Multiple micronutrient supplements in pregnancy: Implementation considerations for integration as part of quality services in routine antenatal care. Objectives, results, and conclusions of the meeting

Cost-Effectiveness Analysis of Multiple Micronutrient Supplementation (MMS) Compared to Iron Folic Acid (IFA) in Pregnancy: A Systematic Review

Introduction

Multiple micronutrient deficiencies might increase the adverse outcome during pregnancy and after birth. Considering the WHO recommendations since 2016 and scientific evidence from previous studies that multiple-micronutrient supplementation (MMS) is more effective than iron folic acid (IFA) in improving pregnant women's health, it is imperative to conduct an economic evaluation to assess the cost-effectiveness of MMS compared with IFA.

Methods

We conducted a systematic review from PubMed and Scopus to identify the cost-effectiveness analyses of MMS compared to IFA for pregnant women up to January 2024. Data extraction included specific study characteristics, input parameters, cost elements, cost-effectiveness results, and key drivers of uncertainty. This systematic review adhered to The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results

After removing 111 duplicates and following the screening process on the title and abstract of 1201 records, resulting in 125 full-text articles assessed for eligibility, a total of 5 studies fulfilled the inclusion criteria and were included in the review. All included studies were from low- and middle-income countries and demonstrated that MMS compared to IFA for pregnant women is cost-effective and even very cost-effective in some countries. All included studies implemented cost-effectiveness analysis (CEA) and estimated its cost-effectiveness using incremental cost-effectiveness ratio (ICER) per disability-adjusted life years (DALY) averted. Results suggested that the transition from IFA to MMS was cost-effective. The range of ICER per DALY averted in this study is USD 3.62 to USD 1024, depending on the scenario. Overall, the main determinant influencing cost-effectiveness was the cost of MMS procurement.

Conclusion

Our findings highlight that transitioning from IFA to MMS in certain conditions has been proven cost-effective, emphasizing this intervention's economic viability. MMS price and micronutrient deficiency-related disease burden are important determinants in assessing cost-effectiveness.

Registration

PROSPERO CRD42022319470.

Nutritional requirements in pregnancy and lactation

Optimal nutrition during pregnancy and lactation is vital for the health of the mother and fetus. Nutritional needs should begin in the preconception period, as the fetus depends on the placenta for essential nutrients required for growth and development. A balanced diet rich in nutrient-dense foods-such as whole grains, vegetables, fruits, dairy, legumes, fish, and lean meats-is essential to meet caloric needs during pregnancy. Assessment of maternal health, including dietary history and micronutrient status, is critical to identify potential risks and ensure adequate nutrition. The increased need for micronutrients must be met to prevent complications and fetal growth. Exclusive breastfeeding is recommended for the first six months, and continued breastfeeding is recommended throughout the first year and beyond. During pregnancy and lactation, calorie intake should be increased by focusing on protein and healthy fats. The composition of breast milk is adapted during the breastfeeding period, so that it can provide the necessary nutrients for the growth of the infant. Personalized nutrition plans, developed in consultation with health care professionals, are critical to optimizing maternal and infant health outcomes. This manuscript supports the importance of comprehensive nutritional strategies during pregnancy and lactation to reduce risks and support healthy growth and development of mother and child.

Dietary micronutrients intake and its effect on haemoglobin levels of pregnant women for clinic visit in the Mount Cameroon health area: a cross-sectional study

Background

Nutritional deficiencies and its consequences such as anaemia are frequent among pregnant women residing in under resource settings. Hence, this study sought to investigate specific dietary micronutrient inadequacy and its effect on maternal haemoglobin levels.

Methods

This institution based cross-sectional survey enrolled 1,014 consenting pregnant women consecutively. Data on socio-demographic, economic and antenatal characteristics were recorded using a structured questionnaire. Minimum dietary diversity for women (MDD-W) was assessed using the 24-h recall method and haemoglobin (Hb) concentration (g/dL) determined using a portable Hb metre. Significant levels between associations was set at p < 0.05.

Results

Among those enrolled, 40.9% were anaemic while 89.6% had inadequate dietary nutrient intake. In addition, uptake of blood supplements, haem iron, plant and animal-based foods rich in vitamin A were 71.5, 86.2, 35.5 and 12.6%, respectively. Moreover, anaemia prevalence was significantly (p < 0.05) lower in women who took iron-folic acid along with food groups rich in haem iron (38.5%) or both plant and animal vitamin A (29.0%). Besides, mean maternal Hb levels was significantly (p < 0.001) higher in women who consumed haem iron (11.08 ± 1.35) and vitamin A food groups (11.34 ± 1.30) when compared with their counterparts who did not consume haem iron (10.54 ± 1.19) and vitamin A food groups (10.74 ± 1.31).

