Nutrition and maternal mortality in the developing world

Who is Anaemic in India? Intersections of class, caste, and gender

Anaemia severely impacts physical and mental abilities, raises health risks, and diminishes the quality of life and work capacity. It is a leading cause of adverse pregnancy outcomes and maternal mortality, especially in developing nations like India, where recent data on anaemia from National Family and Health Survey (NFHS-4) (2015-16) and NFHS-5 (2019-21) indicate a tremendous rise. Anaemia is a marker of poor nutrition and health, and socio-economic factors such as gender norms, race, income, and living conditions influence its impact. As a result, there are disparities in how anaemia affects different segments of society. However, existing research on health inequity and anaemia often employs a single-axis analytical framework of social power. These studies operate under the assumption that gender, economic class, ethnicity, and caste are inherently distinct and mutually exclusive categories and fail to provide a comprehensive understanding of anaemia prevalence. Therefore, the study has adopted the theoretical framework of intersectionality and analysed the NFHS-5 (2019-21) data using bivariate cross-tabulations and binary logistic regression models to understand how gender, class, caste, and place of residence are associated with the prevalence of anaemia. The results suggest that the women of Scheduled Tribes (ST) and Scheduled Castes (SC) share a disproportionate burden of anaemia. This study confirms that economic class and gender, geographical location, level of education, and body mass index significantly determine the prevalence of anaemia. The ST and SC women who are economically marginalised and reside in rural areas with high levels of poverty, exclusion, and poor nutritional status have a higher prevalence of anaemia than other population groups. Thus, the study suggests that intersections of multiple factors such as caste, class, gender, and place of residence significantly determine 'who is anaemic in India'.

Evaluation of In Vivo Folic Acid Bioavailability in Different Mouse Strains Using Enzymatic Digestion Combined with Ultra Performance Liquid Chromatography

By analyzing the folic acid content of various mouse strains through the use of in vivo studies, this study sought to determine whether folic acid bioavailability varies between hosts. In order to examine the stability of folic acid in the gastrointestinal tract, the rate at which it enters the blood, its retention in the organs, and its entry into the brain, folic acid was gavaged for 10 days into male and female mice of the following four strains: C57BL/6, BALB/c, ICR, and Kunming. Folic acid was extracted from eight groups of mice via solid phase extraction and triple enzyme extraction; the folic acid was subsequently quantified by ultraperformance liquid chromatography. In contrast to the other groups, female C57BL/6 mice exhibited substantially greater bioavailability as well as variations in organ retention and blood entry rates, as indicated by the experimental findings. This finding indicated that using female C57BL/6 mice to evaluate the bioavailability of folic acid is more effective.

Maternal Nutritional Status and the Microbiome across the Pregnancy and the Post-Partum Period

Appropriate nutrition during pregnancy and the post-partum period is vital for both the mothers and their offspring. Both under- and over-nourished status may have important microbial implications on the maternal and infant gut microbiomes. Alterations in the microbiome can have implications for a person's risk of obesity and metabolic diseases. In this review, we examine alterations in the maternal gut, vaginal, placental, and milk microbiomes in the context of pre-pregnancy BMI, gestational weight gain, body composition, gestational diabetes, and maternal diet. We also investigate how the infant gut microbiome may be altered by these different parameters. Many of the microbial changes seen in under- and over-nourished states in birthing parents may result in long-term implications for the health of offspring. Differences in diet appear to be a major driver of the maternal and subsequently milk and offspring microbiomes. Further prospective longitudinal cohort studies are needed to examine nutrition and the microbiome to better understand its implications. Additionally, trials involving dietary interventions in child-bearing age adults should be explored to improve the mother and child's risks for metabolic diseases.

Maternal-fetal outcomes of women with hypertensive disorders of pregnancy

OBJECTIVE

The objective of this study was to determine adverse maternal and perinatal outcomes in pregnant women with hypertensive disorders of pregnancy.

METHODS

An analytical cross-sectional study was conducted on women admitted with hypertensive disorders of pregnancies to a university maternity hospital from August 2020 to August 2022. Data were collected using a pretested structured questionnaire. Variables associated with adverse maternal and perinatal outcomes were compared using multivariable binomial regression.

RESULTS

Of 501 women with pregnancies, 2, 35, 14, and 49% had eclampsia, preeclampsia, chronic hypertension, and gestational hypertension, respectively. Women with preeclampsia/eclampsia had significantly higher risks of cesarean section (79.4 vs. 65%; adjusted RR, 2,139; 95%CI, 1,386-3,302; p=0.001) and preterm delivery at <34 weeks' gestation (20.5 vs. 6%; adjusted RR, 2.5; 95%CI, 1.19-5.25; p=0.01) than those of women with chronic/gestational hypertension. Risks of prolonged maternal hospitalization (43.9 vs. 27.1%), neonatal intensive care unit admission (30.7 vs. 19.8%), and perinatal mortality (23.5 vs. 11.2%) were higher among women with preeclampsia/eclampsia.

CONCLUSIONS

Women with preeclampsia/eclampsia had a higher risk of adverse maternal and neonatal outcomes than those with chronic or gestational hypertension. This major maternity care center requires strategies for preventing and managing preeclampsia/eclampsia to improve pregnancy outcomes.

The Effectiveness of a Web-Based Application for a Balanced Diet and Healthy Weight Among Indonesian Pregnant Women: Randomized Controlled Trial

BACKGROUND

Pregnant women have self-declared that they have difficulties in estimating nutrient intakes. The Nutrition Information System for Indonesian Pregnant Women (SISFORNUTRIMIL) application was created as a dietary assessment and calorie-counting tool to guide pregnant women to eat the right portion sizes for each meal.

OBJECTIVE

The study aimed to examine the effectiveness of the SISFORNUTRIMIL application in helping users achieve a balanced diet and healthy maternal weight gain in comparison to nonusers in Indonesia.

METHODS

 First-pregnancy women in the second trimester aged 19-30 years (N=112) participated in the randomized controlled trial. Recruited women who were eligible and consented to participate in the study were allocated into the intervention group, or application user (n=56), and the control group, or application nonuser (n=56). The intervention recommended that pregnant women consume at least 5 food groups and calculate a recommended average portion size for 12 weeks. Both groups were self-monitored and recorded their intake in food records for 3 days every week. The dietary diversity consumed, macro- and micronutrient intake, and maternal weight gain were assessed pre- and postintervention. Data were collected three times during the intervention. Diversity food consumption was measured by the Minimum Dietary Diversity for Women of reproductive age. Furthermore, the Indonesian recommended dietary allowances were used to refer to and validate appropriate energy and nutrient amounts. Independent sample t test was used to compare differences between the intervention and control groups.

RESULTS

The mean dietary diversity score for the application user group (7.79, SD 1.20) was significantly greater than for the application nonuser group (7.02, SD 1.39; adjusted mean difference 0.77, 95% CI 0.28-1.25; d=0.28; P=.005). Macro- and micronutrient intake was significantly more in accordance with the dietary recommendations for the user group compared to the control group, including an energy daily intake of 156.88 kcal (95% CI 114.52-199.23; d=-1.39; P=.002), 102.43 g of carbohydrates (95% CI -125.2 to -79.60; d=-1.68; P=.02), 14.33 g of protein (95% CI 11.40-17.25; d=1.86; P<.001), and 10.96 g of fat (95% CI -13.71 to -8.20; d=-1.49; P<.001). Furthermore, there was a significantly higher intake of daily vitamins and minerals in the intervention group than in the control group. Other results showed that maternal weight gain in the intervention group was in accordance with the parameters of healthy weight gain.

CONCLUSIONS

 Recording food intake using the application was significantly effective in improving the dietary diversity consumed, improving adequate energy and nutrient intake, and producing healthy maternal weight during pregnancy.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN42690828; https://www.isrctn.com/ISRCTN42690828.

A systematic review of individual and ecological determinants of maternal mortality in the world based on the income level of countries

BACKGROUND

This systematic review was conducted to map the literature on all the existing evidence regarding individual and ecological determinants of maternal mortality in the world and to classify them based on the income level of countries. Such a systematic review had not been conducted before.

METHODS

We conducted an electronic search for primary and review articles using "Maternal Mortality" and "Determinant" as keywords or MeSH terms in their Title or Abstract, indexed in Scopus, PubMed, and Google with no time or geographical limitation and also hand searching was performed for most relevant journals. STROBE and Glasgow university critical appraisal checklists were used for quality assessment of the included studies. Data of the determinants were extracted and classified into individual or ecological categories based on income level of the countries according to World Bank classification.

RESULTS

In this review, 109 original studies and 12 review articles from 33 countries or at global level met the inclusion criteria. Most studies were published after 2013. Most literature studied determinants of low and lower-middle-income countries. The most important individual determinants in low and lower-middle-income countries were location of birth, maternal education, any delays in health services seeking, prenatal care and skilled birth attendance. Household-related determinants in low-income countries included improved water source and sanitation system, region of residence, house condition, wealth of household, and husband education. Additionally, ecological determinants including human resources, access to medical equipment and facilities, total fertility rate, health financing system, country income, poverty rate, governance, education, employment, social protection, gender inequality, and human development index were found to be important contributors in maternal mortality. A few factors were more important in higher-income countries than lower-income countries including parity, IVF births, older mothers, and type of delivery.

