Prenatal Iron Deficiency and Replete Iron Status Are Associated with Adverse Birth Outcomes, but Associations Differ in Ghana and Malawi

Does oral iron and folate supplementation during pregnancy protect against adverse birth outcomes and reduced neonatal and infant mortality in Africa: A protocol for a systematic review and meta-analysis?

BACKGROUND

Globally, one-third of pregnant women are at risk of iron deficiency, particularly in the African region. While recent findings show that iron and folate supplementation can lower the risk of adverse birth outcomes and childhood mortality, our understanding of its impact in Africa remains incomplete due to insufficient evidence. This protocol outlines the systematic review steps to investigate the impact of oral iron and folate supplementation during pregnancy on adverse birth outcomes, neonatal mortality and infant mortality in Africa.

METHODS AND ANALYSIS

MEDLINE, PsycINFO, Embase, Scopus, CINAHL, Web of Science, and Cochrane databases were searched for published articles. Google Scholar and Advanced Google Search were used for gray literature and nonindexed articles. Oral iron and/or folate supplementation during pregnancy is the primary exposure. The review will focus on adverse birth outcomes, neonatal mortality and infant mortality. Both Cochrane Effective Practice and Organization of Care and Newcastle-Ottawa Scale risk of bias assessment tools will be used. Meta-analysis will be conducted if design and data analysis methodologies permit. This systematic review and meta-analysis will provide up-to-date evidence about iron and folate supplementation's role in adverse birth outcomes, neonatal mortality and infant mortality in the African region.

ETHICS AND DISSEMINATION

This review will provide insights that help policymakers, program planners, researchers, and public health practitioners interested in working in the region.

PROSPERO REGISTRATION NUMBER

CRD42023452588.

Inverse association between maternal serum concentrations of trace elements and risk of spontaneous preterm birth: a nested case-control study in China

Few studies have evaluated the joint effect of trace elements on spontaneous preterm birth (SPTB). This study aimed to examine the relationships between the individual or mixed maternal serum concentrations of Fe, Cu, Zn, Se, Sr and Mo during pregnancy, and risk of SPTB. Inductively coupled plasma MS was employed to determine maternal serum concentrations of the six trace elements in 192 cases with SPTB and 282 controls with full-term delivery. Multivariate logistic regression, weighted quantile sum regression (WQSR) and Bayesian kernel machine regression (BKMR) were used to evaluate the individual and joint effects of trace elements on SPTB. The median concentrations of Sr and Mo were significantly higher in controls than in SPTB group (P < 0·05). In multivariate logistic regression analysis, compared with the lowest quartile levels of individual trace elements, the third- and fourth-quartile Sr or Mo concentrations were significantly associated with reduced risk of SPTB with adjusted OR (aOR) of 0·432 (95 CI < 0·05). In multivariate logistic regression analysis, compared with the lowest quartile levels of individual trace elements, the third- and fourth-quartile Sr or Mo concentrations were significantly associated with reduced risk of SPTB with adjusted aOR of 0·432 (95 % CI 0·247, 0·756), 0·386 (95 % CI 0·213, 0·701), 0·512 (95 % CI 0·297, 0·883) and 0·559 (95 % CI 0·321, 0·972), respectively. WQSR revealed the inverse combined effect of the trace elements mixture on SPTB (aOR = 0·368, 95 % CI 0·228, 0·593). BKMR analysis confirmed the overall mixture of the trace elements was inversely associated with the risk of SPTB, and the independent effect of Sr and Mo was significant. Our findings suggest that the risk of SPTB decreased with concentrations of the six trace elements, with Sr and Mo being the major contributors.

Maternal low and high hemoglobin concentrations and associations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis

BACKGROUND

Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment.

METHODS

We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals.

RESULTS

The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia.

CONCLUSION

Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.

