Effect of prenatal food supplementation on birth weight: an observational study from Bangladesh

The Impact of Antenatal Balanced Plate Nutrition Education for Pregnant Women on Birth Weight: A Cluster Randomised Controlled Trial in Rural Bangladesh

Low birth weight (LBW) is a global public health problem with the highest prevalence in South Asia. It is strongly associated with maternal undernutrition. In South Asia, intra-household food distribution is inequitable, with lower dietary adequacy in women. Evidence that nutrition education improves diet during pregnancy and reduces LBW is weak. We assessed the impact of nutrition education for pregnant women on birth weight in rural Bangladesh. We conducted a parallel, two-arm, cluster-randomised controlled trial, with 36 clusters allocated equally to intervention (n = 445) or standard care (n = 448). From their first trimester until delivery, intervention participants received education about eating balanced meals to meet daily dietary requirements with diverse food groups. The primary outcome of mean birth weight was 127.5 g higher in the intervention compared to control women, and the intervention reduced the risk of LBW by 57%. Post hoc analyses showed a significantly higher birth weight and a greater reduction in LBW amongst adolescent mothers. The mean number of food groups consumed was significantly higher in the intervention from the third month of pregnancy than in the control. A community-based balanced plate nutrition education intervention effectively increased mean birth weight and reduced LBW, and improved dietary diversity in rural Bangladeshi women.

Cost-effectiveness of antenatal multiple micronutrients and balanced energy protein supplementation compared to iron and folic acid supplementation in India, Pakistan, Mali, and Tanzania: A dynamic microsimulation study

BACKGROUND

Malnutrition among women of childbearing age is especially prevalent in Asia and sub-Saharan Africa and can be harmful to the fetus during pregnancy. In the most recently available Demographic and Health Survey (DHS), approximately 10% to 20% of pregnant women in India, Pakistan, Mali, and Tanzania were undernourished (body mass index [BMI] <18.5 kg/m2), and according to the Global Burden of Disease (GBD) 2017 study, approximately 20% of babies were born with low birth weight (LBW; <2,500 g) in India, Pakistan, and Mali and 8% in Tanzania. Supplementing pregnant women with micro and macronutrients during the antenatal period can improve birth outcomes. Recently, the World Health Organization (WHO) recommended antenatal multiple micronutrient supplementation (MMS) that includes iron and folic acid (IFA) in the context of rigorous research. Additionally, WHO recommends balanced energy protein (BEP) for undernourished populations. However, few studies have compared the cost-effectiveness of different supplementation regimens. We compared the cost-effectiveness of MMS and BEP with IFA to quantify their benefits in 4 countries with considerable prevalence of maternal undernutrition.

METHODS AND FINDINGS

Using nationally representative estimates from the 2017 GBD study, we conducted an individual-based dynamic microsimulation of population cohorts from birth to 2 years of age in India, Pakistan, Mali, and Tanzania. We modeled the effect of maternal nutritional supplementation on infant birth weight, stunting and wasting using effect sizes from Cochrane systematic reviews and published literature. We used a payer's perspective and obtained costs of supplementation per pregnancy from the published literature. We compared disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs) in a baseline scenario with existing antenatal IFA coverage with scenarios where 90% of antenatal care (ANC) attendees receive either universal MMS, universal BEP, or MMS + targeted BEP (women with prepregnancy BMI <18.5 kg/m2 receive BEP containing MMS while women with BMI ≥18.5 kg/m2 receive MMS). We obtained 95% uncertainty intervals (UIs) for all outputs to represent parameter and stochastic uncertainty across 100 iterations of model runs. ICERs for all scenarios were lowest in Pakistan and greatest in Tanzania, in line with the baseline trend in prevalence of and attributable burden to LBW. MMS + targeted BEP averts more DALYs than universal MMS alone while remaining cost-effective. ICERs for universal MMS compared to baseline IFA were $52 (95% UI: $28 to $78) for Pakistan, $72 (95% UI: $37 to $118) for Mali, $70 (95% UI: $43 to $104) for India, and $253 (95% UI: $112 to $481) for Tanzania. ICERs for MMS + targeted BEP compared to baseline IFA were $54 (95% UI: $32 to $77) for Pakistan, $73 (95% UI: $40 to $104) for Mali, $83 (95% UI: $58 to $111) for India, and $245 (95% UI: $127 to $405) for Tanzania. Study limitations include generalizing experimental findings from the literature to our populations of interest and using population-level input parameters that may not reflect the heterogeneity of subpopulations. Additionally, our microsimulation fuses multiple sources of data and may be limited by data quality and availability.