CONCLUSION

A comprehensive list of factors associated with maternal death was gathered through this systematic review, most of which were related to lower-income countries. It seems that the income level of the countries makes a significant difference in determinants of maternal mortality in the world.

Women's experience of unintended pregnancy and changes in contraceptive methods: evidence from a nationally representative survey

Background

Ineffective or no use of contraception following an unintended pregnancy contributes to a subsequent unintended pregnancy. This study aimed to determine whether women’s experiences of unintended pregnancies affect changing their contraceptive using patterns.

Methods

We analysed the 2017/2018 Bangladesh Demographic and Health Survey data. The contraceptive switching pattern was computed by comparing women’s contraceptives using data before and after pregnancy. Women were categorised into the following three groups, depending on their patterns of contraceptive use before and after pregnancy: no change, if there were no change in contraceptive using pattern; switched to higher effective contraceptives, if changed from pre-pregnancy less effective contraceptives to post-pregnancy more effective contraceptives; switched to less effective contraceptives, if changed from pre-pregnancy more effective contraceptives to post-pregnancy less effective contraceptives. Women’s intention in the most recent pregnancy was our primary explanatory variable, classified as wanted, mistimed and unwanted. Multinomial multilevel logistics regression was used to determine the association between women’s intention in the most recent pregnancy and women’s contraceptive methods switching patterns from before to after pregnancy.

Results

Around 20% of the most recent pregnancies that ended with a live birth were unintended at conception. No contraceptive use was reported by 37% of women before their pregnancies which decreased to 24% after pregnancies. Overall, around 54% of women who reported no contraceptive use before pregnancy used modern contraceptives after pregnancy. The rate was higher among women who experienced unwanted pregnancy (73.4%) than mistimed (58.8%) and wanted (53.4%) pregnancy. Experience of mistimed pregnancy was associated with a higher likelihood of no contraceptive change (aOR, 1.84, 95% CI 1.41–2.39) and switching to less effective contraceptives (aOR, 1.58, 95% CI 1.10–2.26) than switching to more effective contraceptives. However, unwanted pregnancy was not associated with any significant change in contraceptives use from before to after pregnancy.

Conclusion

Experience of unintended pregnancy did not change women’s contraception using patterns, which indicates the risk of repeat unintended pregnancies and associated adverse consequences, including maternal and child morbidity and mortality. Policies to ensure access to and use of modern contraceptives among women facing unwanted or mistimed pregnancies are recommended.

Unintended pregnancy is considered a public health challenge in low- and middle-income countries (LMICs). Around 89% of the global occurrences of unintended pregnancies occur in LMICs. In absolute numbers, this is equivalent to nearly 88 million pregnancies. Adverse pregnancy consequences, including bleeding, haemorrhage and maternal mortality are common in this group. The adverse consequences are even higher among women facing unintended pregnancies more than once, i.e., repeat unintended pregnancies, which represent around half of the total occurrences of unintended pregnancies in LMICs. Ensuring proper access to effective contraceptives following birth is key to reducing repeat unintended pregnancies and associated adverse consequences. It is critical to know the patterns of women’s pre-pregnancy contraceptive methods use and whether experiences of unintended pregnancies affect their contraceptive methods uptake and their types. However, this data is completely lacking in the context of LMICs. Using nationally representative survey data from Bangladesh, we examined women’s contraceptive switching patterns from before to after pregnancy and their association with pregnancy types. We found increased likelihood of no change in contraceptive using pattern or switching to less effective contraceptives among women after they experienced mistimed pregnancy compared to those whose pregnancy was wanted. This pattern increases the risk of repeat unintended pregnancies in Bangladesh and associated adverse consequences, including maternal and child morbidity and mortality.

Association Between Early Pregnancy Body Mass Index and Gestational Weight Gain in Relation to Neonatal Birth Weight

Introduction: Maternal early pregnancy body mass index (BMI) and gestational weight gain (GWG) strongly correlate with pregnancy outcomes. Gestational hypertension and diabetes have been associated with overweight and obesity in pregnancy. A low pre-pregnancy BMI has been associated with low birth weight and preterm birth.

Method: This observational study was carried out from November 2018 to July 2020 in a tertiary care hospital in South India with a sample size of 100. Pregnant women with uncomplicated singleton pregnancies booked for regular antenatal care by 10 weeks of gestation were included in the study. During the participants' antenatal check-ups, detailed history and examinations were made. The weight of the participants was recorded at every antenatal check-up. Information about the gestational age at delivery and the birth weight of the neonates were collected following delivery.

Results: The mean age of women was 25.83 + 2.74 years. Of women who delivered low birth weight neonates (<2.5 kg), 86% had GWG below the Institute of Medicine (IOM) recommendation. A total of 57% of women with normal early pregnancy BMI and 67% of obese women had GWG within the IOM recommendation. Early pregnancy BMI had a positive correlation with neonatal birth weight (r (98) = 0.779, p = 0.001). Of the underweight pregnant women, 72% gave birth to small for gestational age (SGA) babies, and 97% percent of normal early pregnancy BMI women delivered neonates with normal weight for gestational age. A total of 33% of overweight and 50% of obese women had large for gestational age (LGA) babies.

Conclusion: Results from this study suggest that maternal early pregnancy BMI is more strongly associated with neonatal birth weight than GWG. Therefore, early pregnancy BMI may be an important focus for counseling during pregnancy.

Food taboos during pregnancy: meta-analysis on cross cultural differences suggests specific, diet-related pressures on childbirth among agriculturalists

Pregnancy is the most delicate stage of human life history as well as a common target of food taboos across cultures. Despite puzzling evidence that many pregnant women across the world reduce their intake of nutritious foods to accomplish cultural norms, no study has provided statistical analysis of cross-cultural variation in food taboos during pregnancy. Moreover, antenatal practices among forager and agriculturalists have never been compared, despite subsistence mode being known to affect staple foods and lifestyle directly. This gap hinders to us from understanding the overall threats attributed to pregnancy, and their perceived nutritional causes around the world. The present study constitutes the first cross-cultural meta-analysis on food taboos during pregnancy. We examined thirty-two articles on dietary antenatal restrictions among agricultural and non-agricultural societies, in order to: (i) identify cross-culturally targeted animal, plant and miscellaneous foods; (ii) define major clusters of taboo focus; (iii) test the hypothesis that food types and clusters of focus distribute differently between agricultural and non-agricultural taboos; and (iv) test the hypothesis that food types distribute differently across the clusters of taboo focus. All data were analysed in SPSS and RStudio using chi-squared tests and Fisher's exact tests. We detected a gradient in taboo focus that ranged from no direct physiological interest to the fear of varied physiological complications to a very specific concern over increased birth weight and difficult delivery. Non-agricultural taboos were more likely to target non-domesticated animal foods and to be justified by concerns not directly linked to the physiological sphere, whereas agricultural taboos tended to targed more cultivated and processed products and showed a stronger association with concerns over increased birth weight. Despite some methodological discrepancies in the existing literature on food taboos during pregnancy, our results illustrate that such cultural traits are useful for detecting perception of biological pressures on reproduction across cultures. Indeed, the widespread concern over birth weight and carbohydrate rich foods overlaps with clinical evidence that obstructed labor is a major threat to maternal life in Africa, Asia and Eurasia. Furthermore, asymmetry in the frequency of such concern across subsistence modes aligns with the evolutionary perspective that agriculture may have exacerbated delivery complications. This study highlights the need for the improved understanding of dietary behaviors during pregnancy across the world, addressing the role of obstructed labor as a key point of convergence between clinical, evolutionary and cultural issues in human behavior.

Impact of Hypertensive Disorders of Pregnancy on Stillbirth and Other Perinatal Outcomes: A Multi-Center Retrospective Study

Objective: The aim of the study is to assess the impact of hypertensive disorders of pregnancy on stillbirths and other perinatal outcomes among women in Karachi, Pakistan.

Methodology: This was a retrospective cohort study conducted at two tertiary care hospitals, Aga Khan Hospital (AKU) and Liaquat National Hospital (LNH) in Karachi, Pakistan. The primary outcome variable of this study was stillbirth. Other outcomes assessed in this study included preterm birth, low birth weight, and early neonatal death.

Results: Data of a total of 840 women were included in this study; 280 (33.33%) women had hypertensive disorders of pregnancy and 560 (66.67%) were normotensive. Among women who had hypertensive disorders of pregnancy, the adjusted odds ratio (AOR) of having a stillbirth was two times more than that for normotensive women (AOR=2.62, 95% CI=1.46-4.40), four times for low birth weight (AOR=4.23, 95% CI=2.88-6.20), five times for early neonatal death (AOR=5.03, 95% CI=2.40-10.50) and six times for pre-term birth (AOR=5.16, 95% CI=3.42-7.79).

Conclusion: The current study found that incidence of stillbirth, low birth weight, pre-term birth, and neonatal mortality is higher in mothers with hypertensive disorders of pregnancy than normotensive mothers.

Comprehensive analysis of the association of seasonal variability with maternal and neonatal nutrition in lowland Nepal

OBJECTIVE

To provide a comprehensive seasonal analysis of pregnant mothers' eating behaviour and maternal/newborn nutritional status in an undernourished population from lowland rural Nepal, where weather patterns, agricultural labour, food availability and disease prevalence vary seasonally.

DESIGN

Secondary analysis of cluster-randomised Low Birth Weight South Asia Trial data, applying cosinor analysis to predict seasonal patterns.

