Maternal adherence to micronutrient supplementation before and during pregnancy in Northwest China: a large-scale population-based cross-sectional survey

Racial Disparities in Medication Use During Pregnancy: Results from the NISAMI Cohort

Purpose

This study aimed to evaluate racial disparities in medication use and associated factors among pregnant women receiving prenatal care at Brazilian Unified Health System primary care health units in the northeast region.

Patients and Methods

A total of 1058 pregnant women in the NISAMI Cohort were interviewed between June 2012 and February 2014. Medicines used during pregnancy were classified according to the Anatomical Therapeutic Chemical (ATC) classification system and ANVISA pregnancy risk categories. Prevalence ratios (crude and adjusted) and 95% confidence intervals (CIs) were estimated using Poisson regression with robust error variance. All analyses were stratified by race (Asian, black, brown/mixed, Brazilian indigenous, and white).

Results

Approximately 84% of the pregnant women used at least one medication, with a lower proportion among white women. The most reported medications were antianemic preparations (71.08%; 95% CI 68.27-73.72%), analgesics (21.74%; 95% CI 19.36-24.32%), and drugs for functional gastrointestinal disorders (18.81%; 95% CI 16.57-21.28%). Approximately 29% of women took potentially risky medications during pregnancy, with a higher prevalence among Asian and white women. Factors associated with medication use during pregnancy include a greater number of prenatal consultations, higher education levels, health problems, and smoking. In addition, maternal age above 25 years, smoking status, and two or more previous pregnancies were associated with potentially risky medication use during pregnancy.

Conclusion

A high prevalence of medication use during pregnancy was found; however, this prevalence was lower among white women. Nonetheless, black and brown women used antianemic preparations less frequently. This finding suggests that race is a factor of inequity in prenatal care, demanding public policies to mitigate it.

Correlation between essential and toxic elements in maternal blood during early pregnancy and atrial septal defects/ventricular septal defects/patent ductus arteriosus in offspring

BACKGROUND

Congenital heart defects (CHDs) are the most common congenital malformation in the world. Recent studies have found that essential and toxic trace element levels may play a crucial role in the risk of neonatal malformation. However, the relationships between element levels in early pregnancy and CHD risk among humans remain unclear. This study investigates the association between maternal essential element (copper [Cu], zinc [Zn], calcium [Ca], manganese [Mg] and iron [Fe]) and toxic element (lead [Pb] and cadmium [Cd]) levels during early pregnancy and CHDs.

METHODS

A hospital-based case-control study was conducted, including 181 cases and 218 controls. Eligible participants underwent antenatal examination during gestational weeks 11-14 and trace element levels were detected by the atomic absorption method. Multi-variable logistic regression was used to examine the associations between the level of maternal trace elements and CHD risks.

RESULTS

Higher levels of Ca in early pregnancy were associated with lower risk of ASD/VSD risks. Moreover, higher Fe, Pb, and Cd levels in the first trimester were associated with higher risks of all CHD and the subtypes risks, and the tests for trend were significant (all p < .05). The restricted cubic spline analysis showed that there was a nonlinear inverted u-shaped dose-response relationship between levels of Zn, Pb, and Cd in the first trimester and risk of CHDs (non-linearity test p < .05).

CONCLUSIONS

A moderate increase in Zn and Ca levels and a decrease in Pb and Cd levels during early pregnancy are needed to reduce the incidence of CHDs in the Chinese population.

Assessment of women's needs, wishes and preferences regarding interprofessional guidance on nutrition in pregnancy - a qualitative study

BACKGROUND

A healthy nutrition in pregnancy supports maternal health and fetal development, decreasing the risk for adverse pregnancy outcomes. Guidance by prenatal care professionals can increase women's awareness regarding the importance of nutrition in pregnancy and thereby contribute to a reduced risk for adverse pregnancy outcomes. The aim of this study was to assess the needs, wishes and preferences of pregnant women regarding the interprofessional guidance on nutrition in pregnancy.

METHODS

Using a qualitative approach and a purposive maximum variation sampling strategy, 25 pregnant women were recruited to participate in six semi-structured, guideline-oriented online focus groups. In addition, two semi-structured, guideline-oriented interviews, with a midwife and an obstetrician, were conducted. The focus groups and interviews were audio-recorded and transcribed. Transcripts were analysed using a systematic deductive-inductive approach to qualitative content analysis according to Kuckartz.

