the women in the IG and 31.4% of the women in the CG took folic acid supplements. Prenatally, about half of the women took folic acid (IG: 54.1%; CG: 52.0%) and iodine (IG: 50.2%; CG: 48.2%). Statistically significant differences between the groups with regard to supplementation behavior could not be observed, neither prior to inclusion in the study nor during the intervention. During pregnancy, 23.0% of all women took docosahexaenoic acid (DHA) supplements and 21.8% iron supplements. 49.4% of the women additionally took vitamin D supplements. A higher educational level (p < 0.001), advanced age (p < 0.001), primiparity (p < 0.001), and a vegetarian diet (p = 0.037) were all associated with a higher level of dietary supplementation.

Conclusion The GeliS lifestyle counselling did not significantly improve the supplementation behavior of women during and after pregnancy. Women should be informed about adequate dietary supplementation early on within the scope of gynecological prenatal care.

Priorities among effective clinical preventive services in British Columbia, Canada

Background

Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing.

Methods

We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a ‘strong or conditional (weak) recommendation for’ by the Canadian Task Force on Preventive Health Care or an ‘A’ or ‘B’ rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained.

Results

Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services.

Conclusions

These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Epigenetic Effect of Maternal Methyl-Group Donor Intake on Offspring’s Health and Disease

Maternal exposure to some dietary and environmental factors during embryonic development can affect offspring’s phenotype and, furthermore, the risk of developing diseases later in life. One potential mechanism responsible for this early programming may be the modification of the epigenome, such as DNA methylation. Methyl-group donors are essential for DNA methylation and are shown to have an important role in fetal development and later health. The main goal of the present review is to summarize the available literature data on the epigenetic effect (DNA methylation) of maternal methyl-group donor availability on reproductivity, perinatal outcome, and later health of the offspring. In our literature search, we found evidence for the association between alterations in DNA methylation patterns caused by different maternal methyl-group donor (folate, choline, methionine, betaine) intake and reproductivity, birth weight, neural tube defect, congenital heart defect, cleft lip and palate, brain development, and the development of obesity and associated non-communicable diseases in later life. We can conclude that maternal methyl-group donor availability could affect offspring’s health via alterations in DNA methylation and may be a major link between early environmental exposure and the development of diseases in the offspring. However, still, further studies are necessary to confirm the associations and causal relationships.

Anemia in Pregnant Women and Children Aged 6 to 59 Months Living in Mozambique and Portugal: An Overview of Systematic Reviews

INTRODUCTION

Globally, anemia is still a public health issue faced by people in low and high-income countries. This study gives an overview of published scientific articles related to the prevalence, nutritional indicators, and social determinants of anemia in pregnant women and children aged 6 to 59 months living in Mozambique and Portugal.

METHODS

We performed a review of scientific literature in April 2021, searching for published indexed articles in the last 15 years (2003-2018) in electronic databases. Subsequently, quality assessment, data extraction, and content analysis were performed.

RESULTS

We have identified 20 relevant publications. Unsurprisingly, anemia plays a relevant role in disability and life imbalances for these subgroups in Mozambique compared with Portugal. For both countries, data on anemia and iron deficiency in pregnant women and children aged 6 to 59 months old are either outdated or remain unclear. Similarly, studies on social determinants and anemia are also still scarce.

CONCLUSIONS

A gap of information on anemia, other nutritional indicators, and social determinants in pregnant women and children between 6 and 59 months of age living in Mozambique and Portugal is highly observed. More research is crucial to help achieve the goals established by the Sustainable Development Goals.

Dietary Supplement Use during Pregnancy: Perceptions versus Reality

This study aimed to examine the prevalence, associated factors and perceptions of dietary supplement use among pregnant Chinese women. A cross-sectional study was conducted to collect data about prevalence, purchase channels, perceptions, and related factors of dietary supplement use from 572 pregnant women, through a face-to-face survey, using a self-designed questionnaire. Of the respondents, 94.8% used at least one dietary supplement, whereas 29.8% used more than four supplements in the previous month. The majority of the pregnant women were highly educated (81.2% had a bachelor’s degree or above) and had the perception that dietary supplements could prevent and improve (89.2%), or treat, nutrition-related diseases (78.7%). Multivariate analysis showed that pregnant women who had used multiple (more than four) supplements were more likely to have a larger gestational age, received fertility treatment, more prenatal visits, and hypothyroidism during pregnancy. Furthermore, pregnant women not only purchased dietary supplements through hospitals (72.6%) and pharmacies (45.1%), but overseas Daigou or online purchases (31.8%) were also a major channel of purchase. A high prevalence of dietary supplement use during pregnancy was observed, with extensive and repeated consumption of nutrients. Pregnant women’s craze for dietary supplements calls for more comprehensive guidelines in China.