OUTCOMES

Maternal mid-upper arm circumference (MUAC), BMI, dietary diversity, meals per day, eating down and food aversion in pregnancy (≥31 weeks' gestation) and neonatal z-scores of length-for-age (LAZ), weight-for-age (WAZ) and head circumference-for-age (HCAZ) and weight-for-length (WLZ).

SETTING

Rural areas of Dhanusha and Mahottari districts in plains of Nepal.

PARTICIPANTS

2831 mothers aged 13-50 and 3330 neonates.

RESULTS

We found seasonal patterns in newborn anthropometry and pregnant mothers' anthropometry, meal frequency, dietary diversity, food aversion and eating down. Seasonality in intake varied by food group. Offspring anthropometry broadly tracked mothers'. Annual amplitudes in mothers' MUAC and BMI were 0·27 kg/m2 and 0·22 cm, with peaks post-harvest and nadirs in October when food insecurity peaked. Annual LAZ, WAZ and WLZ amplitudes were 0·125, 0·159 and 0·411 z-scores, respectively. Neonates were the shortest but least thin (higher WLZ) in winter (December/January). In the hot season, WLZ was the lowest (May/June) while LAZ was the highest (March and August). HCAZ did not vary significantly. Food aversion and eating down peaked pre-monsoon (April/May).

CONCLUSIONS

Our analyses revealed complex seasonal patterns in maternal nutrition and neonatal size. Seasonality should be accounted for when designing and evaluating public heath nutrition interventions.

Perinatal outcomes of women with hypertensive disorders of pregnancy in Jimma Medical Center, southwest Ethiopia: Retrospective cohort study

BACKGROUND

Hypertensive disorders of pregnancy (HDP) increases adverse perinatal outcomes in women with the disorder. About 16% of all still births and 10% of early neonatal deaths are accounted by HDP. In Ethiopia, HDP complicates about 6% of all pregnancies. Hence, the objective of this study was to determine the risk of adverse perinatal outcomes among women with HDP in Jimma Medical Center, southwest Ethiopia.

METHODS

A retrospective cohort study was conducted on a total of 777 women who gave birth from June 2017 to March 2020 at Jimma Medical Center, southwest Ethiopia. Women with HDP and normotensive women who gave birth at or after 28 weeks of gestation were enrolled as exposed and unexposed respectively. Simple random sampling technique was used to select study participants. Data were reviewed using structured data collection performa that was prepared after reviewing relevant literatures. Data were entered to Epi-Data then exported to STATA version 13 for analysis. The adverse perinatal outcomes risk were examined using log binomial and modified Poisson regression model with robust standard errors.

RESULTS

In this study, the overall incidence of adverse perinatal outcome was higher among women with hypertensive disorders of pregnancy (HDP) than normotensive women (64.1% versus 32.8%). After adjusting for confounders, women with HDP were at higher risk of babies with low birth weight (adjusted RR = 2.88 (2.2, 3.75)), preterm birth(aRR = 2.31(1.7, 3.14)), fifth minute low Apgar score (aRR = 2.6(1.53, 4.42)), admission to neonatal intensive care unit (aRR = 1.77(1.32, 2.37), stillbirth (aRR = 2.02(1.11, 3.01)), and perinatal mortality (aRR = 3.88(1.97, 7.66)) than normotensive women.

CONCLUSION

Women with hypertensive disorder of pregnancy were at higher risk of adverse perinatal outcomes than normotensive women who gave birth at Jimma Medical Center, southwest Ethiopia. Therefore, health care providers should strengthen prevention, early diagnosis and prompt management of HDP in order to reduce adverse perinatal outcomes.

Association between maternal plasma ferritin level and infants' size at birth: a prospective cohort study in rural Bangladesh

Background: Iron supplementation in pregnancy is recommended by the WHO to prevent a major public health problem, namely, maternal iron deficiency and its consequences. There are gaps in the existing evidence regarding maternal and neonatal benefits and harms of universal iron supplementation.

Objective: To evaluate the association between maternal iron status during pregnancy and infant size at birth (birth weight and length).

Method: This present prospective cohort study was nested in a food and micronutrient supplementation trial conducted in Matlab (MINIMat study), rural Bangladesh. We randomly selected 573 women recruited into the MINIMat study from January – December 2002 who delivered singletons with available birth anthropometric information. The plasma ferritin of each mother was measured at gestational week 14 (GW14; before the start of micronutrient supplementation) and at week 30 (GW30).

Results: Multivariable linear regression revealed no association between plasma ferritin at GW14 and birth weight. However, newborns of women in the highest tertile of plasma ferritin at GW30 (median = 29 µg/L) had on average a 93-gm lower birth weight (95% CI: −172, – 14; p = 0.021) than the newborns of women in the lowest tertile (median = 8 µg/L). Logistic regression showed that odds of low birth weight were approximately two times higher [odds ratio (OR) = 2.27; 95% CI: 1.40, 3.67] among those with mothers in the highest ferritin tertile than in the lowest tertile at GW30. No association was found between maternal plasma ferritin and birth length.

Conclusion: We observed an inverse association between high plasma ferritin in the last trimester (GW30) and birth weight but not birth length. The results suggested that elevated plasma ferritin in pregnancy could have an untoward effect on birth weight.

Only one in four lactating mothers met the minimum dietary diversity score in the pastoral community, Afar region, Ethiopia: a community-based cross-sectional study

Maternal dietary feeding practice is one of the proxy indicators of maternal nutrient adequacy and it improves outcomes for both mothers and their offspring. The minimum maternal dietary diversity score of lactating women is defined as when the mother ate at least four and above food groups from the nine food groups 24 h preceding the survey regardless of the portion size. Therefore, the present study aimed to determine the minimum dietary diversity score (MDDS) and its predictors among lactating mothers in the Pastoralist community, Ethiopia. A community-based cross-sectional study design was employed on 360 lactating mothers using a multi-stage sampling technique from 5 January 2020 to 10 February 2020. Data were collected using questionnaires and anthropometry measurements. Data were entered using EPI-data 4.6.02 and exported into SPSS version 25. Statistical significance was declared at P-value <0⋅05 at multivariable logistic regression. Only one in four lactating mothers met the MDDS. The majority of them consumed cereals in the preceding 24 h of data collection. The most important predictors were maternal meal frequency (adjusted odds ratio (AOR) 6⋅26; 95 % confidence interval (CI) (3⋅51, 11⋅15)), antenatal care (ANC) follow-up one to three times and four and above times (AOR: 2⋅58; 95 % CI (1⋅24, 5⋅36), 4⋅77 (1⋅90, 11⋅95), respectively) and secondary paternal education (AOR 2⋅97; 95 % CI (1⋅44, 6⋅11)). The MDDS among lactating mothers was low. Paternal education, maternal meal frequency and ANC follow-up were the significant predictors. Therefore, to improve maternal dietary diversity score emphasis should be given to those predictors.

Changes in physiology and immune system during pregnancy and coronavirus infection: A review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the 3rd epidemic coronavirus after severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV). Since December 2019, the outbreak of the Coronavirus Disease 2019 (COVID-19) caused by SARS-CoV-2 has aroused great attention around the world. Pregnant women and their fetuses have been concerned as a high-risk population. We explained why pregnant women are susceptible to coronavirus in terms of their adaptive changes in physiology and immune system during pregnancy, and described the associations between maternal clinical symptoms, perinatal outcomes and coronavirus infections.

Potentials of Musa Species Fruits against Oxidative Stress-Induced and Diet-Linked Chronic Diseases: In Vitro and In Vivo Implications of Micronutritional Factors and Dietary Secondary Metabolite Compounds

Nutritional quality and the well-being of the body system are directly linked aspects of human survival. From the unborn foetus to adulthood, the need for sustainable access to micronutrient-rich foods is pertinent and the global consumption of banana and plantain fruits, in effect, contributes to the alleviation of the scourge of malnutrition. This review is particularly aimed at evaluating the pharmacological dimensions through the biological mechanisms of Musa fruits in the body, which represent correlations with their constituent micronutrient factors and dietary polyphenolic constituents such as minerals, vitamin members, anthocyanins, lutein, α-,β- carotenes, neoxanthins and cryptoxanthins, epi- and gallo catechins, catecholamines, 3-carboxycoumarin, β-sitosterol, monoterpenoids, with series of analytical approaches for the various identified compounds being highlighted therein. Derivative value-products from the compartments (flesh and peel) of Musa fruits are equally highlighted, bringing forth the biomedicinal and nutritional relevance, including the potentials of Musa species in dietary diversification approaches.

Maternal complications and risk factors for mortality

Background: Maternal mortality could be prevented through early detection, including the period preceding pregnancy. Women of childbearing age are faced with extreme uncertainties, hence the purpose of this study was to analyse maternal complications and the possible high-risk factors connected to maternal mortality. Design and methods: A case-control study was used to study the causes of maternal mortalities amongst pregnant, delivering, and postpartum mothers between 2017 and 2018. A total sample size of 48 samples was selected through simple random sampling. Results: The result of logistic regression analysis showed nutritional status, prominence of anemia, history of illness, age, antenatal care ANC examination, method of delivery, late referral, occupational status, as well as postpartum complications, as the most influencing risk factors. This very high significance for maternal mortality was based on the chi-square value of 109.431 (p equal to 0.000), and R square (0.897). Conclusions: In conclusion, the potential risk factors of maternal mortality include nutritional status, state of anemia, history of illness, age, ANC examination, delivery method, late referral, occupational status, and pregnancy complications, which is specifically the most dominant factor.

