Maternal

Nutritional Assessment
"The object of maternity care is to ensure that every expectant and nursing mother
maintains good health, learns the art of child care, has a normal delivery, and bears healthy
children. Maternity care in the narrower sense consists in the care of the pregnant woman,
her safe delivery, her postnatal care and examination, the care of her newly-born infant,
and the maintenance of lactation. In the wider sense, it begins much earlier in measures
aimed to promote the health and well-being of the young people who are potential parents,
and to help them to develop the right approach to family life and to the place of the family
in the community. It should also include guidance in parentcraft and in problems associated with infertility and family planning."-World Health Organization, 1969.

The definition of maternal nutrition must,

therefore, be broad enough to encompass the
periods before, during, between, and after pregnancy, including the period of lactation.

Objectives
In gauging maternal nutritional status, one
must not only identify women requiring remedial
or rehabilitative intervention, but also those who
are likely to become ill unless additional health
maintenance services are provided. Adequate assessment must take into consideration not only
nutritional deficiency but also family income, food
readily available, and previous reproductive performance measured in terms of the birth weight
of earlier babies, maternal weight gains during
past pregnancies, and the record of perinatal
mortality.
Special attention must be paid to certain
groups at greater risk of nutritional deficiency who
should be more meticulously assessed. These include:
1. Adolescents, especially those pregnant
out of wedlock
2. Women with a low pre-pregnacy weight
or those who do not gain sufficient
weight during the pregnancy
3. Women with a history of frequent conception
4. Women in families with low income or
with large number of dependents where
food purchase is an economic problem
5. Women not familiar with the elements of
sound nutrition
6. Women with a history of infants having
low birth weight, or other unfavorable
prognostic factors, such as obesity or
anemia
7. Women with diseases which influence
nutritional status such as diabetes, tu-

berculosis, drug addiction, alcoholism,

or mental depression
8. Women known to be dietary faddists or
with frank pica
In this section, an attempt will be made to
detail how some of the basic investigational techniques outlined earlier can be employed to evaluate pregnancy nutrition more accurately, especially in those population groups at highest risk.

Maternal Community Assessment

General Environmental Clues
If one is attempting to estimate the effort
required to upgrade maternal health and nutrition in a given geographic area, various studies
might be undertaken and the level of effort would
depend on the objectives of the study. Priorities
that might be c,ssiqned to the various types of
study are discussed later in this section. The initial
study should begin with a community assessment.
The first figures to be obtained would be the numbers of the population at risk (women ages 15-44),
their age distribution, racial-ethnic composition,
socioeconomic status, urban-rural and occupational characteristics and, of course, birth rates.
Ideally, age categories for women from 15 to 20
years of age should be listed by individual years,
even if the older groups are broken down into
five or ten-year ranges. These data can usually be
readily assembled and will be of great assistance
in relating etiology and prevalence of nutritional
problems to specific findings as determined by
dietary, clinical, and laboratory evaluation.
Data Related Specifically to Maternal Nutrition
Two results of pregnancy which are closely
associated with poor maternal nutrition are perinatal deaths and low birth-weight infants. The
latter are more subject to morbidity and mortality,
whether they are premature or full-term.
MATERNAL 57

Prematurity is still the major contributing

cause of perinatal mortality (stillbirths and deaths
up to 28 days postnatally), but later deaths in infancy are also much more common among low
birth-weight babies. For low birth-weight infants,
the key information is gestational age (counted
from the mother's last menstrual period), although
many factors may play a role aside from nutrition,
i.e. premature labor, simultaneous multiple conception, toxemia, and hypertension. Such later
fatalities are also, of course, associated with environmental factors, most importantly low economic status and inadequate health care; even
such a factor as polluted water may play a role.
The following factors should be considered
in any maternal assessment:
1. The rate of prematurity, the percentage
of total newborns delivered at weights
under 2500 grams (52 Ibs).
2. Incidence of perinatal mortality will reflect the frequency of underweight
births.
3. Incidence of maternal mortality and morbidity, while not alone reflecting poor
nutrition, is a third area important in
data collection.
4. Availability of health facilities is one
measure of overall care in a community
or region as well as a gauge of the resources at hand to improve the maternal
nutritional situation.
5. Utilization of health facilities-Are
health services and personnel provided
that are adequate, and are they accessible and acceptable to those who need
them? One measure of this is the percentage of mothers-to-be receiving prenatal care and the comparison of inhospital and at-home deliveries.
6. Specialization of health services-Are
services available for special groups,
such as adolescents or women with particular medical problems?
7. Food and nutrition resources-How
available are food assistance programs
and food fortification capabilities?
8. Personnel-Are community nutritionists
available in maternal health services?
How many, and of what degree of training? Is there, in fact, any nutrition program?
9. Health organization-Are all involved
services coordinated? Is there a data
collection system and is there a referral
system that is scrupulously followed?