RESULTS

Focus group participants covered diverse perspectives in terms of their age, different models of prenatal care as well as dietary forms from omnivorous to vegan. The majority of women perceived the guidance on nutrition during pregnancy as insufficient. Involved healthcare professionals, namely midwives and obstetricians, should provide more consistent information, especially to avoid uncertainties exacerbated by the internet and social media. There is a need for individual nutrition information regarding dietary supplements and the specifics of different dietary forms during pregnancy, such as a vegan diet. The majority of participants supported the integration of a free-of-charge professional nutrition counselling in prenatal care. Interviews with experts identified time pressure and the complexity of nutrition as a topic as the main obstacles in consultation settings. Both midwife and obstetrician emphasised the need for improved professional education on nutrition in pregnancy in their respective studies.

CONCLUSION

Professional guidance for pregnant women on nutrition and uncertainties going along with certain forms of diet during pregnancy could alleviate the burden and overwhelming amount of web-based information. Additionally, information adapted to the needs, wishes and preferences of pregnant women would improve prenatal care through a more personalised approach. The quality of nutrition guidance in pregnancy should be improved by the implementation of this topic in the education of involved healthcare professionals.

Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review

OBJECTIVES

Daily calcium supplements are recommended for pregnant women from 20 weeks' gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia.

DESIGN

Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach.

DATA SOURCES

MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022.

ELIGIBILITY CRITERIA

We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators.

RESULTS

Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium.

CONCLUSION

Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions.

PROSPERO REGISTRATION NUMBER

CRD42021239143.

Calcium supplementation in pregnancy: An analysis of potential determinants in an under-resourced setting

INTRODUCTION

Despite the evidence that calcium supplementation in pregnancy improves maternofoetal outcomes, many women still do not take calcium supplements during pregnancy in Cameroon. This study identifies factors that influence calcium supplementation during pregnancy in a low resource setting.

METHODS

We conducted a cross-sectional hospital-based study (from November 2020 to September 2021) targeting 1074 healthy women in late pregnancy at the maternities of four major health facilities in the Nkongsamba Health District, Cameroon. Data were collected using an interview-administered semi-structured questionnaire and analysed using Epi Info version 7.2.4.0, and the statistical threshold for significance set at p-value = 0.05.

RESULTS

The mean age of the participants was 28.20±6.08 years, with a range of 15-47 years. The proportion of women who reported taking any calcium supplements in pregnancy was 72.62 [69.85-75.22]%. Only 12% of calcium-supplemented women took calcium supplements throughout pregnancy, while a majority (50%) took calcium supplements just for 4-5 months. Women believe that taking calcium supplements is more for foetal growth and development (37.12%) and prevention of cramps (38.86%), than for the prevention of hypertensive diseases in pregnancy (2.84%). About all pregnant women (97.65%) took iron and folic acid supplements during pregnancy, and 99.24% took these supplements at least once every two days. Upon control for multiple confounders, the onset of antenatal care before 4 months of pregnancy (AOR = 2.64 [1.84-3.78], p-value = 0.000), having had more than 3 antenatal care visits (AOR = 6.01 [3.84-9.34], p-value = 0.000) and support/reminder from a partner on the necessity to take supplements in pregnancy (AOR = 2.00 [1.34-2.99], p-value = 0.001) were significantly associated with higher odds of taking any calcium supplements in pregnancy.

CONCLUSION

Calcium supplementation practices in pregnancy remain poor in this population and far from WHO recommendations. Early initiation of antenatal care, a high number of antenatal visits and reminders or support from the partner on supplement intake significantly increase the odds of taking any calcium supplements in pregnancy. In line with WHO recommendations, women of childbearing age should be sensitised to initiate antenatal care earlier and attain as many visits as possible. Male involvement in prenatal care might also boost the likelihood of these women taking calcium supplements.

Investigating continuation of folic acid supplementation during peri-conceptional period: a community-based cross-sectional study

BACKGROUND

Maternal folate may not reach an optimal level to prevent neural tube defects if supplementation commenced post-conception or took place pre-conception only. Our study aimed to investigate the continuation of folic acid (FA) supplementation from pre-conception to post-conception during peri-conceptional period and to examine its differences in FA supplementation between the subgroups taking the initiation timing into consideration.

METHODS

This study was conducted in two community health service centers in Jing-an District of Shanghai. Women accompanying their children to pediatric health clinics of the centers were recruited and asked to recall information concerning their socioeconomic and previous obstetric characteristics, utilization of healthcare and FA supplementation before and/or during pregnancy. The continuation of FA supplementation during peri-conceptional period were categorized into three subgroups: Supplementing with FA pre- and post-conception; supplementing with FA preconception only or post-conception only; no FA supplements pre-conception and post-conception. The relationship between FA continuation and couples' characteristics were examined as setting the first subgroup as the base reference.