Safety and effectiveness of intravenous iron sucrose versus standard oral iron therapy in pregnant women with moderate-to-severe anaemia in India: a multicentre, open-label, phase 3, randomised, controlled trial

BACKGROUND

Intravenous iron sucrose is a promising therapy for increasing haemoglobin concentration; however, its effect on clinical outcomes in pregnancy is not yet established. We aimed to assess the safety and clinical effectiveness of intravenous iron sucrose (intervention) versus standard oral iron (control) therapy in the treatment of women with moderate-to-severe iron deficiency anaemia in pregnancy.

METHODS

We did a multicentre, open-label, phase 3, randomised, controlled trial at four government medical colleges in India. Pregnant women, aged 18 years or older, at 20-28 weeks of gestation with a haemoglobin concentration of 5-8 g/dL, or at 29-32 weeks of gestation with a haemoglobin concentration of 5-9 g/dL, were randomly assigned (1:1) to receive intravenous iron sucrose (dose was calculated using a formula based on bodyweight and haemoglobin deficit) or standard oral iron therapy (100 mg elemental iron twice daily). Logistic regression was used to compare the primary maternal composite outcome consisting of potentially life-threatening conditions during peripartum and postpartum periods (postpartum haemorrhage, the need for blood transfusion during and after delivery, puerperal sepsis, shock, prolonged hospital stay [>3 days following vaginal delivery and >7 days after lower segment caesarean section], and intensive care unit admission or referral to higher centres) adjusted for site and severity of anaemia. The primary outcome was analysed in a modified intention-to-treat population, which excluded participants who refused to participate after randomisation, those who were lost to follow-up, and those whose outcome data were missing. Safety was assessed in both modified intention-to-treat and as-treated populations. The data safety monitoring board recommended stopping the trial after the first interim analysis because of futility (conditional power 1·14% under the null effects, 3·0% under the continued effects, and 44·83% under hypothesised effects). This trial is registered with the Clinical Trial Registry of India, CTRI/2012/05/002626.

FINDINGS

Between Jan 31, 2014, and July 31, 2017, 2018 women were enrolled, and 999 were randomly assigned to the intravenous iron sucrose group and 1019 to the standard therapy group. The primary maternal composite outcome was reported in 89 (9%) of 958 patients in the intravenous iron sucrose group and in 95 (10%) of 976 patients in the standard therapy group (adjusted odds ratio 0·95, 95% CI 0·70-1·29). 16 (2%) of 958 women in the intravenous iron sucrose group and 13 (1%) of 976 women in the standard therapy group had serious maternal adverse events. Serious fetal and neonatal adverse events were reported by 39 (4%) of 961 women in the intravenous iron sucrose group and 45 (5%) of 982 women in the standard therapy group. At 6 weeks post-randomisation, minor side-effects were reported by 117 (16%) of 737 women in the intravenous iron sucrose group versus 155 (21%) of 721 women in the standard therapy group. None of the serious adverse events was found to be related to the trial procedures or the interventions as per the causality assessment made by the trial investigators, ethics committees, and regulatory body.

INTERPRETATION

The study was stopped due to futility. There is insufficient evidence to show the effectiveness of intravenous iron sucrose in reducing clinical outcomes compared with standard oral iron therapy in pregnant women with moderate-to-severe anaemia.

FUNDING

WHO, India.

Review of policies, data, and interventions to improve maternal nutrition in Afghanistan

Malnutrition contributes to direct and indirect causes of maternal mortality, which is particularly high in Afghanistan. Women's nutritional status before, during, and after pregnancy affects their own well‐being and mortality risk and their children's health outcomes. Though maternal nutrition interventions have documented positive impact on select child health outcomes, there are limited data regarding the effects of maternal nutrition interventions on maternal health outcomes globally. This scoping review maps policies, data, and interventions aiming to address poor maternal nutrition outcomes in Afghanistan. We used broad search categories and approaches including database and website searches, hand searches of reference lists from relevant articles, policy and programme document requests, and key informant interviews. Inclusion and exclusion criteria were developed by type of source document, such as studies with measures related to maternal nutrition, relevant policies and strategies, and programmatic research or evaluation by a third party with explicit interventions targeting maternal nutrition. We abstracted documents systematically, summarized content, and synthesized data. We included 20 policies and strategies, 29 data reports, and nine intervention evaluations. The availability of maternal nutrition intervention data and the inclusion of nutrition indicators, such as minimum dietary diversity, have increased substantially since 2013, yet few nutrition evaluations and population surveys include maternal outcomes as primary or even secondary outcomes. There is little evidence on the effectiveness of interventions that target maternal nutrition in Afghanistan. Policies and strategies more recently have shifted towards multisectoral efforts and specifically target nutrition needs of adolescent girls and women of reproductive age. This scoping review presents evidence from more than 10 years of efforts to improve the maternal nutrition status of Afghan women. We recommend a combination of investments in measuring maternal nutrition indicators and improving maternal nutrition knowledge and behaviours.

Developmental origins of variability in pelvic dimensions: Evidence from nulliparous South Asian women in the United Kingdom

OBJECTIVES

Pelvic growth may be sensitive to early-life nutrition, with implications for maternal risk of obstructed labor. However, the "developmental origins" of adult pelvic variability require further investigation. We tested whether adult pelvic dimensions are associated with two components of height, indexing different periods of linear growth: tibia length, a proxy for early postnatal growth, and height-residual (height regressed on tibia length), a proxy for later growth. We also tested whether adult pelvic dimensions are associated with birth weight, a marker of nutritional investment in utero.

METHODS

In this cross-sectional study, data were obtained on 68 nulliparous young women of South Asian ancestry. Pelvic dimensions (bi-iliac and bi-acetabular breadth, anteroposterior pelvic inlet and outlet, interspinous and intertuberous diameter) were measured using magnetic resonance imaging. Height and tibia length were measured manually. Birth weight and gestational age were obtained by recall. Multivariable regression models were fitted with a given pelvic dimension regressed on height-residual, tibia, and birth weight, with the latter adjusted for gestational age.

RESULTS

Controlling for birth weight, height-residual was predictive of bi-acetabular breadth, bi-iliac breadth, and the pelvic inlet, while tibia length significantly predicted all dimensions except interspinous diameter. Controlling for the linear growth variables, birth weight was predictive of bi-iliac breadth only.

CONCLUSIONS

Markers of linear growth during both early and later development were associated with adult pelvic dimensions, whereas size at birth was poorly predictive. Efforts to reduce stunting in early life may facilitate the attainment of maximum potential growth for both height and the pelvis.

Dietary Folate Intake and Folic Acid Supplements among Pregnant Women from Southern Italy: Evidence from the "Mamma & Bambino" Cohort

Folate requirement among women who plan to become pregnant should be raised to 600 μg/day during the periconceptional period. To meet this need, several countries began to promote the use of folic acid supplements before and during pregnancy. Here, we investigated prevalence and determinants of dietary folate intake and folic acid supplement use among 397 pregnant women (aged 15–50 years old, median = 37 years old). We also investigated their effects on neonatal outcomes in a subgroup of women who completed pregnancy. For doing that, we used data from the “Mamma & Bambino” project, an ongoing mother-child cohort settled in Catania (Italy). Inadequate folate intake was evaluated using a Food Frequency Questionnaire and defined as an intake < 600 μg/day. Women were also classified as non-users (i.e., women who did not use folic acid supplements), insufficient users (i.e., women who did not take folic acid supplements as recommended), and recommended users of folic acid supplements. Neonatal outcomes of interest were preterm birth (PTB) and small for gestational age (SGA). Nearly 65% of women (n = 257) reported inadequate folate intake, while 74.8% and 22.4% were respectively classified as insufficient or recommended users of supplements. We demonstrated higher odds of inadequate folate intake among smoking women (OR = 1.457; 95%CI = 1.046–2.030; p = 0.026), those who followed dietary restrictions (OR = 2.180; 95%CI = 1.085–4.378; p = 0.029), and those with low adherence to the Mediterranean Diet (OR = 3.194; 95%CI = 1.958–5.210; p < 0.001). In a subsample of 282 women who completed pregnancy, we also noted a higher percentage of SGA among those with inadequate folate intake (p < 0.001). Among 257 women with inadequate folate intake, those with low educational level were more likely to not take folic acid supplements than their more educated counterpart (OR = 5.574; 95%CI = 1.487–21.435; p = 0.012). In a subsample of 184 women with inadequate folate intake and complete pregnancy, we observed a higher proportion of SGA newborns among women who did not take supplement before pregnancy and those who did not take at all (p = 0.009). We also noted that the proportion of PTB was higher among non-users and insufficient users of folic acid supplements, but difference was not statistically significant. Our study underlined the need for improving the adherence of pregnant women with recommendations for dietary folate intake and supplement use. Although we proposed a protective effect of folic acid supplement use on risk of SGA, further research is encouraged to corroborate our findings and to investigate other factors involved.