Individual and Group Assessments

Women in child-bearing years receive services in a variety of settings. The best sites for
58 AJPH SUPPLEMENT, Vol. 63, NOVEMBER, 1973

maternal assessment usually are family planning

service units, the physician's office, and prenatal
and postpartum clinics. In addition to community
or environmental studies, consideration must also
be given to three basic components of the assessment of maternal nutritional status: history, clinical
and anthropometric examination, and biochemical
testing. As each is covered in other sections dealing with methodology, this discussion will tend to
focus more on the problems related to judging
normal values. It must be noted, however, that
evaluating nutritional status of the pregnant woman is handicapped by a lack of precise physiological and biochemical norms for pregnancy.
Historical Information
There is no substitute for a thorough medical, family, and social history. Factors such as
family size and structure, economic status, and
past emotional difficulties may all have a bearing
on the nutritional status of the mother, as will illegitimacy of the child. Following is a summary of
the most important variables that must be documented:
Age-Adolescents and older women are at increased risk for complications of pregnancy.
Age at menarche-Delayed onset of menarche has
been shown to be associated with poor childhood nutrition. Studies conducted in the United
States over the past three decades have shown
a drop of 10 to 12 months in the average age
at onset of menses. Improved nutrition has
been identified as a major cause of this change.
Today, menarche occurs in girls whose average age is 12.5 years.
Previous obstetrical history-A poor reproductive
history may be indicative of nutritional deficiencies. History taking should include:
Weight change: The pattern and amount of
weight change in previous pregnancies
will help identify potential high-risk patients.
Parity and outcome: This includes the total
number of pregnancies, the number of stillbirths, premature infants, and spontaneous
abortions, described sequentially. The use
of a standardized system to collect this information is essential.*
Interconceptual period: Repeated pregnancy and lactation at intervals of less than
one year deplete undernourished mothers
of needed nutritional reserves. Women on
oral contraceptives may have special nutritional needs. Steroidal contraceptives may
* One such method is the four-digit system where each digit
represents a pregnancy outcome:
4th digit
3rd digit
2nd digit
lst digit
Abortions
Premature
Living
Full term
children
deliveries
deliveries
Example: A female who has had one successful full-term
pregnancy, one premature child who died, and
one abortion should be designated as: 1111.

affect nutritional status also, through inhibition of folic acid absorption.

Birth weights of previous infants: Low birth
weights may be suggestive of nutritional
problems with past and future pregnancies.
Intercurrent illnesses-The effects of many chronic
diseases of a metabolic, infectious, or neoplastic nature are intensified during pregnancy.
Diabetes clearly has deleterious effects on the
outcome of pregnancy. Such conditions must
be considered in the nutritional assessment.
Cigarette smoking-Women who smoke during
pregnancy experience a high incidence of low
birth-weight infants and somewhat higher rates
of perinatal mortality. Whether this is attributable to nutritional factors or the metabolic effects of nicotine is not known.
Drugs and alcohol use-Drug addiction and alcoholism create special vulnerability to nutritional
deficiency. A special effort to identify these
problems should be made.
Previous nutritional deficiencies-Conditions such
as anemia should be noted and previous treatment, if any, described in full.
Economic and social factors-Family income available for food, accessibility and utilization of
food assistance programs, and the occupation
and/or physical activity of the mother should
be determined.
Self-administered questionnaires for data
collection and history-taking can be used. Such
questionnaires require pre-testing prior to routine
use and must be used with great caution in lowincome and low-education populations.