Effectiveness of preconception care interventions in primary care: a systematic review protocol

Background

Pregnancy outcomes can be adversely affected by a range of modifiable risk factors, including alcohol consumption, smoking, obesity, drug use, and poor nutrition, during the preconception period. Preconception care (PCC) involves interventions that identify and seek to change behavioural, biomedical, and social risks present in reproductive-aged women and men. Primary care is well situated to offer PCC interventions but the effectiveness of these interventions is not clear.

Aim

To evaluate the effectiveness of primary care-based PCC delivered to reproductive-aged women and/or men to improve health knowledge, reduce preconception risk factors, and improve pregnancy outcomes.

Design & setting

A systematic review of primary care-based PCC.

Method

Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Scopus, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases will be searched for English language studies published between July 1999 and May 2021. For inclusion, the PCC intervention must be provided in a primary care setting and intervention recipients must be reproductive-aged women and/or men. All stages of screening and data extraction will involve a dual review. The Cochrane Risk of Bias 2 (RoB 2) for randomised controlled trials (RCTs) will be used to assess the methodological quality of studies. This protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) reporting guidelines.

Conclusion

Findings will determine the effectiveness of primary care-based preconception interventions delivered to reproductive-aged women and men on improving health knowledge, reducing risk factors, and improving pregnancy outcomes. Findings will be published in a peer-reviewed journal.

Relationship between Eating Habits, Physical Activity and Tobacco and Alcohol Use in Pregnant Women: Sociodemographic Inequalities

Pregnant women must maintain or acquire healthy habits during pregnancy to protect both their own health and their child's. Such habits include an adequate eating pattern along with good adherence to the intake of certain supplements, practice of moderate physical activity and avoiding the consumption of toxic products such as tobacco and alcohol. The objective of this study is to assess the interrelation between such habits and their association with sociodemographic variables. To such end, a cross-sectional study was conducted with a representative sample of pregnant women who attended the scheduled morphology echography consultation at the 20th gestational week in their reference public hospital in the city of Seville (Spain). Results: Younger pregnant women and with lower educational levels are the ones that present the worst eating habits and the highest smoking rate. Pregnant women with lower educational levels are the least active. Non-smoking pregnant women present better eating habits than those who smoke. Pregnant women with lower educational levels are those who accumulate more unhealthy habits during pregnancy. This should be taken into account when planning the health care provided to pregnant women and in public health intersectoral policies.

Folic acid Ameliorates the Declining Quality of Sodium Fluoride-Exposed Mouse Oocytes through the Sirt1/Sod2 Pathway

Excessive sodium fluoride (NaF) intake interferes with reproductive function in humans and animals; however, strategies to prevent these effects are still underexplored. Here, we showed that in vivo and in vitro supplementation of folic acid (FA) efficaciously improved the quality of NaF-exposed oocytes. FA supplementation not only increased ovulation of oocytes from NaF-treated mice but also enhanced oocyte meiotic competency and fertilization ability by restoring the spindle/chromosome structure. Moreover, FA supplementation could exert a beneficial effect on NaF- exposed oocytes by restoring mitochondrial function, eliminating reactive oxygen species accumulation to suppress apoptosis. We also found that FA supplementation restored the defective phenotypes in oocytes through a Sirt1/Sod2-dependent mechanism. Inhibition of Sirt1 with EX527 abolished the FA-mediated improvement in NaF-exposed oocyte quality. Collectively, our data indicated that FA supplementation is a feasible approach to protect oocytes from NaF-related deterioration.

Maternal Folic Acid-Containing Supplement Use in Relation to Offspring Motor Function. A Prospective Study of 503 Mother-Child Dyads

BACKGROUND

The preventive effect of maternal folic acid use on offspring neural tube defects is well-established. However, a putative link between supplement use and other neurodevelopmental outcome is inconsistent. The aim of this study was to examine the association of folic acid-containing supplement use before and during pregnancy with motor function in children aged 3-18 months.

