Preconception care: nutritional risks and interventions

Preconception underweight and the risk of offspring congenital heart diseases in young pregnant women: Evidence from the China Birth Cohort Study

OBJECTIVE

Maternal obesity is a highly suggestive risk factor of offspring congenital heart diseases (CHD). However, the risk of offspring CHD associated with maternal underweight has rarely been mentioned. Therefore, this study aimed to explore the effect of preconception underweight on offspring CHD.

METHODS

From November 2017 to August 2021, 132 386 pregnant women were enrolled in a birth cohort study in China in early pregnancy, and completed follow-up until delivery (or miscarriage/termination). Offspring CHD was diagnosed by prenatal ultrasound examination in both live births and stillbirths. Log-binomial regression and restricted cubic spline were used to estimate the risk of offspring CHD associated with preconception body mass index (BMI). A generalized additive model was used to explore the modification effect of maternal age on the association between preconception BMI and offspring CHD.

RESULTS

A total of 129 096 pregnant women were included in the analysis. The incidence of CHD in the underweight, normal weight, overweight, and obesity groups were 117/17 313 (0.68%), 556/85 695 (0.65%), 128/19 936 (0.64%), 47/6152 (0.76%), respectively. Both underweight and obesity before pregnancy marginally increased the risk of offspring CHD. The association between preconception BMI and offspring CHD varied by maternal age, with low preconception BMI associated with a significantly higher risk of offspring CHD in women <24 years (RR 2.32, 95% CI: 1.07-5.01 for 17 vs 21 kg/m2).

CONCLUSION

Preconception underweight was associated with an increased risk of offspring CHD in young pregnant women. Therefore, weight gain is important to prevent offspring CHD, especially for young women with low preconception BMI.

Effect of preconception multiple micronutrients vs. iron-folic acid supplementation on maternal and birth outcomes among women from developing countries: a systematic review and meta-analysis

Background

Maternal malnutrition affects the somatic growth of the fetus and subsequent adverse events during infancy and childhood period. Though trials have been conducted on multiple micronutrient (MMN) supplements initiated during the preconception period, there is no collated evidence on this.

Materials and methods

We performed a systematic review of published trials with the application of Grading of Recommendations Assessment, Development, and Evaluation (GRADE). The searches were conducted until 30 September 2023. Meta-analysis was performed using Review Manager 5 software. The primary objective was to compare the effect of preconception MMN vs. iron-folic acid (IFA) supplementation on newborn anthropometric parameters at birth.

Results

Of the 11,832 total citations retrieved, 12 studies with data from 11,391 participants [Intervention = 5,767; Control = 5,624] were included. For the primary outcome, there was no significant difference in the birth weight [MD, 35.61 (95% CI, -7.83 to 79.06), p = 0.11], birth length [MD, 0.19 (95% CI, -0.03 to 0.42), p = 0.09], and head circumference [MD, -0.25 (95% CI, -0.64 to -0.14), p = 0.22] between the MMN and control groups. For all the secondary outcomes [except for small for gestational age (SGA) and low birth weight (LBW)], the difference between the MMN and control groups was not significant. The GRADE evidence generated for all the outcomes varied from "very low to moderate certainty."

Conclusion

A "very low certainty" of evidence suggests that MMN supplementation may not be better than routine IFA supplementation in improving newborn anthropometric parameters (weight, length, and head circumference). The adverse events resulting from the supplementation were not significant. We need better quality uniformly designed RCTs before any firm recommendation can be made.Systematic review registration: identifier (CRD42019144878: https://www.crd.york.ac.uk/prospero/#searchadvanced).

Digital preconception interventions targeting weight, diet and physical activity: A systematic review

AIM

Optimising preconception health increases the likelihood of conception, positively influences short- and long-term pregnancy outcomes and reduces intergenerational chronic disease risk. Our aim was to synthesise study characteristics and maternal outcomes of digital or blended (combining face to face and digital modalities) interventions in the preconception period.

METHODS

We searched six databases (PubMed, Cochrane, Embase, Web of Science, CINHAL and PsycINFO) from 1990 to November 2022 according to the PRISMA guidelines for randomised control trials, quasi-experimental trials, observation studies with historical control group. Studies were included if they targeted women of childbearing age, older than 18 years, who were not currently pregnant and were between pregnancies or/and actively trying to conceive. Interventions had to be delivered digitally or via digital health in combination with face-to-face delivery and aimed to improve modifiable behaviours, including dietary intake, physical activity, weight and supplementation. Studies that included women diagnosed with type 1 or 2 diabetes were excluded. Risk of bias was assessed using the Academy of Nutrition and Dietetics quality criteria checklist. Study characteristics, intervention characteristics and outcome data were extracted.

RESULTS

Ten studies (total participants n=4,461) were included, consisting of nine randomised control trials and one pre-post cohort study. Seven studies received a low risk of bias and two received a neutral risk of bias. Four were digitally delivered and six were delivered using blended modalities. A wide range of digital delivery modalities were employed, with the most common being email and text messaging. Other digital delivery methods included web-based educational materials, social media, phone applications, online forums and online conversational agents. Studies with longer engagement that utilised blended delivery showed greater weight loss.

CONCLUSION

More effective interventions appear to combine both traditional and digital delivery methods. More research is needed to adequately test effective delivery modalities across a diverse range of digital delivery methods, as high heterogeneity was observed across the small number of included studies.

Sleep characteristics in underweight young females across their menstrual cycles: A sleep-monitoring survey study with preliminary results

This study investigated the association between underweight and sleep in young females across their menstrual cycles. A lifestyle-monitoring survey was conducted among 38 female university students aged 18-24 years in Japan from January to December 2023. Sleep data from 28 participants were analysed. Participants were categorized into underweight (n = 10) and control (n = 18) groups based on a baseline body mass index cut-off of 18.5 kg m-2. Sleep parameters were assessed using a daily sleep questionnaire, sleep sensor mats, and urinary melatonin metabolites across their menstrual cycles. The results indicated no significant differences in sleep patterns between the underweight and control groups or menstrual cycle phases, as assessed using both the daily sleep questionnaire and the sleep sensor mats. However, underweight participants experienced more difficulty maintaining sleep during the follicular phase. Body mass index significantly correlated with sleep efficiency (rs = 0.52) and wake after sleep onset (rs = -0.56). While urinary melatonin metabolite levels did not differ significantly between the groups or menstrual cycle phases, decreased levels during the luteal phase were more prevalent in the underweight group (7 of 10 participants) than in the control group (3 of 13 participants). This study suggests an association between underweight and sleep quality, especially nocturnal awakening, in young females. These findings underscore the importance of considering sleep quality in the management of underweight young females to improve their overall health outcomes.

Preconception Care Interventions for Adolescents and Young Adults to Prevent Adverse Maternal and Child Health Outcomes: Protocol for an Evidence Gap Map

BACKGROUND

Preconception is the period before a young woman or woman conceives, which draws attention to understanding how her health condition and certain risk factors affect her and her baby's health once she becomes pregnant. Adolescence and youth represent a life-course continuum between childhood and adulthood, in which the prepregnancy phase lacks sufficient research.

OBJECTIVE

The aim of the study is to identify, map, and describe existing empirical evidence on preconception interventions that enhance health outcomes for adolescents, young adults, and their offspring.

METHODS

We will conduct an evidence gap map (EGM) activity following the Campbell guidelines by populating searches identified from electronic databases such as MEDLINE, Embase, CINAHL, and Cochrane Library. We will include interventional studies and reviews of interventional studies that report the impact of preconception interventions for adolescents and young adults (aged 10 to 25 years) on adverse maternal, perinatal, and child health outcomes. All studies will undergo title or abstract and full-text screening on Covidence software (Veritas Health Innovation). All included studies will be coded using the Evidence for Policy and Practice Information (EPPI) Reviewer software (EPPI Centre, UCL Social Research Institute, University College London). Cochrane Risk of Bias tool 2.0 and Assessing the Methodological Quality of Systematic Reviews-2 (AMSTAR-2) tool will be used to assess the quality of the included trials and reviews. A 2D graphical EGM will be developed using the EPPI Mapper software (version 2.2.4; EPPI Centre, UCL Social Research Institute, University College London).

RESULTS

This EGM exercise began in July 2023. Through electronic search, 131,031 publications were identified after deduplication, and after the full-text screening, 18 studies (124 papers) were included in the review. We plan to submit the paper to a peer-reviewed journal once it is finalized, with an expected completion date in May 2024.

CONCLUSIONS

This study will facilitate the prioritization of future research and allocation of funding while also suggesting interventions that may improve maternal, perinatal, and child health outcomes.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56052.

FIGO Preconception Checklist: Preconception care for mother and baby

The preconception period is a unique and opportunistic time in a woman's life when she is motivated to adopt healthy behaviors that will benefit her and her child, making this time period a critical "window of opportunity" to improve short- and long-term health. Improving preconception health can ultimately improve both fetal and maternal outcomes. Promoting health before conception has several beneficial effects, including an increase in seeking antenatal care and a reduction in neonatal mortality. Preconception health is a broad concept that encompasses the management of chronic diseases, including optimal nutrition, adequate consumption of folic acid, control of body weight, adoption of healthy lifestyles, and receipt of appropriate vaccinations. Use of the FIGO Preconception Checklist, which includes the key elements of optimal preconception care, will empower women and their healthcare providers to better prepare women and their families for pregnancy.

Combined effects of pre-pregnancy BMI and gestational weight gain on preterm birth: comparison between spontaneous and ART conception

BACKGROUND

Inappropriate pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) are both linked to preterm birth (PTB); however, which one plays a dominant role in PTB risk is not yet sure. We aimed to evaluate the combined effect of pre-pregnancy BMI and GWG on the risk of PTB in singleton pregnancies conceived both spontaneously and through assisted reproductive technology (ART).