Dietary Evaluation
Dietary assessment of women in child-bearing years needs to include certain specific information, such as:
Cultural food practices-Community diet practices
in relation to cultural factors are especially relevant in maternal nutrition. The pregnant
woman receives many types of culturally determined advice concerning what she should eat.
Special dietary problems of pregnancy-Occurrences of nausea and vomiting in early pregnancy should be recorded since their persistence may lead to nutritional depletion. In addition, where a tropical background appears
in the history, one must check for the occurrence of sprue, schistosomiasis, hook worm, or
other parasitic infections.
Dieting-Recent large weight losses from caloric
restriction may result in the achievement of
"normal" weight but may cause depletion of
nutritional reserves.
Medication-Dietary supplements of vitamins, iron,
and other minerals are commonly prescribed
during pregnancy. They must be considered in

the history, as must sodium restriction and the

use of diuretics.
Allergy-Milk intolerance and food allergies need
to be considered, as do faddist or other abnormal patterns of eating. Unusual eating patterns, such as "macrobiotic" or other arbitrarily
restricted diets, should be elicited by careful
questioning since they may not normally be
mentioned. Pica-craving for unusual items
such as starch-has been shown to be common in some populations.
Economics-Where economic resources are limited, women obtain calories from inexpensive
foods which may be low in protein and high in
carbohydrates or fats.

Clinical and Anthropometric Evaluation

Many studies have suggested that the classical physical signs of late nutritional deficiencies
are of little or no use in identifying malnourished
persons in the United States. This is also true for
females during the reproductive years. While the
recognized signs and symptoms of late nutritional
deficiencies must not be ignored, health workers
should emphasize evidence of factors that have
been shown to predict poor reproductive performances. For example, cheek pigmentation may be
a sign of niacin deficiency. However, it may also be
seen normally during pregnancy or in women taking steroidal (oral) contraceptives. Gingival hypertrophy, which may occur normally in pregnancy,
should not be confused with ascorbic acid (vitamin
C) deficiency.
Two of the most important clinical parameters predictive of the birth weight of a child are
the mother's pre-pregnancy weight and her weight
gain or loss during pregnancy.
In evaluating the nutritional status of a patient, her pre-pregnancy weight is a good clinical
indicator of pregnancy outcome, assuming that
no other serious illnesses co-exist. Pre-pregnancy
weight is the result of her genetic pattern, previous nutritive history, and her environment. Extremes of under- or over-weight are indicative of
other factors that should be investigated in order
to manage the patient properly. It should be determined whether observed excess weight represents fluid accumulation or simply reflects current
over-eating patterns or both.
Even though one may not see the patient
at the onset of pregnancy, knowledge of her prepregnancy weight and her gestational period
makes it possible to ascertain whether she is
within normal ranges. Figure 1 presents a grid
pattern of "normal" weight gains related to duration of the pregnancy in weeks. Patterns of weight
gains in pregnancy that vary from these require
thorough investigation. The use of the grid makes
detection of such abnormalities relatively simple.
MATERNAL 59