METHOD

The study has a prospective cohort design including 503 mother-infant dyads. Motor function was measured by the Infant Motor Profile (IMP) and Ages and Stages Questionnaire Second Edition (ASQ-2). Associations between exposure and outcome were examined using linear regression analysis with robust standard error estimation.

RESULTS

Offspring total IMP score was not associated with any maternal folic acid-containing supplement use when they were used during pregnancy only (adjusted β = 0.11 95% CI = -1.19, 1.40; p = 0.87) or when they were used both before and during pregnancy (adjusted β = 0.22 95% CI = -0.95, 1.40; p = 0.70). When examining the five domain scores separately, only the IMP domain adaptability showed some association with supplement use during pregnancy (adjusted β = 2.87; 95% CI = 0.08, 5.68; p = 0.04), but the strength of the association was weak. Further, supplement use was not associated with any of the two motor domains of ASQ-2.

CONCLUSION

Although no association between folic acid-containing supplement use and offspring motor function was found, the complexity of this topic and its potential mechanisms, requires further investigation. This research should include robust and accurate measures on maternal nutritional status along with thorough endpoint assessments.

Homocysteine and female fertility, pregnancy loss and offspring birthweight: a two-sample Mendelian randomization study

BACKGROUND/OBJECTIVES

Observational studies link elevated homocysteine concentrations (Hcy) with female fertility, pregnancy loss, and low offspring birthweight. Maternal rs1801133, a functional variant in MTHFR strongly associated with lifelong elevated Hcy, is associated with recurrent pregnancy loss and offspring birthweight in Asian women. We investigated if genetically elevated Hcy is associated with fertility, pregnancy loss, and offspring birthweight in European women.

SUBJECTS/METHODS

We performed a two-sample Mendelian randomization (MR) study using publicly available data. We obtained 18 genetic variants (five involved in Hcy metabolism) explaining up to 5.9% of the variance in Hcy from a genome-wide association meta-analysis of 44,147 European individuals (82% women). We investigated fertility (including age at menopause), pregnancy loss, and offspring birthweight in the UK Biobank (N = 194,174), EGG (N = 190,406), and ReproGen (N = 69,360-252,514) consortia using summary statistics. We calculated inverse-variance weighted, and several sensitivity MR regression statistics.

RESULTS

rs1801133 was associated with a 7.45 months (95% CI: 4.09, 10.80) increase in age at menopause and 29.69 (12.87, 46.51) g decrease in offspring birthweight per SD increase in Hcy in the UK biobank, and confirmed in EGG and ReproGen. MR for Hcy metabolism alone (five variants in MTHFR, MTR, CBS) showed similar results for offspring birthweight across consortia. However, using all 18 variants resulted in no association for any of the outcomes across consortia.

CONCLUSION

Hcy and suggestively vitamin B variants are most likely the drug targets for folate supplementation in pregnant women on the offspring birthweight, while Hcy variants related to renal function or diabetes are not involved.

Efficacy of 4.0 mg versus 0.4 mg Folic Acid Supplementation on the Reproductive Outcomes: A Randomized Controlled Trial

Folic acid (FA) supplementation prevents neural tube defects (NTDs), but the effects on other reproductive outcomes are unclear. While common recommendation is 0.4 mg/day in addition to regular nutrition, the most appropriate dose of FA is still under debate. We investigated the effects of a higher dose of periconception FA on reducing adverse reproductive outcomes. In this multicenter double-blind randomized controlled trial (RCT), 1060 women (aged 18-44 years and planning a pregnancy) were randomly assigned to receive 4.0 mg or 0.4 mg of FA daily. The primary outcome was the occurrence of congenital malformations (CMs). A composite outcome including one or more adverse pregnancy outcomes was also evaluated. A total of 431 women had a natural conception within 1 year. The primary outcome occurred in 8/227 (3.5%) women receiving 4.0 mg FA and 9/204 (4.4%) women receiving 0.4 mg FA (RR 0.80; 95%CI 0.31 to 2.03). The composite outcome occurred in 43/227 (18.9%) women receiving 4.0 mg FA and 75/204 (36.8%) women receiving 0.4 mg FA (RR 0.51; 95%CI 0.40 to 0.68). FA 4.0 mg supplementation was not associated with different occurrence of CMs, compared to FA 0.4 mg supplementation. However, FA 4.0 mg supplementation was associated with lower occurrence of other adverse pregnancy outcomes.