RESULTS

Three hundred and ninety-six women were recruited. Over 40% of the women started FA supplementation after conception and 30.3% of them supplemented with FA from pre-conception to the first trimester of their pregnancy. Compared to this one-third of participants, women who didn't supplemented with any FA during peri-conceptional period were more likely to have no utilization of pre-conception healthcare ([Formula: see text]= 2.47, 95% [Formula: see text]: 1.33-4.61) or antenatal care ([Formula: see text]= 4.05, 95% [Formula: see text]: 1.76-9.34), or who had a lower family socioeconomic status ([Formula: see text]= 4.36, 95% [Formula: see text]: 1.79-10.64). Women who supplemented with FA pre-conception only or post-conception only were more likely to have no utilization of pre-conception healthcare ([Formula: see text]= 2.94, 95% [Formula: see text]: 1.79-4.82), or to have no previous pregnancy complication ([Formula: see text]=1.80, 95% [Formula: see text]: 0.99-3.28).

CONCLUSION

Over two-fifth of the women started FA supplementation and only one-third of them had an optimal supplementation from pre-conception to the first trimester. Maternal utilization of healthcare before or during pregnancy together with maternal and paternal socioeconomic status may play a role in the continuation to FA supplementation pre- and post-conception.

Evaluation of a Text Messaging Intervention to Promote Preconception Micronutrient Supplement Use: Feasibility Study Nested in the Healthy Life Trajectories Initiative Study in South Africa

Background

Social messaging strategies such as SMS text messaging and radio are promising avenues for health promotion and behavior change in low- to middle-income settings. However, evidence of their acceptability, feasibility, and impact in the context of young women’s health and micronutrient deficiencies is lacking.

Objective

This study aimed to evaluate the feasibility of an automated 2-way text messaging intervention nested in an ongoing preconception health trial, the Healthy Life Trajectories Initiative (HeLTI; HeLTI Bukhali) in Soweto, South Africa. Second, we aimed to evaluate the acceptability of a health promotion radio serial, which aired concurrently in the region.

Methods

In this feasibility study, 120 participants enrolled in HeLTI Bukhali between November 2020 and February 2021 received the 6-month 2-way text messaging intervention. Quantitative and qualitative data on intervention acceptability, usability, interaction, perceived benefit, and fidelity were collected during 5 focus group discussions (FGDs) and from study data logs. During the FGDs, data were collected on the acceptability of the radio serial. Following the text messaging intervention, capillary hemoglobin levels were assessed, and a participant questionnaire provided information on adherence and attitudes toward supplements. The text messaging control group comprised the first 120 women recruited from November 2019 to February 2020, who received the Bukhali intervention but not the text messages. Statistical significance testing and a linear mixed model were used for indicative effect comparisons between the text message–receiving and control groups.

Results

The text messaging intervention was found to be acceptable and to have perceived benefits, including being reminded to take supplements, gaining knowledge, and feeling supported by the study team. The use of the 2-way text messaging reply function was limited, with only a 10.8% (13/120) response rate by week 24. Barriers to replying included a lack of interest or phone credit and technical issues. Regarding the indicative effect, participants receiving the text messages had higher self-reported adherence at follow-up than the text messaging control group (42/63, 67% vs 33/85, 39% taking supplements every time; P=.02), and altitude-adjusted hemoglobin increased more between baseline and follow-up in the SMS text message–receiving group than in the text messaging control group (1.03, 95% CI 0.49-1.57; P<.001). The radio serial content was acceptable, although few participants reported exposure before the FGD.

Conclusions

Women reported that the text messaging intervention was useful and described the benefits of receiving the messages. Examination of hemoglobin status indicated a promising beneficial effect of text messaging support on adherence to micronutrient supplementation, requiring further exploration through randomized controlled studies. Health promotion through radio and text messages were both found to be acceptable, although more research into the radio serial reach among young women is needed.

Trial Registration

Pan African Clinical Trials Registry (PACTR) PACTR201903750173871; https://tinyurl.com/4x6n32ff

Association of Interpregnancy Interval With Adverse Birth Outcomes

IMPORTANCE

Many studies have reported an association of interpregnancy interval (IPI) between 2 consecutive births with adverse birth outcomes in low- and middle-income countries. However, most of these studies ignore the implications of some unmeasured confounders.

