Multivitamin and iron supplementation to prevent periconceptional anemia in rural tanzanian women: a randomized, controlled trial

Daily oral iron supplementation during pregnancy

BACKGROUND

Iron and folic acid supplementation have been recommended in pregnancy for anaemia prevention, and may improve other maternal, pregnancy, and infant outcomes.

OBJECTIVES

To examine the effects of daily oral iron supplementation during pregnancy, either alone or in combination with folic acid or with other vitamins and minerals, as an intervention in antenatal care.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Registry on 18 January 2024 (including CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO's International Clinical Trials Registry Platform, conference proceedings), and searched reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials that evaluated the effects of oral supplementation with daily iron, iron + folic acid, or iron + other vitamins and minerals during pregnancy were included.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed trial eligibility, ascertained trustworthiness based on pre-defined criteria, assessed risk of bias, extracted data, and conducted checks for accuracy. We used the GRADE approach to assess the certainty of the evidence for primary outcomes. We anticipated high heterogeneity amongst trials; we pooled trial results using a random-effects model (average treatment effect).

MAIN RESULTS

We included 57 trials involving 48,971 women. A total of 40 trials compared the effects of daily oral supplements with iron to placebo or no iron; eight trials evaluated the effects of iron + folic acid compared to placebo or no iron + folic acid. Iron supplementation compared to placebo or no iron Maternal outcomes: Iron supplementation during pregnancy may reduce maternal anaemia (4.0% versus 7.4%; risk ratio (RR) 0.30, 95% confidence interval (CI) 0.20 to 0.47; 14 trials, 13,543 women; low-certainty evidence) and iron deficiency at term (44.0% versus 66.0%; RR 0.51, 95% CI 0.38 to 0.68; 8 trials, 2873 women; low-certainty evidence), and probably reduces maternal iron-deficiency anaemia at term (5.0% versus 18.4%; RR 0.41, 95% CI 0.26 to 0.63; 7 trials, 2704 women; moderate-certainty evidence), compared to placebo or no iron supplementation. There is probably little to no difference in maternal death (2 versus 4 events, RR 0.57, 95% CI 0.12 to 2.69; 3 trials, 14,060 women; moderate-certainty evidence). The evidence is very uncertain for adverse effects (21.6% versus 18.0%; RR 1.29, 95% CI 0.83 to 2.02; 12 trials, 2423 women; very low-certainty evidence) and severe anaemia (Hb < 70 g/L) in the second/third trimester (< 1% versus 3.6%; RR 0.22, 95% CI 0.01 to 3.20; 8 trials, 1398 women; very low-certainty evidence). No trials reported clinical malaria or infection during pregnancy. Infant outcomes: Women taking iron supplements are probably less likely to have infants with low birthweight (5.2% versus 6.1%; RR 0.84, 95% CI 0.72 to 0.99; 12 trials, 18,290 infants; moderate-certainty evidence), compared to placebo or no iron supplementation. However, the evidence is very uncertain for infant birthweight (MD 24.9 g, 95% CI -125.81 to 175.60; 16 trials, 18,554 infants; very low-certainty evidence). There is probably little to no difference in preterm birth (7.6% versus 8.2%; RR 0.93, 95% CI 0.84 to 1.02; 11 trials, 18,827 infants; moderate-certainty evidence) and there may be little to no difference in neonatal death (1.4% versus 1.5%, RR 0.98, 95% CI 0.77 to 1.24; 4 trials, 17,243 infants; low-certainty evidence) or congenital anomalies, including neural tube defects (41 versus 48 events; RR 0.88, 95% CI 0.58 to 1.33; 4 trials, 14,377 infants; low-certainty evidence). Iron + folic supplementation compared to placebo or no iron + folic acid Maternal outcomes: Daily oral supplementation with iron + folic acid probably reduces maternal anaemia at term (12.1% versus 25.5%; RR 0.44, 95% CI 0.30 to 0.64; 4 trials, 1962 women; moderate-certainty evidence), and may reduce maternal iron deficiency at term (3.6% versus 15%; RR 0.24, 95% CI 0.06 to 0.99; 1 trial, 131 women; low-certainty evidence), compared to placebo or no iron + folic acid. The evidence is very uncertain about the effects of iron + folic acid on maternal iron-deficiency anaemia (10.8% versus 25%; RR 0.43, 95% CI 0.17 to 1.09; 1 trial, 131 women; very low-certainty evidence), or maternal deaths (no events; 1 trial; very low-certainty evidence). The evidence is uncertain for adverse effects (21.0% versus 0.0%; RR 44.32, 95% CI 2.77 to 709.09; 1 trial, 456 women; low-certainty evidence), and the evidence is very uncertain for severe anaemia in the second or third trimester (< 1% versus 5.6%; RR 0.12, 95% CI 0.02 to 0.63; 4 trials, 506 women; very low-certainty evidence), compared to placebo or no iron + folic acid. Infant outcomes: There may be little to no difference in infant low birthweight (33.4% versus 40.2%; RR 1.07, 95% CI 0.31 to 3.74; 2 trials, 1311 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. Infants born to women who received iron + folic acid during pregnancy probably had higher birthweight (MD 57.73 g, 95% CI 7.66 to 107.79; 2 trials, 1365 infants; moderate-certainty evidence), compared to placebo or no iron + folic acid. There may be little to no difference in other infant outcomes, including preterm birth (19.4% versus 19.2%; RR 1.55, 95% CI 0.40 to 6.00; 3 trials, 1497 infants; low-certainty evidence), neonatal death (3.4% versus 4.2%; RR 0.81, 95% CI 0.51 to 1.30; 1 trial, 1793 infants; low-certainty evidence), or congenital anomalies (1.7% versus 2.4; RR 0.70, 95% CI 0.35 to 1.40; 1 trial, 1652 infants; low-certainty evidence), comparing iron + folic acid supplementation to placebo or no iron + folic acid. A total of 19 trials were conducted in malaria-endemic countries, or in settings with some malaria risk. No studies reported maternal clinical malaria; one study reported data on placental malaria.