CONCLUSIONS

In this study, we observed that MMS + targeted BEP averts more DALYs and remains cost-effective compared to universal MMS. As countries consider using MMS in alignment with recent WHO guidelines, offering targeted BEP is a cost-effective strategy that can be considered concurrently to maximize benefits and synergize program implementation.

Screening and management options for severe thinness during pregnancy in India

This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources.

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.

Seasonal trends and maternal characteristics as predictors of maternal undernutrition and low birthweight in Eastern Maharashtra, India

Few studies have assessed whether women and infants in rural and peri-urban communities in South Asia experience seasonal fluctuations in nutritional status; however, a handful of studies have documented seasonal variability in risk factors for undernutrition including food availability, physical activity and infections. We used data from the Maternal and Newborn Health (MNH) registry, a population-based pregnancy and birth registry in Eastern Maharashtra, India, to analyse seasonal trends in birthweight and maternal nutritional status-body mass index (BMI) and haemoglobin-in the first trimester of pregnancy. We plotted monthly and seasonal trends in birthweight, and maternal BMI and haemoglobin, and used multivariable regression models to identify seasonal and maternal characteristics that predicted each outcome. Between October 2014 and January 2018, MNH included 29,253 livebirths with recorded birthweight. BMI was assessed in 15,252 women less than 12 weeks of gestation and haemoglobin in 18,278 women less than 13 weeks of gestation. Maternal characteristics (age, education, parity and height) were significantly associated with nutritional status; however, there were minimal seasonal fluctuations in birthweight or maternal nutrition. There were significant secular trends in maternal haemoglobin; between 2014 and 2018, the prevalence of maternal anaemia decreased from 91% to 79% and moderate or severe anaemia from 53% to 37%. The prevalence of maternal underweight (45.3%) and overweight (9.8%) and low birthweight (19.1%) remained relatively constant over the study period. Our findings highlight that in some rural and peri-urban areas in South Asia, tackling systemic drivers of malnutrition may be more effective than targeted interventions based on season.

Effect of Maternal Exposure to Seasons during the Second and Third Trimesters of Pregnancy on Infant Birth Weight in Rural Bangladesh

BACKGROUND

Pregnant women belonging to agricultural communities of low- and middle-income countries often face seasonal food insecurity and energy stress.

OBJECTIVES

We aimed to investigate the effect of maternal exposure to different seasons during the second and third trimesters of pregnancy on infant birth weight in rural Bangladesh.

METHODS

Information on 3831 singleton live births was obtained from the electronic databases of Matlab Health and Demographic Surveillance System and Matlab hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh. We collected information on all term births from July 2011 to June 2015 and excluded congenital anomalies and observations with missing data. Each year was divided into 3 distinct seasons: the post-aman harvest period (January-April), the height of the monsoon (May-August), and the post-aus harvest period (September-December). Seasonal exposure was measured in weeks, and multivariable linear regression models were fitted to determine the independent effect of each week of exposure of different seasons during the second and third trimesters of pregnancy on birth weight.

RESULTS

We observed peak birth weight in the post-aman harvest season, especially among infants born in March (mean ± SD: 2930.5 ± 462.1 g), and the lowest birth weight in the month of July (2830.6 ± 385.4 g) during the monsoon season. Regression analysis showed that exposure to the post-aman harvest season during the third trimester, and the post-aus harvest period during the second trimester of pregnancy had significant positive effects on birth weight. In the final adjusted model, each week of exposure to the post-aman harvest season during the third trimester was associated with a 6.3-g (95% CI: 1.6, 10.9 g; P = 0.008) increase in birth weight.