Australian primary health care nurses

Preconception care (PCC) entails counselling and interventions to optimise health before pregnancy. Barriers to this service delivery include access and time. Primary healthcare nurses (PHCNs) are uniquely placed to deliver PCC. The aim of this study was to understand PHCNs' knowledge, practice and attitudes to PCC. A cross-sectional study was performed of a convenience sample of PHCNs in Australia who were seeing people of reproductive age. Recruitment was via the Australian Primary Health Care Nurses Association (APNA) electronic communication platforms. The 18-item, online, anonymous survey captured demographics, as well as PCC knowledge, practices and attitudes. Descriptive statistics were used to describe our findings. In all, 152 completed surveys were received. Of all respondents, 74% stated they discuss PCC in their practice, although only 13% do so routinely. Of these, more preconception discussions are held with women than with men. In total, 95% of respondents identified at least one barrier to delivery of PCC, with lack of time and knowledge being the most common. The findings of this study can inform targeted strategies, including education programs and resources, and consideration of incentives to support PHCNs deliver PCC. This study identifies areas for improvement at the individual, organisational and health system levels to enhance the role of PHCNs in PCC.

The role of education and migration background in explaining differences in folic acid supplementation intake in pregnancy: results from a German birth cohort study

OBJECTIVE

Official German recommendations advise women to start taking folic acid supplementation (FAS) before conception and continue during the first pregnancy trimester to lower the risk of birth defects. Women from lower socio-economic background and ethnic minorities tend to be less likely to take FAS in other European countries. As little is known about the determinants of FAS in Germany, we aimed to investigate the association between FAS and formal education and migration background, adjusting for demographic factors.

DESIGN

We used data (2013-2016) on nutrition and socio-economic and migration background from the baseline questionnaire of the BaBi cohort study. We performed multivariate regressions and mediation analyses.

SETTING

Bielefeld, Germany.

PARTICIPANTS

Nine-hundred forty-seven women (pregnant or who had given birth in the past 2 months).

RESULTS

16.7% of the participants (158/947) did not use FAS. Migration-related variables (e.g. language, length of stay) were not associated with FAS in the adjusted models. FAS was lower in women with lower level of formal education and in unplanned pregnancies. Reasons given by women for not taking FAS were unplanned pregnancy and lack of knowledge of FAS.

CONCLUSIONS

Health practitioners may be inclined to see migrant women as an inherently at-risk group for failed intake of FAS. However, it is primarily women who did not plan their pregnancy, and women of lower formal education level, who are at risk. Different public health strategies to counter low supplementation rates should be supported, those addressing the social determinants of health (i.e. education) and those more focused on family planning.

Uptake challenges of intermittent preventive malaria therapy among pregnant women and their health care providers in the Upper West Region of Ghana: A mixed-methods study

BACKGROUND

Malaria in pregnancy remains a major public health problem in endemic countries, especially in sub-Saharan Africa (SSA). Existing interventions such as intermittent preventive therapy in pregnancy (IPTp) using sulfadoxine-pyrimethamine (SP) are effective against placental malaria. However, low uptake of this intervention is a challenge in SSA. This study assessed factors affecting IPTp-SP uptake among pregnant women as well as their health care providers, including health system-related factors.

METHODS

From November 2018 until May 2019 a mixed-methods study was conducted in one urban and one rural district of the Upper West Region of Ghana. A multi-stage sampling technique was used to recruit 740 3rd trimester pregnant women and 74 health service providers from 37 antenatal care (ANC) facilities. Quantitative data was collected through a standard questionnaire from pregnant women and ANC service providers. Three focus group discussions (FGDs) were conducted in each district with pregnant women who had defaulted on their IPTp doses to collect information about the challenges in accessing IPTp-SP. The primary outcome was the uptake of IPTp-SP during antenatal care visits. In addition, the health care provider and health system-related factors on the administration of SP were assessed, as well as details of folic acid (FA) supplementation. Data were analysed using descriptive statistics and Poisson regression.