OBJECTIVE

To explore the association of IPI with adverse perinatal outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This large-scale cohort study used the Guangdong Provincial Women and Children Health Information System in Guangdong Province, China, to obtain birth data recorded between January 1, 2014, and December 31, 2020. Matched-sibling design was used. The final cohort included first-born and second-born sibling pairs delivered by mothers who were permanent residents of Guangdong Province.

EXPOSURES

The exposure variable was IPI, which was categorized as follows: less than 6, 6 to 11, 12 to 17, 18 to 23, 24 to 29, 30 to 35, and 36 or more months.

MAIN OUTCOMES AND MEASURES

The outcome variables were adverse birth outcomes: preterm birth (PTB, gestational age <37 weeks), low birth weight (LBW, <2500 g), and small for gestational age (SGA). Adjusted odds ratio (OR) and interaction odds ratio (IOR) associated with IPI were calculated.

RESULTS

The study consisted of 725 392 sibling pairs of multiparous mothers. Among these mothers, 718 111 (99.0%) were aged 20 to 34 years, and 715 583 (98.7%) were of Han Chinese ethnicity. Unmatched analysis showed that a short IPI of less than 6 months was associated with higher risks of PTB (adjusted OR, 1.96; 95% CI, 1.87-2.06), LBW (adjusted OR, 1.88; 95% CI, 1.79-1.98), and SGA (adjusted OR, 1.34; 95% CI, 1.30-1.38) compared with an IPI of 18 to 23 months. These associations were attenuated in the matched-sibling analysis. An association of short IPI (<6 months) with PTB (adjusted IOR, 1.40; 95% CI, 1.30-1.51), LBW (adjusted IOR, 1.30; 95% CI, 1.21-1.40), and SGA (adjusted IOR, 1.16; 95% CI, 1.11-1.22) remained in the matched analysis. For IPI of 36 months or more, the odds of PTB (adjusted OR, 1.08; 95% CI, 1.03-1.14) and LBW (adjusted OR, 1.13; 95% CI, 1.07-1.19) in the unmatched analysis were also greater than the reference interval (18-23 months), but not for SGA (adjusted OR, 0.96; 95% CI, 0.93-0.99). Associations between a long IPI (≥36 months) and PTB (adjusted IOR, 1.10; 95% CI, 1.02-1.19) and LBW (adjusted IOR, 1.16; 95% CI, 1.07-1.26) remained through the sibling comparisons.

CONCLUSIONS AND RELEVANCE

Results of this study indicated that mothers with a short (<6 months) or long (≥36 months) IPI had greater odds of adverse birth outcomes. The findings may inform family planning policies and guide individuals and families who are planning for another pregnancy in China.

Fortification of staple foods with calcium: a novel costing tool to inform decision making

Low calcium intake and its impact on maternal and child health are a major concern in low- and middle-income countries. Given the low calcium in diet, as well as the low adherence and acceptability of calcium pills in those settings, the discussion about policies to increase calcium intake has moved toward staple food fortification strategies. Nevertheless, there is scarce information on the economic feasibility of implementing these strategies. We aimed to design and propose a novel costing tool to estimate the cost of the flour fortification with calcium by carrying out a literature review about costing studies for staple food fortification programs and costing tools previously developed. A deliberative meeting with stakeholders was held to discuss and face-validate the conceptual framework proposed. We showed the costing tool application for the case of Costa Rica (a country with a population with low calcium intake), including the absolute cost of the staple food fortification production process, the incremental cost of fortification according to the public/private sector, and the incremental cost by target population. This open-source and publicly available costing tool can be useful to inform policymaking in countries considering the implementation of staple food fortification programs.

Dietary Supplement Use during Pregnancy: Perceptions versus Reality

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

Cost-Effectiveness of Ferrous Fumarate-Folic Acid and Ferrous Gluconate-Multivitamins in a High Prevalence Area of Iron Deficiency Anemia in Indonesia

BACKGROUND

Up to now, the combinations of ferrous fumarate-folic acid (FF-FA) and ferrous gluconate-multivitamins (FG-MV) have been implemented by the local government in the province of Papua. Nevertheless, there is no a specific economic evaluation that has been applied to investigate the cost-effectiveness of FF-FA and FG-MV.

OBJECTIVE

This study aimed to investigate the cost-effectiveness of FF-FA and FG-MV to be implemented in Teluk Bintuni, as one of the districts with the highest prevalence of iron deficiency anemia in Papua by taking the healthcare perspective into account.