AUTHORS' CONCLUSIONS

Daily oral iron supplementation during pregnancy may reduce maternal anaemia and iron deficiency at term. For other maternal and infant outcomes, there was little to no difference between groups or the evidence was uncertain. Future research is needed to examine the effects of iron supplementation on other maternal and infant health outcomes, including infant iron status, growth, and development.

Compliance of Iron Supplementation and Determinants among Adolescent Girls: A Systematic Review

Background

Iron deficiency anemia in children or women in pregnancy, is a public health problem in some countries. The World Health Organization (WHO) has called on all countries to achieve a 5% reduction in anemia in women of childbearing age, including adolescent girls, by 2025. One of the programs is iron supplementation. The success depends on the adherence of adolescent girls to consume iron tablets. This systematic review aimed to find the level of compliance to iron supplementation consumption among adolescent girls and explore barriers and facilitator factors to such adherence.

Methods

This article was a systematic review and conducted a multi-database search. The articles passed the PRISMA flow diagram process. The inclusion and exclusion rules decided the qualification of studies included. Of 1066 articles, we obtained 20 studies for the systematic review.

Result

The lowest compliance found were 26.2% and 26.3%, and was high (>80%) in intervention studies involving supervision and monitoring and peer educator. All articles' barrier and facilitator factors were classified into four categories; personal, social, environmental, and regimen.

Conclusion

Efforts to improve adolescent compliance to take iron tablets should consider all of these factors.

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).

Anaemia in women of reproductive age in low- and middle-income countries: progress towards the 2025 global nutrition target

Objective

To examine trends in, and projections of, the prevalence of anaemia in women of reproductive age in low- and middle-income countries at national and subpopulation levels.

Methods

We used nationally representative data from repeated cross-sectional Demographic and Health Surveys (DHS) on 1 092 512 women of reproductive age (15-49 years) from 15 low- and middle-income countries. We defined anaemia as haemoglobin < 11 g/dL for pregnant women and < 12 g/dL for non-pregnant women. We analysed data using Bayesian linear regression analyses.

Findings

During 2000-2018, the prevalence of anaemia in women of reproductive age decreased in nine countries, with the highest decrease in Malawi (-2.5%), and increased in six countries, with the highest increase in Burundi (10.9%). All countries are projected to have a prevalence of anaemia ≥ 15% in 2025, with the highest level in Burundi (66.8%). The prevalence of anaemia and projection of prevalence varied between and within countries. Women's education, family wealth and place of residence had the highest impact on the current and projected prevalence rates of anaemia. Seven countries had a prevalence of anaemia ≥ 40%, which we defined as a severe public health problem, in the earliest and latest DHS and this prevalence is projected to persist in 2025.

Conclusion

None of the 15 countries is likely to meet the global nutrition target of a 50% reduction in the prevalence of anaemia in women of reproductive age by 2025. Global and country leaders should reconsider nutrition policies and reallocate resources targeting countries and communities at risk.

Barriers and facilitators of micronutrient supplementation among non-pregnant women of reproductive age in Johannesburg, South Africa

The prevalence of anaemia among South African women of reproductive age (WRA) remains high at 39%. Multiple micronutrient supplementation (MMS) may be an effective strategy in the prevention and management of anaemia. Our aim was to understand facilitators and barriers to preconception MMS adherence and to explore perceptions and beliefs of MMS in the prevention and treatment of anaemia among non-pregnant WRA. This qualitative study was embedded in a preconception MMS intervention trial of WRA and was conducted in two phases. Phase one assessed the barriers and facilitators of MMS adherence. Individual interviews were conducted with the community health workers (n = 7) administering MMS, and with non-pregnant WRA (n = 25) participating in the trial. Phase two included four focus groups with participating WRA (n = 26), which further explored participants' perceptions and beliefs of MMS provision and adherence, and strategies to improve adherence. The reported facilitators to supplementation were family support, interaction with the community health workers, easy access to MMS, and experienced benefits of MMS. Barriers to preconception supplementation included the lack of family support, the link of supplements to antenatal care, and the perceived lack of benefits of MMS. Participants reported negative associations of supplements with medication, individual and societal stigma around medication and challenges around the supplementation schedule. For successful preconception MMS interventions, young women, their families, and communities need to be convinced of the value of supplementation. Public health interventions utilising preconception supplementation will require specialised training for health care providers, targeted counselling materials and community household support.

