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Maternal Nutrition
Issues and
Interventions
The Linkages Project
Academy for Educational Development
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UN
ICEF/C-79-15/G
oodsmith
Maternal
Nutrition
Issues
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Major Issuesin Maternal Nutrition
• Inadequate weight and height
• Micronutrient deficiencies
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Maternal Malnutrition: A Life-Cycle Issue (1)
• Infancy and early childhood (0-24 months)
–Suboptimal breastfeeding practices
– Inadequate complementary foods
– Infrequent feeding
– Frequent infections
•
Childhood (2-9 years) – Poor diets
– Poor health care
– Poor education
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Maternal Malnutrition: A Life-Cycle Issue (2)
• Adolescence (10-19 years)
– Increased nutritional demands– Greater iron needs
– Early pregnancies
• Pregnancy and lactation
– Higher nutritional requirements
– Increased micronutrient needs
– Closely-spaced reproductive cycles
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Maternal Malnutrition: A Life-Cycle Issue (3)
Throughout life
– Food insecurity
– Inadequate diets
– Recurrent infections
– Frequent parasites
– Poor health care– Heavy workloads
– Gender inequities
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Women Giving Birthbefore the Age of 18
18
21
28
0
10
20
30
Asia LAC Africa
UN, World Fertility Survey, 1986
Percent
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Chronic Energy Deficiencyin Women 15-49 Years Old
41.1 40.5
18.722.4
14.6
7.2
0
25
50
S Asia SE Asia China SS Africa C Amer. S. Amer.
ACC/SCN, 1992
Percent Women
BMI<18.5 kg/m2
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Consequences of Maternal Chronic Energy Deficiency
• Infections
• Obstructed labor
• Maternal mortality
• Low birth weight
• Neonatal and infant mortality
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Determinants of IntrauterineGrowth Retardation
Low pre-pregnancy weight
Short stature
Low caloric intake
Maternal low birth-weight
Non nutritional factors
Kramer, 1989
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The Intergenerational Cycle of Malnutrition
Child growthfailure
Early
pregnancy
Small adultwomen
Low birth
weight babiesLow weight andheight in teens
ACC/SCN, 1992
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Iron Deficiency
• Most common form of malnutrition
• Most common cause of anemia
• Other causes of anemia:
−Parasitic infection
−Malaria
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Dietary Iron RequirementsThroughout the Life Cycle
0
2
4
6
8
10
12
0 10 20 30 40 50 60 70
Men
Women
Required iron intake(mg Fe/1000 kcal)
Stoltzfus, 1997
Age (years)
Pregnancy
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Causes of Dietary Iron Deficiency
•
Low dietary iron intake• Low iron bioavailability
− Non-heme iron
− Inhibitors
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Parasitic Infection
• Causes blood loss
•
Increases iron loss
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Malaria
•
Destroys red blood cells• Leads to severe anemia
• Increases risk in pregnancy
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Prevalence of Anemiain Women 15-49 years old
ACC/SCN, 1992
Percent
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Anemic Women(15-49 years old) Worldwide
215
56 56
248
278 11 4 0.5
0
125
250
S/SE Asia Africa China LAC E Asia
Non-PregnantPregnant
ACC/SCN, 1992
DeMaeyer, 1985
Millions
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Severity of Anemiain Pregnant Women
0
50
100
Nepal China
Mild anemia (90<Hb<110 g/L)
Moderate to severe anemia (Hb<90 g/L)
Stoltzfus, 1997
Percent
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Severity of Anemiain Non-Pregnant Women
0
50
100
Zanzibar Indonesia
Mild anemia(90<Hb<120 g/L)
Mod-severe anemia (Hb<90 g/L)
Stoltzfus, 1997
Percent
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Consequencesof Maternal Anemia
• Maternal deaths
• Reduced transfer of iron to fetus• Low birth weight
•
Neonatal mortality• Reduced physical capacity
• Impaired cognition
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Pregnancy Hemoglobinand Low Birth Weight
13.8
11.59.7
8.9 911.4 11
0
5
10
15
80 90 100 110 120 130 140
Lowest pregnancy hemoglobin concentration (g/L)
%
L o w b i r t h w e i g h
t
Garn et al., 1981
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Consequences of Anemiaon Women’s Productivity
UNICEF/9
1-029J/S
chytte
Reduced
productivity
Reduced
roductivit
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Consequences of Anemiaon Children’s Education
UNICEF/C
-72-15/S p
raguei
Reduced learning capacityReduced learning capacity
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Causes of Maternal Vitamin A Deficiency
• Inadequate intake
• Recurrent infections
• Reproductive cycles
U
NICEF/C-16-8/Isa a
c
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Consequences of Vitamin A Deficiency in Pregnancy (1)
Increased risk of:• Nightblindness• Maternal mortality
• Miscarriage
• Stillbirth
• Low birth weight
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Consequences of Vitamin A Deficiency in Pregnancy (2)
•
Reduced
transfer of
vitamin A to
fetusUNICEF
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Consequences of Maternal Vitamin A Deficiency on Lactation
UNICEFC
-92-18/S
prague
Low
vitamin A
concentrat
ion
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Consequences of Vitamin A Deficiency in Childhood
Increased risk of:
• Occular problems
• Morbidity and mortality
• Anemia
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Iodine Deficiency in Women
UNICEF/9
5-0065
Shadid
GoiterGoiter
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Consequences of Iodine Deficiency on Intelligence
Spectrum of Intellectual Impairment:
• cretinism
•
severe mental impairment
• mild mental impairment
Spectrum of Intellectual Impairment:
• cretinism
•
severe mental impairment
• mild mental impairmentUNICEF/C-79-39
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Consequences of Iodine Deficiency on Education