RESULTS

Responses from 697 pregnant women were analysed. Of these, 184 (26.4%) had taken the third dose of SP (SP3) in line with international guidelines. IPTp-SP uptake was low and significantly associated with the number of maternal ANC contacts and their gestational age at 1st ANC contact. Most pregnant women were regularly co-administered SP together with 5 mg of FA, in contrast to the international recommendations of 0.4 mg FA. The main challenges to IPTp-SP uptake were missed ANC contacts, knowledge deficiencies among pregnant women of the importance of IPTp, and frequent drug stock outs, which was confirmed both from the ANC providers as well as from the pregnant women. Further challenges reported were provider negligence/absenteeism, adverse drug reactions, and mobile residency of pregnant women.

CONCLUSIONS

The uptake of IPTp-SP in the study area is still very low, which is partly explained by frequent drug stock outs at health facilities, staff absenteeism, knowledge deficiencies among pregnant women, and missed ANC contacts. The high dosing of co-administered FA is against international recommendations. These observations need to be addressed by the national public health authorities.

Cost-effectiveness of mandatory folic acid fortification of flours in prevention of neural tube defects: A systematic review

BACKGROUND

Neural tube defects (NTDs) constitute the most frequent group among congenital malformations and are the main cause of neonatal morbimortality. Folic acid (FA) can reduce the risk of pregnancies affected by NTDs.

OBJECTIVE

We aimed to investigate whether mandatory folic acid (FA) fortification of flours is cost-effective as compared to non-mandatory fortification, and to verify whether FA dosage, cost composition, and the quality of economic studies influence the cost-effectiveness of outcomes.

METHODS

We conducted a systematic review. The protocol was registered on PROSPERO (CRD 42018115682). A search was conducted using the electronic databases MEDLINE/PubMed, Web of Science, Embase, Scopus, and EBSCO/CINAHL between January 2019 and October 2020 and updated in February 2021. Eligible studies comprised original economic analyses of mandatory FA fortification of wheat and corn flours (maize flours) compared to strategies of non-mandatory fortification in flours and/or use of FA supplements for NTD prevention. The Drummond verification list was used for quality analysis.

RESULTS

A total of 7,859 studies were identified, of which 13 were selected. Most (77%; n = 10) studies originated from high-income countries, while three (23%) were from upper-middle-income countries. Results of a cost-effectiveness analysis showed that fortification is cost-effective for NTD prevention, except for in one study in New Zealand. The cost-benefit analysis yielded a median ratio of 17.5:1 (0.98:1 to 417.1:1), meaning that for each monetary unit spent in the program, there would be a return of 17.5 monetary units. Even in the most unfavorable case of mandatory fortification, the investment in the program would virtually payoff at a ratio of 1:0.98. All FA dosages were cost-effective and offered positive health gains, except in one study. The outcomes of two studies showed that FA dosages above 300 μg/100 g have a higher CBA ratio. The studies with the inclusion of "loss of consumer choice" in the analysis may alter the fortification cost-efficacy ratio.

CONCLUSION

We expect the findings to be useful for public agencies in different countries in decision-making on the implementation and/or continuity of FA fortification as a public policy in NTD prevention.

Provision of folic acid for reducing arsenic toxicity in arsenic-exposed children and adults

BACKGROUND

Arsenic is a common environmental toxin. Exposure to arsenic (particularly its inorganic form) through contaminated food and drinking water is an important public health burden worldwide, and is associated with increased risk of neurotoxicity, congenital anomalies, cancer, and adverse neurodevelopment in children. Arsenic is excreted following methylation reactions, which are mediated by folate. Provision of folate through folic acid supplements could facilitate arsenic methylation and excretion, thereby reducing arsenic toxicity.

OBJECTIVES

To assess the effects of provision of folic acid (through fortified foods or supplements), alone or in combination with other nutrients, in lessening the burden of arsenic-related health outcomes and reducing arsenic toxicity in arsenic-exposed populations.