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.

Trends and determinants of anaemia in women of Nepal: a multilevel analysis

In Nepal, the prevalence of anaemia decreased by 1% from 2006 to 2011 but increased by 6% from 2011 to 2016. In this study, we examined the changes in prevalence by possible factors from 2006 to 2016 along with the factors associated with anaemia among women of reproductive age (15–49 years) using the Nepal Demographic and Health Survey (NDHS) data from years 2006, 2011 and 2016. We used rate of change analysis to explore average annual rate of change (AARC) in anaemia prevalence and concentration curves and indices to assess unequal distribution of anaemia prevalence among socio‐economic quintiles. Multilevel regression was performed to examine the association of multilevel factors with anaemia. Our results showed higher AARC increase in anaemia prevalence from 2006 to 2016, among women aged 30–39 years, with secondary or higher education, who had two or fewer children, not working women, from higher wealth quintiles and who were overweight or obese. Shifting of concentration curve from ‘above the line of equality’ in 2006 and 2011 to ‘under the line of equality’ in 2016 was observed. Women aged 20–29 years, with more than four children, who underwent female sterilization, had experienced violence and from Provinces 1, 2 and 5 were at higher risk of anaemia. Overweight and obese women using hormonal contraception and from lowest wealth quintiles were at lower risk. The change in trends and the associated multilevel factors identified should be considered in designing multilevel interventions that particularly target women at risk for sustainable anaemia reduction.

Counselling and knowledge on iron and folic acid supplementation (IFAS) among pregnant women in Kiambu County, Kenya: a cross-sectional study

Background: The increased demand for iron and folic acid during pregnancy is not met through diet due to insufficiency or reduced bioavailability of nutrients among women from low income countries. Thus, iron and folic acid supplementation (IFAS) is a promising interventional strategy for control of anaemia during pregnancy. Kenya adopted the global IFAS intervention with a target of 80% coverage by 2017, however, the compliance remains low. Increasing awareness, counselling, communication and community education on IFAS have improved compliance among pregnant women. Thus, we aimed to determine: IFAS knowledge, availability, practices, and content of IFAS counselling among pregnant women attending health facilities in Kiambu County, Kenya.

Methods: A cross-sectional study involving 364 pregnant women aged 15-49 years. A two stage cluster sampling, including one sub-county and five public health facilities were used. A pre-tested, structured questionnaire consisting of socio-demographic data, maternal knowledge and counselling on IFAS was used. An observation checklist was used to observe practices and content of antenatal counselling session in each facility. Data was analysed using STATA in which descriptive and inferential statistics were computed.

Results: Of 364 respondents, less than half (40.9%) scored high on knowledge on IFAS. Women who were counselled on duration of IFAS intake, side effects, and their mitigation were more likely (p <0.005) to have high IFAS knowledge. Although all the health facilities had varied IFAS posters displayed, none had key IFAS counselling documents.

Conclusion: Less than half of the pregnant women had high IFAS knowledge, IFAS documents were scarce in health facilities, IFAS counselling information in different health facilities was limited and varied, and content of counselling was associated with levels of knowledge on IFAS. This underscores the need to strengthen focused and targeted IFAS counselling for pregnant women and standardization of counselling messages to improve compliance and pregnancy outcomes.

Counselling and knowledge on iron and folic acid supplementation (IFAS) among pregnant women in Kiambu County, Kenya: a cross-sectional study

Background: The increased demand for iron and folic acid during pregnancy is not met through diet due to insufficiency or reduced bioavailability of nutrients among women from low income countries. Thus, iron and folic acid supplementation (IFAS) is a promising interventional strategy for control of anaemia during pregnancy. Kenya adopted the global IFAS intervention with a target of 80% coverage by 2017, however, the compliance remains low. Increasing awareness, counselling, communication and community education on IFAS have improved compliance among pregnant women. Thus, we aimed to determine: IFAS knowledge, availability, practices, and content of IFAS counselling among pregnant women attending health facilities in Kiambu County, Kenya. Methods: A cross-sectional study involving 364 pregnant women aged 15-49 years. A two stage cluster sampling, including one sub-county and five public health facilities were used. A pre-tested structured questionnaire consisting of socio-demographic data, maternal knowledge and counselling on IFAS was used. An observation checklist was used to observe practices and content of antenatal counselling session in each facility. Data was analysed using STATA in which descriptive and inferential statistics were computed. Results: Of 364 respondents, less than half (40.9%) scored high on knowledge on IFAS. Women who were counselled on duration of IFAS intake, side effects, and their mitigation were more likely (p <0.005) to have high IFAS knowledge. Although all the health facilities had varied IFAS posters displayed, none had key IFAS counselling documents. Conclusion: Less than half of the pregnant women had high IFAS knowledge, IFAS documents were scarce in health facilities, IFAS counselling information in different health facilities was limited and varied and content of counselling was associated with levels of knowledge on IFAS. This underscores the need to strengthen focused and targeted IFAS counselling for pregnant women and standardization of counselling messages to improve compliance and pregnancy outcomes.