Maternal undernutrition induces fetal hepatic lipid metabolism disorder and affects the development of fetal liver in a sheep model

Undernutrition accelerates body fat mobilization to alleviate negative energy balance, which disrupts homeostasis of lipid metabolism in maternal liver. However, little is known about its effect on fetal metabolism and development. Here, a sheep model was used to explore whether maternal undernutrition induces fetal lipid metabolism disorder and further inhibits fetal hepatic development. Twenty pregnant ewes were either fed normally or restricted to 30% level for 15 d, after which fetal hepatic samples were collected to conduct transcriptome, metabolome, histomorphology, and biochemical analysis. Results showed that maternal undernutrition altered the general transcriptome profile and metabolic mode in fetal liver. Fatty acid oxidation and ketogenesis were enhanced in fetal livers of undernourished ewes, which might be promoted by the activated peroxisome proliferator-activated receptor α signaling pathway, whereas cholesterol, steroid, and fatty acid synthesis were repressed. Maternal undernutrition increased triglyceride synthesis, decreased triglyceride degradation, and inhibited phospholipid degradation and synthesis in fetal liver. In addition, our data revealed that maternal undernutrition extremely inhibited DNA replication, cell cycle progression, and antiapoptosis and broke the balance between cell proliferation and apoptosis in fetal liver, indicating that maternal undernutrition affects the growth and development of fetal liver. Generally, these findings provide evidence that maternal undernutrition during pregnancy disturbs fetal lipid metabolism and inhibits fetal hepatic development in sheep, which greatly contribute to the further study of fetal metabolism and development in human beings.-Xue, Y., Guo, C., Hu, F., Zhu, W., Mao, S. Maternal undernutrition induces fetal hepatic lipid metabolism disorder and affects the development of fetal liver in a sheep model.

Undernourishment and recurrent seizures early in life impair Long-Term Potentiation and alter NMDAR and AMPAR expression in rat hippocampus

Undernourishment is a global issue, especially in developing countries, affecting newborns and children in a vulnerable period of brain development. Previous studies of undernourishment models suggested a relationship between undernourishment and epilepsy. The exposure to both undernourishment and recurrent seizures early in life appears to have detrimental effects on the developing brain. This study aims to investigate the neurobiological consequences of undernourishment and recurrent seizures exposure early in life, investigating Long-Term Potentiation (LTP) induction and gene expression of NMDA receptor subunits in the hippocampus during adulthood (P60). Animals were exposed to maternal deprivation protocol from P2 to P15 to control food intake in rat pups and Flurothyl-induced seizures from P7 to P10. Electrophysiological records of hippocampal slices were recorded and gene expression of NR1A, NR2A, NR2B, NR2C, NR2D and BDNF were investigated. Animals exposed to undernourishment or recurrent seizures failed to promote LTP after stimulation. Furthermore, seizure exposure early in life led to increased expression of hippocampal NR1A, NR2A, NR2B, NR2C and NR2D when compared to controls. Interestingly, when animals were exposed to undernourishment paradigm early in life, this upregulation of NDMA subunits was absent. In conclusion, our study showed impaired LTP after undernourishment and recurrent seizures early in life, together with differential expression of NDMA expression in the hippocampus during adulthood.

The Correlation between Hemoglobin Concentration during Pregnancy with the Maternal and Neonatal Outcome

BACKGROUND:

The prevalence of anaemia is higher among women, including pregnant women. The estimation was about 24.8% of the population in the world suffering anaemia. Anaemia during pregnancy is a big problem because it can contribute morbidity and mortality, either in mother or newborn. The impacts of anaemia during pregnancy included post-partum haemorrhage, low birth weight (LBW), preterm delivery, and low Appearance, Pulse, Grimace, Activity, Respiration (APGAR) score.

AIM:

This study aimed to determine the correlation between haemoglobin concentration during pregnancy and the outcome of mothers and newborns.

METHODS:

It was a cohort study that included 200 pregnant women in second or third trimester at antenatal care of Sundari General Hospital Outpatient Clinic on February until September 2018. The participants were interviewed using a questionnaire, and their blood was checked to measure haemoglobin concentration using portable Easy Touch Hemoglobinometer. In the next three until six months, the following investigation was conducted to assess the maternal and neonatal outcome.

RESULTS:

The result of this study showed among the maternal outcome, only antepartum haemoglobin concentration had a statistically significant correlation with the haemoglobin concentration during pregnancy (p < 0.05), meanwhile, among the neonatal outcome. LBW was the only factor that statistically significantly correlated to the haemoglobin concentration during pregnancy (p < 0.05).

CONCLUSION:

We can conclude that once anaemia occurs in pregnant women, then the women kept suffering from anaemia with its correlation was statistically significant.

Maternal risk factors and newborn infant vitamin D status: a scoping literature review

Low vitamin D (VitD) status is common among newborn infants, more so in temperate latitudes with evidence that maternal VitD deficiency is a major risk factor given that the neonate relies solely on maternal-fetal transfer of VitD. This scoping review was conducted to provide an overview of the latest evidence from studies regarding the impact of maternal risk factors on infant 25-hydryoxyvitamin D [25(OH)D] concentrations with a focus on studies in Canada and the United States. Several maternal risk factors that contribute to low maternal-fetal 25(OH)D concentrations have been reported over many decades, but no clear pattern has been established for multiethnic populations. For example, darker skin pigmentation and ethnicity are common risk factors for low VitD status. Studies in predominantly white women showed that supplementation of VitD during pregnancy causes significant increases in maternal serum 25(OH)D which often improves cord serum 25(OH)D values. In addition, VitD recommendations by health care professionals and adherence to supplementation by pregnant women appear to positively influence maternal and infant 25(OH)D concentrations. Conversely, winter season, obesity, lower socioeconomic status including lifestyle factors (smoking), and use of medication pose risk for lower maternal-fetal transfer of VitD. However, there is still a dearth of pertinent data on the relationship between some of the maternal risk factors and newborn 25(OH)D concentrations, for instance, relationships between gestational diabetes and neonatal VitD status. Additional research is required to determine if the same target for 25(OH)D concentrations applies for pregnant women, neonates, and infants.

Regular Antenatal Attendance and Education Influence the Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy: A Cross-Sectional Study at the University Hospital, Kumasi, Ghana

Background

The World Health Organization (WHO) recommends the use of Insecticide Treated Bed-Nets and Intermittent Preventive Treatment (IPT) with Sulphadoxine-Pyrimethamine (SP) as interventions in curbing malaria during pregnancy. However, increasing evidence shows a gap in coverage where not all pregnant women receive the recommended SP dose. This study evaluated the factors influencing uptake of IPTp-SP among pregnant women in Kumasi, Ghana.

Methodology

This cross-sectional study was conducted among 280 pregnant women attending the Kwame Nkrumah University of Science and Technology Hospital in Kumasi, Ghana. Validated structured questionnaires were administered to obtain sociodemographic, medical/reproductive information, and IPTp-SP uptake among participants. Statistical analyses were performed using IBM SPSS 25.0 statistics.

Results

The mean age of respondents was 29.7±4.9 years. Of the 280 women interviewed, 74.6% attended the antenatal care (ANC) clinic at least four times with only 31.8% completing the recommended doses. Tertiary education [aOR=3.15, 95% CI (0.94 -10.97), and p=0.042] and ≥ 4 ANC visits [aOR=24.6, 95% CI (5.87-103.07), p<0.0001] had statistically significant higher odds of completing the recommended IPTp-SP dose. However, participants employed by the formal sector [aOR=0.28, 95% CI (0.09 - 0.79), p=0.016] and participants with more than four children [aOR=0.14, 95% CI (0.03 - 0.63), and p=0.011] had statistically significant lower odds of completing the recommended IPT dose.

Conclusion

ANC attendance is critical in IPTp uptake. The results emphasize the need for the Health Policy Makers in Kumasi to encourage pregnant women, especially women working in the formal sector and women having more than four children to patronize ANC attendance to ensure high coverage of the recommended IPTp dose.

Effect of a Multiple-Micronutrient-Fortified Fruit Powder Beverage on the Nutrition Status, Physical Fitness, and Cognitive Performance of Schoolchildren in the Philippines

This study aimed to determine the effect of a multiple-micronutrient-fortified beverage on the micronutrient status, physical fitness, and cognitive performance of schoolchildren. The study was a randomized, double-blind, placebo-controlled trial of schoolchildren assigned to receive either the fortified or nonfortified beverage with or without anthelmintic therapy. Data on hemoglobin level, urinary iodine excretion (UIE) level, physical fitness, and cognitive performance were collected at baseline and at 16 weeks post-intervention. The fortified beverage significantly improved iron status among the subjects that had hemoglobin levels < 11 g/dl at baseline. The proportion of children who remained moderately to severely anemic was significantly lower among those given the fortified beverage. In the groups that received the fortified product, the median UIE level increased, whereas among those who received the placebo beverage, the median UIE level was reduced significantly. Iron- and/or iodine-deficient subjects who received the fortified beverage showed significant improvements in fitness (post-exercise reduction of heart rate) and cognitive performance (nonverbal mental ability score). The study showed that consumption of a multiple-micronutrient-fortified beverage for 16 weeks had significant effects on iron status, iodine status, physical fitness, and cognitive performance among iron- and/or iodine-deficient Filipino schoolchildren. Anthelmintic therapy improved iron status of anemic children and iodine status of the iron-adequate children at baseline but it had no effect on physical fitness and cognitive performance. The results from the clinical study showed that a multiple-micronutrient-fortified beverage could play an important role in preventing and controlling micronutrient deficiencies.

