Addressing inequities in the global burden of maternal undernutrition: the role of targeting

Gestational weight gain at the national, regional, and income group levels based on 234 national household surveys from 70 low-income and middle-income countries

Gestational weight gain (GWG) estimates enable the identification of populations of women at risk for adverse outcomes. We described GWG distribution in low- and middle-income countries (LMICs). Demographic and Health Surveys and other national surveys were used to calculate the average GWG by regressing the weight of pregnant women (15-49 years) at the time of the interview on their gestational age, adjusting for sociodemographic factors. A mixed-effects hierarchical model was built with survey-specific GWG as the dependent variable and restricted cubic splines for survey year, super-region, and country-level covariates (total fertility rate, gross domestic product, and average female body mass index) to predict the national, regional, and income level average GWG in 2020. Uncertainty ranges (UR) were obtained using bootstrap. Estimates were compared with the Institute of Medicine's GWG recommendations for women with normal weight (11.5kg) and underweight (12.5kg). Survey data were available for 70 LMICs (234 data points, 1991-2022). Predicted country-specific GWG for 2020 ranged from 2.6 to 13.5kg. Ten countries presented estimates above the recommendation for women with underweight; nine of which were from Central Europe, Eastern Europe, and Central Asia; apart from one, these were upper-middle income. Regional GWG was estimated at 5.4kg (95%UR 3.1,7.7) in Sub-Saharan Africa; 6.2kg (95%UR 3.4,9.0) in North Africa and the Middle East; 8.6kg (95%UR 6.0,11.3) in South Asia; 9.3kg (95%UR 6.2,12.3) in Southeast Asia, East Asia, and Oceania; 10.0kg (95%UR 7.1,12.9) in Latin America and the Caribbean; and 13.0kg (95%UR 9.0,16.9) in Central and Eastern Europe, and Central Asia. A gradient was observed across income: 5.3kg (95%UR 2.7,7.9) for low-income, 7.6kg (95%UR 5.2,10.1) for lower-middle-income, and 9.8kg (95%UR 7.1,12.5) for upper-middle-income countries. No income group achieved the minimum recommended weight gain. GWG was estimated to be insufficient in almost all LMICs. Improved data and monitoring are crucial for impactful interventions.

Maternal preconceptional and prenatal exposure to El Niño Southern Oscillation levels and child mortality: a multi-country study

El Niño Southern Oscillation (ENSO) has been shown to relate to the epidemiology of childhood infectious diseases, but evidence for whether they increase child deaths is limited. Here, we investigate the impact of mothers' ENSO exposure during and prior to delivery on child mortality by constructing a retrospective cohort study in 38 low- and middle-income countries. We find that high levels of ENSO indices cumulated over 0-12 lagged months before delivery are associated with significant increases in risks of under-five mortality; with the hazard ratio ranging from 1.33 (95% confidence interval [CI], 1.26, 1.40) to 1.89 (95% CI, 1.78, 2.00). Child mortality risks are particularly related to maternal exposure to El Niño-like conditions in the 0th-1st and 6th-12th lagged months. The El Niño effects are larger in rural populations and those with unsafe sources of drinking water and less education. Thus, preventive interventions are particularly warranted for the socio-economically disadvantaged.

Climate change, air pollution and maternal and newborn health: An overview of reviews of health outcomes

Background

Climate change represents a fundamental threat to human health, with pregnant women and newborns being more susceptible than other populations. In this review, we aimed to describe the current landscape of available epidemiological evidence on key climate risks on maternal and newborn health (MNH).

Methods

We sought to identify published systematic and scoping reviews investigating the impact of different climate hazards and air pollution on MNH outcomes. With this in mind, we developed a systematic search strategy based on the concepts of 'climate/air pollution hazards, 'maternal health,' and 'newborn health,' with restrictions to reviews published between 1 January 2010 and 6 February 2023, but without geographical or language restriction. Following full text screening and data extraction, we synthesised the results using narrative synthesis.

Results

We found 79 reviews investigating the effects of climate hazards on MNH, mainly focussing on outdoor air pollution (n = 47, 59%), heat (n = 24, 30%), and flood/storm disasters (n = 7, 9%). Most were published after 2015 (n = 60, 76%). These reviews had consistent findings regarding the positive association of exposure to heat and to air pollution with adverse birth outcomes, particularly preterm birth. We found limited evidence for impacts of climate-related food and water security on MNH and did not identify any reviews on climate-sensitive infectious diseases and MNH.

Conclusions

Climate change could undermine recent improvements in maternal and newborn health. Our review provides an overview of key climate risks to MNH. It could therefore be useful to the MNH community to better understand the MNH needs for each climate hazard and to strengthen discussions on evidence and research gaps and potential actions. Despite the lack of comprehensive evidence for some climate hazards and for many maternal, perinatal, and newborn outcomes, we observed repeated findings of the impact of heat and air pollutants on birth outcomes, particularly preterm birth. It is time for policy dialogue to follow to specifically design climate policy and actions to protect the needs of MNH.

Targeting strategies for balanced energy and protein (BEP) supplementation in pregnancy: study protocol for the TARGET-BEP cluster-randomized controlled trial in rural Bangladesh

BACKGROUND

The World Health Organization (WHO) recommends balanced energy and protein (BEP) supplementation be provided to all pregnant women living in undernourished populations, usually defined as having a prevalence > 20% of underweight women, to reduce the risk of stillbirths and small-for-gestational-age neonates. Few geographies meet this threshold, however, and a large proportion of undernourished women and those with inadequate gestational weight gain could miss benefiting from BEP. This study compares the effectiveness of individual targeting approaches for supplementation with micronutrient-fortified BEP vs. multiple micronutrient supplements (MMS) alone as control in pregnancy in improving birth outcomes.

