Maternal Nutrition

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• Maternal Nutrition
• Issues and Interventions
• The Linkages Project
• Academy for Educational Development

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Maternal Nutrition Issues
UNICEF/C-79-15/Goodsmith
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Major Issuesin Maternal Nutrition

• Inadequate weight and height
• Micronutrient deficiencies

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Maternal MalnutritionA 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 MalnutritionA 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 MalnutritionA 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
Percent
UN, World Fertility Survey, 1986
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Chronic Energy Deficiencyin Women 15-49 Years Old
Percent Women BMIlt18.5 kg/m2
ACC/SCN, 1992
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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 Intrauterine Growth
Retardation
Kramer, 1989
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The IntergenerationalCycle of Malnutrition
Child growth failure
Early pregnancy
Low birth weight babies
Low weight and height in teens
Small adult women
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
Required iron intake (mg Fe/1000 kcal)
Pregnancy
Age (years)
Stoltzfus, 1997
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Causes of DietaryIron 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
Percent
ACC/SCN, 1992
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Anemic Women (15-49 years old) Worldwide
Millions
ACC/SCN, 1992 DeMaeyer, 1985
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Severity of Anemiain Pregnant Women
Percent
Stoltzfus, 1997
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Severity of Anemiain Non-Pregnant Women
Percent
Stoltzfus, 1997
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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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Severe Anemia andMaternal Mortality (Malaysia)
Maternal deaths / 1000 live births
lt 65
gt 65
Pregnancy hemoglobin concentration (g/L)
Llewellyn-Jones, 1985
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Pregnancy Hemoglobinand Low Birth Weight
Garn et al., 1981
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Consequences of Anemiaon Womens Productivity
UNICEF/91-029 J /Schytte
Reduced productivity
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Consequences of Anemiaon Childrens Education
UNICEF/C-72-15/Spraguei
Reduced learning capacity
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Causes of MaternalVitamin A Deficiency

• Inadequate intake
• Recurrent infections
• Reproductive cycles

UNICEF/C-16-8/Isaac
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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 fetus

UNICEF
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Consequences of MaternalVitamin A Deficiency on
Lactation
Low vitamin A concentration in breastmilk
UNICEFC-92-18/Sprague
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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/95-0065 Shadid

• Goiter

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Consequences of IodineDeficiency on Intelligence

• Spectrum of Intellectual Impairment
• cretinism
• severe mental impairment
• mild mental impairment

UNICEF/C-79-39
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Consequences of Iodine Deficiency on Education

• Educability
• Drop-out rates
• Under utilization of school facilities

UNICEF/C-56-19/Murray-Lee
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Consequences of Maternal Malnutrition on
Productivity

• Chronic Energy Deficiency
• Iron Deficiency
• Iodine Deficiency

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Consequences of MaternalZinc 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 infants brain
• Neurological disorders in infants

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Maternal Nutrition Interventions
UNICEF/C-79-15/Goodsmith
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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 Womens Nutrition
Early Infancy Exclusive breastfeeding
to about six months of age
UNICEF/C-79-10
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Optimal Behaviorsto Improve Womens Nutrition
Late Infancy and Childhood
Appropriate complementary feeding from about six
months
UNICEF/C-55-3F/Watson
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Optimal Behaviorsto Improve Womens Nutrition

• Late Infancy and Childhood
  Continue frequent on-demand breastfeeding to 24
  months and beyond

UNICEF/C-56-7/Murray-Lee
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Optimal Behaviorsto Improve Womens Nutrition

• Pregnancy
• Increase food intake
• Take ironfolic acid supplements daily
• Reduce workload

UNICEF/C-55-10/Watson
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Optimal Behaviorsto Improve Womens Nutrition

• Lactation
• Increase food intake
• Take a high dose
• vitamin A at delivery
• Reduce workload

UNICEF/C-88-15/Goodsmith
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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 possible after delivery

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Optimal Behaviorsto Improve Womens Nutrition

• Delay first pregnancy
• Increase birth intervals

UNICEF90-070/Lemoyne
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Optimal Behaviorsto Improve Womens 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 Womens Micronutrient Status

• Dietary modification
• Parasite control
• Fortification
• Supplementation

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Dietary Modification to Improve Womens
Micronutrient Status

• Increase
• Micronutrient intake
• Bioavailability of micronutrient intake

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Parasite Control to Improve Womens
Micronutrient Status

• Reduce parasite transmission
• Improve hygiene
• Increase access to treatments

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Fortification to Improve Womens
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

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Supplementation to Improve Womens
Micronutrient Status

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

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IronFolic Acid Supplementationfor 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

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IronFolic Acid Supplementationduring Pregnancy

• Daily supplementation
• Start as soon as possible
• Continue for 6 months

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Multiple MicronutrientMaternal Supplementation

• Targeted to
• Pregnant women
• All women of reproductive age
• Ironfolic acidother micronutrients
• Addition increases
• Costs
• Benefits

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Elements of a Successful Supplementation Program

• Supplement supply
• Delivery system
• Womens 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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Womens 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