Conclusion

Dietary uptake of foods rich in haem-iron and vitamin A significantly improves Hb levels in Cameroonian pregnant women. Our findings underscore the importance of improving maternal nutritional awareness and counselling during antenatal period to reduce the anaemia burden.

Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review

OBJECTIVES

Daily calcium supplements are recommended for pregnant women from 20 weeks' gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia.

DESIGN

Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach.

DATA SOURCES

MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022.

ELIGIBILITY CRITERIA

We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators.

RESULTS

Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium.

CONCLUSION

Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions.

PROSPERO REGISTRATION NUMBER

CRD42021239143.

Associations between maternal plasma zinc concentrations in late pregnancy and LINE-1 and Alu methylation loci in the young adult offspring

BACKGROUND

In animal models, prenatal zinc deficiency induced epigenetic changes in the fetus, but data in humans are lacking. We aimed to examine associations between maternal zinc levels during pregnancy and DNA methylation in LINE-1 and Alu repetitive sequences in young adult offspring, as well as anthropometry and cardiometabolic parameters.

METHODS

Participants were 74 pregnant women from the Chiang Mai Low Birth Weight cohort, and their offspring followed up at 20 years of age. Maternal plasma zinc concentrations were measured at approximately 36 weeks of gestation. DNA methylation levels in LINE-1 and Alu repetitive sequences were measured in the offspring, as well as anthropometry and cardiometabolic parameters (lipid profile, blood pressure, and glucose metabolism).

RESULTS

Over half of mothers (39/74; 53%) were zinc deficient (<50 μg/dL) during their third trimester of pregnancy. Maternal zinc concentrations during pregnancy were associated with LINE-1 DNA methylation levels in adult offspring. Specifically, lower prenatal zinc concentrations were associated with: 1) lower levels of total LINE-1 methylation; 2) lower levels of LINE-1 hypermethylation loci; and 3) higher levels of LINE-1 partial methylation loci. Prenatal zinc concentrations were not associated with Alu methylation levels, nor with any anthropometric or cardiometabolic parameters in adult offspring. However, we observed associations between Alu and LINE-1 methylation patterns and cardiometabolic outcomes in offspring, namely total cholesterol levels and diastolic blood pressure, respectively.

CONCLUSIONS

Lower maternal zinc concentrations late in gestation were associated with changes in DNA methylation in later life. Thus, zinc deficiency during pregnancy may induce alterations in total LINE-1 methylation and LINE-1 hypermethylation loci. These results suggest a possible epigenetic link between zinc deficiency during pregnancy and long-term outcomes in the offspring.

Neuroprotective Role of Lactoferrin during Early Brain Development and Injury through Lifespan

Early adverse fetal environments can significantly disturb central nervous system (CNS) development and subsequently alter brain maturation. Nutritional status is a major variable to be considered during development and increasing evidence links neonate and preterm infant impaired brain growth with neurological and psychiatric diseases in adulthood. Breastfeeding is one of the main components required for healthy newborn development due to the many "constitutive" elements breastmilk contains. Maternal intake of specific nutrients during lactation may alter milk composition, thus affecting newborn nutrition and, potentially, brain development. Lactoferrin (Lf) is a major protein present in colostrum and the main protein in human milk, which plays an important role in the benefits of breastfeeding during postnatal development. It has been demonstrated that Lf has antimicrobial, as well as anti-inflammatory properties, and is potentially able to reduce the incidence of sepsis and necrotizing enterocolitis (NEC), which are particularly frequent in premature births. The anti-inflammatory effects of Lf can reduce birth-related pathologies by decreasing the release of pro-inflammatory factors and inhibiting premature cervix maturation (also related to commensal microbiome abnormalities) that could contribute to disrupting brain development. Pre-clinical evidence shows that Lf protects the developing brain from neuronal injury, enhances brain connectivity and neurotrophin production, and decreases inflammation in models of perinatal inflammatory challenge, intrauterine growth restriction (IUGR) and neonatal hypoxia-ischemia (HI). In this context, Lf can provide nutritional support for brain development and cognition and prevent the origin of neuropsychiatric diseases later in life. In this narrative review, we consider the role of certain nutrients during neurodevelopment linking to the latest research on lactoferrin with respect to neonatology. We also discuss new evidence indicating that early neuroprotective pathways modulated by Lf could prevent neurodegeneration through anti-inflammatory and immunomodulatory processes.