METHODS

The TARGET-BEP study is a four-arm, cluster-randomized controlled trial conducted in rural northwestern Bangladesh. Eligible participants are married women aged 15-35 years old identified early in pregnancy using a community-wide, monthly, urine-test-based pregnancy detection system. Beginning at 12-14 weeks of gestation, women in the study area comprising 240 predefined sectors are randomly assigned to one of four intervention arms, with sector serving as the unit of randomization. The interventions involving daily supplementation through end of pregnancy are as follows: (1) MMS (control); (2) BEP; (3) targeted BEP for those with pre-pregnancy body mass index (BMI) < 18.5 kg/m2 and MMS for others; (4) targeted BEP for those with pre-pregnancy BMI < 18.5 kg/m2, MMS for others, and women with inadequate gestational weight gain switched from MMS to BEP until the end of pregnancy. Primary outcomes include birth weight, low birth weight (< 2500 g), and small for gestational age, defined using the 10th percentile of the INTERGROWTH-21st reference, for live-born infants measured within 72 h of birth. Project-hired local female staff visit pregnant women monthly to deliver the assigned supplements, monitor adherence biweekly, and assess weight regularly during pregnancy. Trained data collectors conduct pregnancy outcome assessment and measure newborn anthropometry in the facility or home depending on the place of birth.

DISCUSSION

This study will assess the effectiveness of targeted balanced energy and protein supplementation to improve birth outcomes among pregnant women in rural Bangladesh and similar settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05576207. Registered on October 5th, 2022.

Targeting strategies of antenatal balanced energy and protein supplementation in Addis Ababa, Ethiopia: study protocol for a randomized effectiveness study

BACKGROUND

Antenatal balanced energy and protein (BEP) supplements have well-documented benefits for pregnancy outcomes. However, considerable practical gaps remain in the effective and cost-effective delivery of antenatal BEP supplements at scale in low- and middle-income countries.

METHODS

A randomized effectiveness study will be conducted in two sub-cities of Addis Ababa, Ethiopia, to evaluate the effectiveness, cost-effectiveness, and implementation of different targeting strategies of antenatal BEP supplements. Pregnant women aged 18 to 49, with a gestational age of 24 weeks or less, and attending antenatal visits in one of the nine study health facilities are eligible for enrollment. In six of the health facilities, participants will be randomized to one of three study arms: control (Arm 1), targeted BEP provision based on baseline nutritional status (Arm 2), and targeted BEP supplementation based on baseline nutritional status and monthly gestational weight gain (GWG) monitoring (Arm 3). In the remaining three facilities, participants will be assigned to universal BEP provision (Arm 4). Participants in Arms 2 and 3 will receive BEP supplements if they have undernutrition at enrollment, as defined by a baseline body mass index less than 18.5 kg/m2 or mid-upper arm circumference less than 23 cm. In Arm 3, in addition to targeting based on baseline undernutrition, regular weight measurements will be used to identify insufficient GWG and inform the initiation of additional BEP supplements. Participants in Arm 4 will receive BEP supplements until the end of pregnancy, regardless of baseline nutritional status or GWG. All participants will receive standard antenatal care, including iron and folic acid supplementation. A total of 5400 pregnant women will be enrolled, with 1350 participants in each arm. Participants will be followed up monthly during their visits to the antenatal facilities until delivery. Maternal and infant health status will be evaluated within 72 h after delivery and at 6 weeks postpartum. The effectiveness and cost-effectiveness of the different BEP targeting strategies in preventing adverse pregnancy outcomes will be compared across arms. Qualitative data will be analyzed to assess the feasibility, acceptability, and implementation of different supplementation strategies.

DISCUSSION

This study will inform global recommendations and operational guidelines for the effective and cost-effective delivery of antenatal BEP supplements. The targeted approaches have the potential for broader scale-up in Ethiopia and other low-resource settings with a high burden of undernutrition among pregnant women.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT06125860. Registered November 9, 2023.

A Comparative Analysis of Maternal Nutrition Decision-Making Autonomy During Pregnancy-An Application of the Food Choice Process Model in Burkina Faso and Madagascar

BACKGROUND

Adequate nutrition has been cited as one of the most critical components for optimal health outcomes during pregnancy. Women in Burkina Faso and Madagascar experience high rates of undernutrition due to lack of knowledge, finances, cultural norms, and autonomy. Therefore, this study aimed (1) to describe typical maternal diets during pregnancy in Burkina Faso and Madagascar, (2) to understand the multilevel factors that influence women's nutrition decision-making, and (3) to explore the extent to which women have nutrition decision-making autonomy during pregnancy.

METHODS

This study was conducted between October 2020 and February 2021 in Burkina Faso and Madagascar. Semi-structured interviews, focus group interviews, and free lists were conducted among women of reproductive age and pregnant and lactating women. Textual data from interviews were recorded and translated verbatim from local languages into French. The Food Choice Process Model guided textual content analysis using Dedoose software. Free list data were analyzed using cultural domain analysis approaches.

RESULTS

In Burkina Faso and Madagascar, women primarily consumed staple foods such as rice and tô during pregnancy. Participants cited eating fruits and vegetables when available, while the animal source foods were rarely consumed. Across both contexts, nutrition during pregnancy was influenced by factors that impact food choices, such as social factors, resources, ideals, and personal factors. While women and men in Madagascar had more shared decision-making on critical domains such as finances, men were the primary decision-makers in most areas of inquiry (eg, finances) in Burkina Faso.

