Module 6: Nutrition in Maternal and Child Health

Introduction

This article addresses fundamental aspects of maternal and child nutrition as well as new research on undernutrition and its detrimental impact on long-term health. The topic of maternal and child nutrition includes preconception, antenatal, and postnatal maternal nutrition, women's nutrition throughout their reproductive years, as well as fetal, neonatal, and child nutrition.

The Problem

Globally, food insecurity is associated with micronutrient deficiencies, and an estimated 4.5 billion people worldwide are affected by some form of nutrient deficiency. Of this 4.5 billion, the most vulnerable groups are young children and women of childbearing age.(1) The micronutrients that are most important for maternal and child health outcomes include iron, vitamin B12, folic acid, vitamin D, and selenium.(2)(3)(4)

Deficiencies in micronutrients affect many women of reproductive age and are associated with adverse health effects. A 2008 review of maternal malnutrition concluded that 10–19% of women of reproductive age are seriously undernourished. With a body mass index of less than 18.5, these women are at increased risk of delivering low-birthweight infants.(5) In low- and middle-income countries, the social and health problems that come along with such deficiencies are often compounded by high fertility rates, repeated pregnancies, and short intervals between pregnancies.

Without proper nutrition and essential nutrients, women and their children are at increased risk for disease and poor health outcomes. For example, a study in Haiti found that undernutrition is associated with increased risk for malaria.(6) Haiti, the poorest country in the Western Hemisphere, is heavily affected by both food insecurity and malaria. To find out if these two conditions were associated, researchers studied a sample of 153 women with children 1–5 years of age in Camp Perrin, South Haiti. Analysis revealed that severe food insecurity was a risk factor for clinical malaria. These findings suggest that policies and programs that address food insecurity are also likely to reduce the risk of malaria and other comorbidities.

Another example of the causal association between poor nutrition and ill health can be seen in the case of anemia. Anemia before and during pregnancy is associated with increased maternal and perinatal mortality and morbidity and affects almost two-thirds of pregnant women in low- and middle-income countries.(7) The WHO Quarterly Statistics showed that two-thirds of pregnant women in India have a hemoglobin count so low that it increases the risk of maternal mortality rate to 17–20%.(8) Others have reported that the incidence of anemia varies from 40% to 90% in India and contributes to 10–15% of direct maternal deaths.(9) Women in a study in Northwest Ethiopia were found more likely to have anemia during pregnancy if they had a low income, large family, hookworm infection, or were infected with HIV. (10)

Anemia in pregnancy generally results from nutritional deficiencies; almost 75% of anemia is due to iron deficiency followed by folate and vitamin B12 deficiencies.(11) “Furthermore, physiological changes in pregnancy lead to an increase in the demand of many nutrients; especially iron, folic acid and zinc.”(12) Because most women in low- and middle-income countries have depleted body stores of these nutrients before pregnancy, their deficiency of iron and folic acid is even higher during pregnancy. If these needs are not met, the state of anemia may worsen. Fortunately, anemia during pregnancy is for the most part, easily prevented and treatable with nutrition, supplementation, or fortification.

Nutrition, Supplementation, and Fortification

The approaches available for increasing micronutrient intake include dietary modification, supplementation, and food fortification. Dietary modification involves changing the type and kind of food consumed, while supplementation involves the addition of certain essential micronutrients and vitamins usually in pill form. Food fortification is the public health policy of adding micronutrients (essential trace elements and vitamins) to foodstuffs to ensure that minimum dietary requirements are met.  

“While each approach has its inherent advantages and disadvantages, these different approaches for improving micronutrient status of populations are more often complementary options rather than competing ones.”(13)

The dietary modification approach has the advantage that once the population changes its diet, it is likely to sustain this practice. The disadvantage is that it is often difficult to change behaviors and established practices. The downside of fortification is that fortified, micronutrient-rich foods are often expensive, meaning that they may be beyond the reach of the poorest of the poor.