Sociodemographic patterns of preterm birth and low birth weight among pregnant women in rural Mysore district, India: A latent class analysis

Few studies have utilized person-centered approaches to examine co-occurrence of risk factors among pregnant women in low-and middle-income settings. The objective of this study was to utilize latent class analysis (LCA) to identify sociodemographic patterns and assess the association of these patterns on preterm birth (PTB) and/or low birth weight (LBW) in rural Mysore District, India. Secondary data analysis of a prospective cohort study among 1540 pregnant women was conducted. Latent class analysis was performed to identify distinct group memberships based on a chosen set of sociodemographic factors. Binary logistic regression was conducted to estimate the association between latent classes and preterm birth and low birth weight. LCA yielded four latent classes. Women belonging to Class 1 "low socioeconomic status (SES)/early marriage/multigravida/1 child or more", had higher odds of preterm birth (adjusted Odds Ratio (aOR): 95% Confidence Intervals (CI): 1.77, 95% CI: 1.05-2.97) compared to women in Class 4 "high SES/later marriage/primigravida/no children". Women in Class 2 "low SES/later marriage/primigravida/no children" had higher odds of low birth weight (aOR: 2.52, 95% CI: 1.51-4.22) compared to women in Class 4. Women less than 20 years old were twice as likely to have PTB compared to women aged 25 years and older (aOR: 2.00, 95% CI: 1.08-3.71). Hypertension (>140/>90 mm/Hg) was a significant determinant of PTB (aOR: 2.28, 95% CI: 1.02-5.07). Furthermore, women with a previous LBW infant had higher odds of delivering a subsequent LBW infant (aOR: 2.15, 95% CI: 1.40-3.29). Overall study findings highlighted that woman belonging to low socioeconomic status, and multigravida women had increased odds of preterm birth and low birth weight infants. Targeted government programs are crucial in reducing inequalities in preterm births and low birth weight infants in rural Mysore, India.

Malaria in pregnancy control and pregnancy outcomes: a decade's overview using Ghana's DHIMS II data

Background

Malaria in pregnancy control interventions have been implemented through antenatal care services for more than 2 decades in Ghana. The uptake of these interventions has seen steady improvement over the years. This has occurred within the context of decreasing global trends of malaria infection confirmed by decreasing malaria in pregnancy prevalence in Ghana. However, not much is known about how these improvements in interventions uptake and reduction in malaria infection prevalence have impacted pregnancy outcomes in the country. This study aimed at describing trends of maternal anaemia and low birth weight prevalence and uptake of malaria in pregnancy control interventions over the last decade using data from Ghana’s District Health Information Management System (DHIMS II).

Methods

Data from Ghana’s DHIMS II on variables of interest covering the period 2012 to 2021 was analysed descriptively using Microsoft Excel 365. Results were computed as averages and percentages and presented in tables and graphs.

Results

The prevalence of maternal anaemia at booking and at term and low birth weight increased marginally from 31.0%, 25.5% and 8.5% in 2012 to 36.6%, 31.9% and 9.5% in 2021 respectively. Severe anaemia prevalence at booking and at term remained under 2% over the study period. Women making at least 4 ANC visits, receiving at least 3 doses of intermittent preventive treatment of malaria and an insecticide-treated net increased from 77.0%, 41.4% and 4.1% in 2012 to 82%, 55.0% and 93.3% in 2021, respectively. Malaria test positivity rate reduced from 54.0% to 34.3% between 2014 and 2021 while women receiving iron and folate supplementation for 3 and 6 months rose from 43.0% and 25.5% to 89.7% and 61.8%, respectively between 2017 and 2021.

Conclusion

Maternal anaemia and low birth weight prevalence showed marginal upward trends over the last decade despite reduced malaria infection rate and improved uptake of malaria in pregnancy control interventions. There is room for improvement in current intervention implementation levels but the complex and multi-factorial aetiologies of maternal anaemia and low birth weight need urgent investigation and quantification to inform policy and practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04331-2.