Multiple-micronutrient supplementation for women during pregnancy

BACKGROUND

Multiple-micronutrient (MMN) deficiencies often coexist among women of reproductive age in low- and middle-income countries. They are exacerbated in pregnancy due to the increased demands of the developing fetus, leading to potentially adverse effects on the mother and baby. A consensus is yet to be reached regarding the replacement of iron and folic acid supplementation with MMNs. Since the last update of this Cochrane Review in 2017, evidence from several trials has become available. The findings of this review will be critical to inform policy on micronutrient supplementation in pregnancy.

OBJECTIVES

To evaluate the benefits of oral multiple-micronutrient supplementation during pregnancy on maternal, fetal and infant health outcomes.

SEARCH METHODS

For this 2018 update, on 23 February 2018 we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP), and reference lists of retrieved studies. We also contacted experts in the field for additional and ongoing trials.

SELECTION CRITERIA

All prospective randomised controlled trials evaluating MMN supplementation with iron and folic acid during pregnancy and its effects on pregnancy outcomes were eligible, irrespective of language or the publication status of the trials. We included cluster-randomised trials, but excluded quasi-randomised trials. Trial reports that were published as abstracts were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We identified 21 trials (involving 142,496 women) as eligible for inclusion in this review, but only 20 trials (involving 141,849 women) contributed data. Of these 20 trials, 19 were conducted in low- and middle-income countries and compared MMN supplements with iron and folic acid to iron, with or without folic acid. One trial conducted in the UK compared MMN supplementation with placebo. In total, eight trials were cluster-randomised.MMN with iron and folic acid versus iron, with or without folic acid (19 trials)MMN supplementation probably led to a slight reduction in preterm births (average risk ratio (RR) 0.95, 95% confidence interval (CI) 0.90 to 1.01; 18 trials, 91,425 participants; moderate-quality evidence), and babies considered small-for-gestational age (SGA) (average RR 0.92, 95% CI 0.88 to 0.97; 17 trials; 57,348 participants; moderate-quality evidence), though the CI for the pooled effect for preterm births just crossed the line of no effect. MMN reduced the number of newborn infants identified as low birthweight (LBW) (average RR 0.88, 95% CI 0.85 to 0.91; 18 trials, 68,801 participants; high-quality evidence). We did not observe any differences between groups for perinatal mortality (average RR 1.00, 95% CI 0.90 to 1.11; 15 trials, 63,922 participants; high-quality evidence). MMN supplementation led to slightly fewer stillbirths (average RR 0.95, 95% CI 0.86 to 1.04; 17 trials, 97,927 participants; high-quality evidence) but, again, the CI for the pooled effect just crossed the line of no effect. MMN supplementation did not have an important effect on neonatal mortality (average RR 1.00, 95% CI 0.89 to 1.12; 14 trials, 80,964 participants; high-quality evidence). We observed little or no difference between groups for the other maternal and pregnancy outcomes: maternal anaemia in the third trimester (average RR 1.04, 95% CI 0.94 to 1.15; 9 trials, 5912 participants), maternal mortality (average RR 1.06, 95% CI 0.72 to 1.54; 6 trials, 106,275 participants), miscarriage (average RR 0.99, 95% CI 0.94 to 1.04; 12 trials, 100,565 participants), delivery via a caesarean section (average RR 1.13, 95% CI 0.99 to 1.29; 5 trials, 12,836 participants), and congenital anomalies (average RR 1.34, 95% CI 0.25 to 7.12; 2 trials, 1958 participants). However, MMN supplementation probably led to a reduction in very preterm births (average RR 0.81, 95% CI 0.71 to 0.93; 4 trials, 37,701 participants). We were unable to assess a number of prespecified, clinically important outcomes due to insufficient or non-available data.When we assessed primary outcomes according to GRADE criteria, the quality of evidence for the review overall was moderate to high. We graded the following outcomes as high quality: LBW, perinatal mortality, stillbirth, and neonatal mortality. The outcomes of preterm birth and SGA we graded as moderate quality; both were downgraded for funnel plot asymmetry, indicating possible publication bias.We carried out sensitivity analyses excluding trials with high levels of sample attrition (> 20%). We found that results were consistent with the main analyses for all outcomes. We explored heterogeneity through subgroup analyses by maternal height, maternal body mass index (BMI), timing of supplementation, dose of iron, and MMN supplement formulation (UNIMMAP versus non-UNIMMAP). There was a greater reduction in preterm births for women with low BMI and among those who took non-UNIMMAP supplements. We also observed subgroup differences for maternal BMI and maternal height for SGA, indicating greater impact among women with greater BMI and height. Though we found that MMN supplementation made little or no difference to perinatal mortality, the analysis demonstrated substantial statistical heterogeneity. We explored this heterogeneity using subgroup analysis and found differences for timing of supplementation, whereby higher impact was observed with later initiation of supplementation. For all other subgroup analyses, the findings were inconclusive.MMN versus placebo (1 trial)A single trial in the UK found little or no important effect of MMN supplementation on preterm births, SGA, or LBW but did find a reduction in maternal anaemia in the third trimester (RR 0.66, 95% CI 0.51 to 0.85), when compared to placebo. This trial did not measure our other outcomes.