CONCLUSIONS

Infants born to women who were exposed to the post-aman harvest season for the entire third trimester (14 wk) were associated with 88.2-g higher weight at birth. Further investigations into the complex interplay between seasonal energy stress, maternal, and fetal nutrition and measures to alleviate it are warranted.

Time trends and sociodemographic determinants of preterm births in pregnancy cohorts in Matlab, Bangladesh, 1990-2014

Introduction

Preterm birth is the major cause of under-five mortality. Population-based data on determinants and proportions of children born preterm are limited, especially from low-income countries. This study aimed at assessing time trends and social, reproductive and environmental determinants of preterm births based on a population-based pregnancy cohort over 25 years in rural Bangladesh.

Methods

In this cohort study in Matlab, a rural area in Bangladesh, we used data from the Health and Demographic Surveillance System from 1990 to 2014. Gestational age at birth was based on the reported last menstrual period and verified by ultrasound assessments. Preterm birth proportions were assessed within strata of social and reproductive characteristics, and time series analysis was performed with decomposition for trend and seasonality. We also determined the prevented fractions of preterm birth reduction associated with social and demographic changes during the follow-up period.

Results

Analyses were based on 63 063 live births. Preterm birth decreased from 29% (95% CI 28.6 to 30.1) in 1990-1994 to 11% (95% CI 10.5 to 11.6) in 2010-2014. Low education, older age and multi-parity were associated with higher proportions of preterm births across the study period. Preterm births had a marked seasonal variation. A rapid increase in women's educational level and decrease in parity were associated with the decline in preterm births, and 27% of the reduction observed from 1990 to 2014 could be attributed to these educational and reproductive changes.

Conclusion

The reduction in preterm birth was to a large extent associated with the sociodemographic transition, especially changes in maternal education and parity. The persistent seasonal variation in the proportion of preterm birth may reflect the environmental stressors for pregnant women across the study period. Continued investments in girls' education and family planning programmes may contribute to further reduction of preterm births in Bangladesh.

Household Food Security and Birth Size of Infants: Analysis of the Bangladesh Demographic and Health Survey 2011

BACKGROUND

More than one-third of the population in Bangladesh is affected by household food insecurity in a setting where child survival and well-being are under threat. The relation between household food security and birth size of infants is an important area to explore given its explicit effect on mortality and morbidity.

OBJECTIVE

Our study aims to estimate the association between household food security and birth size of infants.

METHODS

For the analysis we used a nationally representative cross-sectional survey of 8753 households with a live birth between 2006 and 2011, collected under the Bangladesh Demographic and Health Survey (BDHS) 2011. We investigated the association of small birth size with the following potential explanatory variables: sex of the child; birth interval; mother's age at birth, height, body mass index (BMI), anemia status, parity, previous pregnancy loss, antenatal care visits, exposure to television, and participation in health care decisions; cooking fuel; parents' education level; region; place of residence; and wealth index using Pearson's chi-square test. We then constructed a multivariable logistic regression model of birth size on food security after controlling for all potential confounders as well as the cluster sampling design. The odds ratio (OR) was reported for each of the covariates; a P value <0.05 was interpreted as statistically significant.

RESULTS

A total of 1485 (17.3%) children were reported as small at the time of birth and more than one-third of households (35.7%) experienced some degree of food insecurity. Mothers from food-insecure households had 38% higher odds of having small-size infants compared to food-secure households (adjusted OR: 1.38; 95% CI: 1.19, 1.59; P < 0.001).

CONCLUSION

Household food security is one of the key factors associated with small birth size. Interventions to increase birth size should target women belonging to food-insecure households.

Long-term changes in childhood malnutrition are associated with long-term changes in maternal BMI: evidence from Bangladesh, 1996-2011

BACKGROUND

Nutritional transition (from under- to overnutrition) among women of reproductive age (15-49 y) is becoming increasingly common in many developing countries, including Bangladesh. However, the influence of this transition on the nutritional status of children <5 y of age (U5s) is unknown.