Development of a new model for estimating maternal mortality ratio at national and sub-national levels and its application for describing sub-national variations of maternal death in Ethiopia

Background

In developing countries lacking functional vital registration system, statistical models are being increasingly used for estimating maternal mortality ratio (MMR). Yet, most of the models have limited applicability at sub-country level. This paper introduces a new model for estimating MMR at national and sub-national levels based on maternal health-related indicators. Further, it applies the model for explaining sub-national variations of MMR in Ethiopia.

Methods

Country level data on MMR and other nine potential predictors of maternal death were extracted from 248 national Demographic and Health Surveys and other related surveys conducted in 80 low- and middle-income countries since 1990. Additional data were obtained from the World Bank and the World Health Organization databases. The potential model predictors were: contraceptive prevalence rate (CPR); utilizations of antenatal care (ANC), health institution delivery (HID), Caesarian section (CS) and postnatal care (PNC); and prevalence of maternal anemia, thinness (Body Mass Index (BMI < 18.5 kg/m²), short stature (height less than 145 cms) and HIV. Stepwise Generalized Estimating Equation (GEE) with Negative Log-binomial link was employed to model MMR as a function of the covariates.

Results

The ultimate model comprised six significant predictors and the equation is provided as: Ln (MMR) = 6.464–0.013(CPR)– 0.006(HID)– 0.003(PNC)– 0.027(CS rate) + 0.060(HIV prevalence) + 0.011 (thinness prevalence). The variation explained by the model was 54.3%) and the mean (±SD) relative standard error (8.6±2.6%) suggested the model has a reasonable precision. Application of the model to describe sub-national variation of maternal mortality in Ethiopia indicated, in 2016 the highest MMRs per 100,000 live births were in Somali (805) and Afar (795) regions. Between 2000 and 2016, all the regions of Ethiopia have significantly reduced MMRs; yet the rate of decline was lower in the aforementioned two regions. Oromiya region contributed for 46% of all maternal deaths in Ethiopia.

Conclusion

In developing countries lacking dependable maternal mortality data; the model can be used to estimate national and sub-national MMR with reasonable accuracy and precision.

Biomarkers of Nutrition for Development (BOND)-Iron Review

This is the fifth in the series of reviews developed as part of the Biomarkers of Nutrition for Development (BOND) program. The BOND Iron Expert Panel (I-EP) reviewed the extant knowledge regarding iron biology, public health implications, and the relative usefulness of currently available biomarkers of iron status from deficiency to overload. Approaches to assessing intake, including bioavailability, are also covered. The report also covers technical and laboratory considerations for the use of available biomarkers of iron status, and concludes with a description of research priorities along with a brief discussion of new biomarkers with potential for use across the spectrum of activities related to the study of iron in human health.The I-EP concluded that current iron biomarkers are reliable for accurately assessing many aspects of iron nutrition. However, a clear distinction is made between the relative strengths of biomarkers to assess hematological consequences of iron deficiency versus other putative functional outcomes, particularly the relationship between maternal and fetal iron status during pregnancy, birth outcomes, and infant cognitive, motor and emotional development. The I-EP also highlighted the importance of considering the confounding effects of inflammation and infection on the interpretation of iron biomarker results, as well as the impact of life stage. Finally, alternative approaches to the evaluation of the risk for nutritional iron overload at the population level are presented, because the currently designated upper limits for the biomarker generally employed (serum ferritin) may not differentiate between true iron overload and the effects of subclinical inflammation.

Sanitation, Disease Externalities and Anaemia: Evidence From Nepal

Anaemia impairs physical and cognitive development in children and reduces human capital accumulation. The prior economics literature has focused on the role of inadequate nutrition in causing anaemia. This article is the first to show that sanitation, a public good, significantly contributes to preventing anaemia. We identify effects by exploiting rapid and differential improvement in sanitation across regions of Nepal between 2006 and 2011. Within regions over time, cohorts of children exposed to better community sanitation developed higher haemoglobin levels. Our results highlight a previously undocumented externality of open defaecation, which is today practiced by over a billion people worldwide.

Use of a novel supplementary food and measures to control inflammation in malnourished pregnant women in Sierra Leone to improve birth outcomes: study protocol for a prospective, randomized, controlled clinical effectiveness trial

Background

The negative synergy between poor nutritional status and infectious diseases is doubly detrimental in pregnancy. In Sierra Leone, maternal malnutrition is amongst the highest in the world, while maternal mortality is high at 1320/100,000 live births and stunting in under-five is 37.9%, ranked 110/132 worldwide. Maternal malnutrition has been associated with preterm birth, small-for-gestational age infants, and poor maternal outcomes. Infants born prematurely or small-for-gestational age experience higher mortality and are at risk for stunting and decreased cognitive performance. Nutritional interventions alone during pregnancy may not be as effective in the setting of increased inflammation from repeated infections. Interventions are needed to improve maternal outcomes and reduce stunting in this population.

Methods/design

This will be a prospective, randomized, controlled clinical effectiveness trial of an improved supplementary food plus anti-infective therapies compared to standard therapy in malnourished pregnant women. Pregnant women will be randomized to receive a low water activity, ready-to-use supplementary food plus five anti-infective interventions or the standard of care which is 3.5 kg corn/ soy blended flour with 350 mL vegetable oil every two weeks. The five anti-infective interventions are 1) insecticide-treated mosquito net at the time of enrollment into the study, 2) sulfadoxine-pyrimethamine given every 4 weeks, beginning at enrollment or at 13 weeks’ gestation, whichever is later, 3)azithromycin at a dose of 1 g given once at enrollment (after first trimester)and again during 28–34 weeks of gestation, 4)single dose 400 mg albendazole given in second trimester, and 5) testing and treatment for bacterial vaginosis at enrollment and again at 28–34 weeks of gestation. Treatment will be provided for the duration of the pregnancy. The primary outcome measure will be birth length. Secondary outcomes in the mothers will include rates of maternal weight gain and increase in mid-upper arm circumference, and time to maternal anthropometric recovery. Secondary outcomes in the infants will include birth weight, birth head circumference, and linear and ponderal growth.

Discussion

Malnutrition remains a major problem in the developing world with lasting maternal and infant consequences. Maternal malnutrition has been associated with intrauterine growth retardation, low birth weight (LBW), pre-term delivery and poor cognitive development. Nutritional interventions alone have not been successful in reducing stunting. By bundling nutritional and anti-infective interventions, we aim to reduce intrauterine growth restriction and low birth weight in moderately malnourished pregnant women in Sierra Leone. If successful, this bundle can easily be implemented by governments or non-governmental organizations.

Trial registration

Clinicaltrials.govNCT03079388; Date: March 5, 2017.

Association mapping unveils favorable alleles for grain iron and zinc concentrations in lentil (Lens culinaris subsp. culinaris)

Lentil is a major cool-season grain legume grown in South Asia, West Asia, and North Africa. Populations in developing countries of these regions have micronutrient deficiencies; therefore, breeding programs should focus more on improving the micronutrient content of food. In the present study, a set of 96 diverse germplasm lines were evaluated at three different locations in India to examine the variation in iron (Fe) and zinc (Zn) concentration and identify simple sequence repeat (SSR) markers that associate with the genetic variation. The genetic variation among genotypes of the association mapping (AM) panel was characterized using a genetic distance-based and a general model-based clustering method. The model-based analysis identified six subpopulations, which satisfactorily explained the genetic structure of the AM panel. AM analysis identified three SSRs (PBALC 13, PBALC 206, and GLLC 563) associated with grain Fe concentration explaining 9% to 11% of phenotypic variation and four SSRs (PBALC 353, SSR 317-1, PLC 62, and PBALC 217) were associated with grain Zn concentration explaining 14%, to 21% of phenotypic variation. These identified SSRs exhibited consistent performance across locations. These candidate SSRs can be used in marker-assisted genetic improvement for developing Fe and Zn fortified lentil varieties. Favorable alleles and promising genotypes identified in this study can be utilized for lentil biofortification.

Identification and determination of naturally occurring folates in grains of rice (Oryza sativa L.) by UPLC-MS/MS analysis

The genetic potential and biofortification of India-grown rice with bioavailable folate has not been studied yet. The objectives of this study were to determine the folates concentration in four cultivars of rice through UPLC-MS/MS. Total folate concentration in rice cultivars ranged from 11.0 to 51 μg/100 g with a mean of 26.0 μg/100 g. Among the four rice cultivars, the pigmented grain cultivar Nootripathu possesses two-fold rich sources of total folates than the other three non-pigmented grain cultivars. The average value of 100 g serving of rice grains could provide the amount of recommended daily allowance (% RDA) of dietary folates (6.5%) for adults, which ranged from 2.7-12.7%. Among the 5 individual forms of folates, 5-methyltetrahydrofolate was most abundant in rice cultivars followed by 10-Formylfolic acid and folic acid. The result of this study has been useful for biofortification of folates in rice.

Women's decision-making autonomy and utilisation of maternal healthcare services: results from the Bangladesh Demographic and Health Survey

OBJECTIVES

The aim of this study was to determine the association between women's decision-making power and utilisation of maternal healthcare services (MHS) among Bangladeshi women.

SETTINGS

This is a nationally representative survey that encompassed Dhaka, Rajshahi, Rangpur, Chittagong, Khulna, Barisal and Sylhet in Bangladesh. Sample households were selected by a two-stage stratification technique. First, 207 clusters in urban areas and 393 in rural areas were selected for 600 enumeration areas with proportional probability. In the second stage, on average 30 households were selected systematically from the enumeration areas. Finally, 17 989 households were selected for the survey of which 96% were interviewed successfully.