AUTHORS' CONCLUSIONS

Our findings suggest a positive impact of MMN supplementation with iron and folic acid on several birth outcomes. MMN supplementation in pregnancy led to a reduction in babies considered LBW, and probably led to a reduction in babies considered SGA. In addition, MMN probably reduced preterm births. No important benefits or harms of MMN supplementation were found for mortality outcomes (stillbirths, perinatal and neonatal mortality). These findings may provide some basis to guide the replacement of iron and folic acid supplements with MMN supplements for pregnant women residing in low- and middle-income countries.

Who is the Woman in Women's Nutrition? A Narrative Review of Evidence and Actions to Support Women's Nutrition throughout Life

Nutrition interventions that target mothers alone inadequately address women's needs across their lives: during adolescence, preconception, and in later years of life. They also fail to capture nulliparous women. The extent to which nutrition interventions effectively reach women throughout the life course is not well documented. In this comprehensive narrative review, we summarized the impact and delivery platforms of nutrition-specific and nutrition-sensitive interventions targeting adolescent girls, women of reproductive age (nonpregnant, nonlactating), pregnant and lactating women, women with young children <5 y, and older women, with a focus on nutrition interventions delivered in low- and middle-income countries. We found that although there were many effective interventions that targeted women's nutrition, they largely targeted women who were pregnant and lactating or with young children. There were major gaps in the targeting of interventions to older women. For the delivery platforms, community-based settings, compared with facility-based settings, more equitably reached women across the life course, including adolescents, women of reproductive age, and older women. Nutrition-sensitive approaches were more often delivered in community-based settings; however, the evidence of their impact on women's nutritional outcomes was less clear. We also found major research and programming gaps relative to targeting overweight, obesity, and noncommunicable disease. We conclude that focused efforts on women during pregnancy and in the first couple of years postpartum fail to address the interrelation and compounding nature of nutritional disadvantages that are perpetuated across many women's lives. In order for policies and interventions to more effectively address inequities faced by women, and not only women as mothers, it is essential that they reflect on how, when, and where to engage with women across the life course.

Counselling on iron and folic acid supplementation (IFAS) is associated with improved knowledge among pregnant women in a rural county of Kenya: a cross-sectional study

Background:The demand for iron and folic acid, is greatly increased during pregnancy. The high demand is not met through diet due to insufficiency or reduced bioavailability of nutrients among women from low income countries. Thus, iron and folic acid supplementation (IFAS) is a promising interventional strategy for control of anaemia during pregnancy. Kenya adopted the global IFAS intervention with a target of 80% coverage by 2017, however, the compliance remains low. Increasing awareness, counselling, communication and community education on IFAS have improved compliance among pregnant women. Thus, we aimed to determine: availability, practices, and content of IFAS counselling on knowledge of antenatal mothers attending health facilities in Kiambu County, Kenya.Methods:A cross-sectional study involving 364 pregnant women aged 15-49 years attending antenatal clinic. A two stage cluster sampling, including one sub-county and five public primary health facilities were used. A pre-tested structured questionnaire consisting of socio-demographic data, maternal knowledge and counselling on IFAS was used. An observation checklist was used to observe practices and content of antenatal counselling session in each facility. Data was analysed using STATA in which descriptive and inferential statistics were computed.Results:Of 364 respondents, less than half (40.9%) scored high on knowledge on IFAS. Women who were counselled on duration of IFAS intake, side effects, and their mitigation were more likely (p <0.005) to have high IFAS knowledge. Although all the health facilities had varied IFAS posters displayed, none had key IFAS counselling documents.Conclusion:Content of counselling substantially contributed to high level of knowledge on IFAS among pregnant women. Counselling information on the duration of IFAS supplementation, IFAS side effects, and their management are the predictors of IFAS knowledge among pregnant women. This underscores the need to strengthen focused and targeted IFAS counselling for pregnant women to improve compliance and pregnancy outcomes.

Maternal Dietary Diversity and Growth of Children Under 24 Months of Age in Rural Dodoma, Tanzania

Objective:

To identify predictors of maternal dietary diversity in rural Dodoma, Tanzania and assess its association with child growth outcomes.

Methods:

A cross-sectional survey of 361 mothers with children under 24 months of age was conducted in 5 villages in rural Dodoma, Tanzania. Maternal diets were assessed using food frequency questionnaires, and dietary diversity was categorized using Minimum Dietary Diversity for Women (MDD-W) guidelines. Child anthropometric measures were taken to calculate height-for-age z-score (HAZ), weight-for-height z-score (WHZ), and weight-for-age z-score (WAZ). Linear and logistic regressions were used to examine the association between maternal dietary diversity and children’s growth outcomes.