CONCLUSIONS

The lack of adequate diverse diet consumed during pregnancy is primarily due to important factors including social factors and resources. Understanding the ability for women to consume optimal diets during pregnancy is needed to target behavioral change in maternal nutrition programming.

Low quality of maternal and child nutritional care at the primary care in Mexico: an urgent call to action for policymakers and stakeholders

BACKGROUND

Maternal and child malnutrition represents a public health problem in Mexico Primary care (PC) is responsible for introducing women and children under five to the health system, detecting diseases on time, and providing medical services, including pharmacological treatment if necessary. Providing these services with quality is essential to improve maternal and child health. This study evaluated the quality of nutritional care during preconception, pregnancy, postpartum, infancy, and preschool age at the PC health units across six Mexican states between 2020 and 2021.

METHODS

We conducted a cross-sectional study with a mixed approach in units of the Secretary of Health to assess the quality of nutritional care during preconception, pregnancy, postpartum, childhood, and preschool age. The level of quality was calculated by the percentage of compliance with 16 indicators that integrated a Quality Index of Maternal and Child Nutritional Care (ICANMI, by its Spanish acronym). Compliance by indicator, by life stage, and overall was categorized using the following cut-off points: poor quality (≤ 70%), insufficient quality (71-89%), and good quality (≥ 90%). The perceptions of the barriers and facilitators that affect maternal and child nutrition were evaluated through semi-structured interviews with health professionals (HP) and users. All qualitative instruments were developed with a gender and intercultural perspective.

RESULTS

Considering the whole sample studied, maternal and child nutritional care quality during the five life stages evaluated was bad (compliance: ≤12%), reflected in the ICANMI, which had a compliance of 8.3%. Principal barriers identified to providing high-quality nutritional care were the lack of knowledge and training of health professionals, shortages of equipment, medicine, personnel, and materials, the disappearance of the social cash transfer program Prospera, the absence of local indigenous language translators to support communication between doctor and patient, and the persistence of machismo and other practices of control over women.

CONCLUSIONS

These findings underscore the need for initiatives to improve the quality of nutritional care in PC facilities across Chihuahua, State of Mexico, Veracruz, Oaxaca, Chiapas, and Yucatan. It is necessary for government and health authorities, along with various stakeholders, to collaboratively devise, implement, and assess intercultural and gender-oriented policies and programs geared towards ensuring the health infrastructure and enhancing the training of health professionals to diagnose and treat the prevalence and occurrence of diverse forms of malnutrition in both maternal and child populations.

Barriers to adequate nutrition in pregnant adolescent Colombian females

Pregnant adolescent females face nutritional challenges. The nutritional demands of a growing fetus, when added to the requirements for growing adolescent bodies, are risk factors for undernutrition. An adolescent expectant mother's nutritional status therefore affects both the mother's and the child's future growth, development, and potential development of diseases later in life. In Colombia, the rate of female adolescent pregnancies is higher than neighboring countries and the global average. The most recent data suggest that approximately 21 % of all pregnant adolescent females in Colombia are underweight, 27 % suffer from anemia, 20 % suffer from vitamin D deficiency, and 19 % suffer from vitamin B12 deficiency. Contributing factors to these nutritional deficiencies during pregnancy may be the region in which the female lives, the female's ethnicity, and the female's socioeconomic and educational status. In rural parts of Colombia, limitations regarding access to prenatal care and food choices that include animal source proteins may also contribute to nutritional deficiencies. To help remedy this, recommendations include encouraging nutrient dense food sources with higher protein content, eating one additional meal per day, and taking a prenatal vitamin throughout the pregnancy. Making healthy eating choices can be difficult for adolescent females with limited resources and education; therefore, it is recommended that discussions about nutrition begin at the first prenatal visit for optimum benefits. These factors should be considered for the development of future health policies and interventions in Colombia and other low-income and middle-income countries where pregnant adolescent females may be experiencing similar nutritional deficiencies.

Hepcidin across pregnancy and its correlation with maternal markers of iron and inflammation, maternal body weight outcomes, and offspring neurodevelopmental outcomes: a systematic review and meta-analysis

OBJECTIVE

This study evaluated the correlation between maternal hepcidin and other biomarkers of iron status, markers of inflammation, and maternal body weight during pregnancy, as well as neurodevelopment in the offspring.

DATA SOURCES

PubMed, Web of Science, Scopus, and Embase were searched from inception until March 2022.

STUDY ELIGIBILITY CRITERIA

Studies conducted among pregnant women without apparent pregnancy complications were included. Eligible studies reported correlation coefficients between maternal hepcidin and any outcomes of maternal biomarkers of iron status or inflammatory load during pregnancy, prenatal maternal body weight, and offspring neurodevelopment. Studies without correlation data were eligible if they quantitatively reported volumes of both maternal hepcidin and any marker of iron status and/or inflammatory load during gestation.

METHODS

Pooled correlation coefficients between maternal hepcidin and outcomes of interest were calculated using the Fisher r-to-Z transformation. Both fixed-effects and DerSimonian and Laird random-effects models were used to calculate pooled correlation coefficient. When meta-analysis was not feasible, results were descriptively synthesized.

