Maternal Nutrition

Issues and Interventions

The LINKAGES Project

Academy for Educational Development
 Issues
Nutrition
Maternal

UNICEF/HQ97-0317/ Noorani
 Major Issues
in Maternal Nutrition

• Inadequate weight and height

• Micronutrient deficiencies

3
 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
4
 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
5
 Maternal Malnutrition:
A Life-Cycle Issue (3)
• Throughout life
– Food insecurity
– Inadequate diets
– Recurrent infections
– Frequent parasites
– Poor health care
– Heavy workloads
– Gender inequities
6
 Women Giving Birth
Before the Age of 18

Percent
30 28

21
20 18

10

0
Asia LAC Africa

UN, World Fertility Survey, 1986

7
 Chronic Energy Deficiency
in Women 15-49 Years Old
Percent Women
BMI<18.5 kg/m2
50
41.1 40.5

25 22.4
18.7
14.6

7.2

0
S Asia SE Asia China SS Africa C Amer. S. Amer.

8 ACC/SCN, 1992
 Consequences of Maternal
Chronic Energy Deficiency

• Infections
• Obstructed labor
• Maternal mortality
• Low birth weight
• Neonatal and infant mortality
9
 Determinants of Intrauterine
Growth Retardation

Low pre-pregnancy weight

Short stature

Low caloric intake

Maternal low birth-weight

Non nutritional factors

Kramer, 1989
10
 The Intergenerational
Cycle of Malnutrition

Child growth failure

Low birth Early Low weight and

weight babies pregnancy height in teens

Small adult women

ACC/SCN, 1992
11
 Dietary Iron Requirements
Throughout the Life Cycle
Required iron intake
(mg Fe/1000 kcal)
12
Pregnancy
10 Men
Women
8

0
0 10 20 30 40 50 60 70

Age (years)
12 Stoltzfus, 1997
 Iron Deficiency

• Most common form malnutrition

• Most common cause of anemia

• Other causes of anemia:

− Parasitic infection
− Malaria
13
 Causes of Dietary
Iron Deficiency

• Low dietary iron intake

• Low iron bioavailability

− Non-heme iron
− Inhibitors

14
 Parasitic Infection

• Causes blood loss

• Increases iron loss

15
 Malaria

• Destroys red blood cells

• Leads to severe anemia

• Increases risk in pregnancy

16
 Prevalence of Anemia
in Women 15-49 years old
Percent
70
Non-Pregnant
Pregnant

35

0
S/SE Asia Africa China LAC E Asia
ACC/SCN, 1992
17
 Anemic Women
(15-49 years old) Worldwide
Millions
250
215
Non-Pregnant
Pregnant

125

56 56
27 24
8 11 4 8 0.5
0
S/SE Asia Africa China LAC E Asia

ACC/SCN, 1992
18
DeMaeyer, 1985
 Severity of Anemia
in Pregnant Women
Percent
Mild anemia (90<Hb<110 g/L)
100 Moderate to severe anemia (Hb<90 g/L)

50

0
Nepal China

Stoltzfus, 1997
19
 Severity of Anemia
in Non-Pregnant Women

Percent Mild anemia(90<Hb<120 g/L)

100 Mod-severe anemia (Hb<90 g/L)

50

0
Zanzibar Indonesia

Stoltzfus, 1997
20
 Consequences
of Maternal Anemia

• Maternal deaths
• Reduced transfer of iron to fetus
• Low birth weight
• Neonatal mortality
• Reduced physical capacity
• Impaired cognition
21
 Severe Anemia and
Maternal Mortality (Malaysia)

Maternal deaths / 1000 live births

20
15.5

10

3.5

0
< 65 > 65
Pregnancy hemoglobin concentration (g/L)

Llewellyn-Jones, 1985
22
 Pregnancy Hemoglobin
and Low Birth Weight

15 13.8
11.5
% Low birth weight

11.4 11
9.7 9
10 8.9

0
80 90 100 110 120 130 140
Lowest pregnancy hemoglobin concentration (g/L)

Garn et al., 1981

23
 Consequences of Anemia
on Adult Productivity

UNICEF/HQ95-0974 /Noorani
Reduced productivity
24
 Consequences of Anemia
on Children’s Education

UNICEF/C-79-45/Goodsmith
Reduced learning capacity
25
 Causes of Maternal
Vitamin A Deficiency

• Inadequate intake

• Recurrent infections

UNICEF/DOI93-1879/Zamman
• Reproductive cycles

26
 Consequences of Vitamin A
Deficiency in Pregnancy (1)

Increased risk of:

• Night blindness
• Maternal mortality

• Miscarriage

• Stillbirth

• Low birth weight

27
 Consequences of Vitamin A
Deficiency in Pregnancy (2)

Increased risk of:

• Reduced transfer of vit. A to fetus

• HIV vertical transmission

28
 Consequences of Maternal
Vitamin A Deficiency on Lactation

Low vitamin A

concentration

UNICEF/81-105/John Isaac
in breastmilk

29
 Consequences of Vitamin A
Deficiency in Childhood

Increased risk of:

• Occular problems

• Morbidity and mortality

• Anemia

30
 Iodine Deficiency in Women

Goiter UNICEF/95-0065 Shadid

31
 Consequences of Iodine
Deficiency on Intelligence

• 3% cretins

• 10% severely mentally impaired

UNICEF/C-92/Sprague
• 87% mildly mentally impaired

32
 Consequences of Iodine
Deficiency on Education

• Educability

UNICEF/C-56-19/Murray-Lee
• Drop-out rates

• Under utilization
of school facilities

33
 Consequences of Maternal
Malnutrition on Productivity

Chronic Energy
Deficiency

Iron Deficiency

Iodine Deficiency
34
 Consequences of Maternal
Zinc Deficiency

• Rupture of membranes
• Prolonged labor
• Preterm delivery
• Low birth weight
• Maternal and infant mortality
35
 Consequences of Maternal
Folic Acid Deficiency

• Maternal anemia

• Neural tube defects

• Low birth weight

36
 Consequences of Maternal
Vitamin B-6 and B-12 Deficiency

• Maternal anemia
• Impaired development
of infant’s brain
• Neurological disorders
in infants
37
 Maternal
Nutrition

UNICEF/HQ97-0317/ Noorani
Interventions
 Major Interventions
in Maternal Nutrition

• Improve weight and height

• Improve micronutrient status

39
 Improving Maternal Weight

• Increase caloric intake

• Reduce energy expenditure

• Reduce caloric depletion

40
 Improving Maternal Height

• Increase birth weight

• Enhance infant growth

• Improve adolescent growth

41
 Optimal Behaviors
to Improve Women’s Nutrition

Early Infancy:
Exclusive
breastfeeding

UNICEF/92-070/John Isaac
to six months
of age

42
 Optimal Behaviors
to Improve Women’s Nutrition

Late Infancy
and Childhood:
Appropriate

UNICEF/C-55-3F/Watson
complementary
feeding from
about six months
43
 Optimal Behaviors
to Improve Women’s Nutrition

Late Infancy
and Childhood:
Continue
frequent
on-demand

UNICEF/HQ96-0304/Charton
breastfeeding
to 24 months
and beyond
44
 Optimal Behaviors
to Improve Women’s Nutrition

Pregnancy:
• Increase food intake
• Take iron+folic acid

UNICEF/90-196/J. Schytte
supplements daily
• Reduce workload

45
 Optimal Behaviors
to Improve Women’s Nutrition

Lactation:
• Increase food intake
• Take a high dose

UNICEF/C-88-15/Goodsmith
vitamin A at delivery
• Reduce workload
46
 Vit A Postpartum
Supplementation (Indonesia)

Jan-June 96 18.8

July-Dec 95 12.5

0 10 20
Percentage of mothers receiving postpartum Vitamin A supplements

Helen Keller International, 1997

47
 Optimal Behaviors
to Improve Women’s Nutrition
• Delay first pregnancy
• Increase birth intervals

UNICEF/HQ97-0934/Noorani
48
 Optimal Behaviors
to 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

49
 Improving Women’s
Micronutrient Status

• Dietary modification
• Parasite control
• Fortification
• Supplementation
50
 Dietary Modification to Improve
Women’s Micronutrient Status

Increase:

• Micronutrient intake

• Bioavailability of micronutrient intake

51
 Parasite Control to Improve
Women’s Micronutrient Status

Reduce parasite transmission:

• Improve hygiene

• Increase access to treatments

52
 Fortification to Improve
Women’s Micronutrient Status

Medium-term strategy:
• Improves micronutrient intake
• Without changing food habits

Requires:
• Appropriate nutrient fortificant
• Appropriate food vehicle
53
 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
54
 Supplementation to Improve
Women’s Micronutrient Status

• Preventive or therapeutic
• Daily or periodic
• Targeted to groups
• Mass distribution

55
 Iron+Folic Acid Supplementation
for Women of Reproductive Age

Prior to and between pregnancies:

• Periodic daily supplementation

or

• Ongoing weekly supplementation

56
 Iron+Folic Acid Supplementation
during Pregnancy

• Daily supplementation
• Start as soon as possible
• Continue for six months

57
 Multiple Micronutrient
Maternal Supplementation

Targeted to:
− Pregnant women
− All women of reproductive age
Iron+folic acid+other micronutrients
Addition increases:
− Costs
− Benefits
58
 Elements of a Successful
Supplementation Program

• Supplement supply
• Delivery system
• Women’s demand and compliance
• Monitoring and evaluation

59
 Supplement Supply

• Data-based ordering

• Timely procurement process

• Timely distribution to delivery points

60
 Supplement Delivery System

• Accessible to target population

• Appropriate Staff:
− Motivated
− Approachable
− Supportive
− Adequately trained
61
 Women’s Demand and Compliance

• Communications component
− Community awareness

− Information on side effects

• Good quality supplements

62
 Monitoring and Evaluation

• Monitoring at all levels:

− Supply
− Coverage
− Compliance
− Communications component

• Evaluate impact on prevalence

63
 Produced by

The Linkages Project