The Association between Iron and Folic Acid Supplementation and Malaria Prophylaxis and Linear Growth among Children and Neonatal Mortality in Sub-Saharan Africa—A Pooled Analysis

The majority of research on linear growth among children is confined to South Asia and focuses on iron and folic acid (IFA) supplementation during pregnancy, without considering malaria prophylaxis. Similarly, there is limited evidence on the association of antenatal IFA supplementation and malaria prophylaxis with neonatal mortality in sub-Saharan Africa (SSA). This study aims to address these gaps. A pooled analysis of demographic and health survey (DHS) data from 19 countries in SSA was conducted to study the association between IFA supplementation and malaria prophylaxis and linear growth and neonatal mortality. Multivariate logistic and linear regression models were used. Malaria prophylaxis was significantly associated with stunting, height-for-age Z scores (HAZ scores), and neonatal mortality, but IFA supplementation was not associated with these outcomes. When women’s height and body mass index (BMI) were introduced in the model, a significant association between combined malaria prophylaxis and IFA supplementation was found with HAZ scores only. For severe stunting, no significant association was found with either in the two models. In conclusion, this study underscores the importance of antenatal malaria prophylaxis as a potential intervention for nutrition outcomes (linear growth) and neonatal mortality, as well as the importance of coordinating efforts between malaria and the health and nutrition sectors to improve these outcomes in the countries of SSA.

Beyond hemoglobin: uncovering iron deficiency and iron deficiency anemia using serum ferritin concentration among pregnant women in eastern Ethiopia: a community-based study

BACKGROUND

Although the high burden of anemia among pregnant women in low-resource settings like Ethiopia is well documented, evidence is scarce on the underlying causes using biochemical tests. Therefore, this study assessed the iron status and factors associated with iron deficiency (ID) using serum ferritin concentration among pregnant women in Haramaya district, eastern Ethiopia.

METHODS

A community-based cross-sectional study was conducted among randomly selected pregnant women in Haramaya district, eastern Ethiopia. The serum ferritin (SF) concentration was measured in the National Biochemical Laboratory of Ethiopia on a fully automated Cobas e411 (German, Japan Cobas 4000 analyzer series) immunoassay analyzer using the electro-chemiluminescence (ECL) method and standard procedures. A log-binomial regression analysis identified variables associated with iron deficiency, and defined as serum ferritin concentration < 15 μg/L (per the World Health Organization recommendation in developing countries). An adjusted risk ratio (aRR), and a 95% confidence interval (CI), were used to report associations. Finally, the p-value < 0.05 was the cut-off point for the significant association.

RESULTS

A total of 446 pregnant women with a mean age of 24.78 (+ 5.20) were included in the study. A total of 236 (52.91%; 95% CI: 48.16-57.63) had iron deficiency. The overall prevalence of anemia and iron deficiency anemia (IDA) was 45.96% (95% CI: 41.32-50.71) and 28.03% (95% CI: 21.27-32.44), respectively. The risk of iron deficiency was more likely among women with low dietary diversity (aRR = 1.36; 95% CI = 1.07-1.72) and those who skipped meals (aRR = 1.29; 95% CI = 1.05-1.57), but less among women who had antenatal care (aRR = 0.73 (95% CI = 0.61-0.88).

CONCLUSION

More than half of the pregnant women in eastern Ethiopia had iron deficiency. Improving dietary diversity, meal frequency, and prenatal follow-up is essential to improve the high burden of ID and the adverse effect on pregnant women and the fetus. Moreover, a prospective study comparing maternal and perinatal outcomes among these spectra-iron depletion, ID, and IDA-is crucial for understanding their impact on maternal and perinatal mortality and morbidity.