METHODS

A prospective observational study was applied by considering two groups of women (15-49 years old) with iron deficiency anemia who received FF-FA and FG-MV from September to November 2018. Applying a purposive sampling method, respondents were selected from 875 targeted women in six sub-districts, who met inclusion criteria. To estimate the total cost, we applied a healthcare perspective that considered direct medical cost only (eg, the procurement cost of iron tablets, cost of Hb test, and cost of healthcare visit). To estimate the effectiveness of intervention, we applied two major parameters, such as Hb level and utility score in quality-adjusted life year (QALY). The cost-effectiveness values were evaluated by using the criteria on the cost-effectiveness of healthcare intervention according to the threshold of gross domestic product (GDP) per capita (cost per QALY gained).

RESULTS

From 875 targeted women in six sub-districts who met inclusion criteria, we found approximately 222 women with moderate-severe iron deficiency anemia and 110 women with complete data in the group of FF-FA (n=69) and FG-MV (n-41). The results showed that there were significant differences (p-value <0.05) on the number of respondents, age, oral iron cost, total healthcare cost and utility score in both intervention groups. Comparing the use of FG-MV with FF-FA, we estimated the incremental cost-effectiveness ratios (ICERs) would be $255.77 per controlled patient, $142.09 per patient with Hb increment >2.00 g/dL, $79.93 per patient with Hb increment >1.00 g/dL, and $11.59 per QALY gained.

CONCLUSION

The ICER was estimated to be $11.59 per QALY gained, which was highly cost-effective, according to GDP-based cost-effectiveness threshold. In addition, the utility score of women with iron deficiency anemia was considered to be the most influential factor impacting the cost-effectiveness value.

Association of Short and Long Interpregnancy Intervals with Adverse Birth Outcomes: Evidence from a Cross-Sectional Study in Northwest China

Purpose

To analyze the effects of a short interpregnancy interval (IPI) (<6 months) and a long IPI (>120 months) on neonatal adverse birth outcomes including low birth weight (LBW), small for gestational age (SGA), preterm birth (PTB), and birth defects in Shaanxi Province.

Patients and Methods

A stratified multistage random sampling method was used to recruit participants who gave birth between 2010 and 2013 in Shaanxi province. A self-designed questionnaire was used to collect the information of the participants. With the confounding factors controlled, the generalized linear model (GLM) was used to investigate the association between IPI and neonatal birth outcomes. The restricted cubic spline (RCS) function was used to evaluate the dose–response relationship between IPI and birth outcomes.

Results

A total of 13,231 women were included. The prevalence of LBW, SGA, PTB, and birth defects was 3.24%, 12.96%, 2.93%, and 2.12%, respectively. GLM showed that a short IPI (<6 months) was associated with a higher risk of SGA (RR=1.25, 95% CI: 1.04–1.52) and birth defects (RR=2.55, 95% CI: 1.45–4.47), and a long IPI (≥120 months) was associated with a higher risk of LBW (RR=1.54, 95% CI: 1.01–2.34) and PTB (RR=1.73, 95% CI: 1.08–2.76) than an IPI of 18–23 months. The RCS showed that LBW, SGA, and PTB demonstrated a j-shaped relationship with IPI (P for overall association < 0.001 for these three birth outcomes), and birth defects (P for overall association <0.001) had an inversely non-linear relationship with IPI.

Conclusion

Both short and long IPIs are associated with an increased risk of adverse birth outcomes.

Association between maternal iron supplementation and newborn birth weight: a quantile regression analysis

Objective

Our study aimed to explore the association between maternal iron supplementation and newborn birth weight (BW) in Shaanxi Province using quantile regression (QR).

Method

The data used in this study were derived from a large cross-sectional survey of a population in Shaanxi Province, Northwest China. A total of 28,209 women and their infants were selected using a stratified multistage random sampling method. The effect of iron supplementation on the newborn BW was assessed by a multiple linear regression model and QR.

Results

A total of 5.15% of the women took iron supplements during pregnancy. Multiple linear regression showed that the iron supplementation during pregnancy had positive effects on the BW, with an average increase of 43.07 g (β = 43.07, t = 3.55, and p < 0.001). The QR showed that the iron supplementation during pregnancy was associated with an increased newborn BW from very low to higher percentiles (quantiles: 0 ~ 0.40), with the β ranging from 136.51 to 43.86. As the percentiles of the BW increased, the neonatal BW gain gradually declined in the iron supplementation group compared with the group that did not receive iron supplementation (quantiles: 0 ~ 0.40, with the β ranging from 136.51 to 43.86). Iron supplementation was more effective among women who suffered from anemia during pregnancy (β = 45.84, t = 2.05, and p = 0.04; quantiles: 0 ~ 0.15, 0.30, 0.80, with β ranging from 150.00 to 39.29) than it was in any other group (β = 38.18, t = 2.62, and p = 0.009; quantiles: 0 ~ 0.15, with β ranging from 133.33 to 28.32).