METHODS

The data included all mothers (n = 17,540,977) who had a live singleton birth from the US National Vital Statistics System (NVSS) 2015-2019. Logistic regression models, quantile-g-computation, and generalized additive model were used to analyze the combined association of pre-pregnancy BMI and GWG with PTB.

RESULTS

The singleton PTB rate was significantly higher in ART pregnancies (11.5%) than in non-ART pregnancies (7.9%). When compared to those women with pre-pregnancy normal weight and GWG within Institute of Medicine (IOM) guidelines, the highest PTB risk was observed in non-ART women with pre-pregnancy underweight and GWG below IOM guidelines (aOR 2.56; 95% CI 2.53-2.60) and in ART women with pre-pregnancy obese and GWG below IOM guidelines (aOR 2.56; 95%CI 2.36-2.78). GWG dominated the combined effect with its joint effect coefficient of - 0.281 (P < 0.05) in non-ART women and - 0.108 (P < 0.05) in ART women.

CONCLUSIONS

Inappropriate GWG played a dominant role in increasing the risk of PTB in both non-ART and ART populations. Counseling regarding pre-pregnancy BMI and especially GWG appears to be even more crucial for pregnancies conceived via ART, given their impact on PTB.

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.

Development and validation of a self-management self-efficacy scale for premature birth prevention (SMSE-PBP) for women of childbearing age

BACKGROUND

This study aimed to develop and evaluate the validity and reliability of a self-management self-efficacy for premature birth prevention (SMSE-PBP) in women of childbearing age (WCA).

METHODS

Instrument development and validation were undertaken in three phases: conceptualization, item generation and evaluation of content validity, and evaluation of construct and concurrent validity and reliability. Data were analyzed using exploratory and second-order confirmatory factor analyses, and concurrent validity was examined using Pearson's correlation coefficients. The reliability was analyzed using omega hierarchical and Cronbach's ⍺.

RESULTS

Content validity was assessed by experts and cognitive interviews of WCA. The SMSE-PBP consists of a second-order 3-dimension and 10-factor scale with 60 items; therefore, the construct and concurrent validity of the SMSE-PBP were supported. The omega values were 0.93 for pre-pregnancy SMSE-PBP, 0.92 for pregnancy SMSE-PBP, and 0.94 for hospital SMSE-PBP. Cronbach's ⍺ was 0.88 for pre-pregnancy SMSE-PBP, 0.96 for pregnancy SMSE-PBP, and 0.96 for hospital SMSE-PBP.

CONCLUSIONS

The SMSE-PBP scale is valid and reliable for WCA; it is helpful for WCA and health professionals to assess women's SMSE-PBP and pre-pregnancy, pregnancy, or hospital SMSE-PBP. The next steps should include assessing the relationship with pregnancy health behaviors.

Double burden of malnutrition and associated factors among women of reproductive age in sub-Saharan Africa: a multilevel multinomial logistic regression analysis

BACKGROUND

Globally, malnutrition among women of reproductive age is on the rise and significantly contributing to non-communicable disease, deaths and disability. Even though the double burden of malnutrition (DBM) is a common problem among women in sub-Saharan Africa (SSA), there are limited studies examining the factors contributing to underweight, overweight, and obesity at the SSA level.

OBJECTIVE

To determine the factors associated with the DBM, and their relative magnitude, among women of reproductive age in SSA.

DESIGN

Cross-sectional study design.

SETTING

33 SSA countries.

PARTICIPANTS

240 414 women of reproductive age.

PRIMARY AND SECONDARY OUTCOME MEASURES

A multilevel multinomial logistic regression model was applied to identify factors associated with malnutrition. The adjusted relative risk ratio with 95% CI was used to declare the statistical significance of the association.

RESULTS

The pooled prevalence of underweight, overweight and obesity among women in SSA were 8.87%, 16.47% and 6.10%, respectively. Women who are from rural residence and smoke cigarettes were more likely to be underweight. Conversely, women between the age of 24-34 and 35-49, who have higher education, belong to a middle and rich household, are ever married, have high parity, use contraceptives, have media exposure and smoke cigarettes were more likely to be overweight and/or obese.

CONCLUSION

The findings of our study suggest that certain factors such as residence, education status, wealth, marital status, occupation, cigarette smoking, and contraceptive use have a significant assocation with malnutrition among women. Therefore, it is important for public health programs aimed at preventing the double burden of malnutrition to focus on these factors through comprehensive public awareness and cost-effective operational health interventions.

Characteristics of Global Data on Adolescent's Dietary Intake: A Systematic Scoping Review

Data on adolescents' dietary intake are essential to improve their diets and nutrition. However, the availability of (high-quality) data on adolescents' dietary intake is scarce with great global differences. We conducted a systematic scoping review to investigate the availability, characteristics, and gaps in global adolescent dietary data, following the Preferred Reporting Items for Systematic Reviews and Meta Analyses-Extension for Scoping Reviews checklist and guidelines (registered under PROSPERO no. 171170 https://www.crd.york.ac.uk/PROSPERO/). We included peer-reviewed and grey literature articles (2010 onwards) on the dietary intake of male and female adolescents (10-24 y). Studies from all countries and languages and including any information related to types of food consumed, diet composition, dietary diversity, or meal patterns were considered. We excluded studies with insufficient methodological information, unclear description of population, samples sizes <25, school-based data sets containing <6 schools, and studies that focused on pregnant or unhealthy study populations. Data, including year(s) of data collection, age, gender, sample size, dietary assessment methods, number of food items/groups, study design, location, and representativeness, were extracted. A total of 52,889 titles were identified and 722 articles, describing 1,322 data sets, were retained for analysis. Nationally representative, detailed dietary data for adolescents aged 10-24 y are still lacking, particularly in sub-Saharan Africa, South Asia, and low-income countries. Data quality and representativeness remain limited, highlighting the need for data disaggregation by age, gender, locality, comprehensive dietary information, and broader geographic coverage. A notable amount of data was available through grey literature, especially in data-scarce countries. The study underscores the importance of addressing adolescent nutrition, emphasizing the urgent need for more robust, accessible, and representative data on adolescents' dietary intake to support effective nutritional efforts.

Triple Burden of Malnutrition among Children in India: Current Scenario and the Way Forward

The triple burden of malnutrition (undernutrition, overnutrition and micronutrient deficiency) or TBM among under-five (U5) children is an increasingly recognised public health challenge. A literature search was conducted to identify studies published from 1976 to 2022, which had focused on information regarding different factors of child malnutrition. The findings were analysed and contextualised from policy and programmatic perspective. There is a high burden of various forms of malnutrition in India. Insufficient dietary intake and illnesses are immediate and most common causes of triple burden of malnutrition (TBM): (undernutrition, overnutrition and micronutrient deficiency). The other key factors associated with the TBM are lifestyle, nutritional practices, unsafe water, food insecurity, lack of sanitation & basic hygiene, unhealthy feeding & caring practices, inadequate health infrastructure, and suboptimal implementation of government nutrition schemes etc. There is scientific evidence that TBM has long term consequences on physical and mental development of children and has high cost to any society. The situation of TBM persists inspite of multiple ongoing government programs to tackle these challenges. The health service provision needs to move from the first 1,000 d to the first 3,000 d as well as focus on the interventions aimed at early childhood development. Multi-sectoral interventions through Anganwadi centres and schools (through education department) need to be conducted. The public health programs and primary healthcare services need to be realigned and health interventions should be implemented along with tackling social determinants of health and sustained community engagement and participation. Tackling TBM should be made a political priority. The life cycle approach for healthier children and society needs to be fully implemented.

Investigating the pathways from preconception care to preventing maternal, perinatal and child mortality: A scoping review and causal loop diagram

In recent years, there has been a growing recognition that developing preconception care provides an opportunity to significantly reduce maternal and child mortality and morbidity. This involves targeting multiple risk factors through a large array of medical, behavioural and social interventions. In this study, we created a Causal Loop Diagram (CLD) to describe several pathways by which a set of preconception interventions may lead to women's improved health and better pregnancy outcomes. The CLD was informed by a scoping review of meta-analyses. It summarises evidence on the outcomes and interventions related to eight preconception risk factors. The authors reviewed literature from two databases (PubMed and Embase) and used the framework developed by Arksey and O'Malley. The CLD includes 29 constructs categorised into five different levels (mortality, causes of death, preconception risk factors, intermediate factors, interventions or policies). The model indicates interconnections between five sub-systems and highlights the role of preventing early and rapidly repeated pregnancies, as well as optimising women's nutritional status in the preconception period. It also shows the prevention of preterm birth as a privileged route for lowering child mortality and morbidity. The CLD demonstrates the potential benefits of strategies that address multiple preconception risk factors simultaneously and can be used as a tool to promote the integration of preconception care into efforts to prevent maternal and child mortality. With further improvements, this model could serve as a basis for future research on the costs and benefits of preconception care.

Drivers of malnutrition among late adolescent and young women in rural Pakistan: a cross-sectional assessment of the MaPPS trial

OBJECTIVE

This study aimed to characterise the burden of malnutrition and assess how underlying determinants at the structural and intermediary levels contributed to malnutrition among late adolescent and young women in rural Pakistan.

DESIGN

Cross-sectional enrolment data assessment.

SETTING AND PARTICIPANTS

This study was conducted using data from adolescent and young women (n=25 447) enrolled in the Matiari emPowerment and Preconception Supplementation Trial, collected from June 2017 to July 2018 in Matiari District, Pakistan. The WHO-based cut-offs were applied to anthropometric measures to estimate body mass index (BMI) categories (underweight, overweight, obese) and stunting. Hierarchical models were generated to evaluate the association between the determinants with BMI categories and stunting among late adolescent girls and young women, respectively.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcomes of interest were BMI categories and stunting. Explanatory variables included measures of socioeconomic status, education, occupation, health, well-being, food security, empowerment and food practices.