OBJECTIVES

The aim was to determine whether a nutritional transition has taken place in the past 15 y (1996-2011) among U5s and their mothers in Bangladesh and to examine how the association between maternal body mass index (BMI) and malnutrition in U5s has changed over time.

DESIGN

We analyzed data assembled from 5 Demographic and Health Surveys conducted between 1996 and 2011 in Bangladesh to describe the nutritional status of 28,941 U5s and their mothers. A Poisson regression model was used to examine the associations between maternal BMI and stunting, underweight, and wasting in U5s over time.

RESULTS

A nutritional transition among mothers of U5s was observed between 1996 and 2011. The height- or length-for-age and weight-for-age z score distributions of U5s showed consistent improvement; however, there was no indication of a nutritional transition. An interaction was found between maternal BMI categorized as underweight [BMI (kg/m²) <18.5], healthy BMI (BMI: 18.5-24.9), and overweight or obese (BMI ≥25) and year of survey on the risks of stunting and underweight in children. In 1996, children of underweight mothers had a 5% higher risk of being stunted than those born to healthy-BMI mothers (RR: 1.05; 95% CI: 1.00, 1.10); in 2011, children of underweight mothers had a 21% higher risk of being stunted (RR: 1.21; 95% CI: 1.13, 1.30). Maternal overweight or obesity was associated with a reduced risk of malnutrition in children.

CONCLUSIONS

A nutritional transition among U5s has yet to occur in Bangladesh. However, our results indicate that improvement in maternal BMI in the past 15 y was accompanied by a reduction in malnutrition in U5s.

Cost-effectiveness of invitation to food supplementation early in pregnancy combined with multiple micronutrients on infant survival: analysis of data from MINIMat randomized trial, Bangladesh

BACKGROUND

Absence of cost-effectiveness (CE) analyses limits the relevance of large-scale nutrition interventions in low-income countries. We analyzed if the effect of invitation to food supplementation early in pregnancy combined with multiple micronutrient supplements (MMS) on infant survival represented value for money compared to invitation to food supplementation at usual time in pregnancy combined with iron-folic acid.

METHODS

Outcome data, infant mortality (IM) rates, came from MINIMat trial (Maternal and Infant Nutrition Interventions, Matlab, ISRCTN16581394). In MINIMat, women were randomized to early (E around 9 weeks of pregnancy) or usual invitation (U around 20 weeks) to food supplementation and daily doses of 30 mg, or 60 mg iron with 400 μgm of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 μgm of folic acid. In MINIMat, EMMS significantly reduced IM compared to UFe60F (U plus 60 mg iron 400 μgm Folic acid). We present incremental CE ratios for incrementing UFe60F to EMMS. Costing data came mainly from a published study.

RESULTS

By incrementing UFe60F to EMMS, one extra IM could be averted at a cost of US$907 and US$797 for NGO run and government run CNCs, respectively, and at US$1024 for a hypothetical scenario of highest cost. These comparisons generated one extra life year (LY) saved at US$30, US$27, and US$34, respectively.

CONCLUSIONS

Incrementing UFe60F to EMMS in pregnancy seems worthwhile from health economic and public health standpoints.

TRIAL REGISTRATION

Maternal and Infant Nutrition Interventions, Matlab; ISRCTN16581394 ; Date of registration: Feb 16, 2009.