Conclusions

Iron supplementation during pregnancy is associated with an increased newborn BW, and the effect was more obvious in the newborns with the lower BW and newborns whose mothers suffered from anemia during pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13052-021-01084-7.

Interventions to increase adherence to micronutrient supplementation during pregnancy: a systematic review

Prenatal micronutrient supplements are cost‐effective in reducing nutritional deficiencies and adverse pregnancy and birth outcomes. However, poor adherence remains a potential barrier to the successful implementation of these supplementation programs. This systematic review assessed the effectiveness of interventions designed to increase adherence to prenatal micronutrient supplementation. Following the Cochrane Collaboration Methodology, literature searches were conducted in six electronic databases and gray literature (on July 24, 2020), and abstract screening, data extraction, and risk of bias assessment were conducted independently by two reviewers. We included 22 studies. Interventions that resulted in increased adherence were most of the education‐based strategies, consumption monitoring by volunteer health workers or family members, SMS reminders, free provision of supplements, a multicomponent intervention with community mobilization, and a participatory action research intervention. In several studies, increased adherence was accompanied by beneficial effects on pregnancy and birth outcomes. Given the heterogeneity of study designs and methods used to define and measure adherence, a meta‐analysis was not appropriate. We identified several potentially effective strategies to improve supplementation adherence, which may need to be adapted to specific contexts when considered for program implementation. However, additional high‐quality studies are critically needed to effectively guide policies and programs.

Hypocalcaemia and calcium intake in pregnancy: A research protocol for critical analysis of risk factors, maternofoetal outcomes and evaluation of diagnostic methods in a third-category health facility, Cameroon

INTRODUCTION

Hypocalcaemia in pregnancy remains a major health issue, particularly in the developing world where daily calcium intakes are suboptimal. This electrolyte imbalance can lead to severe maternofoetal and childhood consequences. Calcium supplementation, amongst others, contributes significantly to meeting calcium demands in pregnancy. With ionised calcaemia as the gold standard for diagnosis, total calcaemia and albumin-corrected calcaemia in other pathological states have been found to overestimate the burden of hypocalcaemia. The main objectives of this study are to describe the blood calcium level (total, albumin corrected, and ionised calcaemia) and associated maternofoetal outcomes while identifying determinants of calcium supplementation and ionised hypocalcaemia. This study will also evaluate the sensitivity and specificity of albumin corrected calcaemia as a diagnostic tool for hypocalcaemia (ionised calcaemia as the gold standard) among pregnant women in the Nkongsamba Regional Hospital, Cameroon.

METHODS

Our study will target a total of 1067 term pregnant women who shall be included consecutively into the study as they arrive the maternity of the Nkongsamba Regional Hospital for their last antenatal care visit. Data shall be collected using a semi-structured interview-administered questionnaire and blood samples collected for total plasma calcium, albumin and serum ionized calcium assays. Additional data will be collected at birth (maternal and foetal variables; foetal outcomes evaluated as secondary outcomes). Total calcaemia and albuminemia shall be measured by atomic absorption spectrophotometry, while ionised calcaemia will be measured by ion-selective electrode potentiometry(using MSLEA15-H electrolyte analyzer) per standard BIOLABO and MSLEA15 protocols, respectively. Data will be analysed using the statistical softwares epi-Info version 7.2.2.16 and STATA version 16.

EXPECTED RESEARCH OUTCOME

This study will present a more precise estimate of the burden of hypocalcaemia in late pregnancy as well as identify and analyse the different factors associated with calcium supplementation and ionised hypocalcaemia among term pregnant women in a developing world setting. Maternofoetal outcomes associated with hypocalcaemia will be determined as well as the sensitivity and specificity of total and albumin-corrected calcaemia in diagnosing hypocalcaemia. Our findings will contribute significantly to designing or strengthening interventions to control this electrolyte imbalance.

Associations between maternal calcium intake from diet and supplements during pregnancy and the risk of preterm birth in a Chinese population

BACKGROUND/OBJECTIVES

Preterm birth is a global public health priority related to maternal nutrition. The effect of maternal calcium intake during pregnancy on preterm birth is inconclusive and data is lacking in China. We aimed to estimate the role of calcium intake from diet and supplements on preterm birth in the Chinese population.

METHODS

We used data of 7195 women from a large-scale cross-sectional study in Northwest China. Dietary intake was evaluated via a validated food frequency questionnaire, and other information was collected by a structured questionnaire. Generalized estimating equation models were used to estimate the relationship between calcium intake and preterm birth.