RESULTS

Regardless of age group, the prevalence of underweight was high (36.9%; 95% CI 36.3% to 37.5%). More late adolescent girls were underweight, while more young women were overweight/obese (p<0.001). Stunting affected 9.2% (95% CI 8.9% to 9.6%) of participants, of which 35.7% were additionally underweight and 7.3% overweight/obese. Compared with those in the normal weight category, those underweight were more likely to be impoverished and less empowered. Those overweight/obese were more likely to be from a higher wealth quintile and food secure. Increased education level and food security were associated with reductions stunting risk.

CONCLUSIONS

This study informs the data gap and need for comprehensive research on adolescent nutritional status. Findings suggest factors related to poverty played an important, underlying role in undernutrition among participants. Commitment to improving the nutritional status of all adolescent and young women in Pakistan will be critical given the observed burden of malnutrition.

TRIAL REGISTRATION NUMBER

NCT03287882.

Vitamins and minerals, education, and self-care need during preconception to 1000 days of life in Southeast Asia: An expert panel opinion

Addressing maternal malnutrition and its drivers is paramount in Southeast Asia. This article summarizes the key clinical learnings and evidence-based opinions from the experts to understand the need for vitamins and minerals supplementation, education, and self-care from preconception to the first 1000 days of life, which warranted further attention since COVID-19 pandemic. Evidence describing the importance of vitamins and minerals during preconception, pregnancy, and lactation stages was identified using literature databases. A pre-meeting survey was conducted to determine the current practices and challenges in Southeast Asia. Based on the literature review and clinical experience, experts defined the topics, and an online meeting was held on 13th July 2021. During the meeting, nine experts from Southeast Asia provided evidence-based opinion on the vitamins and minerals supplementation, education, and self-care need during preconception, pregnancy, and lactation stages. The expert opinions underpin maternal malnutrition as a prevalent issue and discuss appropriate interventions and prevention strategies for women in Southeast Asia. The recent pandemic further impacted nutrition status, pregnancy, and neonatal health outcomes. The expert panel emphasized a need to improve existing inadequacies in education, self-care, and social support, and discussed the role of policymakers in addressing the barriers to dietary changes. As inadequacies in regular vitamins and minerals supplementation, education, and self-care for women of reproductive age implicate maternal and child health outcomes, there is an urgent need for addressing malnutrition concerns in this population. Thus, a strong partnership between policymakers, healthcare professionals, and other relevant sectors is required.

Long term association between of maternal preconception hemoglobin and anemia and child health and development in Vietnam

BACKGROUND

The long-term association between preconception maternal hemoglobin (Hb) concentrations and child health and development is unclear.

OBJECTIVE

We examined associations between maternal preconception Hb concentrations and anemia with: a) birth outcomes (weight, length, preterm, gestational age, small-for-gestational-age); b) child Hb at 3 mo, 6 mo, 12 mo, and 24 mo; c) motor and mental development at 12 mo and 24 mo (Bayley scales for infant development) and cognitive functioning at 6-7y (Wechsler Intelligence Scale for Children).

METHODS

We used data from a randomized controlled trial (PRECONCEPT) conducted in Vietnam. Over 5000 women who were intending to conceive were recruited and offspring were prospectively followed from birth (n=1599) through 6-7y (n=1318). Multivariable linear and logistic regressions were used to assess the association between preconception Hb or anemia (Hb < 11g/dL) on child health and development outcomes, adjusted by supplementation group (tested for interactions) and confounding at maternal, child and household levels.

RESULTS

At preconception enrollment, 20% of the women were anemic. Maternal preconception Hb was positively associated with child Hb at 3 mo (0.06; 95% CI: 0.01,0.12), 6 mo (0.08; 95% CI: 0.03,0.13), 12 mo (0.10; 95% CI: 0.04-0.15) and 24 mo (0.07; 95% CI: 0.02,0.12). Likewise, maternal preconception Hb was associated with reduced risk of child anemia at 6mo (0.89; 95% CI: 0.81-0.98), 12 mo (0.81; 95% CI: 0.74-0.89) and 24 mo (0.87; 95% CI: 0.79-0.95). Maternal preconception anemia was negatively associated with cognition (-1.64; 95% CI: -3.09, -0.19) and language development (-1.61; 95% CI: -3.20, -0.03) at 24mo. Preconception Hb was not associated with birth outcomes or cognitive outcomes at 6-7y.

CONCLUSION

Maternal preconception Hb was associated with child Hb across the first 1000 days of life. However, preconception Hb was not a significant predictor of birth outcomes or cognitive outcomes at 6-7y in this cohort from Vietnam.

Development, Implementation, and Process Evaluation of Bukhali: An Intervention from Preconception to Early Childhood

The Healthy Life Trajectories Initiative, an international consortium developed in partnership with the World Health Organization, is addressing childhood obesity from a life-course perspective. It hypothesises that an integrated complex intervention from preconception, through pregnancy, infancy and early childhood, will reduce childhood adiposity and non-communicable disease risk, and improve child development. As part of the Healthy Life Trajectories Initiative in South Africa, the Bukhali randomised controlled trial is being conducted with 18–28-year-old women in Soweto, where young women face numerous challenges to their physical and mental health. The aims of this paper were to describe the intervention development process (including adaptations), intervention components, and process evaluation; and to highlight key lessons learned. Intervention materials have been developed according to the life-course stages: preconception (Bukhali), pregnancy (Bukhali Baby), infancy (Bukhali Nana; birth—2 years), and early childhood (Bukhali Mntwana, 2–5 years). The intervention is delivered by community health workers, and includes the provision of health literacy resources, multi-micronutrient supplementation, in-person health screening, services and referral, nutrition risk support, SMS-reminders and telephonic contacts to assist with behaviour change goals. A key adaption is the incorporation of principles of trauma-information care, given the mental health challenges faced by participants. The Bukhali process evaluation is focussing on context, implementation and mechanisms of impact, using a mixed methods approach. Although the completion of the trial is still a number of years away, the documentation of the intervention development process and process evaluation of the trial can provide lessons for the development, implementation, and evaluation of such complex life-course trials.

Burden and Trend of Macrosomia and Large-for-Gestational-Age Neonates Attributable to High Pre-Pregnancy Body Mass Index in China, 2013-2017: A Population-Based Retrospective Cohort Study

Background: The world is transitioning to an obese future, but few studies have measured the burden of increased maternal body mass index (BMI) on pathological fetal overgrowth, especially the trends in this burden and its heterogeneity in populations with different characteristics. Methods: A population-based retrospective cohort study was conducted with 7,998,620 Chinese females who had participated in the National Free Pre-Pregnancy Check-ups Project and became pregnant during 2013-2017. The proportions of macrosomic and LGA neonates attributable to high BMI (population attributable fraction, PAF) and annual percent change of yearly PAFs were estimated. Results: We found that the burden of macrosomic and LGA (large-for-gestational-age) neonates attributable to high pre-pregnancy BMI increased among Chinese females with planned pregnancies during 2013-2017. The PAF of macrosomia attributable to high BMI increased from 3.16% (95% confidence interval: 2.97-3.35%) to 7.11% (6.79-7.42%) by 23.60% (16.76-30.85%) annually, and the PAF of LGA increased from 2.35% (2.21-2.48%) to 5.00% (4.79-5.21%) by 21.98% (16.14-28.11%) annually. Our study identified that participants with disadvantaged socioeconomic status (including those without higher education, living in provinces with GDP per capita < 40,000 CNY, tier IV, and tier V cities) and residing in northern and southwestern China were at high risk of a rapidly expanding burden. Conclusions: Government authorities should control pre-pregnancy BMI through nationwide intervention programs and direct more resources to focus on the unfair burden on females with disadvantaged socioeconomic status.

Effect of a theory-based nutrition education intervention during pregnancy through male partner involvement on newborns' birth weights in Southwest Ethiopia. A three-arm community based Quasi-Experimental study

BACKGROUND

Low birth weight is one of the most serious public health issues affecting newborns, with estimates ranging from 15% to 20% of all births worldwide. According to the Ethiopian demographic health survey report, the prevalence of Low Birth Weight rose from 11% in 2011 to 13% in 2016. The high proportion of birth weight in Ethiopia is hypothesized to be due to inadequate maternal diet which is associated with poor nutrition education during pregnancy. This study aimed to assess the effect of theory-based nutrition education during pregnancy through male partner involvement on birth weight in rural parts of the southwest Ethiopia.

STUDY DESIGN

A community-based quasi-experimental study was conducted.

METHODS

A total of 403 pregnant women were selected from 22 rural kebeles of Illu Aba Bor Zone, Southwest Ethiopia from June to December 2019. Participants were assigned to one of the three study arms: Couple group:-husband and wife received nutrition education together, women alone:-pregnant women received the nutrition education alone and control group:-received the routine care during Antenatal care. The nutrition education was guided by theory of planned behavior. Monthly home visits were made to the pregnant women in the intervention groups and leaflets with key counseling messages were distributed to each woman in the intervention arms. A structured interviewer-administered questionnaire was used to collect the data. A qualitative 24-h dietary recall was used to assess dietary data, and the Mid-Upper Arm Circumference was used to assess nutritional status. Birth weight was measured within 24 hours of birth. Analysis of variance, linear mixed-effects model, and mediation analysis were used to assess effect of the intervention on birth weight.

RESULTS

A higher proportion of the newborns in the control group had low birth weight as compared to the couple group and the women alone group (18.1% vs 7.0% vs 11.5%, p = 0.037) respectively. The mean birth weight of babies born to women from the couple group was 0.42 kg greater than that of newborns born to women in the comparison group (3.34 vs 2.92 kg, p< 0.001). The linear mixed effect model showed that the average birth weight of babies born from women in the couple group was 0.40 kg higher than that of the control group (β = 0.400, P<0.001). The direct effect of the intervention on birth weight of babies born from women in the couple group was 0.23 (β = 0.227, P<0.001) whereas the indirect effect mediated by maternal dietary diversity practice was 0.18 (β = 0.178, P<0.001), accounting for 43.9% of the total effect of the intervention.