Figure 1-Prenatal Gain

Weight*

In

14 16 18 20 22 24 26 28 30 32 34 36 3840 42

~~~~.

.,

tein of blood. Other causes of anemia may also be

present and should be considered in differential
diagnosis (Table 1).

42
Hoisht

40

mnCeh

Plus one inch

36

34

Standtad *ht

32

30
28
26

28
26

24
22

24
22
20
18

I,

1-

20
18
16
14

Table 1-Common Causes of Anemia in Pregnant

Women in the United States*
Acquired
Iron-deficiency anemia
Anemia due to acute blood loss
Megaloblastic anemia due to folate deficiency

Anemia caused by infection

Acquired hemolytic anemia
Aplastic

or

hypoplastic anemia

Hereditary

16

Thalassemia

14

Sickle cell

12

Sickle cell hemoglobin C disease

Other hemoglobinopathies
Hereditary hemolytic anemia without hemoglobinopathy

anemia

_
_ _ I
_____

illEI i
i
lI illllIlIiIT___6

D
2

_I

101
*

I_lllll lllllllll ___

I4

CS- S

10

10 12 14 16 18 20 22 24 26 28 30 32 34 :16 38 40 42

Source: Maternal Nutrition and the Course of Pregnancy, National

Academy of Sciences, Committee on Maternal Nutrition/Food
and Nutrition Board, Washington, D.C. 1970.

Height and weight measurements, dental

examination, and inspection of skin, mucous membranes, eye, tongue, and hair condition, are useful
in assessing nutritional status during pregnancy as
well as at other times.

Laboratory Studies
Laboratory studies include the entire range
of hematologic and biochemical analysis that can
be performed on blood, urine or other tissue samples. Since some of these change during pregnancy, Table 1 in this chapter and Appendix B to
the Laboratory Section should be consulted for
interpretation of norms. The tests to be performed
depend on the resources available and the individual's potential need for the test. Problems of a
specific locality, such as thyroid testing in an
iodine-deficient area, should be considered in deciding what screening tests are appropriate.
The following laboratory determinations are
particularly relevant in assessing the nutritional
status of pregnant women:
Anemia evaluation-The most common nutritional complication of pregnancy and the interconceptual period is anemia. Adequate protein,
folic acid, vitamin B12, and iron intake are needed
to produce hemoglobin, the oxygen-carrying pro60 AJPH SUPPLEMENT, Vol. 63, NOVEMBER, 1973

Source: Maternal Nutrition and the Course of Pregnancy, National

Academy of Sciences, p. 81, 1970.

Hemoglobin and hematocrit levels, and the

examination of the stained smear in cases of low
levels, are the first basic studies in assessing
maternal nutrition. If the hemoglobin level is less
than 11.0 g/100 ml (or %) late in pregnancy, anemia should be suspected, and if it is less than
10.0 g%, a hematologic abnormality almost certainly exists. The hemoglobin concentration during
pregnancy rarely falls below 10.0 g% except in the
case of maternal nutritional deficiency or disease.
With iron supplementation, most studies show a
value of 12.0 g% or more in late pregnancy, although the hemoglobin level may be lower in the
second trimester. Hematocrit levels usually follow
a similar pattern, with a range from 33 to 36%. In
the pre- or interconceptual period, a hemoglobin
of less than 12.0 g/100 ml or a hematocrit of less
than 36% may be an indicator of anemia (Table 2).
Table 2-Criteria of Deficiency for Hematological
Laboratory Tests in Adult Women*
Determination

Hemoglobin
Pregnant
Non-pregnant
Hematocrit
Pregnant
Non-pregnant
Serum Iron
Saturation
-Serum Folate
Serum Vitamin B12
%

Level

< 11 g/100 ml
< 12 g/100 ml
< 33%
< 36%

< 50 , g%
< 15%
< 3 ng/ml t

< 80 pg/ml t

* Modified from W.H.O. Tech. Rep. Ser. No. 405, 1968.

t nanograms per ml
t picograms per ml

Examination of the stained erythrocyte

smear may be extremely helpful in determining
the cause of the anemia. Hypochromic microcytic
red blood cells (smaller than normal cells with
fading red color) are characteristic of iron deficiency. The peripheral smear may also provide
clues as to associated diseases, such as sickle
cell anemia or thalassemia. Neutrophil hypersegmentation in the peripheral white blood cell sample is an early sign of folate deficiency (Table 3).
Table 3-Morphologic and Biochemical Sequence
of Events in Folic Acid Deficiency in
Man*
Time of Onset
After Folate
Event

Low concentration of serum

folate (< 3ng/ml)
Hypersegmentation of neutrophils
in peripheral blood
Elevated FIGLU excretion
Low folate in erythrocytes
(< 20 ng/ml)
Macroovalocytosis
Megaloblastic marrow
Anemia
*

Deprivation

(weeks)
3
7
14
16
18
19
19

Source: Herbert, V.: Experimental nutritional folate deficiency in

man, Tr. A. Am. Physicians, 75:307-320, 1962.