Results:

About 40% of mothers did not consume a diverse diet (MDD-W < 5), and 35% of children were stunted. Household production of greater number of crops was associated with greater MDD-W scores ( P < .01). Greater maternal dietary diversity was associated with significantly greater child WHZ (mean difference = 0.44; 95% confidence interval [CI]: 0.10-0.78; P = .01), WAZ (mean difference = 0.37; 95% CI: 0.08-0.65; P = .01), and reduced risk of wasting (odds ratio = 0.22; 95% CI: 0.07-0.66; P = .01).

Conclusions:

Greater maternal dietary diversity was associated with improved child WHZ and WAZ outcomes. Sustainable interventions to increase maternal dietary diversity may improve WHZ and WAZ in young children in similar settings.

Effective nutrition education and communication for sustainable maternal and child health

Maternal and child health (MCH) consists of an interdependent reproductive system that collectively determines the survival of the mother during childbirth, and determines the health and survival of the child. This interdependency underscores the importance of appropriate and timely interventions during pregnancy through the first 1000 d at the minimum. The Millennium Development Goals (MDG) recommended the use of the continuum of care for the development of interventions by addressing all the stages of MCH. The purpose of the present paper is to review the factors that contributed to the attainment of the MDG 4 and MDG 5 by analysing the interventions conducted by the countries that achieved at least 5·0 and 5·5 %, respectively, and determine the level of their intervention based on the MCH conceptual framework. Out of the eighteen selected countries discussed, fifteen countries achieved their target for either MDG 4 or MDG 5 or both, while three countries did not achieve their target. The countries that were more likely to achieve their targets addressed the societal, underlying and direct causes, and implemented country wide policies. In contrast, the countries that did not succeed were more likely to address the direct causes with poor policy implementation. Understanding the motivation and limitations of the target population, including nutrition education and targeting behaviour change has the potential to result in sustainable MCH. This information has the potential to enlighten the policymakers as we progress to the sustainable development goals, specifically goals 2 and 3.

Impact of Preconception Micronutrient Supplementation on Anemia and Iron Status during Pregnancy and Postpartum: A Randomized Controlled Trial in Rural Vietnam

Objective

Preconception micronutrient interventions may be a promising approach to reduce anemia and iron deficiency during pregnancy, but currently we have limited data to inform policies. We evaluated whether providing additional pre-pregnancy weekly iron-folic acid (IFA) or multiple micronutrient (MM) supplements compared to only folic acid (FA) improves iron status and anemia during pregnancy and early postpartum.

Methods

We conducted a double blind randomized controlled trial in which 5011 Vietnamese women were provided with weekly supplements containing either only 2800 μg FA (control group), IFA (60 mg Fe and 2800 μg FA) or MM (15 micronutrients with similar amounts of IFA). All women who became pregnant (n = 1813) in each of the 3 groups received daily IFA (60 mg Fe and 400 μg FA) through delivery. Hematological indicators were assessed at baseline (pre-pregnancy), during pregnancy, 3 months post-partum, and in cord blood. Adjusted generalized linear models were applied to examine the impact of preconception supplementation on anemia and iron stores, using both intention to treat and per protocol analyses (women consumed supplements ≥ 26 weeks before conception).

Results

At baseline, 20% of women were anemic, but only 14% had low iron stores (ferritin <30 μg/L) and 3% had iron deficiency (ferritin <12 μg/L). The groups were balanced for baseline characteristics. Anemia prevalence increased during pregnancy and post-partum but was similar among intervention groups. In intention to treat analyses, prenatal ferritin was significantly higher among women receiving MM (geometric mean (μg/L) [95% CI]: 93.6 [89.3–98.2]) and IFA (91.9 [87.6–96.3]) compared to control (85.3 [81.5–89.2]). In per protocol analyses, women receiving MM or IFA had higher ferritin 3 months postpartum (MM 118.2 [109.3–127.8]), IFA 117.8 [108.7–127.7] vs control 101.5 [94.0–109.7]) and gave birth to infants with greater iron stores (MM 184.3 [176.1–192.9]), IFA 189.9 [181.6–198.3] vs control 175.1 [167.9–182.6]).

Conclusion

Preconception supplementation with MM or IFA resulted in modest increases in maternal and infant iron stores but did not impact anemia. Further research is needed to characterize the etiology of anemia in this population and identify effective interventions for reducing prenatal anemia.

Trial Registration

ClinicalTrials.Gov NCT01665378

Iron Supplementation Affects Hematologic Biomarker Concentrations and Pregnancy Outcomes among Iron-Deficient Tanzanian Women

BACKGROUND

Iron deficiency is a highly prevalent micronutrient abnormality and the most common cause of anemia globally, worsening the burden of adverse pregnancy and child outcomes.

OBJECTIVE

We sought to evaluate the response of hematologic biomarkers to iron supplementation and to examine the predictors of the response to iron supplementation among iron-deficient pregnant women.