CONCLUSION

The involvement of males and the application of the theory of planned behavior in nutrition education interventions during pregnancy resulted in improved birth weight. Maternal dietary diversity mediated the effect of nutrition education on birth weight. The findings highlight the implication of improving pregnant women's nutrition education through male involvement and the application of theories to improve birth weight.

Multiple modifiable maternal, household and health service factors are associated with maternal nutrition and early breastfeeding practices in Burkina Faso

Low coverage of effective nutrition interventions in many high-burden countries, due to service provision and demand factors, result in poor uptake of recommended practices and nutrition outcomes. We examined the factors that influence maternal nutrition and early breastfeeding practices and determined the extent that the key factors could improve these practices in two regions in Burkina Faso. We used household survey data among pregnant (n = 920) and recently delivered women (n = 1840). Multivariable regression analyses were conducted to identify the determinants of a diverse diet and iron-folic acid (IFA) supplement consumption, weight monitoring during pregnancy and early initiation of breastfeeding (EIBF). Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal conditions of interventions that address the modifiable determinants. During pregnancy, 21% of women achieved minimum diet diversity (MDD-W), 70% consumed 90+ IFA tablets and 65% were weighed 4+ times; EIBF was 40%. Nutrition knowledge was associated with MDD-W (odds ratio [OR]: 3.2), 90+ IFA (OR: 1.5) and EIBF (OR: 1.9). Positive social norms and family support were associated with 90+ IFA (OR: 1.5). Early and 4+ ANC visits were associated with 90+ IFA (OR: 1.5 and 10) and 4+ weight monitoring (OR: 6.2). Nutrition counselling was associated with 90+ IFA (OR: 2.5) and EIBF (OR: 1.5). Under optimal programme conditions, 41% of women would achieve MDD-W, 93% would consume 90+ IFA, 93% would be weighed 4+ times and 57% would practice EIBF. Strengthening the delivery and uptake of interventions targeted at these modifiable factors has the potential to improve maternal nutrition practices.

Impact of prepregnancy body mass index on adverse pregnancy outcomes: analysis from the Longitudinal Indian Family hEalth cohort study

BACKGROUND

Both high and low maternal prepregnancy body mass index can lead to suboptimal fetal growth and risk of pregnancy complications. In developed countries, nearly half of all women of childbearing age are either overweight or obese, and most data linking maternal body mass index and adverse pregnancy complications are limited to these populations.

OBJECTIVE

This study aimed to prospectively evaluate the relationships between prepregnancy body mass index and adverse pregnancy outcomes using the Longitudinal Indian Family hEalth (LIFE) study.

STUDY DESIGN

We modeled the relationships between prepregnancy body mass index and adverse pregnancy outcomes such as low birthweight, preterm birth, cesarean delivery, intrauterine growth restriction, miscarriage, and fetal death among 675 women aged 15 to 35 years with singleton pregnancies in the Longitudinal Indian Family hEalth study, a population-based prospective pregnancy cohort study conducted in Telangana, India. Prepregnancy body mass index was calculated as weight in kilograms divided by height in meters squared and was classified into 4 categories using the World Health Organization recommendations for Asian adults. Prepregnancy body mass index was assessed at a mean of 12.3 months before pregnancy. Odds ratios and 95% confidence intervals of adverse pregnancy outcomes were modeled and adjusted for confounders.

RESULTS

Obese women had a 3-fold increased risk of cesarean delivery (odds ratio, 3.13; 95% confidence interval, 1.56-6.29) compared with normal-weight women. Those who were overweight also had a marginally increased risk of cesarean delivery, albeit not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.61-2.24). Underweight women had a modestly increased risk of low birthweight, compared with normal-weight women (odds ratio, 1.12; 95% confidence interval, 0.71-1.77), although results were not significant. Conversely, obese (odds ratio, 0.71; 95% confidence interval, 0.28-1.77) and overweight (odds ratio, 0.61; 95% confidence interval, 0.24-1.51) women had a marginally decreased risk of low birthweight.

CONCLUSION

Our data suggest that women with elevated prepregnancy body mass index may have a higher risk of adverse pregnancy outcomes, especially cesarean delivery. Although this study has limited generalizability, our findings are generalizable to rural to periurban regions of India. Further studies exploring the translatability of these findings to other populations are needed. In addition, targeted prepregnancy intervention studies and programs that include counseling on optimization of preconception health and lifestyle modification for improvement of subsequent pregnancy outcomes among overweight and obese women are needed.

Impact of a package of health, nutrition, psychosocial support, and WaSH interventions delivered during preconception, pregnancy, and early childhood periods on birth outcomes and on linear growth at 24 months of age: factorial, individually randomised controlled trial

OBJECTIVE

To determine the effect of integrated and concurrent delivery of health, nutrition, water, sanitation and hygiene (WaSH), and psychosocial care interventions during the preconception period alone, during pregnancy and early childhood, and throughout preconception, pregnancy, and early childhood on birth outcomes and linear growth at 24 months of age compared with routine care.

DESIGN

Individually randomised factorial trial.

SETTING

Low and middle income neighbourhoods of Delhi, India.

PARTICIPANTS

13 500 women were randomised to receive preconception interventions (n=6722) or routine care (n=6778). 2652 and 2269 pregnant women were randomised again to receive pregnancy and early childhood interventions or routine care. The analysis of birth outcomes included 1290 live births for the preconception, pregnancy, and early childhood interventions (group A), 1276 for the preconception intervention (group B), 1093 for the pregnancy and early childhood interventions (group C), and 1093 for the control (group D). Children aged 24 months by 30 June 2021 were included in the 24 month outcome analysis (453 in group A, 439 in B, 293 in C, and 271 in D).

INTERVENTIONS

Health, nutrition, psychosocial care and support, and WaSH interventions were delivered during preconception, pregnancy, and early childhood periods.

MAIN OUTCOME MEASURES

The primary outcomes were low birth weight, small for gestational age, preterm, and mean birth weight. At 24 months, the outcomes were mean length-for-age z scores and proportion stunted. Three prespecified comparisons were made: preconception intervention groups (A+B) versus no preconception intervention groups (C+D); pregnancy and early childhood intervention groups (A+C) versus routine care during pregnancy and early childhood (B+D) and preconception, pregnancy, and early childhood interventions groups (A) versus control group (D).

RESULTS

The proportion with low birth weight was lower in the preconception intervention groups (506/2235) than in the no preconception intervention groups (502/1889; incidence rate ratio 0.85, 98.3% confidence interval 0.75 to 0.97; absolute risk reduction -3.80%, 98.3% confidence interval -6.99% to -0.60%). The proportion with low birth weight was lower in the pregnancy intervention groups (502/2096) than in the no pregnancy intervention groups (506/2028) but the upper limit of the confidence interval crossed null effect (0.87, 0.76 to 1.01; -1.71%, -4.96% to 1.54%). There was a larger effect on proportion with low birth weight in the group that received interventions in the preconception and pregnancy periods (267/1141) compared with the control group (267/934; 0.76, 0.62 to 0.91; -5.59%, -10.32% to -0.85%). The proportion stunted at 24 months of age was substantially lower in the pregnancy and early childhood intervention groups (79/746) compared with the groups that did not receive these interventions (136/710; 0.51, 0.38 to 0.70; -8.32%, -12.31% to -4.32%), and in the group that received preconception, pregnancy, and early childhood interventions (47/453) compared with the control group (51/271; 0.49, 0.32 to 0.75; -7.98%, -14.24% to -1.71%). No effect on stunting at 24 months was observed in the preconception intervention groups (132/892) compared with the no preconception intervention groups (83/564).

CONCLUSIONS

An intervention package delivered during preconception, pregnancy, and early childhood substantially reduced low birth weight and stunting at 24 months. Pregnancy and early childhood interventions alone had lower but important effects on birth outcomes and 24 month outcomes. Preconception interventions alone had an important effect on birth outcomes but not on 24 month outcomes.

TRIAL REGISTRATION

Clinical Trial Registry-India CTRI/2017/06/008908.

Non-Linear and Sex-Specific Effect of Maternal Pre-Pregnancy BMI on Emotional and Behavioral Development of Preschool Children: A Population-Based Cohort Study

(1) Background: The aim was to examine the non-linear and sex-specific outcomes of maternal pre-pregnancy BMI on emotional and behavioral development of preschool children; (2) Methods: This study was based on the China-Anhui Birth Cohort (C-ABCS), including 3648 mother-child pairs. Maternal pre-pregnancy BMI was calculated from the maternal pre-pregnancy height and weight measured at the first antenatal checkup. Main caregivers completed the Strengths and Difficulties Questionnaire (SDQ) to assess children's preschool emotional and behavioral development. A restricted cubic spline model was drawn using Stata version 15.1 to analyze the association between maternal pre-pregnancy BMI and preschoolers' SDQ scores by sex; (3) Results: Among boys, maternal pre-pregnancy underweight was associated with the increased risk of conduct problems and pro-social behaviors, and pre-pregnancy overweight/obesity related with the increased risk of peer problems. Interestingly, when maternal pre-pregnancy BMI was between 18.50 kg/m² and 18.67 kg/m², boys had the increased risk of conduct problems. When pre-pregnancy BMI was between 18.50 kg/m² and 19.57 kg/m², boys had the increased risk of pro-social problems. No significant associations were observed; (4) Conclusions: A non-linear effect of maternal pre-pregnancy BMI on emotional and behavioral development has been found in preschool boys. In particular, pre-pregnancy normal weight may still affect boys' emotional and behavioral development.