One-half to two-thirds of patients with significant

numbers of hypersegmented neutrophils (more
than 3% with five or more distinct nuclear segments) are found to lack folic acid. The combination of iron and folate deficiencies is quite common. The megaloblastic anemias may be caused
by vitamin B12 deficiency. Therefore, further studies should be conducted to determine the exact
cause of the anemia.
When red blood cell counts can be determined, the use of these in conjunction with the
hemoglobin and hematocrit levels permits evaluation of the size and hemoglobin content of the red
corpuscles. Mean corpuscular volume (MCV) and
mean corpuscular hemoglobin concentration
(MCHC) can be calculated and used in determining micro- or macrocytosis and hypochromia. A
mean corpuscular volume (MCV) of 79 or less can
be regarded as indicating microcytosis and values
above 96 represent macrocytosis. Mean corpuscular hemoglobin (MCH) below 32 is indicative of
hypochromia.
Further evaluation of iron deficiency anemia
can be obtained by determining serum iron and
total iron binding capacity (TIBC) levels. The TIBC
is generally elevated in pregnancy. Serum iron
levels below 50 mg/100 ml in pregnancy indicate possible iron deficiency anemia. TIBC ranges

show great variability and standard error in the

test should be defined for each laboratory. A high
TIBC does not always correlate with a low serum
iron. Therefore, percent saturation of transferrin,
obtained by dividing the serum iron level by the
TIBC, has proven to be a good index of iron deficiency anemia in population surveys. Levels of
less than 15% saturation are indicative of iron deficiency anemia. As are the hemoglobin and hematocrit levels, all of these criteria for deficiency
should be higher in the non-pregnant female.
To establish a definitive diagnosis of folic
acid deficiency and to distinguish it from vitamin
B12 deficiency, specific tests are necessary. Of
the biochemical and microbiologic tests available,
measurement of serum folate and vitamin B12 levels
have proved to be the most accurate. As many
as 50-60% of pregnant females appear to show
serum folate depletion. Again, ranges differ with
the method of determination, and those for the
particular laboratory used should be applied.
Other evaluations-Routine testing of urine
for sugar and ketone bodies will uncover the latent
diabetic mother who will need special testing and
more extensive nutritional care. Chronic renal disease may be suspected if persistent proteinuria
is present without obstetrical complications. Urinalysis may also identify patients with acute urinary
tract infections requiring treatment. Screening for
syphilis and skin testing for tuberculosis are to be
encouraged. The identification of any infectious
processes that may interfere with metabolic and
nutritional functions should be included in nutritional assessment.
The value of most of the other laboratory
tests in nutritional assessment is limited by the
lack of established norms for pregnant subjects.
The direct effect on the outcome of pregnancy or
health of the mother of inadequate intake of vitamins and trace elements is known only in severe
deficiencies, which are very rare. Further study
of the effects of the distribution of maternal plasma
proteins, serum cholesterol, and triglycerides on
future health of the infant is necessary. Calcium
is essential for fetal development, but plasma
levels may not reflect maternal stores (and adequacy), as this and other minerals are kept in
equilibrium in the plasma by the body. Steroidal
contraceptives have recently been incriminated in
causing alterations in serum folate, vitamin C, vitamin B6, and vitamin B12 levels. This may be important in the development of a stage of chronic
depletion in maternal stores. Evidence of a progressive decrease in plasma ascorbic acid concentrations during the course of pregnancy has
been found. The measurement of the enzymes
adenyl kinase and pyruvic kinase levels in white
blood cells has been suggested as a possible
means of assessing maternal nutrition. While their
MATERNAL 61

measurements are available in the research laboratory, further studies are required to determine
their value in assessing the nutritional status of
population groups.

Priorities in Maternal Nutrition Studies

The extent of the assessment of maternal
nutrition previously outlined will be determined by
the availability of personnel, facilities, and funds.
It is anticipated that few people using this manual
will need to perform all of the tests cited or gather
all data which have been described. For this reason, a hierarchy of priorities is offered in Table 4.