From Maternal Diet to Neurodevelopmental Disorders: A Story of Neuroinflammation

Providing the appropriate quantity and quality of food needed for both the mother's well-being and the healthy development of the offspring is crucial during pregnancy. However, the macro- and micronutrient intake also impacts the body's regulatory supersystems of the mother, such as the immune, endocrine, and nervous systems, which ultimately influence the overall development of the offspring. Of particular importance is the association between unhealthy maternal diet and neurodevelopmental disorders in the offspring. Epidemiological studies have linked neurodevelopmental disorders like autism spectrum disorders, attention-deficit-hyperactivity disorder, and schizophrenia, to maternal immune activation (MIA) during gestation. While the deleterious consequences of diet-induced MIA on offspring neurodevelopment are increasingly revealed, neuroinflammation is emerging as a key underlying mechanism. In this review, we compile the evidence available on how the mother and offspring are both impacted by maternal dietary imbalance. We specifically explore the various inflammatory and anti-inflammatory effects of dietary components and discuss how changes in inflammatory status can prime the offspring brain development toward neurodevelopmental disorders. Lastly, we discuss research evidence on the mechanisms that sustain the relationship between maternal dietary imbalance and offspring brain development, involving altered neuroinflammatory status in the offspring, as well as genetic to cellular programming notably of microglia, and the evidence that the gut microbiome may act as a key mediator.

Integrating Calcium Into Antenatal Iron-Folic Acid Supplementation in Ethiopia: Women's Experiences, Perceptions of Acceptability, and Strategies to Support Calcium Supplement Adherence

Recommendations for antenatal calcium supplementation to prevent preeclampsia could substantially reduce maternal mortality, but adherence to multiple daily doses may constrain effectiveness. World Health Organization guidelines recommend 3 daily calcium supplements (1.5-2 g/d), taken separately from 1 iron-folic acid (IFA) supplement; however, limited data suggest lower calcium doses may also be effective. We conducted mixed-methods household trials to identify strategies for supporting adherence and integrating calcium into antenatal IFA supplementation programming in Ethiopia. Participants were randomly assigned to 3 regimens varying in dose and timing and were later given a choice of regimens. Semistructured interviews conducted over 6 weeks explored acceptability, barriers, and facilitators and offered opportunities to choose calcium pill type. Interviews were transcribed, translated, and analyzed thematically. Calcium adherence was measured using medication event monitoring. All participants (N=48) agreed to try supplementation. Adherence barriers included forgetting to take pills when busy or travelling and perceived side effects. Midday doses were the most challenging because of farming, market, and social events; women avoided taking supplements in public due to fear of being perceived as HIV positive. Social support from families, visual reminders, and anticipated benefits motivated adherence. More participants (75%) selected chewable versus conventional supplements due to organoleptic properties, but this preference declined over time. Adherence rates did not substantially differ across regimens with 2 (81.1%), 3 (83.4%), or 4 (77.1%) pill-taking events. Women indicated that the 2-event regimen was more acceptable than 3- and 4-event regimens, but this acceptability was not associated with higher adherence. Consequently, mean daily calcium consumption (811.3 mg) was lower than for 3-event (1,251.1 mg) and 4-event (1,156.4 mg) regimens. Integrating calcium into antenatal IFA supplementation is acceptable to Ethiopian women, with a 3-event regimen yielding the highest consumption rates. Despite women experiencing challenges with midday dosing and stigma, using simple home-based strategies and being counseled on the purpose of supplementation were more effective than reducing dosage for mitigating barriers and improving adherence.

Multiple micronutrient supplements in pregnancy: Implementation considerations for integration as part of quality services in routine antenatal care. Objectives, results, and conclusions of the meeting

Health promotion, screening, diagnosis, and disease prevention are essential services of quality routine antenatal care for pregnant adult and adolescent women. Supplementation programmes in pregnancy, generally implemented in the context of antenatal care services, have had less than optimal results in many countries, generally attributed to limited access, low coverage, and reduced adherence to the recommended regimens and counselling. The World Health Organization Department of Nutrition for Health and Development, in collaboration with the United Nations Children's Fund and Nutrition International, convened the technical consultation "Multiple micronutrient supplements in pregnancy: Implementation considerations for successful incorporation into existing programmes." The objectives of the technical consultation were to (a) examine implementation experiences of micronutrient supplementation interventions in pregnant women, lessons learnt, and best practices; (b) discuss programmatic and technical considerations of interventions on multiple micronutrient supplementation in pregnant women in low-, middle-, and high-income countries; and (c) identify implementation considerations that can be useful to scaling up efforts by national policymaker and their advisors considering multiple micronutrient supplementation in pregnant women as part of existing antenatal care programmes as well as other delivery platforms. The consultation was based on presentations of background papers, case studies, and plenary discussions. Country representatives were asked to discuss the context of micronutrient supplementation for their countries and share implementation challenges they faced. This paper provides the background and rationale of the technical consultation, synopsises the presentations, and provides a summary of the main considerations and conclusions reached during plenary discussions.