Preconception and periconception interventions to prevent low birth weight, small for gestational age and preterm birth: a systematic review and meta-analysis

Background

Low birth weight (LBW), including preterm birth (PTB) and small for gestational age (SGA), contributes a significant global health burden. We aimed to summarise current evidence on the effect of preconception and periconception interventions on LBW, SGA and PTB.

Methods

In this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane Library and WHO Global Index Medicus for randomised controlled trials and quasi-experimental studies published by 28 November 2020, which assessed interventions delivered in preconception and periconception or preconception and pregnancy. Primary outcomes were LBW, SGA and PTB. Studies were categorised by intervention type and delivery during preconception and periconception or during preconception and pregnancy. Estimates were pooled using fixed-effects or random-effects restricted maximum likelihood method meta-analyses. Quality of evidence for primary outcomes was assessed using the Grades of Recommendations, Assessment, Development and Evaluation approach.

Results

We included 58 studies. Twenty-eight studies examined nutrition interventions (primarily micronutrient or food supplementation). Thirty studies (including one reporting a nutrition intervention) provided health interventions (general preconception health, early adverse pregnancy outcome prevention, non-communicable disease and infectious disease prevention and management). One study assessed a social intervention (reproductive planning). Studies varied in terms of specific interventions, including delivery across preconception or pregnancy, resulting in few studies for any single comparison. Overall, the evidence was generally very uncertain regarding the impact of any intervention on LBW, SGA and PTB. Additionally, preconception and periconception nutritional supplementation containing folic acid was associated with reduced risk of birth defects (10 studies, N=3 13 312, risk ratio: 0.37 (95% CI: 0.24 to 0.55), I²: 74.33%).

Conclusion

We found a paucity of evidence regarding the impact of preconception and periconception interventions on LBW, SGA and PTB. Further research on a wider range of interventions is required to clearly ascertain their potential effectiveness.

Trial registration number

This review was prospectively registered with PROSPERO (CRD42020220915).

What a paediatric nephrologist should know about preeclampsia and why it matters

Preeclampsia is a protean syndrome causing a kidney disease characterised by hypertension and proteinuria, usually considered transitory and reversible after delivery. Its prevalence ranges from 3-5 to 10% if all the related disorders are considered. This narrative review, on behalf of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology, focuses on three reasons why preeclampsia should concern paediatric nephrologists and how they can play an important role in its prevention, as well as in the prevention of future kidney and cardiovascular diseases. Firstly, all diseases of the kidney and urinary tract diagnosed in paediatric age are associated with a higher risk of adverse pregnancy-related outcomes, including preeclampsia. Secondly, babies with low birth weights (small for gestational age, born preterm, or both) have an increased risk of developing the full panoply of metabolic diseases (obesity, hypertension, early-onset cardiopathy and chronic kidney disease) and girls are at higher risk of developing preeclampsia when pregnant. The risk may be particularly high in cases of maternal preeclampsia, highlighting a familial aggregation of this condition. Thirdly, pregnant teenagers have a higher risk of developing preeclampsia and the hypertensive disorders of pregnancy, and should be followed up as high risk pregnancies. In summary, preeclampsia has come to be seen as a window on the future health of both mother and baby. Identification of subjects at risk, early counselling and careful follow-up can contribute to reducing the high morbidity linked with this disorder.

Prevalence of preconception risk factors for adverse pregnancy outcome among women from tribal and non-tribal blocks in Nashik district, India: a cross-sectional study

BACKGROUND

Although critical, the preconception phase in women's lives is comparatively ignored. The presence of some risk factors during this phase adversely affects the wellbeing of the woman and the pregnancy outcome. The study objectives were to measure the prevalence of various known risk factors for adverse pregnancy outcome in the preconception period of women and their comparison between blocks.

METHODS

This was a community-based cross-sectional study in two tribal and two non-tribal blocks each in Nasik district, Maharashtra, India. The study included married women desiring to conceive within 1 year. Trained Accredited Social Health Activists (field level health worker) collected information from women using a validated interview schedule through house-to-house visits and obtained women's anthropometric measurements in a standard manner. The study assessed the presence of 12 documented risk factors.

RESULTS

The study enlisted 7875 women desiring pregnancy soon. The mean age of women was 23.19 (± 3.71) years, and 16% of them were adolescents. Women's illiteracy was higher in tribal areas than non-tribal (p < 0.001). About two-thirds of women have at least one risk factor, and 40.0% have a single risk factor. The most common risk factor observed was no formal education (44.35%). The prevalence of selected risk factors was significantly higher among women from tribal areas. The mean BMI of women was 19.73 (± 3.51), and a higher proportion (40.5%) of women from tribal areas had BMI < 18.5. Despite being of high parity status (≥ 4), about 7.7% of women from the tribal area and 3% from non-tribal desired pregnancy. Tobacco and alcohol consumption was higher among tribal women. The majority of women consumed meals with family members or husbands. Protein and calorie intake of about 1.4% of women was less than 50% of the recommended daily allowance; however, most of them perceived to have abundant food.

CONCLUSIONS

Health risks, namely younger age, illiteracy, high parity, consumption of tobacco, low protein, and calorie intake, were quite prevalent, and the risks were significantly more among women from tribal areas. "Continuum of care" must comprise preconception care inclusive of Behavioral Change Communication, particularly for easily modifiable risk factors and specially for tribal women.

Relationships between Women's and Men's Modifiable Preconception Risks and Health Behaviors and Maternal and Offspring Health Outcomes: An Umbrella Review

Parental health before conception effects maternal and offspring health outcomes. Preconception care provides healthcare to prospective parents addressing modifiable preconception risks and health behaviors. This umbrella review aimed to consolidate evidence on women's and men's modifiable preconception risks or health behaviors associated with maternal and offspring health outcomes. MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, and PsycINFO were searched from March 4, 2010, to March 4, 2020. Eligible studies were systematic reviews or meta-analyses of observational studies examining associations between modifiable preconception risks or health behaviors and maternal and offspring health outcomes. Screening, data extraction, and methodological quality assessment (AMSTAR 2) occurred independently by two reviewers. Degree of overlap was examined. Findings were summarized for evidence synthesis. Twenty-seven systematic reviews were included. Modifiable preconception risks and health behaviors were identified across categories: body composition (e.g., overweight, obesity), lifestyle behaviors (e.g., caffeine, smoking), nutrition (e.g., micronutrients), environmental exposures (e.g., radiation), and birth spacing (e.g., short interpregnancy intervals). Outcomes associated with exposures affected embryo (e.g., embryonic growth), maternal (e.g., gestational diabetes mellitus), fetal/neonate (e.g., preterm birth), and child (e.g., neurocognitive disorders) health. For real-world practice and policy relevance, evidence-based indicators for preconception care should include body composition, lifestyle, nutrition, environmental, and birth spacing.

Adherence to Mediterranean Diet and Its Association with Maternal and Newborn Outcomes

Background: Pregnancy is a crucial stage in a woman’s life and can be affected by epigenetic and environmental factors. Diet also plays a key role in gestation. This study aimed to evaluate how a greater or lesser adherence to the Mediterranean Diet (MD) influences specific parameters of mother and newborn. Methods: After delivery, the women participating in the study answered a questionnaire: demographic information; anthropometric data (pre-pregnancy weight, height, and gestational weight gain); dietary habits information (adherence to MD before and during pregnancy, using the validated Mediterranean Diet Adherence Screener (MEDAS), quality of protein intake); pregnancy information (onset of complications, cesarean/vaginal delivery, gestational age at birth, birth weight, birth length); and clinical practitioner for personalized dietary patterns during pregnancy. Results: A total of 501 respondents have been included in the study, and 135 were excluded for complications. Women who followed the advice of clinical nutritionists showed better adherence to MD (p = 0.02), and the baby’s birth weight was higher (p = 0.02). Significant differences in gestational weight gain (p < 0.01) between groups with dissimilar diet adherence were demonstrated. Conclusion: Our data demonstrate a significant relationship between adherence to MD and birthweight.

Interconception Health: Improving Equitable Access to Pregnancy Planning

Challenges remain with the implementation of preconception care, as many women do not plan their pregnancies and clinicians do not initiate preconception consultations. However, the interconception period may present a more opportune time to address health issues that impact on pregnancy outcomes and may influence future conceptions. It is also an important time to focus on pregnancy complications that may influence a person's health trajectory. This review discusses the evidence pointing to a need for greater attention on interconception health and focuses on five areas of care that may be particularly important in affecting equitable access to good care before a subsequent pregnancy: interpregnancy intervals, contraception, weight, nutrition, and gestational diabetes follow-up. Several programs internationally have developed models of care for interconception health and this review presents one such model developed in the United States that explicitly seeks to reach vulnerable populations of women who may otherwise not receive preconception care.

The importance of nutrition in pregnancy and lactation: lifelong consequences

Most women in the United States do not meet the recommendations for healthful nutrition and weight before and during pregnancy. Women and providers often ask what a healthy diet for a pregnant woman should look like. The message should be “eat better, not more.” This can be achieved by basing diet on a variety of nutrient-dense, whole foods, including fruits, vegetables, legumes, whole grains, healthy fats with omega-3 fatty acids that include nuts and seeds, and fish, in place of poorer quality highly processed foods. Such a diet embodies nutritional density and is less likely to be accompanied by excessive energy intake than the standard American diet consisting of increased intakes of processed foods, fatty red meat, and sweetened foods and beverages. Women who report “prudent” or “health-conscious” eating patterns before and/or during pregnancy may have fewer pregnancy complications and adverse child health outcomes. Comprehensive nutritional supplementation (multiple micronutrients plus balanced protein energy) among women with inadequate nutrition has been associated with improved birth outcomes, including decreased rates of low birthweight. A diet that severely restricts any macronutrient class should be avoided, specifically the ketogenic diet that lacks carbohydrates, the Paleo diet because of dairy restriction, and any diet characterized by excess saturated fats. User-friendly tools to facilitate a quick evaluation of dietary patterns with clear guidance on how to address dietary inadequacies and embedded support from trained healthcare providers are urgently needed.