RESULTS

Inadequate dietary calcium intake was universal in our population (85.9%), and no association was found between daily dietary calcium intake and preterm birth. Maternal calcium supplementation was significantly associated with reduced risk of preterm birth (OR 0.72, 95% CI 0.60, 0.87, P = 0.001), particularly among women who commenced calcium supplementation in the second and third trimester of pregnancy with longer duration (OR 0.62, 95% CI 0.42, 0.91, P = 0.015). Higher daily calcium intake from supplements was linked with lower preterm birth risk (every 100 mg increase: OR 0.87, 95% CI 0.79, 0.96, P = 0.004). There is a negative association between daily total calcium intake and preterm birth among calcium supplement users (every 100 mg increase: OR 0.91, 95% CI 0.84, 0.97, P = 0.007).

CONCLUSIONS

In conclusion, appropriate calcium supplementation during pregnancy could be beneficial in the prevention of preterm birth, and it might be suitable for implementing in low calcium intake areas of China.

Association of antenatal vitamin B complex supplementation with neonatal vitamin B12 status: evidence from a cluster randomized controlled trial

PURPOSE

Evidence about the effect of maternal vitamin B₁₂ supplementation on offspring's vitamin B₁₂ status is limited. The present interventional study sought to evaluate the association of antenatal vitamin B complex supplementation with neonatal vitamin B₁₂ status.

METHODS

In an ongoing cluster randomized controlled trial conducted in three rural counties in northwest China, pregnant women < 20 weeks of gestation were randomized to three treatment groups: blank control, iron supplements, or vitamin B complex supplements. All women were administered folic acid supplements during the periconceptional period. In a sub-study, we collected cord blood samples of 331 participants from the control or vitamin B complex groups in the Xunyi county from January 2017 to December 2017. Plasma concentrations of folate, vitamin B₁₂, and homocysteine were measured. Linear mixed models with a random intercept for cluster were used to compare biochemical indexes between groups after controlling for covariates.

RESULTS

Compared with newborns whose mothers were in the control group, newborns of the vitamin B complex-supplemented women had significantly higher cord plasma vitamin B₁₂ (P = 0.001) and lower homocysteine concentrations (P = 0.043). The association of antenatal vitamin B complex supplementation with cord blood vitamin B₁₂ concentrations appeared to be more pronounced among newborns with high folate status than those with low folate status (P_interaction = 0.060).

CONCLUSIONS

Maternal vitamin B complex supplementation during pregnancy was associated with better neonatal vitamin B₁₂ status in rural northwest China.

Prospects for improving future mental health of children through prenatal maternal micronutrient supplementation in China

Prenatal micronutrients in pregnant women's diets, including supplements, have an essential role in fetal brain development and may reduce the risk of mental disorders in offspring. Folic acid, vitamin D, omega-3 fatty acids, and choline have been investigated for this purpose. Folic acid supplementation throughout pregnancy has well-established positive effects. Vitamin D, administered to the mother before birth or to the newborn, has also been shown to reduce the risk of neurodevelopmental disorders. Omega-3 fatty acids during pregnancy have a more uncertain role, with recent trials questioning a beneficial effect on cognition and attention deficit disorder, despite positive effects on prematurity and neonatal wheezing prevention. Choline supplementation is associated with positive effects on cognition and behavior, including early behaviors associated with the development of autism and schizophrenia. There is no experience yet with COVID-19, but adverse effects on fetal brain development of most common coronaviruses are mitigated by higher choline levels. Maternal dietary supplementation of nutrients is a benign and inexpensive intervention in pregnancy to prevent life-long disability from mental illness. Use of dietary supplements in poorer, rural areas of China is below recommendations. Physicians, midwives, and public health officials in China can promote prenatal nutrient supplementation to reduce the future burden of mental illnesses that might be prevented before birth.