PARTICIPANTS

Cross-sectional data on 4309 non-pregnant women were collected from Bangladesh demographic and health survey 2014. Decision-making status on respondent's own healthcare, large household purchases, having a say on child's healthcare and visiting to family or relatives were included in the analysis.

RESULTS

Prevalence of at least four antenatal attendance, facility delivery and postnatal check-up were respectively 32.6% (95% CI 31.2 to 34), 40.6% (95% CI 39.13 to 42.07) and 66.3% (95% CI 64.89 to 67.71). Compared with women who could make decisions alone, women in the urban areas who had to decide on their healthcare with husband/partner had 20% (95% CI 0.794 to 1.799) higher odds of attending at least four antenatal visits and those in rural areas had 35% (95% CI 0.464 to 0.897) lower odds of attending at least four antenatal visits. Women in urban and rural areas had respectively 43% (95% CI 0.941 to 2.169) and 28% (95% CI 0.928 to 1.751) higher odds of receiving postnatal check-up when their health decisions were made jointly with their husband/partner.

CONCLUSION

Neither making decisions alone, nor deciding jointly with husband/partner was always positively associated with the utilisation of all three types of MHS. This study concludes that better spousal cooperation on household and health issues could lead to higher utilisation of MHS services.

Anaemia in pregnancy and associated factors: a cross sectional study of antenatal attendants at the Sunyani Municipal Hospital, Ghana

BACKGROUND

Anaemia in pregnancy is an important health issue resulting in high maternal morbidity and mortality. The purpose of the current study was to identify factors associated with anaemia among pregnant women receiving antenatal care at the Sunyani Municipal Hospital in Ghana.

METHODS

A cross-sectional study involving pregnant women seeking antenatal care at the Sunyani Municipal Hospital was conducted between May and June, 2015. It involved the collection of data on socio demographic and obstetric variables, medical interventions and malaria infection, consumption of iron containing foods and supplements using a case record form and a structured questionnaire. Also, data on haemoglobin concentrations at first and current antenatal visit were collected. Bivariate and multivariate statistical analysis were done to determine factors associated with anaemia.

RESULTS

Out of the 316 participants, 129 (40.8%) were found to be anaemic (Hb <11.0 g/dl) at the time of their first ANC visit (mean Hb: 11.21 g/dl, range 6.8-15.1 g/dl). Seventy-nine (61.2%) of them had mild anemia (Hb 9.0-10.9 g/dl), 48 (37.2%) had moderate anemia (Hb 7.0-8.9 g/dl) whilst 2 (1.6%) had severe anemia (Hb <7.0 g/dl). During their most recent ANC visit, the prevalence of anaemia was found to be similar to that of the first visit with 131 (41.5%) of them being anaemic [mean Hb: 11.24 g/dl, range 8.10-14.5 g/dl]. The haemoglobin levels however improved significantly during the most recent visit compared to the first with none of the women being severely anaemic (Hb <7.0 g/dl). The prevalence of moderate anaemia reduced from 37.2% (CI 28.9-46.2) during the first visit to 19.1% (12.7-26.9) during the most recent visit, a reduction of 48.7%. Malaria infection, frequency at which one consumed fish/snails and gestational age at first ANC visit were the main factors found to be associated with anaemia among the pregnant women.

CONCLUSIONS

Malaria infection, fish/snails intake and gestational age at first ANC visit were significantly associated with anaemia. Addressing these factors can reduce the incidence of anaemia in pregnancy.

Safety and benefits of antenatal oral iron supplementation in low-income countries: a review

The World Health Organization recommends universal iron supplementation of 30-60 mg/day in pregnancy but coverage is low in most countries. Its efficacy is uncertain, however, and there has been a vigorous debate in the last decade about its safety, particularly in areas with a high burden of malaria and other infectious diseases. We reviewed the evidence on the safety and efficacy of antenatal iron supplementation in low-income countries. We found no evidence that daily supplementation at a dose of 60 mg leads to increased maternal Plasmodium infection risk. On the other hand, recent meta-analyses found that antenatal iron supplementation provides benefits for maternal health (severe anaemia at postpartum, blood transfusion). For neonates, there was a reduced prematurity risk, and only a small or no effect on birth weight. A recent trial showed, however, that benefits of antenatal iron supplementation on maternal and neonatal health vary by maternal iron status, with substantial benefits in iron-deficient women. The benefits of universal iron supplementation are likely to vary with the prevalence of iron deficiency. As a consequence, the balance between benefits and risks is probably more favourable in low-income countries than in high-income countries despite the higher exposure to infectious pathogens.

Mineral and Anti-Nutritional Contents of Niger Seed (Guizotia abyssinica (L.f.) Cass., Linseed (Linumusitatissimum L.) and Sesame (Sesamumindicum L.) Varieties Grown in Ethiopia

Oilseeds are rich sources of micronutrients and contribute to combating malnutrition caused by micronutrient deficiency. The objective of this study was to investigate the mineral and anti-nutritional contents of different varieties of niger seed, linseed and sesame. Five niger seed, eight linseed and ten sesame varieties were used. Inductively Coupled Plasma Atomic Emission Spectrometry (ICP-AES) was used for mineral analysis and the standard method was adopted to estimate tannin and phytate. Twelve mineral elements; Ca, K, Mg, Na, P, B, Cu, Fe, Mn, S, Se and Zn were analyzed for each oilseed variety. In niger seed, phosphorous was the most abundant mineral element ranging from 661 to 867 mg/100 g and selenium was the least, ranging from 0.1 to 0.33 mg/100 g. Potassium was recorded in the range of 502 to 732 mg/100 g for linseed varieties. Calcium was the most common mineral element in sesame (1112 to 1787 mg/100 g). The average phytate contents of niger seed, linseed and sesame varieties were353 mg/100 g, 104 mg/100 g and 285 mg/100 g, respectively. Tannin ranged from 91 to 201 mg/100 g, 96 to 695 mg/100 g and 85 to 660 mg/100 g in niger seed, linseed and sesame, respectively. In conclusion, there is a significant variation among the varieties within each crop species as well as among the different oilseeds in terms of their mineral and anti-nutritional contents.

The effects of women's education on maternal health: Evidence from Peru

This article examines the causal effect of women's education on maternal health in Peru, a country where maternal mortality has declined by more than 70% in the last two and a half decades. To isolate the effects of education, the author employs an instrumented regression discontinuity that takes advantage of an exogenous source of variation-an amendment to compulsory schooling laws in 1993. The results indicate that extending women's years of schooling reduced the probability of several maternal health complications at last pregnancy/birth, sometimes by as much as 29%. Underlying these effects, increasing women's education is found to decrease the probability of short birth intervals and unwanted pregnancies (which may result in unsafe abortions) and to increase antenatal healthcare use, potentially owing to changes in women's cognitive skills, economic resources, and autonomy. These findings underscore the influential role of education in reducing maternal morbidity and highlight the contributions of women's education to population health and health transitions.

Effect of a Multiple-Micronutrient-Fortified Fruit Powder Beverage on the Nutrition Status, Physical Fitness, and Cognitive Performance of Schoolchildren in the Philippines

This study aimed to determine the effect of a multiple-micronutrient-fortified beverage on the micronutrient status, physical fitness, and cognitive performance of schoolchildren. The study was a randomized, double-blind, placebo-controlled trial of schoolchildren assigned to receive either the fortified or nonfortified beverage with or without anthelmintic therapy. Data on hemoglobin level, urinary iodine excretion (UIE) level, physical fitness, and cognitive performance were collected at baseline and at 16 weeks post-intervention. The fortified beverage significantly improved iron status among the subjects that had hemoglobin levels < 11 g/dl at baseline. The proportion of children who remained moderately to severely anemic was significantly lower among those given the fortified beverage. In the groups that received the fortified product, the median UIE level increased, whereas among those who received the placebo beverage, the median UIE level was reduced significantly. Iron- and/or iodine-deficient subjects who received the fortified beverage showed significant improvements in fitness (post-exercise reduction of heart rate) and cognitive performance (nonverbal mental ability score). The study showed that consumption of a multiple-micronutrient-fortified beverage for 16 weeks had significant effects on iron status, iodine status, physical fitness, and cognitive performance among iron- and/or iodine-deficient Filipino schoolchildren. Anthelmintic therapy improved iron status of anemic children and iodine status of the iron-adequate children at baseline but it had no effect on physical fitness and cognitive performance. The results from the clinical study showed that a multiple-micronutrient-fortified beverage could play an important role in preventing and controlling micronutrient deficiencies.

How maternal malnutrition affects linear growth and development in the offspring

Maternal malnutrition is common in the developing world and has detrimental effects on both the mother and infant. Pre-pregnancy nutritional status and weight gain during pregnancy are positively related to fetal growth and development. Internationally, there is no agreement on the method of diagnosis or treatment of moderate or severe malnutrition during pregnancy. Establishing clear guidelines for diagnosis and treatment will be essential in elevating the problem. Possible anthropometric measurements used to detect and monitor maternal malnutrition include pre-pregnancy BMI, weight gain, and mid upper arm circumference. Food supplements have the potential to increase gestational weight gain and energy intake which are positively associated with fetal growth and development. Overall more studies are needed to conclude the impact of food/nutrient supplements on infant growth in undernourished pregnant women in developing countries. Currently, a study underway may provide much needed documentation of the benefits of treating malnutrition in pregnancy.