METHODS

We identified 600 iron-deficient (serum ferritin ≤12 μg/L) pregnant women, aged 18-45 y, presenting to 2 antenatal clinics in Dar es Salaam, Tanzania using rapid ferritin screening tests, and prospectively followed them through delivery and postpartum. All women received 60 mg Fe and 0.25 mg folate daily from enrollment until delivery. Proportions meeting the thresholds representing deficient hematologic status including hemoglobin <110 g/L, ferritin ≤12 μg/L, serum soluble transferrin receptor (sTfR) >4.4 mg/L, zinc protoporphyrin (ZPP) >70 mmol/L, or hepcidin ≤13.3 μg/L at baseline and delivery were assessed. The prospective change in biomarker concentration and the influence of baseline hematologic status on the change in biomarker concentrations were assessed. Regression models were estimated to assess the relation of change in biomarker concentrations and pregnancy outcomes.

RESULTS

There was significant improvement in maternal biomarker concentrations between baseline and delivery, with increases in the concentrations of hemoglobin (mean difference: 15.2 g/L; 95% CI: 13.2, 17.2 g/L), serum ferritin (51.6 μg/L; 95% CI: 49.5, 58.8 μg/L), and serum hepcidin (14.0 μg/L; 95% CI: 12.4, 15.6 μg/L) and decreases in sTfR (-1.7 mg/L; 95% CI: -2.0, -1.3 mg/L) and ZPP (-17.8 mmol/L; 95% CI: -32.1, 3.5 mmol/L). The proportions of participants with low hemoglobin, ferritin, and hepcidin were 73%, 93%, and 99%, respectively, at baseline and 34%, 12%, and 46%, respectively, at delivery. The improvements in biomarker concentrations were significantly greater among participants with poor hematologic status at baseline - up to 12.1 g/L and 14.5 μg/L for hemoglobin and ferritin concentrations, respectively. For every 10-g/L increase in hemoglobin concentration, there was a 24% reduced risk of perinatal mortality (RR = 0.76; 95% CI: 0.59, 0.99) and a 23% reduced risk of early infant mortality (RR = 0.77; 95% CI: 0.60, 0.99). The risk of anemia at delivery despite supplementation was predicted by baseline anemia (RR = 2.11; 95% CI: 1.39, 3.18) and improvements in ferritin concentration were more likely to be observed in participants who took iron supplements for up to 90 d (RR = 1.41; 95% CI: 1.13, 1.76).

CONCLUSION

Iron supplementation decreases the risk of maternal anemia and increases the likelihood of infant survival among iron-deficient Tanzanian pregnant women. Interventions to promote increased duration and adherence to iron supplements may also provide greater health benefits.

Daily iron supplementation for improving anaemia, iron status and health in menstruating women

BACKGROUND

Iron-deficiency anaemia is highly prevalent among non-pregnant women of reproductive age (menstruating women) worldwide, although the prevalence is highest in lower-income settings. Iron-deficiency anaemia has been associated with a range of adverse health outcomes, which restitution of iron stores using iron supplementation has been considered likely to resolve. Although there have been many trials reporting effects of iron in non-pregnant women, these trials have never been synthesised in a systematic review.

OBJECTIVES

To establish the evidence for effects of daily supplementation with iron on anaemia and iron status, as well as on physical, psychological and neurocognitive health, in menstruating women.

SEARCH METHODS

In November 2015 we searched CENTRAL, Ovid MEDLINE, EMBASE, and nine other databases, as well as four digital thesis repositories. In addition, we searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and reference lists of relevant reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing daily oral iron supplementation with or without a cointervention (folic acid or vitamin C), for at least five days per week at any dose, to control or placebo using either individual- or cluster-randomisation. Inclusion criteria were menstruating women (or women aged 12 to 50 years) reporting on predefined primary (anaemia, haemoglobin concentration, iron deficiency, iron-deficiency anaemia, all-cause mortality, adverse effects, and cognitive function) or secondary (iron status measured by iron indices, physical exercise performance, psychological health, adherence, anthropometric measures, serum/plasma zinc levels, vitamin A status, and red cell folate) outcomes.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures of Cochrane.