Recent evidence has shown that although excessive gestational weight gain predicts adverse perinatal outcomes among women with normal weight, the degree of prepregnancy obesity predicts adverse perinatal outcomes to a greater degree than gestational weight gain among women with obesity. Furthermore, low body mass index and insufficient gestational weight gain are associated with poor perinatal outcomes. Observational data have shown that first-trimester gain is the strongest predictor of adverse outcomes. Interventions beginning in early pregnancy or preconception are needed to prevent downstream complications for mothers and their children. For neonates, human milk provides personalized nutrition and is associated with short- and long-term health benefits for infants and mothers. Eating a healthy diet is a way for lactating mothers to support optimal health for themselves and their infants.

The Impact of the Quality of Nutrition and Lifestyle in the Reproductive Years of Women with PKU on the Long-Term Health of Their Children

A woman’s nutritional status before and during pregnancy can affect the health of her progeny. Phenylketonuria (PKU), a rare disorder causing high blood and brain phenylalanine (Phe) concentrations, is associated with neurocognitive disability. Lifelong treatment is mainly dietetic with a Phe-restricted diet, supplemented with a low-Phe protein substitute. Treatment adherence commonly decreases in adolescence, with some adults ceasing dietary treatment. In maternal PKU, elevated blood Phe is harmful to the fetus so a strict Phe-restricted diet must be re-established preconception, and this is particularly difficult to achieve. A woman’s reproductive years introduces an opportunity to adopt healthier behaviours to prepare for successful pregnancies and positive health outcomes for both themselves and their children. Several factors can influence the health status of women with PKU. Political, socioeconomic, and individual food and lifestyle choices affect diet quality, metabolic control, and epigenetics, which then pre-condition the overall maternal health and long-term health of the child. Here, we reflect on a comprehensive approach to treatment and introduce practical recommendations to optimize the wellbeing of women with PKU and the resultant health of their children.

Effectiveness of preconception care interventions in primary care: a systematic review protocol

Background

Pregnancy outcomes can be adversely affected by a range of modifiable risk factors, including alcohol consumption, smoking, obesity, drug use, and poor nutrition, during the preconception period. Preconception care (PCC) involves interventions that identify and seek to change behavioural, biomedical, and social risks present in reproductive-aged women and men. Primary care is well situated to offer PCC interventions but the effectiveness of these interventions is not clear.

Aim

To evaluate the effectiveness of primary care-based PCC delivered to reproductive-aged women and/or men to improve health knowledge, reduce preconception risk factors, and improve pregnancy outcomes.

Design & setting

A systematic review of primary care-based PCC.

Method

Ovid MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Scopus, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases will be searched for English language studies published between July 1999 and May 2021. For inclusion, the PCC intervention must be provided in a primary care setting and intervention recipients must be reproductive-aged women and/or men. All stages of screening and data extraction will involve a dual review. The Cochrane Risk of Bias 2 (RoB 2) for randomised controlled trials (RCTs) will be used to assess the methodological quality of studies. This protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) reporting guidelines.

Conclusion

Findings will determine the effectiveness of primary care-based preconception interventions delivered to reproductive-aged women and men on improving health knowledge, reducing risk factors, and improving pregnancy outcomes. Findings will be published in a peer-reviewed journal.

Perceptions and Practice of Preconception Care by Healthcare Workers and High-Risk Women in South Africa: A Qualitative Study

Preconception care is biomedical, behavioural, and social health interventions provided to women and couples before conception. This service is sometimes prioritised for women at high risk for adverse pregnancy outcomes. Evidence revealed that only very few women in Africa with severe chronic conditions receive or seek preconception care advice and assessment for future pregnancy. Thus, this study aimed to explore the perceptions and practice of preconception care by healthcare workers and high-risk women in Kwa-Zulu-Natal, South Africa. This exploratory, descriptive qualitative study utilised individual in-depth interviews to collect data from 24 women at high risk of adverse pregnancy outcomes and five healthcare workers. Thematic analysis was conducted using Nvivo version 12. Five main themes that emerged from the study include participants’ views, patients’ access to information, practices, and perceived benefits of preconception care. The healthcare workers were well acquainted with the preconception care concept, but the women had inconsistent acquaintance. Both groups acknowledge the role preconception care can play in the reduction of maternal and child mortality. A recommendation is made for the healthcare workers to use the ‘One key’ reproductive life plan question as an entry point for the provision of preconception care.

Pre-natal nutrition education: Health care providers' knowledge and quality of services in primary health care centres in Lagos, Nigeria

INTRODUCTION

A healthy and balanced diet is very important during pregnancy. By enhancing maternal nutritional status, healthcare providers can lower the risks of pregnancy complications and adverse birth outcomes.

OBJECTIVES

To assess the pre-natal nutrition knowledge and services rendered by healthcare providers in antenatal clinics at Primary Health care Centres in Lagos, Nigeria.

METHODOLOGY

This was a cross-sectional study carried out in June-September 2019. Self-administered questionnaires were used to collect data on nutritional knowledge from 391 nurses and midwives who provided pre-natal nutrition education. Direct observation with checklist was used to assess the nutrition education services at the ANC clinics and covered: adequacy of the venue, availability/use of nutrition education resources, education content and teaching strategies. EPi-Info version 3.5 was used for data analysis. Inferential statistics such as chi square and multiple logistic regression were used to determine associated factors and predictors of nutrition knowledge. The level of significance was set at 5% (p<0.05).

RESULTS

The mean age of respondents was 41.71±10.33years, all were females; 44.8% were Registered Nurses, 12.0% were Registered Midwives, and 23.8% had a B.Sc. in Nursing. Majority (81.3%) had taken a nutrition course in nursing training program, 62.1% as elective classes. Majority (81.1%) had good knowledge of prenatal nutrition. Respondents who were older (51-60years) (p<0.001), single (p<0.001) and Christian (p = 0.001) had significantly better knowledge. Nurses who had University degrees (p<0.001), of higher cadre (p<0.001), more years of practice (p<0.001) and involved in treating severely malnourished children (p = 0.013) were also significantly more knowledgeable. Respondents below 40 years (OR 0.104, CI 0.049-0.218) and those with 10 years or less of practice (OR 0.189, CI 0.092-0.387) had less odds of having good nutrition knowledge. Being single (OR 8.791, CI 3.125-24.731), and Christian (OR = 5.810, CI: 3.321-10.164) predict good nutrition knowledge. In 39% of the 41 PHCs observed, quality of nutrition education services was inadequate. Gaps were mainly in availability of certain nutrition education facilities/resources and teaching strategies.

CONCLUSION

The majority of the respondents had good knowledge of pre-natal nutrition. Overall, however, nutrition education services provided by two-fifths of the facilities were inadequate. Interventions to improve prenatal nutrition knowledge of nurses/midwives should be focused more on those who are younger and have less work experience. All necessary equipment required for health service providers to execute their roles as nutrition counselors and educators should also be provided by the government.

Association of maternal pre-pregnancy dietary intake with adverse maternal and neonatal outcomes: A systematic review and meta-analysis of prospective studies

This study aimed to summarize the evidence regarding the effects of dietary intake before conception on pregnancy outcomes by performing a systematic review and meta-analysis of prospective studies. Electronic databases were searched from inception up to August 2021. Overall, 65 studies involving 831 798 participants were included and 38 studies were quantitatively pooled. With regard to maternal outcomes, pre-pregnancy intake of fried food, fast food, red and processed meat, heme iron and a low-carbohydrate dietary pattern was positively associated with the risk of gestational diabetes mellitus (GDM) (all P < 0.05). However, a high dietary fiber intake and folic acid supplementation were negatively associated with GDM risk (both P < 0.05). With regard to neonatal outcomes, maternal caffeine intake before pregnancy significantly increased the risk of spontaneous abortion, while folic acid supplementation had protective effects on total adverse neonatal outcomes, preterm birth, and small-for-gestational age (SGA, all P < 0.05). However, no significant associations were found between adverse pregnancy outcomes (i.e., GDM and SGA) and the pre-pregnancy dietary intake of sugar-sweetened beverages, potato, fish, and carbohydrates and the Healthy Eating Index. Our study suggests that maintaining a healthy diet before conception has significant beneficial effects on pregnancy outcomes.Supplemental data for this article is available online at https://doi.org/10.1080/10408398.2021.1989658.

Pregnancy after stillbirth: maternal and neonatal outcomes and health service utilization

BACKGROUND

Stillbirth occurs in every 3.5 of 1000 pregnancies in Ireland and is a devastating event for a family. Women who have a pregnancy after stillbirth require increased antenatal support.

OBJECTIVE

This study aimed to determine maternal and fetal outcomes and to quantify health service utilization in pregnancy after stillbirth.

STUDY DESIGN

A retrospective cohort study of all pregnancies after stillbirth was conducted from 2011 to 2017 in a large tertiary referral university maternity teaching hospital with approximately 8000 births annually.

RESULTS

There were 222 stillbirths from 2011 to 2017. Two-thirds of women (145 of 222 [64.3%]) had a pregnancy after stillbirth. Almost one-fifth of these women (28 of 145 [19.3%]) had a miscarriage, but 16 of 28 women (57.1%) had a subsequent live birth, giving an overall live birth rate of 90.3% (131/145). The average interval from index loss to booking in the next pregnancy was 13 months, with almost half of the women (72 of 145 [49.7%]) booking within 1 year. The average number of antenatal appointments was twice than expected (10; range, 2-27), and the average number of ultrasound scans was 5 times higher than expected (5; range, 0-29). Rates of induction of labor (63 of 131 [48.1%]) and cesarean delivery (53 of 131 [40.5%]) were significantly higher than national rates for multiparous women. Almost two-thirds of women (40 of 63 [63.5%]) cited previous history of stillbirth as the indication for induction. There was a significantly higher rate of preterm delivery (30 of 131 [22.9%]). Moreover, 1 in 4 babies (35 of 137 [25.5%]) required admission to the neonatal intensive care unit, more than twice the number expected (median gestation, 37 0/7 weeks; range, 25 4/7 to 39 2/7 weeks).

