Opinion: Engaging nutrition to improve pregnancy outcomes

A community health volunteer visits a pregnant woman to advise about good health and nutrition practices in Nepal. Photo by: USAID / CC BY-NC

Good nutrition sets off a ripple effect. It can dismantle inequity, poverty, and poor health and drive progress at every stage in life. It supports physical and cognitive development, helps prevent a number of medical conditions — from spina bifida to diabetes — and saves lives.

During and after pregnancy, nutrition demands are greater — as are the consequences of not meeting them. For mothers, ensuring a healthy pregnancy limits the risk of life-threatening complications. And for their children, good nutrition during pregnancy can be the difference between being born healthy and being born physically or mentally disadvantaged.

Building capacity — and leadership — for the next decade of progress on nutrition

It is critical that we sustain our momentum on nutrition, a task that requires greater investment in cultivating a cadre of leaders to take us there, argues Klaus Kraemer, director at Sight and Life.

While diet diversity remains the preferred means for women to meet nutrient requirements during pregnancy, many nutrient needs cannot be met through diet alone, especially in resource-constrained settings. As such, it is imperative that we reach women and girls with effective interventions for improving maternal nutrition that are ready for global scale-up now. Multiple micronutrient supplementation, or MMS, during pregnancy could be one way to help meet maternal nutrition needs.

Reducing the risk of low birth weight

Each year, approximately 20.5 million babies are born with low birth weight, or LBW, accounting for 14.6% of all births worldwide, with the majority in sub-Saharan Africa and South Asia. Moreover, 15 million babies are born preterm. Being born too small or too soon are major underlying factors for child undernutrition, and nearly half of all under-five child deaths are attributable to poor nutrition.

Poor diets and deficiencies in key nutrients impact pregnancy outcomes and neonatal health. Maternal iron deficiency, in particular, is associated with the risks of LBW, preterm birth, and perinatal or neonatal mortality in low- and middle-income countries. LBW, in turn, is associated with problems throughout the course of life — from fetal and neonatal morbidity and mortality to chronic diseases in adulthood.

Recent systematic reviews and studies conducted in 14 low- and middle-income countries and covering a total population of nearly 142,000 pregnant women — including reviews and studies from the Cochrane Library, The American Journal of Clinical Nutrition, The Journal of Nutrition, and The Lancet — show that MMS reduces the risk of maternal anemia and helps prevent infants from being born underweight, too small, and too soon. Studies also conclude that it reduces the risk of low birth weight by 19%, small-for-gestational-age birth by 8%, and preterm birth by 16%.

Breaking the cycle of malnutrition

Growth failure is transmitted across generations through the mother. Malnourished mothers give birth to underweight babies, who are more likely to have growth faltering during childhood and become small adults, then become malnourished pregnant women, continuing the intergenerational cycle of malnutrition. This negative sequence is even stronger in case of adolescent pregnancies. Approximately 20% of chronic childhood malnutrition has its origin already in the fetal period.

MMS can help to improve maternal nutrition, thereby ensuring the health of children and breaking the perpetual succession of malnutrition. However, MMS is not readily available where it is most needed — to women in LMICs — resulting in poor birth outcomes compared with women in high-income countries. Thus, populations that would especially benefit from MMS are those in countries with a high prevalence of anemia or underweight in women of reproductive age.

A need to evaluate the evidence

To help meet women’s increased nutritional demands during pregnancy, WHO recommends iron and folic acid — referred to together by the acronym IFA — as the current standard of care for pregnant women. However, that policy has not changed in 50 years. The most recent WHO antenatal care guidelines from 2016, though, opened a window for MMS.

The guidelines counsel against the use of MMS due to “some evidence of risk, and some important gaps in the evidence” but stipulate that “policy-makers in populations with a high prevalence of nutritional deficiencies might consider the benefits of [multiple micronutrient] supplements on maternal health to outweigh the disadvantages [such as cost], and may choose to give MMN supplements that include iron and folic acid.”

The scientific community has met all of WHO’s concerns regarding risk. Starting in 2016, a task force was convened by the New York Academy of Sciences to evaluate new evidence not available at the time of the development of the WHO guidelines and to help countries interpret the guidelines in relation to MMS in pregnancy. It concluded that MMS is safe and provides greater benefit than IFA for birth outcomes and infant mortality.

Building an investment case

MMS has a small incremental cost compared with IFA because of the added micronutrients but is still very cost-effective. To help governments build an investment case for MMS, Nutrition International and Limestone Analytics developed a model for calculating the cost-effectiveness of transitioning from IFA to MMS, showing that the transition is very advantageous. In Bangladesh, for example, changing from IFA to MMS would prevent the deaths of an additional 12,640 children and avert an additional 1.2 million disability-adjusted life years — commonly referred to as DALYs — at an incremental cost of only $9.93 per DALY averted, leading to benefits that are 294 times greater than the cost.

Time for a change

Implementing MMS globally would save lives and give more babies the healthy start they deserve, no matter where they live. It’s time to ensure that women in LMICs have access to MMS during pregnancy and support governments in their efforts to accelerate improvement of maternal nutrition.

The path forward is clear. WHO’s policy on IFA must consider the latest evidence and update its guidelines to definitively recommend MMS over IFA. Additionally, countries with a high prevalence of nutrient deficiencies must consider the benefits and move to integrate MMS within their antenatal care packages. Technical agencies must provide support to countries in creating and executing MMS programs, testing innovative and efficient ways to strengthen delivery and use. Collaboration is key: Governments, civil society, and the private sector must work together to build a supply of MMS at a high quality that is readily accessible and affordable.

Update, Dec. 17, 2019: Text and links related to research on MMS have been updated for accuracy and clarity.

This focus area, powered by DSM, is exploring innovative solutions to improve nutrition, tackle malnutrition, and influence policies and funding. Visit the Focus on: Improving Nutrition page for more.

About the author

  • Klaus Kraemer

    Dr. Klaus Kraemer is managing director of Sight and Life Foundation and adjunct associate professor in the Department of International Health of Johns Hopkins Bloomberg School of Public Health. He serves several professional societies dedicated to nutrition, food systems, micronutrients, and implementation science. He has published about 140 scientific articles, monographs, reviews, book chapters, and co-edited 12 books. He serves on the board of the Micronutrient Forum, assumes several advisory functions, and is the recipient of distinguished international honors.