Multiple micronutrient supplements versus iron-folic acid supplements and maternal anemia outcomes: an iron dose analysis

Antenatal multiple micronutrient supplements (MMS) are more effective than iron and folic acid (IFA) supplements in reducing adverse pregnancy outcomes. Questions remain, however, about the ability of MMS to prevent anemia as effectively as IFA, especially at a lower dose of daily iron and in areas of high anemia prevalence. Analyzing data from 11 trials from a recent Cochrane review, we compared MMS to IFA, delivering either 30 or 60 mg of iron, in sustaining hemoglobin and preventing third trimester anemia and iron deficiency anemia (IDA), accounting for daily iron dose, total supplemental iron intake, and baseline prevalence of anemia. There were no differences between MMS and IFA in third trimester hemoglobin concentration or risks of anemia or IDA by iron dose or total supplemental iron consumed. MMS providing 30 mg of iron was comparable to IFA with 60 mg of iron: mean hemoglobin difference of −0.26 g/L (95% CI: −1.41 to 0.89), risk ratios of 0.99 (95% CI: 0.92–1.07) for anemia, and 1.31 (95% CI: 0.66–2.60) for IDA. Baseline prevalence of anemia did not explain heterogeneity in findings. Compared to IFA, MMS results in comparable hemoglobin concentration and protection against anemia during pregnancy, independently of iron dose.

Associations between hair levels of trace elements and the risk of preterm birth among pregnant Wwomen: A prospective nested case-control study in Beijing Birth Cohort (BBC), China

Trace elements have various physiochemical functions in humans and are associated with the occurrence of preterm birth (PB). However, their mixed effects on PB risk have rarely been studied. We aimed to investigate the associations between hair levels of trace elements and PB risk among pregnant women. A nested case-control study with a prospective cohort was conducted in Beijing City, China. We included 82 women who had a PB [total PB (tPB)] as cases [including 40 with a spontaneous PB (SPB)] and 415 who had a term delivery as controls. Hair levels of the concerned trace elements were measured including endocrine disrupting metal(loid)s [EDMs; lead, mercury (Hg), arsenic, and cadmium] and nutritional trace metal(loid)s [NTMs; zinc (Zn), iron (Fe), copper, and selenium]. Logistic regression analysis was performed to estimate the odds ratios (ORs) for PB. Bayesian kernel machine regression (BKMR) was used to assess the associations between mixed exposure to the trace elements and PB risk. Significantly lower maternal hair concentrations of Zn and Fe were observed in the SPB cases than in the controls, whereas no differences for the other trace elements. Single-element modeling results suggested second-quartile Hg maternal hair concentrations, third-quartile Zn concentrations, and fourth-quartile Fe concentrations were associated with a reduced risk of tPB with adjusted ORs of 0.43 [95% confidence interval (CI): 0.21-0.87], 0.38 (95% CI: 0.18-0.82), and 0.48 (95% CI: 0.24-0.98), respectively, compared to first-quartile values. Similar results were obtained for SPB. According to the BKMR models, hair NTMs were significantly, monotonously, and inversely associated with the risk of SPB, after controlling for covariates and levels of the four EDMs. Fe and Zn contributed the most strongly to the association. We concluded that maternal higher levels of NTMs, especially Fe and Zn, may reduce the risk of PB.

Prevalence and determinants of Anemia among pregnant women in sub-Saharan Africa: a systematic review and Meta-analysis

BACKGROUND

Anemia is one of the world's leading cause of disability and the most serious global public health issues. This systematic review and meta-analysis was carried out very prudently in order to give up the pooled prevalence and determinants of anemia in Sub-Saharan Africa.

METHODOLOGY

To carry out this ephemeral systematic review and meta-analysis, a correlated literature review was done from various sources, PubMed Medline and Google Scholar Journals. Anemia related searching engine was used to make the study more evocative and intensive. We used modified Newcastle-Ottawa quality assessment scale for cross sectional studies to evaluate the quality of the study in relations of their inclusion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was tracked to conduct this study. The pooled effect size was computed using the review manager and Compressive Meta-analysis software.