The effect of balanced protein energy supplementation in undernourished pregnant women and child physical growth in low- and middle-income countries: a systematic review and meta-analysis

The beneficial effect of balanced protein energy supplementation during pregnancy on subsequent child growth is unclear and may depend upon the mother entering pregnancy adequately nourished or undernourished. Systematic reviews to-date have included studies from high-, middle- and low-income countries. However, the effect of balanced protein energy supplementation should not be generalised. This review assesses the effect of balanced protein energy supplementation in undernourished pregnant women from low- and middle-income countries on child growth. A systematic review of articles published in English (1970-2015) was conducted via MEDLINE, Scopus, the Cochrane Register and hand searching. Only peer-reviewed experimental studies analysing the effects of balanced protein energy supplementation in undernourished pregnant women from low- and middle-income countries with measures of physical growth as the primary outcome were included. Two reviewers independently assessed full-text articles against inclusion criteria. Validity of eligible studies was ascertained using the Quality Assessment Tool for Quantitative Studies (EPHPP QAT). In total, seven studies met the inclusion criteria. All studies reported on birthweight, five on birth length, three on birth head circumference, and one on longer-term growth. Standardised mean differences were calculated using a random-effects meta-analysis. Balanced protein energy supplementation significantly improved birthweight (seven randomised controlled trials, n = 2367; d = 0.20, 95% confidence interval, 0.03-0.38, P = 0.02). No significant benefit was observed on birth length or birth head circumference. Impact of intervention could not be determined for longer-term physical growth due to limited evidence. Additional research is required in low- and middle-income countries to identify impacts on longer-term infant growth.

Short-term nutrition education reduces low birthweight and improves pregnancy outcomes among urban poor women in Bangladesh

BACKGROUND

Maternal malnutrition and poor gestational weight gain are the most important causes of low birthweight and infant mortality in Bangladesh.

OBJECTIVE

To assess the effect of short-term nutrition education on weight gain in the third trimester of pregnancy, birth outcomes, and breastfeeding.

METHODS

Three hundred pregnant women participated in this randomized, controlled trial during a 3-month intervention period. The study was conducted in two antenatal clinics in urban Dhaka. One group of women was given monthly education sessions during the third trimester of pregnancy to promote consumption of khichuri, while the control group received only routine services from the health facilities. Birthweight was recorded within 24 hours after delivery. Breastfeeding practices were observed for 1 month after delivery.

RESULTS

In the intervention group, maternal weight gain in the third trimester was 60% higher (8.60 vs. 5.38 kg, p = .011), mean birthweight was 20% higher (2.98 vs. 2.49 kg, p < .001), the rate of low birthweight was 94% lower (2.7% vs. 44.7%; p < .001), and the rate of initiation of breastfeeding within 1 hour after birth was 52% higher (86.0% vs. 56.7%, p < .001), in comparison with the control group. Birthweight was associated with frequency of intake of khichuri (p < 0.001).

CONCLUSIONS

Nutrition education with a focus on promoting consumption of khichuri during the third trimester of pregnancy significantly reduced the rate of low birthweight and increased maternal weight gain.

Potential first trimester metabolomic biomarkers of abnormal birth weight in healthy pregnancies

OBJECTIVE

Macrosomia and low birth weight (LBW) can be associated with pregnancy complications and may affect the long-term health of the child. The aim of this study was to evaluate the metabolomic serum profiles of healthy pregnant women to identify early biomarkers of macrosomia and LBW and to understand mechanisms leading to abnormal fetal growth not related to mother's body mass index or presence of gestational diabetes.

METHOD

Serum samples from 770 women were collected between the 12th and 14th gestational week. Delivery samples were divided into three groups according to the infant birth weight as follows: low, <2500 g; normal, 2500-4000 g; and high >4000 g. Samples from women with any complications of pregnancy were excluded. Serum fingerprinting was performed by LC-QTOF-MS.

RESULTS

Lower levels of phospholipids, lysophospholipids, and monoacylglycerols; low vitamin D3 metabolites; and increased bilirubin level were associated with macrosomia. Because most changes involved lipids, as a concept of validation, adipocyte fatty acid-binding protein (A-FABP) levels were measured and found correlated with the studied lipids and birth weight.

CONCLUSION

Serum fingerprinting in early pregnancy can predict the risk of macrosomia. Serum levels of A-FABP and several lipids are promising prognostic markers for macrosomia in healthy pregnancies.