RESULTS

Forty-six studies with 6624 participants were eligible. Hepcidin was significantly correlated with hemoglobin in the third trimester (r=0.21; 95% confidence interval, 0.1-0.32); ferritin in the first (r=0.31; 95% confidence interval, 0.01-0.61) and third trimester (r=0.35; 95% confidence interval, 0.23-0.48); soluble transferrin receptor in the second trimester (r=-0.27; 95% confidence interval, -0.4 to -0.14); total iron-binding capacity in the second trimester (r=0.37; 95% confidence interval, 0.24-0.50); and serum iron in the third trimester (r=0.11; 95% confidence interval, 0.02-0.19). Hepcidin was significantly correlated with the inflammatory marker interleukin-6 in the third trimester (r=0.26; 95% confidence interval, 0.17-0.34) and C-reactive protein in the second (r=0.16; 95% confidence interval, 0.03-0.30) and third trimester (r=0.28; 95% confidence interval, 0.04-0.52). Four out of 5 studies reported weak-to-moderate positive correlation between hepcidin and body mass index. Hepcidin levels varied across body mass index categories. No single study reported the relationship between maternal hepcidin and neurodevelopment in offspring.

CONCLUSION

Hepcidin weakly to moderately correlates with biomarkers of iron and inflammation in pregnancy.

Dietary Diversity and Haemoglobin Level Associated With Under Nutrition Among Pregnant Women at Sidama Hawassa, Ethiopia: Facility Based Cross-Sectional Study

Background

Under nutrition among pregnant women is common public health problem in developing countries including Ethiopia. It leads to poor maternal and neonatal outcomes. Despite its consequences there is shortage of research evidence to support intervention in this regard in the southern part of the country. Therefore, the aim of the study was to assess the determinates of under nutrition among pregnant women visiting antenatal care clinics at selected health facilities in Hawassa town.

Methods

Health facility based cross-sectional study was employed among 454 systematically selected study participants. Data were collected by using structured and pre-tested questionnaires with face to face interview. Data were entered into Epi info and then exported to SPSS version 26 statistical software for analysis. Data were analyzed with descriptive statistics; bivariate and multivariate binary logistic regression.

Result

The over all of prevalence of under nutrition among pregnant women was 27.6% [95% CI (22.6, 30.8)]. In multivariate logistic regression model, lowest wealth quintile [AOR = 3.3, 95% CI (1.7, 7.0)], women with dietary diversity [AOR = 2.0, 95% CI (1.3, 4.0)], presence of anemia [AOR = 10.7, 95% CI (5.8,19.8)], lower pregnant women education level [AOR = 3.3, 95% CI (1.4, 7.9)], lower partner education level [AOR = 3.1, 95% CI (1.1, 8.5)], not ate flush/meat food [AOR = 2.8, 95% CI (1.7, 4.8)], and not ate other fruits [AOR = 1.8, 95% CI (1.1, 2.8)] had significant association with under nutrition.

Conclusion

In this health facility based study, the burden of under nutrition was high. Lowest wealth quintiles, low dietary diversity scores, being anemic and low education of the pregnant women and her partner were associated with under nutrition. Therefore, counseling for dietary diversity during antenatal care, health promotion and education for pregnant women and empowering women on income generation activities are a key intervention to tackle under nutrition.

Effects of prenatal nutritional supplements on gestational weight gain in low- and middle-income countries: a meta-analysis of individual participant data

BACKGROUND

Gestational weight gain (GWG) below or above the Institute of Medicine (IOM) recommendations has been associated with adverse perinatal outcomes. Few studies have examined the effect of prenatal nutrient supplementations on GWG in low- and middle-income countries (LMICs).

OBJECTIVES

We aimed to investigate the effects of multiple micronutrient supplements (MMSs) and small-quantity lipid-based nutrient supplements (LNSs) on GWG in LMICs.

METHODS

A 2-stage meta-analysis of individual participant data was conducted to examine the effects of MMSs (45,507 women from 14 trials) and small-quantity LNSs (6237 women from 4 trials) on GWG compared with iron and folic acid supplements only. Percentage adequacy of GWG and total weight gain at delivery were calculated according to the IOM 2009 guidelines. Binary outcomes included severely inadequate (percentage adequacy <70%), inadequate (<90%), and excessive (>125%) GWG. Results from individual trials were pooled using fixed-effects inverse-variance models. Heterogeneity was examined using I2, stratified analysis, and meta-regression.

RESULTS

MMSs resulted in a greater percentage adequacy of GWG [weighted mean difference (WMD): 0.86%; 95% CI: 0.28%, 1.44%; P < 0.01] and higher GWG at delivery (WMD: 209 g; 95% CI: 139, 280 g; P < 0.01) than among those in the control arm. Women who received MMSs had a 2.9% reduced risk of severely inadequate GWG (RR: 0.971; 95% CI: 0.956, 0.987; P < 0.01). No association was found between small-quantity LNSs and GWG percentage adequacy (WMD: 1.51%; 95% CI: -0.38%, 3.40%; P = 0.21). Neither MMSs nor small-quantity LNSs were associated with excessive GWG.

CONCLUSIONS

Maternal MMSs were associated with greater GWG percentage adequacy and total GWG at delivery than was iron and folic acid only. This finding is consistent with previous results on birth outcomes and will inform policy development and local recommendations of switching routine prenatal iron and folic acid supplements to MMSs.