Folic acid rescues corticosteroid-induced vertebral malformations in chick embryos through targeting TGF-β signaling

Folic acid (FA) is routinely supplemented in the food of pregnant women or women planning a pregnancy, but whether FA exerts a positive effect on preventing fetal bone malformation remains obscure. In this study, we first exposed chick embryos with different concentrations of FA (1-10,000 pmol/egg) and studied vertebral mineralization and ossification through alcian blue and alizarin red as well as hematoxylin and eosin staining. Morphological measurements of the thoracic vertebral bodies demonstrated that 100 pmol/egg FA exhibited the tendency of shortening the growth plate, extended the ossification center, and increased the amount of Type I collagen. Second, we suggested that FA treatment promotes osteogenesis by demonstrating increased RUNX family transcription factor 2 (Runx2) and Osterix expressions in MC3T3-E1 and ATDC5 cells. Transforming growth factor-β (TGF-β) signaling was also upregulated by FA exposure, and addition of smad2/3 small interfering RNA knocks down FA-induced increased p-smad2/3, Runx2, and Osterix expression in vitro during chondrogenesis induction. Third, we employed dexamethasone (Dex), exposed chick embryos as an animal model of skeletal developmental retardation, to explore whether FA could rescue the loss of embryonic bone mass. Micro-computed tomography imaging showed that the addition of FA improved the reduction of bone mass in our model. Histological analysis of the vertebral bodies revealed that FA dramatically improved the delayed turnover of the zones of growth plate caused by Dex exposure. Immunofluorescence on the chick embryonic vertebrae and chondrocytes showed that FA supplementation upregulated the expression of TGF-β1, p-smad2/3, and improved Runx2 as well as Osterix expression in the Dex + FA group compared with the Dex group. Lastly, we found that supplementation with TGF-β1 (1 ng/egg) rescued bone mass loss caused by Dex as was also seen in FA exposure. Taken together these results, our data revealed that FA supplementation was able to rescue Dex exposure-induced inhibitive osteogenesis through targeting on the TGF-β signaling pathway.

Maternal dietary diversity during pregnancy and congenital heart defects: a case-control study

BACKGROUND/OBJECTIVES

Maternal diet is critical to fetal development. This study aimed to explore the association between maternal dietary diversity during pregnancy and congenital heart defects (CHD) in Chinese population.

METHODS

A hospital-based case-control study was conducted including 474 cases and 948 controls in Northwest China. We recruited eligible women waiting for delivery in the hospital and gathered their diets during the whole pregnancy by a validated food frequency questionnaire. According to the FAO Minimum Dietary Diversity for Women (MDD-W) guideline, the participants were categorized into "inadequate dietary diversity score (DDS)" (DDS < 5) and "adequate DDS" (DDS ≥ 5) groups. The association between dietary diversity and CHD was estimated using the mixed logistic regression models.

RESULTS

Case mothers had a lower DDS during pregnancy than the controls (P < 0.001). The proportions of women consuming all the ten defined food groups were lower in the inadequate DDS group than in the adequate DDS group among both cases and controls (all P < 0.001). The prevalence of inadequate micronutrient intake was higher in the inadequate DDS group than in the adequate DDS group among both cases and controls (all P < 0.05). Women in the adequate DDS group had reduced risks of having fetuses with total CHD (OR = 0.62, 95% CI = 0.45-0.84) and ventricular septal defects (OR = 0.58, 95% CI = 0.38-0.88).

CONCLUSIONS

Adequate DDS during pregnancy might be associated with a lower risk of CHD in offspring. Efforts to promote dietary diversity during pregnancy need to be strengthened to reduce the prevalence of CHD in Chinese population.

Interventions to increase adherence to micronutrient supplementation during pregnancy: a protocol for a systematic review

Micronutrient supplementation during pregnancy has been shown to be a cost‐effective method to reduce the risk of adverse pregnancy and birth outcomes. However, one of the main barriers to the successful implementation of a micronutrient supplementation program in pregnancy is poor adherence. Our review will assess the effectiveness of interventions designed to increase adherence to micronutrient supplements in pregnancy. Following the Cochrane Collaboration Methodology, we will start by conducting the literature searches on Medline (via PubMed), Embase, Scopus, Web of Science, and Cochrane Library, in addition to sources of gray literature, to retrieve all the available relevant studies. We will include randomized controlled trials and nonrandomized studies with a control group, where participants are pregnant women taking any micronutrient supplements in the context of antenatal care globally. We will include studies with targeted interventions designed to improve adherence to micronutrient supplementation in pregnant women compared with (1) usual care or no intervention or (2) other targeted micronutrient adherence intervention. Abstract selection, data extraction, and risk of bias assessment (according to the type of studies) will be conducted by two independent reviewers. The pooled results will be reported using the standardized mean differences for continuous data, and odds ratio or risk ratio for dichotomous data. We will assess sources of heterogeneity and publication bias. By following this protocol, we will systematically assess and synthesize the existing evidence about interventions designed to increase adherence to micronutrient supplementation in pregnant women. Understanding which strategies are more effective to increase the consumption of micronutrient supplements during this critical stage of life will have significant implications for clinicians and policymakers involved in the delivery of prenatal micronutrient supplementation interventions.