SEARCH METHODS

In September 2020, we searched CENTRAL, MEDLINE, Embase, 10 other international databases, nine regional databases, and two trials registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing the provision of folic acid (at any dose or duration), alone or in combination with other nutrients or nutrient supplements, with no intervention, placebo, unfortified food, or the same nutrient or supplements without folic acid, in arsenic-exposed populations of all ages and genders.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two RCTs with 822 adults exposed to arsenic-contaminated drinking water in Bangladesh. The RCTs compared 400 µg/d (FA400) or 800 µg/d (FA800) folic acid supplements, given for 12 or 24 weeks, with placebo. One RCT, a multi-armed trial, compared FA400 plus creatine (3 g/d) to creatine alone. We judged both RCTs at low risk of bias in all domains. Due to differences in co-intervention, arsenic exposure, and participants' nutritional status, we could not conduct meta-analyses, and therefore, provide a narrative description of the data. Neither RCT reported on cancer, all-cause mortality, neurocognitive function, or congenital anomalies. Folic acid supplements alone versus placebo Blood arsenic. In arsenic-exposed individuals, FA likely reduces blood arsenic concentrations compared to placebo (2 studies, 536 participants; moderate-certainty evidence). For folate-deficient and folate-replete participants who received arsenic-removal water filters as a co-intervention, FA800 reduced blood arsenic levels more than placebo (percentage change (%change) in geometric mean (GM) FA800 -17.8%, 95% confidence intervals (CI) -25.0 to -9.8; placebo GM -9.5%, 95% CI -16.5 to -1.8; 1 study, 406 participants). In one study with 130 participants with low baseline plasma folate, FA400 reduced total blood arsenic (%change FA400 mean (M) -13.62%, standard error (SE) ± 2.87; placebo M -2.49%, SE ± 3.25), and monomethylarsonic acid (MMA) concentrations (%change FA400 M -22.24%, SE ± 2.86; placebo M -1.24%, SE ± 3.59) more than placebo. Inorganic arsenic (InAs) concentrations reduced in both groups (%change FA400 M -18.54%, SE ± 3.60; placebo M -10.61%, SE ± 3.38). There was little to no change in dimethylarsinic acid (DMA) in either group. Urinary arsenic. In arsenic-exposed individuals, FA likely reduces the proportion of total urinary arsenic excreted as InAs (%InAs) and MMA (%MMA) and increases the proportion excreted as DMA (%DMA) to a greater extent than placebo (2 studies, 546 participants; moderate-certainty evidence), suggesting that FA enhances arsenic methylation. In a mixed folate-deficient and folate-replete population (1 study, 352 participants) receiving arsenic-removal water filters as a co-intervention, groups receiving FA had a greater decrease in %InAs (within-person change FA400 M -0.09%, 95% CI -0.17 to -0.01; FA800 M -0.14%, 95% CI -0.21 to -0.06; placebo M 0.05%, 95% CI 0.00 to 0.10), a greater decrease in %MMA (within-person change FA400 M -1.80%, 95% CI -2.53 to -1.07; FA800 M -2.60%, 95% CI -3.35 to -1.85; placebo M 0.15%, 95% CI -0.37 to 0.68), and a greater increase in %DMA (within-person change FA400 M 3.25%, 95% CI 1.81 to 4.68; FA800 M 4.57%, 95% CI 3.20 to 5.95; placebo M -1.17%, 95% CI -2.18 to -0.17), compared to placebo. In 194 participants with low baseline plasma folate, FA reduced %InAs (%change FA400 M -0.31%, SE ± 0.04; placebo M -0.13%, SE ± 0.04) and %MMA (%change FA400 M -2.6%, SE ± 0.37; placebo M -0.71%, SE ± 0.43), and increased %DMA (%change FA400 M 5.9%, SE ± 0.82; placebo M 2.14%, SE ± 0.71), more than placebo. Plasma homocysteine: In arsenic-exposed individuals, FA400 likely reduces homocysteine concentrations to a greater extent than placebo (2 studies, 448 participants; moderate-certainty evidence), in the mixed folate-deficient and folate-replete population receiving arsenic-removal water filters as a co-intervention (%change in GM FA400 -23.4%, 95% CI -27.1 to -19.5; placebo -1.3%, 95% CI -5.3 to 3.1; 1 study, 254 participants), and participants with low baseline plasma folate (within-person change FA400 M -3.06 µmol/L, SE ± 3.51; placebo M -0.05 µmol/L, SE ± 4.31; 1 study, 194 participants). FA supplements plus other nutrient supplements versus nutrient supplements alone In arsenic-exposed individuals who received arsenic-removal water filters as a co-intervention, FA400 plus creatine may reduce blood arsenic concentrations more than creatine alone (%change in GM FA400 + creatine -14%, 95% CI -22.2 to -5.0; creatine -7.0%, 95% CI -14.8 to 1.5; 1 study, 204 participants; low-certainty evidence); may not change urinary arsenic methylation indices (FA400 + creatine: %InAs M 13.2%, SE ± 7.0; %MMA M 10.8, SE ± 4.1; %DMA M 76, SE ± 7.8; creatine: %InAs M 14.8, SE ± 5.5; %MMA M 12.8, SE ± 4.0; %DMA M 72.4, SE ±7.6; 1 study, 190 participants; low-certainty evidence); and may reduce homocysteine concentrations to a greater extent (%change in GM FA400 + creatinine -21%, 95% CI -25.2 to -16.4; creatine -4.3%, 95% CI -9.0 to 0.7; 1 study, 204 participants; low-certainty evidence) than creatine alone.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that FA supplements may benefit blood arsenic concentration, urinary arsenic methylation profiles, and plasma homocysteine concentration versus placebo. There is low-certainty evidence that FA supplements plus other nutrients may benefit blood arsenic and plasma homocysteine concentrations versus nutrients alone. No studies reported on cancer, all-cause mortality, neurocognitive function, or congenital anomalies. Given the limited number of RCTs, more studies conducted in diverse settings are needed to assess the effects of FA on arsenic-related health outcomes and arsenic toxicity in arsenic-exposed adults and children.