CONCLUSION

Pregnancy after stillbirth was associated with increased surveillance and intervention. The women in this study had higher rates of cesarean delivery, induction of labor, and preterm delivery than the general multiparous population. Decision-making for intervention was often based on previous history of stillbirth. Clinicians should be cognizant of additional supports required for this population and focus on evidence-based interventions that improve maternal well-being and perinatal outcomes in pregnancy after stillbirth.

Magnitude of Intestinal Parasitosis, Malnutrition, and Predictors of Anemia Among Nonpregnant Reproductive-Age Women Attending Healthcare Services in Olenchity General Hospital, Central Ethiopia

Background

Anemia and malnutrition remain a public health challenge in developing worlds. Anemia during a nonpregnant state is one of the neglected medical conditions affecting reproductive-age women around the world. Globally, it is estimated that one-third of all reproductive-age women are anemic. Although it has negative consequences and extensive burden, anemia in nonreproductive-age women is rarely studied in Africa. In Ethiopia, studies investigating anemia and malnutrition among nonpregnant reproductive-age women are limited. Therefore, this study was aimed to assess intestinal parasitic infection, malnutrition, and predictors of anemia among nonpregnant reproductive-age women in Olenchity General Hospital, central Ethiopia.

Methods

A facility-based cross-sectional study design was employed among 405 nonpregnant reproductive-age women in Olenchity General Hospital, central Ethiopia from February 14 to March 24, 2018. Data were collected using a pretested interviewer-administered questionnaire. Blood samples were collected and tested to determine hemoglobin levels by using a hematology analyzer machine. Collected data were entered into EpiData version 3.02 and exported to SPSS version 20 (IBM SPSS Statistics, 2012) for further analysis. Multivariable logistic regression analysis was done to identify factors independently associated with anemia after controlling for possible confounders. Statistical significance was declared at p-value &lt;0.05.

Result

Overall, the magnitude of anemia was found to be 47.4% [95% CI (42.7, 52.6)], of which 34.8% were mild, 11.4% were moderate, and 1.2% were severely anemic. The prevalence of intestinal parasitic infection, wasting, and overweight was 34.6%, 26.2%, and 8.1%, respectively. Having no formal education [AOR=2.25, CI (1.02, 4.97)], using three to five sanitary pads per day during menses [AOR=1.66 CI (1.02, 2.68)], history of chewing khat [AOR= 4.45, CI (1.18, 16.83)], being from households with mild food insecurity [AOR=3.41, CI (1.10, 10.58)], and intestinal parasitic infection [AOR=2.28, CI (1.39, 3.47)] were factors independently associated with anemia.

Conclusion

The magnitude of anemia, malnutrition, and intestinal parasitic infection among nonpregnant reproductive-age women was found to be a considerable public health problem. Therefore, attention should be given to nonpregnant reproductive-age women visiting different healthcare services to reduce risks of anemia and malnutrition for possible future pregnancies and to ensure women’s health. Deworming of nonpregnant reproductive-age women is also very crucial to reduce the risks of anemia.

Associations of Knowledge, Attitude, and Practices toward Anemia with Anemia Prevalence and Height-for-Age Z-Score among Indonesian Adolescent Girls

BACKGROUND

Crucial gaps persist in knowledge, attitude, and practice (KAP) of adolescent girls that affect anemia and linear growth failure.

OBJECTIVE

To understand the role of KAP as a risk factor of anemia and linear growth problem in adolescent girls.

METHODS

We conducted a cross-sectional survey of 335 adolescent girls selected by clustered random sampling. The KAP questionnaire had 18 variables consisting of 9 knowledge, 3 attitude, and 6 practice components. Twelve variables addressed nutrition, dietary diversity, and health environments related to both anemia and stunting. The questionnaire was adapted from the 2014 Food and Agriculture Organization nutrition-related KAP guidelines for anemia. Dietary practice was evaluated from 2-day 24-hour recalls and a semi-quantitative food-frequency questionnaire. Associations between KAP and anemia, and height-for-age z-score (HAZ), were analyzed using multivariate logistic and linear regression models, respectively.

RESULTS

The mean hemoglobin (Hb) level was 119.7 g/L, with 44% of the adolescent girls being anemic (Hb < 120 g/L) and mean height was 151.0 cm with 25% being stunted (HAZ < -2 standard deviation [SD]). The median KAP score was 7 and ranged from 3 to 10. Low to moderate KAP scores were not significantly associated with being anemic (adjusted odds ratio [AOR] = 1.26; P = .43), however 1-point KAP score increment was associated with an increase of HAZ by 0.037 SD (P = .012).

CONCLUSIONS

The KAP related to diet and healthy environments was not associated with anemia prevalence, but was positively associated with increased HAZ among adolescent girls. Strategy to reduce anemia risk in this population should combine KAP improvement with other known effective nutrition interventions.

Associations between periconceptional lifestyle behaviours and adverse pregnancy outcomes

Background

While the potential adverse outcomes of prenatal exposure to unhealthy lifestyle are widely evidenced, little is known about these exposures in the periconception period. We investigated the associations between lifestyle behaviours and adverse pregnancy outcomes with a unique distinction between preconceptional- and prenatal lifestyle behaviours.

Methods

A secondary analysis took place within a prospective multicentre cohort study in the Netherlands, including 3,684 pregnant women. Baseline characteristics and preconceptional and first trimester lifestyle behaviours were assessed through a self-administered questionnaire in the first trimester. Adverse pregnancy outcomes (hypertensive disorders in pregnancy (HDP), small for gestational age (SGA), gestational diabetes (GDM) and spontaneous preterm birth (sPTB)) were reported by healthcare professionals. Data were collected between 2012 and 2014 and analysed using multivariate logistic regression.

Results

Women who are overweight, and especially obese, have the highest odds of developing any adverse pregnancy outcome (adjusted odds ratio (aOR) 1.61 (95 % Confidence Interval (CI) 1.31–1.99) and aOR 2.85 (95 %CI 2.20–3.68), respectively), particularly HDP and GDM. Women who prenatally continued smoking attained higher odds for SGA (aOR 1.91 (95 %CI 1.05–1.15)) compared to the reference group, but these odds decreased when women prenatally quit smoking (aOR 1.14 (95 %CI 0.59–2.21)). Women who did not use folic acid supplements tended to have a higher odds of developing adverse pregnancy outcomes (aOR 1.28 (95 %CI 0.97–1.69)), while women who prenatally started folic acid supplements did not (aOR 1.01 (95 %CI 0.82–1.25)).

Conclusions

Our results indicate that smoking cessation, having a normal body mass index (BMI) and initiating folic acid supplements preconceptionally may decrease the risk of adverse pregnancy outcomes. Therefore, intervening as early as the preconception period could benefit the health of future generations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03935-x.

Female awareness about the preconception use of folic acid supplements in childbearing age: A cross-sectional study

AIMS

Folic acid is required for the growth and development of the fetus. There is strong evidence that taking folic acid before pregnancy and during the first trimester reduces the risk of neural tube defects (NTDs). This study aimed to assess women's awareness of preconception folic acid supplementation and its importance to the mother and the fetus.

METHODS

This was a cross-sectional questionnaire study conducted in Saudi Arabia between January and April 2019. An electronic questionnaire tool was designed and distributed using Google Forms through social media (Facebook and WhatsApp) websites. Binary logistics regression was used to estimate odds ratios (ORs), with 95% confidence intervals (CIs) for predictors of poor levels of awareness about folic acid.

RESULTS

A total of 514 women participated in this study. The age range for the study participants was 18-45 years. Only 24.1% of the participants reported that they routinely took folic acid. The most commonly reported source of information about folic acid use was the doctor. The majority of the participants had poor awareness of folic acid use. Older age (30 years and above) and not taking regular folic acid supplements were important predictors of poor awareness of folic acid. Having a university degree or higher education was an important predictor of increased awareness about folic acid.

CONCLUSION

Our study found that the awareness of the Saudi women was poor in identifying the generic name of folic acid, recognising the sources of folic acid, the correct dose of folic acid, and the side effects of high doses of folic acid and that there was good knowledge about the importance of folic acid, the consequences of folic acid deficiency, and the belief that even non-pregnant women and girls of childbearing age should take folic acid.

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

Background

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

Objectives

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

Search Methods

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

Selection Criteria

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

Data Collection and Analysis

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

Main Results

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

Authors' Conclusions

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

Effects of preconception care and periconception interventions on maternal nutritional status and birth outcomes in low- and middle-income countries: A systematic review

Background

The preconception period is an ideal time to introduce interventions relating to nutrition and other lifestyle factors to ensure good pregnancy preparedness, and to promote health of mothers and babies. In adolescents, malnutrition and early pregnancy are the common challenges, particularly among those who live in low- and middle-income countries (LMIC) where 99% of all maternal and newborn deaths occur. These girls receive little or no attention until their first pregnancy and often the interventions after pregnancy are too late to revert any detrimental health risks that may have occurred due to malnutrition and early pregnancy.

Objectives

To synthesise the evidence of the effectiveness of preconception care interventions relating to delayed age at first pregnancy, optimising inter-pregnancy intervals, periconception folic acid, and periconception iron-folic acid supplementation on maternal, pregnancy, birth and child outcomes.

Search Methods

Numerous electronic databases (e.g., CINAHL, ERIC) and databases of selected development agencies or research firms were systematically searched for all available years up to July 2019. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished studies.