RESULTS

Twenty-fife studies, which encompassed 15,061 pregnant women, were chosen for the analysis. From those an overall prevalence of anemia in pregnancy in SSA was 35.6%. However, the result from meta-analysis showed that women who were infected with intestinal parasite were 3.59 times more likely to develop anemia compared to those who were not infected [OR:3.59, 95% CI (2.44,5.28)].The result showed that women who had no iron and folic-acid supplementation were 1.82 times more likely to develop anemia compared to those women who had iron and folic-acid supplementation {OR:1.82, 95% CI (1.22,2.70]. Women who had women were in third trimester pregnancy were 2.37 times more likely to develop anemia compared to those who were in first and second trimester [OR:2.37, 95% CI (1.78, 3.24)]. Women who had low dietary diversity score were 3.59 times more likely to develop anemia compared to those who had high dietary diversity score [OR: 3.59, 95% CI (2.44, 5.28].

CONCLUSIONS

Our finding from this systematic review and meta-analysis displays the high case in prevalence of anemia among pregnant women in Sub-Saharan Africa. Predictors for this includes: intestinal parasite, iron and folic-acid supplementation, third trimester pregnancy and dietary diversified intake score were statistically correlated positively with anemia in pregnancy. These need cautious evaluation of impact of prevention effort for operational policy, programs and design nutrition intrusions for refining maternal food consumption during pregnancy. Also, dietary education intrusion requires to be prearranged to satisfy the desires of pregnant women. The finding of this work will be used as an evidences for policy makers of Africa; entirely for maternal and child health care. Lastly, we suggested further investigations to be carried out in the area of the study for more rigorous and comprehensive recommendations.

Iron status in late pregnancy is inversely associated with birth weight in Colombia

OBJECTIVE

Gestational anaemia (GA) is common in developing countries. This study assessed the relationship of late GA and negative perinatal outcomes in participants recruited in a reference maternity unit of the Caribbean region of Colombia.

DESIGN

Prospective analytical birth cohort study. Maternal Hb and serum ferritin (SF) levels were measured. GA was defined as Hb levels <6·82 mmol/l (<11 g/dl), SF depletion as SF levels <12 µg/l. Birth outcomes such as low birth weight (LBW), preterm birth (PB) and small for gestational age (SGA) were examined.

SETTING

Mothers in the first stage of labour, living in urban or rural areas of Bolívar, were enrolled in an obstetrical centre located in Cartagena, Colombia. Blood and stool samples were taken prior delivery. Maternal blood count, SF levels and infant anthropometric data were recorded for analysis.

PARTICIPANTS

1218 pregnant women aged 18-42 years and their newborns.

RESULTS

Prevalence of GA and SF depletion was 41·6 % and 41·1 %, respectively. GA was positively associated with poverty-related sociodemographic conditions. Prenatal care attendance lowered the risk of PB, LBW and SGA. Birth weight was inversely associated with Hb levels, observing a -36·8 g decrease in newborn weight per 0·62 mmol/l (or 1 g/dl) of maternal Hb. SF depletion, but not anaemia, was associated with PB. SGA outcome showed a significant association with anaemia, but not a significant relationship with SF depletion.

CONCLUSIONS

Birth weight and other-related perinatal outcomes are negatively associated with Hb and SF depletion. Prenatal care attendance reduced the risk of negative birth outcomes.

Effects of vitamin and mineral supplementation during pregnancy on maternal, birth, child health and development outcomes in low- and middle-income countries: A systematic review

Background

Almost two billion people who are deficient in vitamins and minerals are women and children in low- and middle-income countries (LMIC). These deficiencies are worsened during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child. To reduce micronutrient deficiencies, several strategies have been implemented, including diet diversification, large-scale and targeted fortification, staple crop bio-fortification and micronutrient supplementation.

Objectives

To evaluate and summarize the available evidence on the effects of micronutrient supplementation during pregnancy in LMIC on maternal, fetal, child health and child development outcomes. This review will assess the impact of single micronutrient supplementation (calcium, vitamin A, iron, vitamin D, iodine, zinc, vitamin B12), iron-folic acid (IFA) supplementation, multiple micronutrient (MMN) supplementation, and lipid-based nutrient supplementation (LNS) during pregnancy.