Pregnancy Interventions to Improve Birth Outcomes: What Are the Effects on Maternal Outcomes? A Scoping Review

Objectives: Interventions in pregnancy are commonly evaluated for their effects on birth outcomes because maternal infection and poor nutrition are the primary contributors to adverse pregnancy outcomes, especially in low- and middle-income countries (LMICs). However, the extent to which such interventions directly impact maternal health and nutrition has not been succinctly characterized. Methods: We conducted a scoping review of systematic reviews and meta-analyses of 27 pregnancy interventions to summarize the evidence of impact on maternal outcomes. Results: Overall, these were reported incompletely, and we failed to find any evidence for eight interventions. Influenza vaccination, insecticide-treated bed nets, intermittent preventive treatment for malaria, anthelmintic therapy, and treatment of bacterial vaginosis, asymptomatic bacteriuria, and periodontal disease during pregnancy provided direct benefit to women, with reductions in infection risk. Nutritional interventions such as micronutrient supplementation and balanced energy and protein improved outcomes of maternal anemia and gestational weight gain, particularly in deficient populations. Calcium and low dose aspirin significantly reduced the risk of pre-eclampsia. Conclusion: These findings highlight antenatal interventions benefitting maternal health and provide insights into pathways for impacting birth and infant outcomes.

Pregnancy as a Fundamental Determinant of Child Health: a Review

PURPOSE OF REVIEW

Maternal conditions and exposures during pregnancy including over- and undernutrition are associated with poor childbirth outcomes, growth, development and chronic childhood diseases. We examined contemporary pregnancy-related determinants of child health.

RECENT FINDINGS

While maternal undernutrition remains a major contributor to low birth weight, maternal obesity affects foetal growth, birth weight, survival and is associated with childhood obesity, asthma and autistic spectrum disorders. Emerging evidence suggests that epigenetic changes, the prenatal microbiome and maternal immune activation (MIA), a neuroinflammatory process induced by diet and other exposures cause foetal programming resulting in these chronic childhood diseases. Maternal diet is potentially a modifiable risk factor for controlling low birth weight, obesity and chronic disease in childhood. Further studies are warranted to refine guidance on dietary restriction and physical activity during pregnancy and determine how MIA and prenatal microbiota can be applied to control childhood diseases arising from programming.

Maternal Underweight and Its Association with Composite Index of Anthropometric Failure among Children under Two Years of Age with Diarrhea in Bangladesh

Malnutrition in women has been a long-standing public health concern, with serious effects on child survival and development. Maternal body mass index (BMI) is an important maternal nutritional indicator. There are few published studies although child anthropometric failures do not occur in isolation and identifying children with single versus several co-occurring failures can better capture cases of growth failure in combination: stunting, wasting, and underweight. In the context of multiple anthropometric failures, traditional markers used to assess children's nutritional status tend to underestimate overall undernutrition. Using the composite index of anthropometric failure (CIAF), we aimed to assess the association between maternal undernutrition and child undernutrition among children with diarrhea under the age of two and to investigate the correlates. Using 1431 mother-child dyads from the Antibiotic for Children with Diarrhea (ABCD) trial, we extracted children's data at enrollment and on day 90 and day 180 follow-ups. ABCD was a randomized, multi-country, multi-site, double-blind, placebo-controlled clinical trial. The Bangladesh site collected data from July 2017 to July 2019. The outcome variable, CIAF, allows combinations of height-for-age, height-for-weight, and weight-for-age to determine the overall prevalence of undernutrition. The generalized estimating equation was used to explore the correlates of CIAF. After adjusting all the potential covariates, maternal undernutrition status was found to be strongly associated with child undernutrition using the CIAF [aOR: 1.4 (95% CI: 1.0, 1.9), p-value = 0.043] among the children with diarrhea under 2 years old. Maternal higher education had a protective effect on CIAF [aOR: 0.7 (95% CI: 0.5, 0.9), p-value = 0.033]. Our study findings highlight the importance of an integrated approach focusing on maternal nutrition and maternal education could affect a reduction in child undernutrition based on CIAF.

Eco-geographic patterns of child malnutrition in India and its association with cereal cultivation: An analysis using demographic health survey and agriculture datasets

Background: High prevalence of maternal malnutrition, low birth-weight and child malnutrition in India contribute substantially to the global malnutrition burden. Rural India has disproportionately higher levels of child malnutrition. Stunting and wasting are the primary determinants of child malnutrition and their district-level distribution shows clustering in different geographies and regions. Cereals, particularly millets, constitute the bulk of protein intake among the poor, especially in rural areas in India where high prevalence of wasting persists. Methods: The previous round of National Family Health Survey (NFHS4) has disaggregated data by district, enabling a more fine-scale characterisation of the prevalence of markers of malnutrition. We used data from NFHS4 and agricultural statistics datasets to analyse relationship of prevalence of malnutrition at the district level and area under cereal cultivation. We analysed malnutrition through data on under-5 stunting and wasting by district.  Results: Stunting and wasting patterns across districts show a distinct geographical and age distribution; districts with higher wasting showed relatively higher prevalence at six months of age. Wasting prevalence at district level was associated with higher cultivation of millets, with a stronger association seen for jowar and other millets (Kodo millet, little millet, proso millet, barnyard millet and foxtail millet). District level stunting was associated with higher district level cultivation of wheat. In multivariable analysis, wasting was positively associated with women's body mass index and stunting with women's short stature. Conclusions: Well-designed intervention studies will be required to confirm causal pathways contributing to ecogeographic patterns of child malnutrition. The cultivation of other millets has a strong association with prevalence of wasting. State-of-the-art studies that improve our understanding of bio-availability of amino acids and other nutrients from the prevalent dietary matrices of rural poor communities will be needed to confirm causal pathways contributing to potential eco-geographic patterns.