Metabolic engineering of folate and its precursors in Mexican common bean (Phaseolus vulgaris L.)

Folate (vitamin B9) deficiency causes several health problems globally. However, folate biofortification of major staple crops is one alternative that can be used to improve vitamin intakes in populations at risk. We increased the folate levels in common bean by engineering the pteridine branch required for their biosynthesis. GTP cyclohydrolase I from Arabidopsis (AtGchI) was stably introduced into three common bean Pinto cultivars by particle bombardment. Seed-specific overexpression of AtGCHI caused significant increases of up to 150-fold in biosynthetic pteridines in the transformed lines. The pteridine boost enhanced folate levels in raw desiccated seeds by up to threefold (325 μg in a 100 g portion), which would represent 81% of the adult recommended daily allowance. Unexpectedly, the engineering also triggered a general increase in PABA levels, the other folate precursor. This was not observed in previous engineering studies and was probably caused by a feedforward mechanism that remains to be elucidated. Results from this work also show that common bean grains accumulate considerable amounts of oxidized pteridines that might represent products of folate degradation in desiccating seeds. Our study uncovers a probable different regulation of folate homoeostasis in these legume grains than that observed in other engineering works. Legumes are good sources of folates, and this work shows that they can be engineered to accumulate even greater amounts of folate that, when consumed, can improve folate status. Biofortification of common bean with folates and other micronutrients represents a promising strategy to improve the nutritional status of populations around the world.

Investigation of Nutritional Behaviors in the First and Second Trimesters in Pregnant Women Referring to Clinics in Hamadan, Iran, in 2013

Background:

Pregnancy is a particular period in women’s life that is accompanied by an increase in nutritional needs. Having a normal pregnancy period and successful pregnancy outcomes depends on the intake of sufficient amount of food. The present study aimed to determine nutritional behaviors in pregnant women in the first and second trimesters referring to clinics in Hamadan, Iran.

Methods:

This cross-sectional study was conducted on 170 women referred to health and treatment centers of Hamadan in 2013. Among Hamadan’s health and treatment centers, 10 were selected as the research setting through cluster sampling. Then, the pregnant women at 8-24 weeks of gestation were randomly entered into the study. The data were collected using nutritional behaviors questionnaire in three months. Accordingly, mean scores below 50, between 50 and 75, and above 75 were considered as weak, moderate, and perfect nutritional behaviors, respectively. The data were analyzed using the SPSS statistical software, version 21 and P<0.05 was considered as statistically significant.

Results:

The results showed that more than three fourths of the study participants had moderate nutritional behaviors. Insufficient intake of fruit, vegetables, and cereals was detected in 80.6%, 54.1%, and 47.1% of the participants, respectively. Besides, 30% of the women had not used folic acid supplement during their pregnancy period or were not aware of its necessity. The results of multivariate analysis indicated that age was only significantly associated with pregnant women’s score of nutritional behaviors (P=0.010). Additionally, no significant relationship was found between the women’s nutritional behaviors and their strategies for elimination of common pregnancy complications, such as constipation, heartburn, urinary tract infection, and anemia.

Discussion and Conclusion:

Considering the participants’ moderate nutritional behaviors, health and treatment centers are recommended to provide the necessary training for improving pregnant women’s nutritional behaviors and supervise and follow their execution and evaluation.

Maternal Dietary Patterns and Pregnancy Outcome

Maternal nutritional status during pregnancy will affect the outcomes for the mother and the baby. Many analyses of the relationship between diet and outcome are often based on a single or a few food items or nutrients. However, foods are not consumed in isolation and dietary patterns can be used to assess the whole diet consumed. The use of dietary pattern analysis to understand nutritional intake and pregnancy outcome is becoming more and more popular. Many published studies have showed the association between maternal dietary patterns and pregnancy outcome. This review examined articles about the relationship between maternal dietary patterns and pregnancy outcome. As a modifiable factor, dietary patterns may be more applicable to clinical and pregnant health interventions.

Risk factors for small-for-gestational-age and preterm births among 19,269 Tanzanian newborns

Background

Few studies have differentiated risk factors for term-small for gestational age (SGA), preterm-appropriate for gestational age (AGA), and preterm-SGA, despite evidence of varying risk of child mortality and poor developmental outcomes.

Methods

We analyzed birth outcome data from singleton infants, who were enrolled in a large randomized, double-blind, placebo-controlled trial of neonatal vitamin A supplementation conducted in Tanzania. SGA was defined as birth weight <10th percentile for gestation age and sex using INTERGROWTH standards and preterm birth as delivery at <37 complete weeks of gestation. Risk factors for term-SGA, preterm-AGA, and preterm-SGA were examined independently using log-binomial regression.

Results

Among 19,269 singleton Tanzanian newborns included in this analysis, 68.3 % were term-AGA, 15.8 % term-SGA, 15.5 % preterm-AGA, and 0.3 % preterm-SGA. In multivariate analyses, significant risk factors for term-SGA included maternal age <20 years, starting antenatal care (ANC) in the 3^rd trimester, short maternal stature, being firstborn, and male sex (all p < 0.05). Independent risk factors for preterm-AGA were maternal age <25 years, short maternal stature, firstborns, and decreased wealth (all p < 0.05). In addition, receiving ANC services in the 1^st trimester significantly reduced the risk of preterm-AGA (p = 0.01). Significant risk factors for preterm-SGA included maternal age >30 years, being firstborn, and short maternal stature which appeared to carry a particularly strong risk (all p < 0.05).

Conclusion

Over 30 % of newborns in this large urban and rural cohort of Tanzanian newborns were born preterm and/or SGA. Interventions to promote early attendance to ANC services, reduce unintended young pregnancies, increased maternal height, and reduce poverty may significantly decrease the burden of SGA and preterm birth in sub-Saharan Africa.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) – ACTRN12610000636055, registered on 3^rd August 2010.

Survival analysis and prognostic factors of timing of first childbirth among women in Nigeria

Background

First childbirth in a woman’s life is one of the most important events in her life. It marks a turnaround when she might have to drop roles of career building and education, for motherhood and parenthood. The timing of the commencement of these roles affects the child bearing behavior of women as they progress in their reproductive ages. Prevalent early first childbirth in Nigeria has been reported as the main cause of high population growth and high  fertility, mortality and morbidity among women, but little has been documented on the progression into first birth as well as factors affecting it in Nigeria. This paper modelled timing of first birth among women in Nigeria and determined socio-demographic and other factors affecting its timing.

Methods

We hypothesized that background characteristics of a woman will influence her progression into having first birth. We developed and fitted a survival analysis model to understand the timing of first birth among women in Nigeria using a national representative 2013 NDHS data. Women with no children were right censored as of the date of the survey. The Kaplan Meier survival function was used to estimate the probabilities of first birth not occurring until certain ages of women while Cox proportional hazard regression was used to model the timing of first births at 5 % significance level.

Results

About 75.7 % of the respondents had given birth in the Northern region of Nigerian compared with 63.8 % in the South. Half (50.1 %) of the first childbirth occurred within the 15–19 years age bracket and 38.1 % within 20–29 years. The overall median survival time to first birth was 20 years (North 19, South 22), 27 years among women with higher education and 18 years for those with no formal education. The adjusted hazard of first birth was higher in the Northern region of Nigeria than in the South (aHR = 1.24, 95 % CI: 1.20-1.27), and higher in rural areas than in urban areas (aHR = 1.15, 95 % CI: 1.12-1.19). Also, hazard of earlier first birth tripled among women with no education (aHR = 3.36, 95 % CI: 3.17-3.55) compared to women with higher education. The significant factors affecting age at first birth are education, place and zone of residence, age at first marriage, religion, ethnicity and use of contraceptives.

Conclusions

This study showed that progression into early first birth is most affected by the education standing of women as well as age at first marriage. Delay of first childbirths as a strategy for fertility reduction and maternal health improvement can be achieved if women are empowered early in life with quality education. Stakeholders should therefore, give adequate attention to educating the girl child. Adverse socio-cultural norms of betrothing and marrying young girls should be abrogated, while health education and promotion of need to delay child bearing must be intensified especially among rural dwellers and also in Northern Nigeria.

Iron Regulation of Pancreatic Beta-Cell Functions and Oxidative Stress

Dietary advice is the cornerstone in first-line treatment of metabolic diseases. Nutritional interventions directed at these clinical conditions mainly aim to (a) improve insulin resistance by reducing energy-dense macronutrient intake to obtain weight loss and (b) reduce fluctuations in insulin secretion through avoidance of rapidly absorbable carbohydrates. However, even in the majority of motivated patients selected for clinical trials, massive efforts using this approach have failed to achieve lasting efficacy. Less attention has been given to the role of micronutrients in metabolic diseases. Here, we review the evidence that highlights (a) the importance of iron in pancreatic beta-cell function and dysfunction in diabetes and (b) the integrative pathophysiological effects of tissue iron levels in the interactions among the beta cell, gut microbiome, hypothalamus, innate and adaptive immune systems, and insulin-sensitive tissues. We propose that clinical trials are warranted to clarify the impact of dietary or pharmacological iron reduction on the development of metabolic disorders.