Equity in adherence to and effect of prenatal food and micronutrient supplementation on child mortality: results from the MINIMat randomized trial, Bangladesh

Background

Evidence is often missing on social differentials in effects of nutrition interventions. We evaluated the adherence to and effect of prenatal food and micronutrient supplementations on mortality before the age of five years in different social groups as defined by maternal schooling.

Methods

Data came from the MINIMat study (Maternal and Infant Nutrition Interventions, Matlab), a randomized trial of prenatal food supplementation (invitation early, about 9 weeks [E], or at usual time, about 20 weeks [U] of pregnancy) and 30 mg or 60 mg iron with 400 μgm folic acid, or multiple micronutrients (Fe30F, Fe60F, MMS) resulting in six randomization groups, EFe30F, UFe30F, EFe60F, UFe60F, EMMS, and UMMS (n = 4436). Included in analysis after omissions (fetal loss and out-migration) were 3625 women and 3659 live births of which 3591 had information on maternal schooling. The study site was rural Matlab, Bangladesh. The main stratifying variable was maternal schooling dichotomized as <6 years and ≥6 years. We used Cox proportional hazard model for survival analyses.

Results

Overall, women having <6 years of schooling adhered more to food (81 vs. 69 packets, P=0.0001) but a little less to micronutrient (104 vs. 120 capsules, P = 0.0001) supplementation compared to women having more schooling, adjusted for maternal age (years), parity and body mass index (BMI, kg/m²) at week 8 pregnancy. Children of mothers with ≥6 years of schooling had lower under-five mortality, but the EMMS supplementation reduced the social difference in mortality risk (using standard program and schooling <6 years as reference; standard program and schooling ≥6 years HR 0.54, 95% CI 0.27-1.11; EMMS and schooling ≥6 years HR 0.28, 95% CI 0.12-0.70; EMMS and schooling <6 years HR 0.26, 95% CI 0.11-0.63), adjusted for maternal age (years), parity and body mass index (kg/m²) at week 8 pregnancy.

Conclusions

The combination of an early invitation to prenatal food supplementation and multiple micronutrient supplementation lowered mortality in children before the age of five years and reduced the gap in child survival chances between social groups. The pattern of adherence to the supplementations was complex; women with less education adhered more to food supplementation while those with more education had higher adherence to micronutrients.

Trial registration

ISRCTN16581394.

Effect of Women's Decision-Making Autonomy on Infant's Birth Weight in Rural Bangladesh

Background. Low birth weight (LBW), an outcome of maternal undernutrition, is a major public health concern in Bangladesh where the problem is most prominent. Women's decision-making autonomy is likely an important factor influencing maternal and child health outcomes. The aim of the study was to assess the effect of women's decision-making autonomy on infant's birth weight (BW). Methods. The study included data of 2175 enrolled women (14-45 years of age) from the Maternal and Infant Nutritional Intervention in Matlab (MINIMat-study) in Bangladesh. Pearson's chi-square test, analysis of covariance (ANCOVA), and logistic regression analysis were applied at the collected data. Results. Women with lowest decision-making autonomy were significantly more likely to have a low birth weight (LBW) child, after controlling for maternal age, education (woman's and her husband's), socioeconomic status (SES) (odds ratio (OR) = 1.4; 95% confidence interval (CI) 1.0, 1.8). BW was decreased significantly among women with lowest decision making autonomy after adjusting for all confounders. Conclusion. Women's decision-making autonomy has an independent effect on BW and LBW outcome. In addition, there is a need for further exploration to identify sociocultural attributes and gender related determinants of women decision-making autonomy in this study setting.