Community Pharmacist-Led Interventions to Improve Preconception and Pregnancy Health: A Systematic Review

Background: Community pharmacist-led interventions are effective in improving health outcomes; however, their impact in improving preconception and pregnancy health is not clear. This study evaluated the effectiveness of community pharmacist-led interventions which aimed to improve health outcomes of preconception and pregnant women. Methods: A systematic review of the literature, consistent with PRISMA guidelines, was performed. Five electronic databases were searched up to February 2021. Results: Four studies, three in pregnant women and one in preconception women, were identified. The studies focused on improving micronutrient status and smoking cessation. The studies increased knowledge about, and use of, iron supplements, and improved iron status and smoking cessation rates in pregnant women, while improving knowledge regarding, and increasing the use of, preconception folic acid. The studies were ranked as weak to moderate quality. Conclusion: This review provides preliminary evidence for the potential benefit of community pharmacist-led interventions to improve the health of women before and during pregnancy.

Histopathological and immunohistochemical changes of the marginal periodontium in patients with Turner syndrome

Turner syndrome (TS) is characterized by partial or complete loss of a sexual chromosome, resulting in an incomplete development of the body, gonadic failure, cardiac and renal abnormalities, oro-dental changes, etc. In our study, we proposed to perform a histological and immunohistochemical (IHC) study of the periodontium changes in patients with TS. The biological material under study was represented by fragments of gingival mucosa harvested from 18 patients with TS who presented advanced periodontal lesions and required dental extractions. The fragments of gingival mucosa were processed by the classical histological technique of paraffin inclusion, subsequently the obtained sections being stained by the Hematoxylin–Eosin (HE) and examined under the optical microscope. For the IHC study, there were performed serial sections incubated with anti-cluster of differentiation (CD) 3, anti-CD20 and anti-CD68 antibodies for highlighting immune cells, as well as with anti-matrix metalloproteinase (MMP) 2 and anti-MMP8 antibodies for highlighting MMPs (MMP2 and MMP8) involved in the periodontal tissue lesions. In the present study, during the histological examination, there were observed morphological changes, both in the epithelium and in the gingival mucosa chorion. Epithelial changes consisted in the onset of acanthosis processes, in the thickening of the epithelium due to the increase of the spinous layer, as well as in the parakeratosis phenomenon. In the chorion, there was observed the presence of inflammatory infiltrates in various stages, presence of fibrosis (extended in some cases) and the presence of an important vascularization in some cases, with a high number of immunocompetent cells involved in the inborn immune response, but also in the adaptive one, as well as a more or less intense immunoexpression of MMP2 and MMP8. Our study suggests that TS may contribute to the development of some inflammatory processes in the marginal periodontium.