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Maternal Nutrition Issues and Interventions

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Maternal Nutrition   Issues and Interventions Powered By Docstoc
					  Maternal Nutrition
Issues and Interventions

         The Linkages Project
   Academy for Educational Development
                     Issues
                              Nutrition
                              Maternal




UNICEF/C-79-15/Goodsmith
          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
              Iron Deficiency

        Most common form of malnutrition

        Most common cause of anemia

        Other causes of anemia:
                Parasitic infection
                Malaria
12
              Dietary Iron Requirements
              Throughout the Life Cycle
          Required iron intake
          (mg Fe/1000 kcal)
     12
                                      Pregnancy
     10                                                         Men
                                                                Women
     8

     6

     4

     2

     0
          0          10          20        30         40   50    60         70

                                        Age (years)
13                                                              Stoltzfus, 1997
     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
     % Low birth weight




                                        11.5                                 11.4       11
                                                  9.7                9
                          10                               8.9


                          5


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


                                                                              Garn et al., 1981
23
     Consequences of Anemia
     on Women’s Productivity




                               UNICEF/91-029 J /Schytte
        Reduced productivity
24
     Consequences of Anemia
     on Children’s Education




                                    UNICEF/C-72-15/Spraguei
        Reduced learning capacity
25
              Causes of Maternal
             Vitamin A Deficiency


     • Inadequate intake

     • Recurrent infections




                                    UNICEF/C-16-8/Isaac
     • Reproductive cycles



26
     Consequences of Vitamin A
     Deficiency in Pregnancy (1)

         Increased risk of:
            Nightblindness
            Maternal mortality

            Miscarriage

            Stillbirth

            Low birth weight

27
          Consequences of Vitamin A
          Deficiency in Pregnancy (2)



        Reduced transfer of
          vitamin A to fetus




                                        UNICEF
28
         Consequences of Maternal
     Vitamin A Deficiency on Lactation




                                     UNICEFC-92-18/Sprague
      Low vitamin A
      concentration
      in breastmilk
29
     Consequences of Vitamin A
      Deficiency in Childhood

          Increased risk of:
           Occular   problems

           Morbidity   and mortality

           Anemia


30
     Iodine Deficiency in Women




                              UNICEF/95-0065 Shadid
               Goiter
31
       Consequences of Iodine
      Deficiency on Intelligence


     Spectrum of Intellectual Impairment:

           cretinism

           severe mental impairment




                                            UNICEF/C-79-39
           mild mental impairment

32
          Consequences of Iodine
          Deficiency on Education


        Educability

        Drop-out rates




                                    UNICEF/C-56-19/Murray-Lee
        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

Interventions




                UNICEF/C-79-15/Goodsmith
       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
     to about six
     months of age




                                    UNICEF/C-79-10
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/C-56-7/Murray-Lee
     breastfeeding to 24
     months and beyond

44
          Optimal Behaviors
     to Improve Women’s Nutrition

       Pregnancy:
     • Increase food intake
     • Take iron+folic acid supplements daily
     • Reduce workload




                                                UNICEF/C-55-10/Watson
45
            Optimal Behaviors
       to Improve Women’s Nutrition


      Lactation:
     • Increase   food intake




                                      UNICEF/C-88-15/Goodsmith
     • Take a   high dose
      vitamin A at delivery
     • Reduce    workload

46
               Vitamin A Postpartum
                  Supplementation

     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

47
          Optimal Behaviors
     to Improve Women’s Nutrition

     •   Delay
     first pregnancy
         Increase




                               UNICEF90-070/Lemoyne
     •

     birth intervals

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 supplementation (60 mg of iron and
      400 μg folic acid) daily for 3 months for:
             before puberty and during
       ● Girls
        adolescence
       ● Women   of childbearing age
56
     Iron+Folic Acid Supplementation
           during Pregnancy


           Daily supplementation

           Start as   soon as possible
           Continue    for 6 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

         Monitor at all levels:
              Supply
              Coverage
              Compliance
              Communications component

         Evaluate impact on prevalence
63
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