“Supplementation has the advantage that it can provide a rapid improvement in the nutritional situation of target groups, but has the disadvantage that the recipients are usually required to take the supplement with some regularity.”(14) Even if the issue of adherence is resolved, the challenge remains of ensuring the continuous distribution and local availability of the supplements. Supplementation is the best option where the prevalence of a micronutrient deficiency in a population is high and if the requirement for a nutrient is difficult to achieve through the normal diet.(15)

Supplements are normally provided to a specific target group rather than the whole population, and only for a limited period of time. As mentioned, infants and pregnant and lactating women represent the most at-risk groups whose nutrient needs are highest and who merit provision of micronutrient supplements during this period of increased vulnerability. Lastly, supplementation requires an existing distribution system that will allow the target population to be fully covered.

Conclusion

Appropriate strategies for the prevention and management of maternal and child undernutrition in low- and middle-income countries must be a global priority. Evidence-based interventions that can improve maternal nutritional status and fetal growth include “fortified food supplements, conditional cash transfers to address household food insecurity, and micronutrient interventions.”(16)

Furthermore, measures to reduce the burden of maternal infections such as HIV infection, malaria, and worm infection can improve nutrition, and improved nutritional status may aid in the combat of such diseases.(17) Ultimately, optimal maternal and child nutrition should be achieved through multiple interventions supported and promoted by different strategies, rather than by one intervention alone.

Footnotes

(1) Dickinson, N et al. A framework to explore micronutrient deficiency in maternal and child health in Malawi, Southern Africa. Environmental Health 2009, 8 (Suppl 1):S13.

(2) de Benoist B. Conclusions of a WHO technical consultation on folate and vitamin B12 deficiencies. Food Nutr Bull 2008;29(Suppl 2):S238–44.

(3) Kovacs CS. Vitamin D in pregnancy and lactation: maternal, fetal, and neonatal outcomes from human and animal studies. Am J Clin Nutr 2008;88:520S–8S.

(4) Kupka R, Mugusi F, Aboud S, et al. Randomized, double-blind, placebo-controlled trial of selenium supplements among HIV-infected pregnant women in Tanzania: effects on maternal and child outcomes. Am J Clin Nutr 2008;87:1802–8.

(5) Black RE, Allen LH, Bhutta ZA, et al.; Maternal and Child Under nutrition Study Group. Maternal and child under nutrition: global and regional exposures and health consequences. Lancet 2008;371:243–60.

(6) Perez-Escamilla, R et al. Household Food Insecurity Is Associated with Childhood Malaria in Rural Haiti. Journal of Nutrition, Vol. 139, No. 11, 2132-2138.

(7) Royston E, ‌Armstrong S. ‌1989. Preventing maternal deaths. Geneva: WHO. pp 85–147.

(8) WHO. 1998. WHO/UNICEF and UNU Iron deficiency: Indicators for assessment and strategies for prevention. Geneva: WHO.

(9) Mudaliar AL, ‌Menon MK. ‌2005. Clinical obstetrics. Hyderabad: Orient Longman. p 147.

(10) Melku, M., Addis, Z., Alem, M., & Enawgaw, B. (2014). Prevalence and predictors of maternal anemia during pregnancy in Gondar, Northwest Ethiopia: an institutional based cross-sectional study. Anemia, 2014.

(11) Allen L, ‌Casterline-Sabel J. ‌2000. Prevalence and causes of nutritional anemias. In: Ramakrishnan U, ‌editor. Nutritional anaemias. Boca Raton: CRC Press. pp 17–21.

(12) Mohammed K, ‌Hyten F. ‌1989. Iron and folate supplementation in pregnancy. In: Chalmers H, ‌Enkin MJ, ‌editors. Effective care in pregnancy and childbirth. Oxford: Oxford University Press.

(13) Shrimpton R, Schultink W. Can supplements help meet the micronutrient needs of the developing world? Proc Nutr Soc. 2002;61:223–9.

(14) Ibid.

(15) Ibid.

(16) Bhutta ZA, Haider BA. Prenatal micronutrient supplementation: are we there yet? CMAJ. 2009;180(12): 1188–1189.

(17) Bhutta ZA, Ahmed T, Black RE, et al.; Maternal and Child Under-nutrition Study Group. What works? Interventions for maternal and child under-nutrition and survival. Lancet 2008;371:417–40.