Dietary Quality of Women of Reproductive Age in Low-Income Settings: A Cross-Sectional Study in Kyrgyzstan

Dietary diversity and adequate nutrient intake are essential for conducting a healthy life. However, women in low-income settings often face difficulties in ensuring dietary quality. This research assessed relationships between the dietary diversity, nutrient adequacy, and socio-economic factors among women of reproductive age (WRA) in Kyrgyzstan. A cross-sectional study was undertaken in four locations, including two rural and two urban areas in the north and south of Kyrgyzstan. A survey with pre-coded and open-ended questions was employed during the interviews of 423 WRAs aged 18-49. Data collection was conducted in March-May 2021. The average value body mass index (BMI) of WRA was 24.2 ± 4.6 kg/m2. The dietary diversity score (DDS) was higher among rural women (common language effect size) cles = 0.67, adjusted p < 0.001) in the northern region (cles = 0.61, p < 0.05) who have cropland (cles = 0.60, p < 0.001) and a farm animal (cles = 0.60, p < 0.05). Mean nutrient adequacy ratio (NAR) was below 1 in most micronutrients, whereas thiamine, riboflavin, vitamins B6 and C, folic acid, calcium, and magnesium were even lower than 0.5. Women with a kitchen garden or a cropland had better NAR energy (cles = 0.57), NAR carbohydrate (cles = 0.60), NAR fiber (cles = 0.60), NAR vitamin B1 (cles = 0.53), and NAR folic acid (cles = 0.54). Respondents who receive remittances and a farm animal have better NARs for energy, carbohydrates, fiber, vitamin B1, folic acid, iron, zinc, and mean adequacy ratio for 16 nutrients (MAR 16) than those who do not. Education and income have a negative correlation with dietary quality. This study contributes to the limited literature on the quality of diets in Kyrgyzstan. Hidden hunger and undernutrition are a severe problem among WRA in low-income settings. Recommendations are including study programs in nutrition, teaching households farming practices, and raising awareness on adequate nutrition.

Nutritional support and prophylaxis of azithromycin for pregnant women to improve birth outcomes in peri-urban slums of Karachi, Pakistan-a protocol of multi-arm assessor-blinded randomized controlled trial (Mumta PW trial)

BACKGROUND

Maternal undernutrition is critical in the etiology of poor perinatal outcomes and accounts for 20% of small-for-gestational-age (SGA) births. High levels of food insecurity, antenatal undernourishment, and childhood undernutrition necessitate the supplementation of fortified balanced energy protein (BEP) during pregnancy in low-income settings especially with scarce literature available in this subject. Hence, this paper extensively covers the protocol of such a trial conducted in an urban slum of Karachi, Pakistan.

METHODS

The trial is community-based, open-labelled, four-arm, and randomized controlled that will include parallel group assignments with a 1:1:1:1 allocation ratio in low-income squatter settlements in urban Karachi, Pakistan. All pregnant women (PW), if identified between > 8 and < 19 weeks of gestation based on ultrasound, will be offered routine antenatal care (ANC) counseling and voluntary participation in the trial after written informed consent. A total number of 1836 PW will be enrolled with informed consent and randomly allocated to one of the four arms receiving: (1) ANC counseling only (control group), (2) ANC counseling plus BEP supplement (intervention arm 1), (3) ANC counseling plus BEP supplement plus 2 doses azithromycin (intervention arm 2), or (4) ANC counseling plus BEP supplement plus daily single dose of nicotinamide and choline (intervention arm 3).

TRIAL REGISTRATION

ClinicalTrials.gov NCT04012177 . Registered on July 9, 2019.

Scoping Review of Intervention Strategies for Improving Coverage and Uptake of Maternal Nutrition Services in Southeast Asia

Maternal undernutrition can lead to protein-energy malnutrition, micronutrient deficiencies, or anemia during pregnancy or after birth. It remains a major problem, despite evidence-based maternal-nutrition interventions happening on ground. We conducted a scoping review to understand different strategies and delivery mechanisms to improve maternal nutrition, as well as how interventions have improved coverage and uptake of services. An electronic search was conducted in PubMed and Google Scholar for published studies reporting on the effectiveness of maternal-nutrition interventions in terms of access or coverage, health outcomes, compliance, and barriers to intervention utilization. The search was limited to studies published within ten years before the initial search date, 8 November 2019; later, it was updated to 17 February 2021. Of 31 studies identified following screening and data extraction, 22 studies were included for narrative synthesis. Twelve studies were reported from India and eleven from Bangladesh, three from Nepal, two from both Pakistan and Thailand (Myanmar), and one from Indonesia. Nutrition education and counselling, home visits, directly observed supplement intake, community mobilization, food, and conditional cash transfer by community health workers were found to be effective. There is a need to incorporate diverse strategies, including various health education approaches, supplementation, as well as strengthening of community participation and the response of the health system in order to achieve impactful maternal nutrition programs.

Estimating the Burden of Child Undernutrition for Smaller Electoral Units in India

IMPORTANCE

Geographic targeting of public health interventions is needed in resource-constrained developing countries.

OBJECTIVE

To develop methods for estimating health and development indicators across micropolicy units, using assembly constituencies (ACs) in India as an example.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included children younger than 5 years who participated in the fourth National Family and Health Survey (NFHS-4), conducted between January 2015 and December 2016. Participants lived in 36 states and union territories and 640 districts in India. Children who had valid weight and height measures were selected for stunting, underweight, and wasting analysis, and children between age 6 and 59 months with valid blood hemoglobin concentration levels were included in the anemia analysis sample. The analysis was performed between February 1 and August 15, 2020.

EXPOSURES

A total of 3940 ACs were identified from the geographic location of primary sampling units in which the children's households were surveyed in NFHS-4.

MAIN OUTCOMES AND MEASURES

Stunting, underweight, and wasting were defined according to the World Health Organization Child Growth Standards. Anemia was defined as blood hemoglobin concentration less than 11.0 g/dL.

