maternal nutrition power point

Maternal NutritionIssues and Interventions

The LINKAGES ProjectAcademy for Educational Development

Maternal Nutrition

Issues

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Major Issuesin Maternal Nutrition

• Inadequate weight and height

• Micronutrient deficiencies

44

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

55


• 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

66


• Throughout life– Food insecurity– Inadequate diets– Recurrent infections– Frequent parasites– Poor health care– Heavy workloads– Gender inequities

77

Women Giving BirthBefore the Age of 18

1821

28

0

10

20

30

Asia LAC Africa

UN, World Fertility Survey, 1986

Percent

88

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 WomenBMI<18.5 kg/m2

99

Consequences of MaternalChronic Energy Deficiency

• Infections

• Obstructed labor

• Maternal mortality

• Low birth weight

• Neonatal and infant mortality

1010

Determinants of IntrauterineGrowth Retardation

Low pre-pregnancy weight

Short stature

Low caloric intake

Maternal low birth-weight

Non nutritional factors

Kramer, 1989

1111

The IntergenerationalCycle of Malnutrition

Child growth failure

Early pregnancy

Small adult women

Low birth weight babies

Low weight and height in teens

ACC/SCN, 1992

1212

Dietary Iron RequirementsThroughout the Life Cycle

0

2

4

6

8

10

12

0 10 20 30 40 50 60 70

MenWomen

Required iron intake(mg Fe/1000 kcal)

Stoltzfus, 1997Age (years)

Pregnancy

1313

Iron Deficiency

• Most common form malnutrition

• Most common cause of anemia

• Other causes of anemia:

− Parasitic infection

− Malaria

1414

Causes of DietaryIron Deficiency

• Low dietary iron intake

• Low iron bioavailability− Non-heme iron− Inhibitors

1515

Parasitic Infection

• Causes blood loss

• Increases iron loss

1616

Malaria

• Destroys red blood cells

• Leads to severe anemia

• Increases risk in pregnancy

1717

Prevalence of Anemiain Women 15-49 years old

0

35

70

S/SE Asia Africa China LAC E Asia

Non-PregnantPregnant

ACC/SCN, 1992

Percent

1818

Anemic Women(15-49 years old) Worldwide

215

56 5624

827

8 11 4 0.50

125

250

S/SE Asia Africa China LAC E Asia

Non-PregnantPregnant

ACC/SCN, 1992DeMaeyer, 1985

Millions

1919

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

2020

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

2121

Consequencesof Maternal Anemia

• Maternal deaths• Reduced transfer of iron to fetus• Low birth weight• Neonatal mortality• Reduced physical capacity• Impaired cognition

2222

Severe Anemia andMaternal Mortality (Malaysia)

15.5

3.5

0

10

20

Llewellyn-Jones, 1985

< 65 > 65

Pregnancy hemoglobin concentration (g/L)

Maternal deaths / 1000 live births

2323

Pregnancy Hemoglobinand Low Birth Weight

13.811.5

9.7 8.9 911.4 11

0

5

10

15

80 90 100 110 120 130 140

Lowest pregnancy hemoglobin concentration (g/L)

% L

ow b

irth

wei

ght

Garn et al., 1981

2424

Consequences of Anemiaon Adult Productivity

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Reduced productivityReduced productivity

2525

Consequences of Anemiaon Children’s Education

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Reduced learning capacityReduced learning capacity

2626

Causes of MaternalVitamin A Deficiency

•• Inadequate intake

• Recurrent infections

• Reproductive cycles

UN

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I93-

1879

/Zam

man

2727

Consequences of Vitamin ADeficiency in Pregnancy (1)

Increased risk of:• Night blindness• Maternal mortality• Miscarriage• Stillbirth• Low birth weight

2828

Consequences of Vitamin ADeficiency in Pregnancy (2)

Increased risk of:

• Reduced transfer of vit. A to fetus

• HIV vertical transmission

2929

Consequences of MaternalVitamin A Deficiency on Lactation

Low vitamin A

concentration

in breastmilk

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Isaa

c

3030

Consequences of Vitamin ADeficiency in Childhood

Increased risk of:

• Occular problems

• Morbidity and mortality

• Anemia

3131

Iodine Deficiency in Women

UN

ICEF

/95-

0065

Sha

did

Goiter

3232

Consequences of IodineDeficiency on Intelligence

UN

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/C-9

2/Sp

ragu

e

• 3% cretins

• 10% severely mentally impaired

• 87% mildly mentally impaired

• 3% cretins3% cretins

•• 10% severely mentally impaired10% severely mentally impaired

•• 87% mildly mentally impaired87% mildly mentally impaired

3333

Consequences of IodineDeficiency on Education

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Lee

• Educability

• Drop-out rates

• Under utilizationof school facilities

3434

Consequences of MaternalMalnutrition on Productivity

Chronic EnergyDeficiency

Iron Deficiency

Iodine Deficiency

3535

Consequences of MaternalZinc Deficiency

• Rupture of membranes

• Prolonged labor

• Preterm delivery


• Maternal and infant mortality

3636

Consequences of MaternalFolic Acid Deficiency

• Maternal anemia

• Neural tube defects


3737

Consequences of MaternalVitamin B-6 and B-12 Deficiency

• Maternal anemia

• Impaired developmentof infant’s brain

• Neurological disordersin infants

Maternal Nutrition

Interventions

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Major Interventionsin Maternal Nutrition

• Improve weight and height

• Improve micronutrient status

4040

Improving Maternal Weight

• Increase caloric intake

• Reduce energy expenditure

• Reduce caloric depletion

4141

Improving Maternal Height

• Increase birth weight

• Enhance infant growth

• Improve adolescent growth

4242

Optimal Behaviorsto Improve Women’s Nutrition

Early Infancy:Exclusivebreastfeedingto six monthsof age

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4343


Late Infancyand Childhood:Appropriatecomplementaryfeeding fromabout six months U

NIC

EF/C

-55-

3F/W

atso

n

4444


Late Infancyand Childhood:Continuefrequenton-demandbreastfeedingto 24 monthsand beyond

UN

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Cha

rton

4545


Pregnancy:

• Increase food intake

• Take iron+folic acid

supplements daily

• Reduce workload

UN

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J. S

chyt

te

4646


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

UN

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/C-8

8-15

/Goo

dsm

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4747

Vit A PostpartumSupplementation (Indonesia)

12.5

18.8

0 10 20

July-Dec 95

Jan-June 96

Percentage of mothers receiving postpartum Vitamin A supplements

Helen Keller International, 1997

4848


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• Delay first pregnancyDelay first pregnancy

•• Increase birth intervals Increase birth intervals

4949


At all times:• Increase food intake if underweight• Diversify the diet• Use iodized salt• Control parasites• Take micronutrient supplements if needed

5050

Improving Women’sMicronutrient Status

• Dietary modification

• Parasite control

• Fortification

• Supplementation

5151

Dietary Modification to ImproveWomen’s Micronutrient Status

Increase:

• Micronutrient intake

• Bioavailability of micronutrient intake

5252

Parasite Control to ImproveWomen’s Micronutrient Status

Reduce parasite transmission:

• Improve hygiene

• Increase access to treatments

5353

Fortification to ImproveWomen’s Micronutrient Status

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

Requires:• Appropriate nutrient fortificant• Appropriate food vehicle

5454

Examples of MicronutrientFood Fortification

• Vitamin A in sugar

• Iron in wheat flour

• Iodine in salt

• Multiple fortification- iron + iodine in salt- iron + vit B in wheat flour

5555

Supplementation to ImproveWomen’s Micronutrient Status

• Preventive or therapeutic

• Daily or periodic

• Targeted to groups

• Mass distribution

5656

Iron+Folic Acid Supplementationfor Women of Reproductive Age

Prior to and between pregnancies:

• Periodic daily supplementation

or

• Ongoing weekly supplementation

5757

Iron+Folic Acid Supplementationduring Pregnancy

• Daily supplementation

• Start as soon as possible

• Continue for six months

5858

Multiple MicronutrientMaternal Supplementation

Targeted to:− Pregnant women− All women of reproductive age

Iron+folic acid+other micronutrientsAddition increases:

− Costs− Benefits

5959

Elements of a SuccessfulSupplementation Program

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

6060

Supplement Supply

• Data-based ordering

• Timely procurement process

• Timely distribution to delivery points

6161

Supplement Delivery System

• Accessible to target population

• Appropriate Staff:− Motivated− Approachable− Supportive− Adequately trained

6262

Women’s Demand and Compliance

• Communications component− Community awareness

− Information on side effects

• Good quality supplements

6363

Monitoring and Evaluation

• Monitoring at all levels:− Supply− Coverage− Compliance− Communications component

• Evaluate impact on prevalence

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maternal nutrition power point

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