Early prenatal food supplementation ameliorates the negative association of maternal stress with birth size in a randomised trial

Low birthweight increases the risk of infant mortality, morbidity and poor development. Maternal nutrition and stress influence birth size, but their combined effect is not known. We hypothesised that an early-invitation time to start a prenatal food supplementation programme could reduce the negative influence of prenatal maternal stress on birth size, and that effect would differ by infant sex. A cohort of 1041 pregnant women, who had delivered an infant, June 2003-March 2004, was sampled from among 3267 in the randomised controlled trial, Maternal Infant Nutritional Interventions Matlab, conducted in Matlab, Bangladesh. At 8 weeks gestation, women were randomly assigned an invitation to start food supplements (2.5 MJ d(-1) ; 6 days a week) either early (∼9 weeks gestation; early-invitation group) or at usual start time for the governmental programme (∼20 weeks gestation; usual-invitation group). Morning concentration of cortisol was measured from one saliva sample/woman at 28-32 weeks gestation to assess stress. Birth-size measurements for 90% of infants were collected within 4 days of birth. In a general linear model, there was an interaction between invitation time to start the food supplementation programme and cortisol with birthweight, length and head circumference of male infants, but not female infants. Among the usual-invitation group only, male infants whose mothers had higher prenatal cortisol weighed less than those whose mothers had lower prenatal cortisol. Prenatal food supplementation programmes that begin first trimester may support greater birth size of male infants despite high maternal stress where low birthweight is a public health concern.

Effects of third trimester counseling on pregnancy weight gain, birthweight, and breastfeeding among urban poor women in Bangladesh

BACKGROUND

Maternal malnutrition and poor gestational weight gain are the most important causes of low birth weight and high rates of newborn mortality.

OBJECTIVE

To assess the effects of nutrition counseling in the third trimester of pregnancy on maternal weight gain, birth weight of newborn, and breastfeeding practices.

METHODS

This was a longitudinal experimental study with nutrition intervention for a period of 3 months. One hundred fifteen women (57 in the intervention group and 58 in the comparison group) who were visiting the Maternal and Child Health Training Institute at 6 months of pregnancy were randomly selected. The intervention group was given nutrition education twice in the first month and once a month for the next 2 months before delivery; the comparison group received routine hospital advice on food intake, immunization, personal hygiene, and breastfeeding. The women were weighed monthly up to delivery, the newborn infants' birth weights were measured within 24 hours after delivery, and breastfeeding practices were observed 1 month after delivery.

RESULTS

Women in the intervention group gained 1.73 kg more weight during the third trimester than women in the comparison group (5.61 vs. 3.88 kg, p < 0.001). The mean birthweight of babies of women in the intervention group was 0.44 kg greater than that of babies of women in the comparison group (2.86 vs. 2.42 kg, p < 0.001). In the intervention group, 10.5% of babies were born with low birthweight, compared with 48.3% of the babies of women in the comparison group (p < 0.001). In the intervention group, 75.4% of mothers initiated breastfeeding within 1 hour after birth, compared with 34.5% of mothers in the comparison group (p < 0.001).

CONCLUSIONS

Nutrition education only during the third trimester improved weight gain during pregnancy, reduced 78% of low birth weight, and improved breastfeeding practices.

Scaling up Maternal Nutrition Programs to Improve Birth Outcomes: A Review of Implementation Issues

Background

Maternal nutrition interventions are efficacious in improving birth outcomes. It is important to demonstrate that if delivered in field conditions they produce improvements in health and nutrition.

Objective

Analyses of scaling-up of five program implemented in several countries. These include micronutrient supplementation, food fortification, food supplements, nutrition education and counseling, and conditional cash transfers (as a platform for delivering interventions). Evidence on impact and cost-effectiveness is assessed, especially on achieving high, equitable, and sustained coverage, and reasons for success or failure

Methods

Systematic review of articles on large-scale programs in several databases. Two separate reviewers carried out independent searches. A separate review of the gray literature was carried out including websites of the most important organizations leading with these programs. With Google Scholar a detailed review of the 100 most frequently cited references on each of the five above topics was conducted.

Results

Food fortification programs: iron and folic acid fortification were less successful than salt iodization initiatives, as the latter attracted more advocacy. Micronutrient supplementation programs: Nicaragua and Nepal achieved good coverage. Key elements of success are antenatal care coverage, ensuring availability of tablets, and improving compliance. Integrated nutrition programs in India, Bangladesh, and Madagascar with food supplementation and/or behavioral change interventions report improved coverage and behaviors, but achievements are below targets. The Mexican conditional cash transfer program provides a good example of use of this platform to deliver maternal nutritional interventions.