Search Methods

We searched papers published from 1995 to 31 October 2019 (related programmes and good quality studies pre-1995 were limited) in CAB Abstracts, CINAHL, Cochrane Central Register of Controlled Trials, Embase, International Initiative for Impact Evaluations, LILACS, Medline, POPLINE, Web of Science, WHOLIS, ProQuest Dissertations & Theses Global, R4D, WHO International Clinical Trials Registry Platform. Non-indexed grey literature searches were conducted using Google, Google Scholar, and web pages of key international nutrition agencies.

Selection Criteria

We included randomized controlled trials (individual and cluster-randomized) and quasi-experimental studies that evaluated micronutrient supplementation in healthy, pregnant women of any age and parity living in a LMIC. LMIC were defined by the World Bank Group at the time of the search for this review. While the aim was to include healthy pregnant women, it is likely that these populations had one or more micronutrient deficiencies at baseline; women were not excluded on this basis.

Data Collection and Analysis

Two authors independently assessed studies for inclusion and risk of bias, and conducted data extraction. Data were matched to check for accuracy. Quality of evidence was assessed using the GRADE approach.

Main Results

A total of 314 papers across 72 studies (451,723 women) were eligible for inclusion, of which 64 studies (439,649 women) contributed to meta-analyses. Seven studies assessed iron-folic acid (IFA) supplementation versus folic acid; 34 studies assessed MMN vs. IFA; 4 studies assessed LNS vs. MMN; 13 evaluated iron; 13 assessed zinc; 9 evaluated vitamin A; 11 assessed vitamin D; and 6 assessed calcium. Several studies were eligible for inclusion in multiple types of supplementation. IFA compared to folic acid showed a large and significant (48%) reduction in the risk of maternal anaemia (average risk ratio (RR) 0.52, 95% CI 0.41 to 0.66; studies = 5; participants = 15,540; moderate-quality evidence). As well, IFA supplementation demonstrated a smaller but significant, 12% reduction in risk of low birthweight (LBW) babies (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). MMN supplementation was defined as any supplement that contained at least 3 micronutrients. Post-hoc analyses were conducted, where possible, comparing the differences in effect of MMN with 4+ components and MMN with 3 or 4 components. When compared to iron with or without FA, MMN supplementation reduced the risk of LBW by 15% (average RR 0.85, 95% CI 0.77 to 0.93; studies = 28; participants = 79,972); this effect was greater in MMN with >4 micronutrients (average RR 0.79, 95% CI 0.71 to 0.88; studies = 19; participants = 68,138 versus average RR 1.01, 95% CI 0.92 to 1.11; studies = 9; participants = 11,834). There was a small and significant reduction in the risk of stillbirths (average RR 0.91; 95% CI 0.86 to 0.98; studies = 22; participants = 96,772) and a small and significant effect on the risk of small-for-gestational age (SGA) (average RR 0.93; 95% CI 0.88 to 0.98; studies = 19; participants = 52,965). For stillbirths and SGA, the effects were greater among those provided MMN with 4+ micronutrients. Children whose mothers had been supplemented with MMN, compared to IFA, demonstrated a 16% reduced risk of diarrhea (average RR 0.84; 95% CI 0.76 to 0.92; studies = 4; participants = 3,142). LNS supplementation, compared to MMN, made no difference to any outcome; however, the evidence is limited. Iron supplementation, when compared to no iron or placebo, showed a large and significant effect on maternal anaemia, a reduction of 47% (average RR 0.53, 95% CI 0.43 to 0.65; studies = 6; participants = 15,737; moderate-quality evidence) and a small and significant effect on LBW (average RR 0.88, 95% CI 0.78 to 0.99; studies = 4; participants = 17,257; high-quality evidence). Zinc and vitamin A supplementation, each both compared to placebo, had no impact on any outcome examined with the exception of potentially improving serum/plasma zinc (mean difference (MD) 0.43 umol/L; 95% CI -0.04 to 0.89; studies = 5; participants = 1,202) and serum/plasma retinol (MD 0.13 umol/L; 95% CI -0.03 to 0.30; studies = 6; participants = 1,654), respectively. When compared to placebo, vitamin D supplementation may have reduced the risk of preterm births (average RR 0.64; 95% CI 0.40 to 1.04; studies = 7; participants = 1,262), though the upper CI just crosses the line of no effect. Similarly, calcium supplementation versus placebo may have improved rates of pre-eclampsia/eclampsia (average RR 0.45; 95% CI 0.19 to 1.06; studies = 4; participants = 9,616), though the upper CI just crosses 1.