RESULTS

The main analytic sample included 222 172 children (mean [SD] age, 30.03 [17.01] months; 114 902 [51.72%] boys) from 3940 ACs in the stunting, underweight, and wasting analysis and 215 593 children (mean [SD] age, 32.63 [15.47] months; 112 259 [52.07%] boys) from 3941 ACs in the anemia analysis. The burden of child undernutrition varied substantially across ACs: from 18.02% to 60.94% for stunting, with a median (IQR) of 35.56% (29.82%-42.42%); from 10.40% to 63.24% for underweight, with a median (IQR) of 32.82% (25.50%-40.96%); from 5.56% to 39.91% for wasting, with a median (IQR) of 19.91% (15.70%-24.27%); and from 18.63% to 83.05% for anemia, with a median (IQR) of 55.74% (48.41%-63.01%). The degree of inequality within states varied across states; those with high stunting, underweight, and wasting prevalence tended to have high levels of inequality. For example, Uttar Pradesh, Jharkhand, and Karnataka had high mean AC-level prevalence of child stunting (Uttar Pradesh, 45.29%; Jharkhand, 43.76%; Karnataka, 39.77%) and also large SDs (Uttar Pradesh, 6.90; Jharkhand, 6.02; Karnataka, 6.72). The Moran I indices ranged from 0.25 to 0.80, indicating varying levels of spatial autocorrelation in child undernutrition across the states in India. No substantial difference in AC-level child undernutrition prevalence was found after adjusting for possible random displacement of geographic location data.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, substantial inequality in child undernutrition was found across ACs in India, suggesting the importance of considering local electoral units in designing targeted interventions. The methods presented in this paper can be further applied to measuring health and development indicators in small electoral units for enhanced geographic precision of public health data in developing countries.

Eco-geographic patterns of child malnutrition in India and its association with cereal cultivation: An analysis using demographic health survey and agriculture datasets

Background: High prevalence of maternal malnutrition, low birth-weight and child malnutrition in India contribute substantially to the global malnutrition burden. Rural India has disproportionately higher levels of child malnutrition. Stunting and wasting are the primary determinants of child malnutrition and their district-level distribution shows clustering in different geographies and regions. Cereals, particularly millets, constitute the bulk of protein intake among the poor, especially in rural areas in India where high prevalence of wasting persists. Methods: The last round of National Family Health Survey (NFHS4) has disaggregated data by district, enabling a more fine-scale characterisation of the prevalence of markers of malnutrition. We used data from NFHS4 and agricultural statistics datasets to analyse relationship of prevalence of malnutrition at the district level and area under cereal cultivation. We analysed malnutrition through data on under-5 stunting and wasting by district.  Results: Stunting and wasting patterns across districts show a distinct geographical and age distribution; districts with higher wasting showed relatively higher prevalence before six months of age. Wasting prevalence at district level was associated with higher cultivation of millets, with a stronger association seen for jowar and other millets (Kodo millet, little millet, proso millet, barnyard millet and foxtail millet). District level stunting was associated with higher district level cultivation of all crops (except other millets). The analysis was limited by lack of fine-scale data on prevalence of low birth-weight and type of cereal consumed. Conclusions: Better cereal cultivation and consumption data will be needed to confirm causal pathways contributing to potential ecogeographic patterns. The cultivation of other millets has a strong association with prevalence of wasting. State-of-the-art studies that improve our understanding of bio-availability of amino acids and other nutrients from the prevalent dietary matrices of rural poor communities will be needed to confirm causal pathways contributing to potential eco-geographic patterns.

Association of Parental Height With Offspring Stunting in 14 Low- and Middle-Income Countries

Background: Maternal height has been confirmed to be associated with offspring stunting in low- and middle-income countries (LMICs), but only limited studies have examined the paternal-offspring association, and few studies have examined the joint effect of maternal and paternal height on stunting.

Objective: To investigate the association between parental height and stunting of children aged under five in LMICs.

Methods: We obtained data from the Demographic and Health Surveys (DHS) conducted in 14 LMICs from 2006 to 2016. The association between maternal and paternal height and height-for-age z score (HAZ) of children aged under five was analyzed using a linear regression model in consideration of complex survey design, and regression coefficients (β) with 95% confidence intervals (CIs) were reported. Then, the association between maternal and paternal height quintile and child stunting was analyzed using a modified Poisson regression approach with robust error variance in consideration of complex survey design with adjustment for covariates. The effect estimates were expressed as relative risks (RRs) with 95% CIs.

Results: A total of 50,372 singleton children were included and the weighted prevalence of stunting was 34.5%. Both maternal height and paternal height were associated with child HAZ (β = 0.047; 95% CI, 0.043, 0.050; and β = 0.022; 95% CI, 0.018, 0.025, respectively). Compared with those born to the tallest mothers and fathers, children from the shortest mothers and the shortest fathers had higher risks of stunting (adjusted RR = 1.89; 95% CI, 1.78, 2.01; adjusted RR = 1.56; 95% CI, 1.47, 1.65, respectively). The mother-offspring associations are substantively larger than the father-offspring associations for each corresponding height quintile. Children from the shortest parents had the highest risk of stunting compared with children from the tallest parents (adjusted RR = 3.23; 95% CI, 2.83, 3.68).

Conclusions: Offspring born to short parents are at increased risk of stunting in LMICs, and this intergenerational effect is partly driven by maternal intrauterine influence. This suggests the importance of improving the nutritional status of children and adults in LMICs, especially female caregivers.