Conclusions

Programs differ in complexity, and key elements for success vary with the type of program and the context in which they operate. Special attention must be given to equity, as even with improved overall coverage and impact inequalities may even be increased. Finally, much greater investments are needed in independent monitoring and evaluation.

Food provisioning experiences of ultra poor female heads of household living in Bangladesh

Ultra poor women in Bangladesh are especially vulnerable to poverty and food insecurity, and they have generally been excluded from recent improvements in hunger and poverty rates in the country. An examination of the food provisioning narratives of 43 ultra poor female heads of household in Bangladesh was conducted in order to deepen understanding of this obstacle to the country's achievement of the First Millennium Development Goal. All participants were the household's sole income provider, had dependent children, and earned less than $1 USD per day. Women were purposively selected based on occupational group, context, and personal characteristics. Ethnographic interviews were conducted in January and February, 2008. Analysis of women's accounts of their daily food routine revealed chronic and pervasive food insecurity punctuated by acute episodes of absolute food deprivation that resulted from seasonal fluctuations in earnings, rising food prices, illness disrupting work, and healthcare costs. Women's accounts of their daily food provisioning experiences suggested compromises in, and trade-offs between, multiple basic needs as a result of inadequate income. Women were further constrained by social norms and gender roles that influenced their ability to work outside the home. Our method of inquiry led us to construct an organizing framework that extends knowledge of ultra poor women in Bangladesh's complex and multi-sphered experience of poverty and food insecurity. Based on these findings, we propose a strategy called whole person development (WPD), which seeks small adjustments to services, programs, and policies based on leverage points identified through in-depth narratives.

Arsenic exposure during pregnancy and size at birth: a prospective cohort study in Bangladesh

The authors evaluated the association of prenatal arsenic exposure with size at birth (birth weight, birth length, head and chest circumferences). This prospective cohort study, based on 1,578 mother-infant pairs, was conducted in Matlab, Bangladesh, in 2002-2003. Arsenic exposure was assessed by analysis of arsenic in urine collected at around gestational weeks 8 and 30. The association of arsenic exposure with size at birth was assessed by linear regression analyses. In analysis over the full range of exposure (6-978 microg/L), no dose-effect association was found with birth size. However, significant negative dose effects were found with birth weight and head and chest circumferences at a low level of arsenic exposure (<100 microg/L in urine). In this range of exposure, birth weight decreased by 1.68 (standard error (SE), 0.62) g for each 1-microg/L increase of arsenic in urine. For head and chest circumferences, the corresponding reductions were 0.05 (SE, 0.03) mm and 0.14 (SE, 0.03) mm per 1 microg/L, respectively. No further negative effects were shown at higher levels of arsenic exposure. The indicated negative effect on birth size at a low level of arsenic exposure warrants further investigation.

Urinary arsenic concentration adjustment factors and malnutrition

This study aims at evaluating the suitability of adjusting urinary concentrations of arsenic, or any other urinary biomarker, for variations in urine dilution by creatinine and specific gravity in a malnourished population. We measured the concentrations of metabolites of inorganic arsenic, creatinine and specific gravity in spot urine samples collected from 1466 individuals, 5-88 years of age, in Matlab, rural Bangladesh, where arsenic-contaminated drinking water and malnutrition are prevalent (about 30% of the adults had body mass index (BMI) below 18.5 kg/m(2)). The urinary concentrations of creatinine were low; on average 0.55 g/L in the adolescents and adults and about 0.35 g/L in the 5-12 years old children. Therefore, adjustment by creatinine gave much higher numerical values for the urinary arsenic concentrations than did the corresponding data expressed as microg/L, adjusted by specific gravity. As evaluated by multiple regression analyses, urinary creatinine, adjusted by specific gravity, was more affected by body size, age, gender and season than was specific gravity. Furthermore, urinary creatinine was found to be significantly associated with urinary arsenic, which further disqualifies the creatinine adjustment.