Authors' Conclusions

The findings suggest that MMN and vitamin supplementation improve maternal and child health outcomes, including maternal anaemia, LBW, preterm birth, SGA, stillbirths, micronutrient deficiencies, and morbidities, including pre-eclampsia/eclampsia and diarrhea among children. MMN supplementation demonstrated a beneficial impact on the most number of outcomes. In addition, MMN with >4 micronutrients appeared to be more impactful than MMN with only 3 or 4 micronutrients included in the tablet. Very few studies conducted longitudinal analysis on longer-term health outcomes for the child, such as anthropometric measures and developmental outcomes; this may be an important area for future research. This review may provide some basis to guide continual discourse around replacing IFA supplementation with MMN along with the use of single micronutrient supplementation programs for specific outcomes.

Compliance with Iron and Folic Acid Supplementation (IFAS) and associated factors among pregnant women in Sub-Saharan Africa: A systematic review and meta-analysis

Background

Anemia is one of the world’s leading cause of disability and the most serious global public health issues. This systematic review and meta-analysis was conducted very carefully in order to give up the pooled compliance of Iron and Folic-Acid Supplementation in Sub-Saharan Africa.

Methods

To conduct this brief systematic review and meta-analysis, a related literature search was done from different sources, PubMed Medline and Google Scholar Journals. Then IFA Supplementation related searching engine was used to make the work more meaningful and intensive. Moreover, we used modified Newcastle-Ottawa quality assessment scale for cross sectional studies to assess the quality of the study in terms of their inclusion. Then, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed to carry out the work in a carful manner. Finally, the pooled effect size was computed using the review manager and Compressive Meta-analysis software.

Results

Twenty-three studies, which encompassed 24272 pregnant women, were chosen for the analysis. From those an overall prevalence of compliance with Iron and Folic Acid Supplementation (IFAS) in pregnancy in SSA was 39.2%. However, the result from meta-analysis showed that women who were counseled on IFAS in their courses of pregnancy were 1.96 times more likely to adhere to IFAS compared to those who were not counseled [OR:1.96, 95% CI (1.76-,5.93)]. Moreover, it showed that women who had knowledge of IFAS were 2.71 times more likely to have compliance with IFAS as compared to those who had no knowledge of IFAS [OR:2.71, 95% CI (1.33,5.54)]. Also it revealed that those women who had knowledge of anemia were 5.42 times more likely to have compliance with IFAS as compared with those who had no knowledge of anemia [OR5.42, 95% CI (1.52, 19.43)]. Furthermore, women who had received fourth visit for ANC were 1.54 times more likely to have compliance with IFAS as compared to those who had not received for ANC [OR 1.54, 95% CI (0.66, 3.58.43)].

Conclusions

Our finding from this systematic review and meta-analysis shows the low case in prevalence of compliance to IFAS among pregnant women in SSA. Predictors for this includes: knowledge about anemia, knowledge about IFAS, counseling on IFAS and receiving fourth antenatal care visit were statistically correlated positively with compliance to IFAS. This demands careful appraisal of effect of prevention work for functioning policy, programs and plan nutrition intrusions for refining maternal dietary intake in gestation. Also dietary education intrusion requires to be planned to satisfy the needs of pregnant women. So we hope that the result of this study might be essential as a bridging stone for policy makers of Africa; exclusively for maternal and child health care. Finally, we recommended further studies to be conducted in the area of the study for more intensive and detailed suggestions.