Selection Criteria

Primary studies, including large-scale programme evaluations that assessed the effectiveness of interventions using randomised controlled trials (RCTs) or quasi-experimental designs (natural experiments, controlled before-after studies, regression discontinuity designs, interrupted time series [ITS]), that targeted women of reproductive age (i.e., 10-49 years) during the pre- and periconceptional period in LMICs were included. Interventions were compared against no intervention, standard of care or placebo.

Data Collection and Analysis

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data and assessed risk of bias. We used random-effects model to conduct meta-analyses, given the diverse contexts, participants, and interventions, and separate meta-analyses for the same outcome was performed with different study designs (ITS, RCTs and controlled before after studies). For each comparison, the findings were descriptively summarised in text which included detailing the contextual factors (e.g., setting) to assess their impact on the implementation and effectiveness of each intervention.

Main Results

We included a total of 43 studies; two of these were included in both delaying pregnancy and optimising interpregnancy intervals resulting in 26 studies for delaying the age at first pregnancy (14 RCTs, 12 quasi-experimental), four for optimising interpregnancy intervals (one RCT, three quasi-experimental), five on periconceptional folic acid supplementation (two RCTs, three quasi-experimental), and 10 on periconceptional iron-folic acid supplementation (nine RCTs, one quasi-experimental). Geographically, studies were predominantly conducted across Africa and Asia, with few studies from North and Central America and took place in a combination of settings including community, schools and clinical. The education on sexual health and contraception interventions to delay the age at first pregnancy may make little or no difference on risk of unintended pregnancy (risk ratio [RR], 0.42; 95% confidence internal [CI], 0.07-3.26; two studies, =490; random-effect; χ ² p .009; I ² = 85%; low certainty of evidence using GRADE assessment), however, it significantly improved the use of condom (ever) (RR, 1.54; 95% CI, 1.08-2.20; six studies, n = 1604; random-effect, heterogeneity: χ ² p .004; I ² = 71%). Education on sexual health and and provision of contraceptive along with involvement of male partneron optimising interpregnancy intervals probably makes little or no difference on the risk of unintended pregnancies when compared to education on sexual health only (RR, 0.32; 95% CI, 0.01-7.45; one study, n = 45; moderate certainty of evidence using GRADE assessments). However, education on sexual health and contraception intervention alone or with provision of contraceptive showed a significant improvement in the uptake of contraceptive method. We are uncertain whether periconceptional folic acid supplementation reduces the incidence of neural tube defects (NTDs) (RR, 0.53; 95% CI, 0.41-0.77; two studies, n = 248,056; random-effect; heterogeneity: χ ² p .36; I ² = 0%; very low certainty of evidence using GRADE assessment). We are uncertain whether preconception iron-folic acid supplementation reduces anaemia (RR, 0.66; 95% CI, 0.53-0.81; six studies; n = 3430, random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessment) even when supplemented weekly (RR, 0.70; 95% CI, 0.55-0.88; six studies; n = 2661; random-effect; heterogeneity: χ ² p < .001; I ² = 88%; very low certainty of evidence using GRADE assessments),and in school set-ups (RR, 0.66; 95% CI, 0.51-0.86; four studies; n = 3005; random-effect; heterogeneity: χ ² p < .0001; I ² = 87%; very low certainty of evidence using GRADE assessment). Data on adverse effects were reported on in five studies for iron-folic acid, with the main complaint relating to gastrointestinal side effects. The quality of evidence across the interventions of interest was variable (ranging from very low to moderate) which may be attributed to the different study designs included in this review. Concerning risk of bias, the most common concerns were related to blinding of participants and personnel (performance bias) and whether there were similar baseline characteristic across intervention and comparison groups.

Authors' Conclusions

There is evidence that education on sexual health and contraception interventions can improve contraceptive use and knowledge related to sexual health, this review also provides further support for the use of folic acid in pregnancy to reduce NTDs, and notes that weekly regimes of IFA are most effective in reducing anaemia. However the certainty of the evidence was very low and therefore more robust trials and research is required, including ensuring consistency for reporting unplanned pregnancies, and further studies to determine which intervention settings (school, community, clinic) are most effective. Although this review demonstrates promising findings, more robust evidence from RCTs are required from LMICs to further support the evidence.

Mediation role of low birth weight on the factors associated with newborn mortality and the moderation role of institutional delivery in the association of low birth weight with newborn mortality in a resource-poor setting

OBJECTIVES

To assess low birth weight's (LBW) mediation role on the factors associated with newborn mortality (NM), including stillbirth and the role of institutional delivery in the association between LBW and NM.

DESIGN AND PARTICIPANTS

I used the 2011-2015 event histories health demographic data collected by Iganga-Mayuge Health Demographic and Surveillance Site (HDSS). The dataset consisted of 10 758 registered women whose birth occurred at least 22 weeks of the gestation period and records of newborns' living status 28 days after delivery.

SETTING

The Iganga-Mayuge HDSS is in Eastern Uganda, which routinely collects health and demographic data from a registered population of at least 100 000 people.

OUTCOME MEASURE

The study's key outcomes or endogenous factors were perinatal mortality (PM), late NM and LBW (mediating factor).

RESULTS

The factors that were directly associated with PM were LBW (OR=2.55, 95% CI 1.15 to 5.67)), maternal age of 30+ years (OR=1.68, 95% CI 1.21 to 2.33), rural residence (OR=1.38, 95% CI 1.02 to 1.85), mothers with previous experience of NM (OR=3.95, 95% CI 2.86 to 5.46) and mothers with no education level (OR=1.63, 95% CI 1.21 to 2.18). Multiple births and mother's prior experience of NM were positively associated with NM at a later age. Institutional delivery had a modest inverse role in the association of LBW with PM. LBW mediated the association of PM with residence status, mothers' previous NM experience, multiple births, adolescent mothers and mothers' marital status. Of the total effect attributable to each of these factors, LBW mediated +25%, +22%, +100%, 25% and -38% of rural resident mothers, mothers with previous experience of newborn or pregnancy loss, multiple births, adolescent mothers and mothers with partners, respectively.

CONCLUSION

LBW mediated multiple factors in the NM pathways, and the effect of institutional delivery in reducing mortality among LBW newborns was insignificant. The findings demonstrate the need for a holistic life course approach that gears the health systems to tackle NM.

Tipping the scale: the role of a national nutritional supplementation programme for pregnant mothers in reducing low birth weight and neonatal mortality in India

With over 1·3 million Anganwadi centres (AWC) (meaning ‘courtyard shelter’), the Indian government runs a nationwide intervention providing nutrition supplement to pregnant mothers to improve the health of their children. Using two successive rounds of the nationally representative cross-sectional National Family Health Survey data (collected during 2005–2006 and 2015–2016) of India, we assessed whether nutrition supplements given to pregnant mothers through AWC were associated with select child health indicators – extremely low birth weight (ELBW), very low birth weight (VLBW), low birth weight (LBW) and neonatal mortality (death during day 0–27) stratified by death during day 0–1, day 2–6 and day 7–27. A total of 148 019 children and 205 593 children were eligible for analysing birth weight and neonatal mortality, respectively. OR with 95% CI, estimated from multivariate logistic regression models, suggest that receipt of nutrition supplements was associated with decreased risk of VLBW (OR: 0·73, 95% CI 0·63, 0·83, P < 0·001), LBW (OR: 0·92, 95% CI 0·88, 0·96, P < 0·001), but not ELBW (OR: 0·80, 95% CI 0·56, 1·15, P = 0·226). Women who always received nutrition supplements during their pregnancy saw lower risk of death of their neonates (OR: 0·67, 95% CI 0·61, 0·73, P < 0·001), including death on day 0–1 (OR: 0·66, 95% CI 0·58, 0·74, P < 0·001), day 2–6 (OR: 0·69, 95% CI 0·58, 0·82, P < 0·001) and day 7–27 (OR: 0·68, 95% CI 0·53, 0·87, P = 0·002). Therefore, nutritional supplementation to pregnant mothers appears to be helpful in deterring various stages of neonatal mortality, VLBW and LBW, though it might not be effective in mitigating ELBW. Findings were discussed considering possible limitations of the study.

The association between pre-conception intuitive eating and gestational weight gain

PURPOSE

To determine if pre-conception intuitive eating, an adaptive eating behavior, was related to gestational weight gain (GWG) and the likelihood of exceeding GWG recommendations.

METHODS

This prospective survey study took place in an outpatient obstetric clinic. Participants completed the pre-conception Intuitive Eating Scale for Pregnancy during a prenatal check-up appointment and total GWG was collected from the medical record. The pre-conception Intuitive Eating Scale for Pregnancy assesses unconditional permission to eat, eating for physical rather than emotional reasons, and reliance on hunger and satiety to inform what, when, and how much to eat. Hierarchical linear multiple regression and logistic multiple regression analyses determined associations between pre-conception intuitive eating and GWG on the total sample and stratified by weight status (normal/underweight, overweight, and obese).

RESULTS

The majority of the sample (n = 253) was white, married, employed, had annual household income > $50,000, and had a college degree. No aspects of pre-conception intuitive eating predicted the likelihood of excess GWG. However, in the total sample, unconditional permission to eat (subscale) was inversely related to total GWG (B = -0.16, p < 0.05). Among women with obesity (n = 36), eating for physical rather than emotional reasons (subscale) was inversely related to total GWG (B = -0.47, p < 0.05).

DISCUSSION

Some aspects of intuitive eating during the pre-conception period were related to total GWG, particularly for women with obesity. However, intuitive eating scores did not increase or decrease the likelihood of excess GWG. More research is needed to understand the mechanisms for this association before clinical recommendations can be made.

LEVEL OF EVIDENCE

Level III (Evidence obtained from well-designed cohort or case-control analytic studies).