MAIN RESULTS

The search strategy identified 31,767 records; after screening, 90 full-text reports were assessed for eligibility. We included 67 trials (from 76 reports), recruiting 8506 women; the number of women included in analyses varied greatly between outcomes, with endpoint haemoglobin concentration being the outcome with the largest number of participants analysed (6861 women). Only 10 studies were considered at low overall risk of bias, with most studies presenting insufficient details about trial quality.Women receiving iron were significantly less likely to be anaemic at the end of intervention compared to women receiving control (risk ratio (RR) 0.39 (95% confidence interval (CI) 0.25 to 0.60, 10 studies, 3273 women, moderate quality evidence). Women receiving iron had a higher haemoglobin concentration at the end of intervention compared to women receiving control (mean difference (MD) 5.30, 95% CI 4.14 to 6.45, 51 studies, 6861 women, high quality evidence). Women receiving iron had a reduced risk of iron deficiency compared to women receiving control (RR 0.62, 95% CI 0.50 to 0.76, 7 studies, 1088 women, moderate quality evidence). Only one study (55 women) specifically reported iron-deficiency anaemia and no studies reported mortality. Seven trials recruiting 901 women reported on 'any side effect' and did not identify an overall increased prevalence of side effects from iron supplements (RR 2.14, 95% CI 0.94 to 4.86, low quality evidence). Five studies recruiting 521 women identified an increased prevalence of gastrointestinal side effects in women taking iron (RR 1.99, 95% CI 1.26 to 3.12, low quality evidence). Six studies recruiting 604 women identified an increased prevalence of loose stools/diarrhoea (RR 2.13, 95% CI 1.10, 4.11, high quality evidence); eight studies recruiting 1036 women identified an increased prevalence of hard stools/constipation (RR 2.07, 95% CI 1.35 to 3.17, high quality evidence). Seven studies recruiting 1190 women identified evidence of an increased prevalence of abdominal pain among women randomised to iron (RR 1.55, 95% CI 0.99 to 2.41, low quality evidence). Eight studies recruiting 1214 women did not find any evidence of an increased prevalence of nausea among women randomised to iron (RR 1.19, 95% CI 0.78 to 1.82). Evidence that iron supplementation improves cognitive performance in women is uncertain, as studies could not be meta-analysed and individual studies reported conflicting results. Iron supplementation improved maximal and submaximal exercise performance, and appears to reduce symptomatic fatigue. Although adherence could not be formally meta-analysed due to differences in reporting, there was no evident difference in adherence between women randomised to iron and control.

AUTHORS' CONCLUSIONS

Daily iron supplementation effectively reduces the prevalence of anaemia and iron deficiency, raises haemoglobin and iron stores, improves exercise performance and reduces symptomatic fatigue. These benefits come at the expense of increased gastrointestinal symptomatic side effects.

Effects and safety of periconceptional oral folate supplementation for preventing birth defects

BACKGROUND

It has been reported that neural tube defects (NTD) can be prevented with periconceptional folic acid supplementation. The effects of different doses, forms and schemes of folate supplementation for the prevention of other birth defects and maternal and infant outcomes are unclear.

OBJECTIVES

This review aims to examine whether periconceptional folate supplementation reduces the risk of neural tube and other congenital anomalies (including cleft palate) without causing adverse outcomes in mothers or babies. This is an update of a previously published Cochrane review on this topic.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015). Additionally, we searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 August 2015) and contacted relevant organisations to identify ongoing and unpublished studies.

SELECTION CRITERIA

We included all randomised or quasi-randomised trials evaluating the effect of periconceptional folate supplementation alone, or in combination with other vitamins and minerals, in women independent of age and parity.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy and assessed the risk of bias of the included studies. We assessed the quality of the body of evidence using the GRADE approach.

MAIN RESULTS

Five trials involving 7391 women (2033 with a history of a pregnancy affected by a NTD and 5358 with no history of NTDs) were included. Four comparisons were made: 1) supplementation with any folate versus no intervention, placebo or other micronutrients without folate (five trials); 2) supplementation with folic acid alone versus no treatment or placebo (one trial); 3) supplementation with folate plus other micronutrients versus other micronutrients without folate (four trials); and 4) supplementation with folate plus other micronutrients versus the same other micronutrients without folate (two trials). The risk of bias of the trials was variable. Only one trial was considered to be at low risk of bias. The remaining studies lacked clarity regarding the randomisation method or whether the allocation to the intervention was concealed. All the participants were blinded to the intervention, though blinding was unclear for outcome assessors in the five trials.The results of the first comparison involving 6708 births with information on NTDs and other infant outcomes, show a protective effect of daily folic acid supplementation (alone or in combination with other vitamins and minerals) in preventing NTDs compared with no interventions/placebo or vitamins and minerals without folic acid (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.17 to 0.58); five studies; 6708 births; high quality evidence). Only one study assessed the incidence of NTDs and showed no evidence of an effect (RR 0.07, 95% CI 0.00 to 1.32; 4862 births) although no events were found in the group that received folic acid. Folic acid had a significant protective effect for reoccurrence (RR 0.34, 95% CI 0.18 to 0.64); four studies; 1846 births). Subgroup analyses suggest that the positive effect of folic acid on NTD incidence and recurrence is not affected by the explored daily folic acid dosage (400 µg (0.4 mg) or higher) or whether folic acid is given alone or with other vitamins and minerals. These results are consistent across all four review comparisons.There is no evidence of any preventive or negative effects on cleft palate (RR 0.73, 95% CI 0.05 to 10.89; three studies; 5612 births; low quality evidence), cleft lip ((RR 0.79, 95% CI 0.14 to 4.36; three studies; 5612 births; low quality evidence), congenital cardiovascular defects (RR 0.57, 95% CI 0.24 to 1.33; three studies; 5612 births; low quality evidence), miscarriages (RR 1.10, 95% CI 0.94 to 1.28; five studies; 7391 pregnancies; moderate quality evidence) or any other birth defects (RR 0.94, 95% CI 0.53 to 1.66; three studies; 5612 births; low quality evidence). There were no included trials assessing the effects of this intervention on neonatal death, maternal blood folate or anaemia at term.

AUTHORS' CONCLUSIONS

Folic acid, alone or in combination with vitamins and minerals, prevents NTDs, but does not have a clear effect on other birth defects.