• Educability
• Drop-out rates
• Under utilizationof school facilities
UN
ICEF/C-56-19/M
urray-Lee
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Consequences of Maternal Malnutrition on Productivity
Chronic EnergyDeficiency
Iron Deficiency
IodineDeficiency
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Consequences of Maternal Zinc Deficiency
• Rupture of membranes
• Prolonged labor
• Preterm delivery
• Low birth weight
• Maternal and infant mortality
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Consequences of Maternal Folic Acid Deficiency
•
Maternal anemia
• Neural tube defects
• Low birth weight
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Consequences of Maternal Vitamin B-6 and B-12 Deficiency
• Maternal anemia
• Impaired development of infant’s brain
• Neurological disorders in infants
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Maternal
Nutrition
Interventions
U
NICEF/C
-79-15/G
oo
dsmith
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Major Interventionsin Maternal Nutrition
• Improve weight and height
• Improve micronutrient status
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Improving Maternal Weight
• Increase caloric intake
• Reduce energy expenditure
• Reduce caloric depletion
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Improving Maternal Height
• Increase birth weight
• Enhance infant growth
• Improve adolescent growth
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Optimal Behaviorsto Improve Women’s Nutrition
Early Infancy: Exclusive
breastfeedingto about
six months of age U
NICEF/C
-79-10
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Optimal Behaviorsto Improve Women’s Nutrition
Late Infancyand
Childhood: Appropriate
complementaryfeeding from
about six
UNICEF/C
-55-3
F/Watson
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Optimal Behaviorsto Improve Women’s Nutrition
UNICEF/C-56-7/M
urray-Lee
Late Infancyand Childhood: Continue frequenton-demand
breastfeeding to 24months and beyond
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Optimal Behaviorsto Improve Women’s Nutrition
Pregnancy:
• Increase food intake
• Take iron+folic acid
supplements daily
• Reduce workload
UNICEF/C
-55-10/Watson
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Optimal Behaviorsto Improve Women’s Nutrition
UNICEF/C-88-15/G
oodsmith
Lactation:• Increase food intake
• Take a high dose
vitamin A at delivery
• Reduce workload
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Vitamin A PostpartumSupplementation
Recommendations
Current (WHO):200,000 IU in 1 dose, as soon as possible
after delivery
Proposed (IVACG):400,000 IU in 2 doses of 200,000 IU at
least 1 day apart, as soon as possibleafter delivery
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Optimal Behaviorsto Improve Women’s Nutrition
UNICEF9
0-070/Lem
oyne
•
Delay
firstpregnancy
•
Increase
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Optimal Behaviorsto Improve Women’s Nutrition
At all times:
•Increase food intake if underweight•Diversify the diet
•Use iodized salt
•Control parasites• Take micronutrient supplements if needed
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Improving Women’sMicronutrient Status
• Dietary modification
• Parasite control
•
Fortification• Supplementation
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Dietary Modification to ImproveWomen’s Micronutrient Status
Increase:
•Micronutrient intake
•Bioavailability of micronutrient intake
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Parasite Control to ImproveWomen’s Micronutrient Status
Reduce parasite transmission:
• Improve hygiene
•
Increase access to treatments
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Fortification to ImproveWomen’s Micronutrient Status
Medium-term strategy:
•
Improves micronutrient intake• Without changing food habits
Requires:
• Appropriate nutrient fortificant
• Appropriate food vehicle
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Examples of Micronutrient Food Fortification
• Vitamin A in sugar
• Iron in wheat flour
• Iodine in salt
• Multiple fortification- iron + iodine in salt
- iron + vit B in wheat flour
l
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Supplementation to ImproveWomen’s Micronutrient Status
• Preventive or therapeutic
• Daily or periodic
• Targeted to groups
• Mass distribution
l A d S l
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Iron+ Folic Acid Supplementation for Women of Reproductive Age
Prior to and between pregnancies:
Periodic supplementation (60 mg of iron and 400 μg
folic acid) daily for 3 months for:
●Girls before puberty and during adolescence
●Women of childbearing age
I F l A d S l
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Iron+ Folic Acid Supplementationduring Pregnancy
•Daily supplementation
•Start as soon as possible
•Continue for 6 months
M l l M
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Multiple Micronutrient Maternal Supplementation
Targeted to:
− Pregnant women
− All women of reproductive age
Iron+folic acid+other micronutrients
Addition increases:− Costs
− Benefits
El f S f l
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Elements of a Successful Supplementation Program
•
Supplement supply• Delivery system
• Women’s demand and compliance
• Monitoring and evaluation
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Supplement Supply
•
Data-based ordering
• Timely procurement process
• Timely distribution to delivery points
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Supplement Delivery System
• Accessible to target population
• Appropriate Staff:− Motivated
− Approachable
− Supportive
− Adequately trained
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Women’s Demand and Compliance
• Communications component
− Community awareness
− Information on side effects
• Good quality supplements
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Monitoring and Evaluation
• Monitor at all levels:
− Supply
− Coverage
− Compliance
−
Communications component
• Evaluate impact on prevalence
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Produced by
The Linkages Project