Association between gestational anemia in different trimesters and neonatal outcomes: a retrospective longitudinal cohort study

BACKGROUND

Previous studies investigated the association between gestational anemia and neonatal outcomes. However, few studies explored whether the effects of gestational anemia could be eliminated by subsequent correction of anemia in the later stages of pregnancy. This study aimed to investigate the relationship between anemia in different trimesters and neonatal outcomes.

METHODS

The study was conducted in Shanghai, China, with a sample of 46,578 pregnant women who delivered between January 1, 2016 and July 1, 2019. A multivariable logistic regression model was adopted to analyse the associations between maternal anemia and neonatal outcomes.

RESULTS

The incidence of gestational anemia was 30.2%, including 4.4% in the first trimester, 9.6% in the second trimester, and 16.2% in the third trimester. Only 24.5% (507/2066) of anemia that occurred in the first trimester and 29.6% (1320/4457) that occurred in the second trimester could be corrected in the later stages of pregnancy. Anemia occurring in the first trimester was associated with small for gestational age [odds ratio (OR) 1.46; 95% confidence interval (CI) 1.20-1.78] and with fetal distress (OR 1.23; 95% CI 1.08-1.40). Anemia corrected in the first trimester also was associated with a higher risk of small for gestational age.

CONCLUSIONS

Gestational anemia is a public health problem in China impacting neonatal health. Anemia in pregnancy could be corrected in only about a quarter of the women. Anemia in the first trimester, whether corrected or not, still led to lower birth weight; therefore, the prevention of anemia prior to pregnancy is important.

Exploring factors influencing adverse birth outcomes in a regional hospital setting in Ghana: A configuration theoretical perspective

BACKGROUND

Understanding the complexity of factors that influence adverse childbirth outcomes at health facilities can be enhanced by the theoretical articulation of the interplay between external socio-structural and internal technical dynamics of the birthplace in context. Guided by configuration theory, this study explored the factors that influence adverse birth outcomes at a regional hospital setting in Ghana.

METHODS

Qualitative data were collected from the Upper West regional hospital in Ghana. In-depth interviews were administered to 30 purposively selected respondents comprising 20 postpartum mothers and 10 midwives. The data was electronically audio-recorded, transcribed and analysed using thematic analysis.

FINDINGS

The study revealed three key dimensions of socio-technical configurations shaping adverse birth outcomes within the hospital setting. These are mother-midwife personality and behavioral dynamics including personality clashes and poor communication; birth process dynamics consisting of diverse paradigms of safe birthing process and socio-technical conflicts on caesarean section; and birthplace context, comprising nature of the birthing environment, confidence in the safety of the birthplace and national health policy implementation challenges. These socio-technical interactions result in late reporting at facilities by mothers and delay in care delivery by midwives, contributing to adverse birth outcomes.

CONCLUSION

In line with configuration theory, our study positions the influences of adverse birth outcomes in hospital settings in alignment with a subtle and iterative interplay of socio-technical factors. To comprehensively address adverse birth outcomes in hospital settings, health policymakers and practitioners need to understand and contextualise the socio-technical interactions that shape notable outcomes at specific hospital settings.

Population-Based Estimation of the Preterm Birth Rate in Lilongwe, Malawi: Making Every Birth Count

Objective  The objective of this study was to perform a population-based estimation of the preterm birth (PTB) rate in regions surrounding Lilongwe, Malawi. Study Design  We partnered with obstetrician specialists, community health workers, local midwives, and clinicians in a 50 km region surrounding Lilongwe, Malawi, to perform a population-based estimation of the PTB rate during the study period from December 1, 2012 to May 19, 2015. Results  Of the 14,792 births captured, 19.3% of births were preterm, including preterm early neonatal deaths. Additional PTB risk factors were similarly prevalent including domestic violence, HIV, malaria, anemia, and malnutrition. Conclusion  When performing a population-based estimation of the rate of PTB, including women without antenatal care and women delivering at home, the 19.3% rate of PTB is among the highest recorded globally. This is accompanied by a high rate of risk factors and comorbid conditions.