Modest reduction in adverse birth outcomes following the COVID-19 lockdown

Background

Widespread lockdowns imposed during the coronavirus disease 2019 crisis may impact birth outcomes.

Objective

This study aimed to evaluate the association between the COVID-19 lockdown and the risk of adverse birth outcomes in Botswana.

Study Design

In response to the coronavirus disease 2019 crisis, Botswana enforced a lockdown that restricted movement within the country. We used data from an ongoing nationwide birth outcomes surveillance study to evaluate adverse outcomes (stillbirth, preterm birth, small-for-gestational-age fetuses, and neonatal death) and severe adverse outcomes (stillbirth, very preterm birth, very-small-for-gestational-age fetuses, and neonatal death) recorded prelockdown (January 1, 2020–April 2, 2020), during lockdown (April 3, 2020–May 7, 2020), and postlockdown (May 8, 2020–July 20, 2020). Using difference-in-differences analyses, we compared the net change in each outcome from the prelockdown to lockdown periods in 2020 relative to the same 2 periods in 2017–2019 with the net change in each outcome from the prelockdown to postlockdown periods in 2020 relative to the same 2 periods in 2017–2019.

Results

In this study, 68,448 women delivered a singleton infant in 2017–2020 between January 1 and July 20 and were included in our analysis (mean [interquartile range] age of mothers, 26 [22–32] years). Across the included calendar years and periods, the risk of any adverse outcome ranged from 27.92% to 31.70%, and the risk of any severe adverse outcome ranged from 8.40% to 11.38%. The lockdown period was associated with a 0.81 percentage point reduction (95% confidence interval, −2.95% to 1.30%) in the risk of any adverse outcome (3% relative reduction) and a 0.02 percentage point reduction (95% confidence interval, −0.79% to 0.75%) in the risk of any severe adverse outcome (0% relative reduction). The postlockdown period was associated with a 1.72 percentage point reduction (95% confidence, −3.42% to 0.02%) in the risk of any adverse outcome (5% relative reduction) and a 1.62 percentage point reduction (95% confidence interval, −2.69% to −0.55%) in the risk of any severe adverse outcome (14% relative reduction). Reductions in adverse outcomes were largest among women with human immunodeficiency virus and among women delivering at urban delivery sites, driven primarily by reductions in preterm birth and small-for-gestational-age fetuses.

Conclusion

Adverse birth outcomes decreased from the prelockdown to postlockdown periods in 2020, relative to the change during the same periods in 2017–2019. Our findings may provide insights into associations between mobility and birth outcomes in Botswana and other low- and middle-income countries.

Association between Maternal Dietary Diversity and Low Birth Weight in Central India: A Case-Control Study

Low birth weight (LBW) is one of the major public health challenges in India. LBW etiology is multifactorial and linked to multiple determinants, including maternal undernutrition and sociodemographic characteristics. The objective of the present endeavor was to assess how maternal dietary diversity and other sociodemographic factors among marginalized populations are associated with the incidence of LBW. The study was a part of the community-based intervention that aimed to improve maternal and child health in the Morena district of Madhya Pradesh, a state in central India. In this case-control study, cases were defined as mothers with an LBW child (<2500 grams) and controls as mothers without an LBW child. A quantitative survey was done with women of reproductive age, having at least one child aged 0–24 months. We calculated the dietary diversity based on the number of food groups consumed during pregnancy by women on a daily basis. Stepwise logistic regression models were built to test for associations between sociodemographic and dietary diversity variables and LBW incidence. There were 157 mothers with and 214 without an LBW child. Women's diets mainly consisted of grains, such as wheat, rice, maize, and roots and tubers. Eggs and meat were consumed by less than 1% of the women. There were 20% lesser chances of an LBW child with increasing maternal dietary diversity scores (odds ratio: 0.79; 95% CI: 0.65, 0.96). The poor maternal diet quality during pregnancy may result in adverse birth outcomes with long-term consequences in a child.

Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda

13 years after the first Lancet Series on maternal and child undernutrition, we reviewed the progress achieved on the basis of global estimates and new analyses of 50 low-income and middle-income countries with national surveys from around 2000 and 2015. The prevalence of childhood stunting has fallen, and linear growth faltering in early life has become less pronounced over time, markedly in middle-income countries but less so in low-income countries. Stunting and wasting remain public health problems in low-income countries, where 4·7% of children are simultaneously affected by both, a condition associated with a 4·8-times increase in mortality. New evidence shows that stunting and wasting might already be present at birth, and that the incidence of both conditions peaks in the first 6 months of life. Global low birthweight prevalence declined slowly at about 1·0% a year. Knowledge has accumulated on the short-term and long-term consequences of child undernutrition and on its adverse effect on adult human capital. Existing data on vitamin A deficiency among children suggest persisting high prevalence in Africa and south Asia. Zinc deficiency affects close to half of all children in the few countries with data. New evidence on the causes of poor growth points towards subclinical inflammation and environmental enteric dysfunction. Among women of reproductive age, the prevalence of low body-mass index has been reduced by half in middle-income countries, but trends in short stature prevalence are less evident. Both conditions are associated with poor outcomes for mothers and their children, whereas data on gestational weight gain are scarce. Data on the micronutrient status of women are conspicuously scarce, which constitutes an unacceptable data gap. Prevalence of anaemia in women remains high and unabated in many countries. Social inequalities are evident for many forms of undernutrition in women and children, suggesting a key role for poverty and low education, and reinforcing the need for multisectoral actions to accelerate progress. Despite little progress in some areas, maternal and child undernutrition remains a major global health concern, particularly as improvements since 2000 might be offset by the COVID-19 pandemic.