The assessment of maternal nutritional status can take advantage of a number of trends
such as:
* Use of family health workers and/or
other personnel trained to evaluate the
family constellation and its effect on
nutritional status;
* Use of standardized reporting forms for
nutritional assessment-which will facilitate comparison and evaluation among
population groups; and
* Development of new techniques and
methodologies such as multiphasic
screening-which will facilitate detection
of intercurrent disease and nutritional
disorders.
The indiscriminate mixing of data from dissimilar groups obscures important findings and
problems. This is illustrated by comparing data
from communities within a city. These may differ
markedly from city-wide averages. Therefore, all
data should be clearly defined in terms of the
characteristics of the population studied.

In summary, consideration of these priorities is important in evaluating maternal nutritional

status:
1. First Priority (minimum data to be collected)
A. Analysis and Interpretation of
Usually Available Data
1. Maternal and perinatal mortality
rates
2. Prematurity rates
3. Birth and fertility rates
4. Social and economic indicators
from census data
5. Availability of food resources
and food fortification
6. Data from birth certificates
Other data that are often available:
a. Birth weight
b. Length of gestation
c. Demographic data
d. Services and facilities available
for maternal care
B. Analysis of Data that May Have to
Be Collected
1. Maternal weight and weight gain
2. Previous pregnancy outcomes
3. Hemoglobin and/or hematocrit
levels
4. Addictions, including alcohol
5. Dietary patterns and estimates
of adequacy
6. Presence of special populations
at risk
11. Second Priority (highly desirable in addition to those listed under First Priority, Parts A and B)

Table 4 Levels of Maternal Nutritional Assessment

History
Level of
Approach
Minimal

Mid-level

In-depth level

Medical and
Socioeconomic
Obstetrical:
Present basic diet;
meal patterns;
Age: parity; interval
between pregnancies;
fad or abnormal diets;
previous obstetrical
supplements
history
Medical:
Intercurrent diseases
and illnesses; drug use;
smoking history
Family and Social:
Size of family; "wanted"
pregnancy; socioeconomic status
The above, plus semiThe above, plus occupaquantitative determination tional patterns; utilization
of food intake
of maternity care and
family planning services
The above, plus household survey data; dietary
history; quantitative
24-hour recall

Dietary

62 AJPH SUPPLEMENT, Vol. 63, NOVEMBER, 1973

Clinical Evaluation
Laboratory Evaluation
Pre-pregnancy weight;
Hemoglobin; hematocrit
weight gain pattern during
pregnancy; signs and
symptoms of gross

nutritional deficiencies

The above, plus screening The above, plus blood

for intercurrent disease
smear; RBC indices;
serum iron; sickle preparation
The above, plus special
The above, plus folate and
anthropometric measure- other vitamin levels
ments of skinfold, arm

circumference, etc.

A. Existing Data
1. Occupational patterns
2. Disease prevalence
3. Utilization of maternity care and
family planning services
4. Family size, structure and religion
5. Induced abortion rate
B. Data that May Have to Be Collected
1. Maternal morbidity data
2. Dietary intake and evaluation
data
3. Interval between pregnancies
4. Smoking habits
5. Hematological indices, e.g.
blood smear, RBC indices,
serum iron
6. Utilization of food assistance
programs
7. Distribution of maternal heights
Ill. Third Priority
A. Special Dietary Surveys, i.e. nutrient intake, prevalence of pica etc.
B. Special Anthropometric Measurements, i.e. skinfold thickness, arm
circumference, etc.
C. Special Laboratory Studies, i.e. iron
folate and other vitamin levels

Selected References
Eastman, N. J., Jackson, E.: Weight Relationships in Pregnancy. Obst. & Gynec. Survey, 23:1003, 1968.

Jacobson, H. N.: Nutrition and Pregnancy. J. Amer. Dietet.

Assn., 60:26, 1972.
Mason, M., Rivers, J. M.: Plasma Ascorbic Acid Levels in
Pregnancy. Amer. J. Obst. & Gynec. 109:960, 1971.
Maternal Nutrition and the Course of Pregnancy. National
Academy of Sciences, Washington, D.C. 1970.
Rothman, D. Folic Acid in Pregnancy. Amer. J. Obst. & Gynec.,
108:149, 1970.
Wertalik, L. F., Metz, E. N., LoBuglio, A. F. et al: Decreased
Bi, Levels with Oral Contraceptives. JAMA 221:1371, 1972.
Wintrobe, N. M.: Clinical Hematology. Lea & Febiger, Philadelphia, p. 92, 1967.
Workshop on Nutritional Supplementation and the Outcome of
Pregnancy. 1972. Committee on Maternal Nutrition, Food
and Nutrition Board, NAS-NRC. (In Press).
World Health Organization. The Organization and Administration of Maternal and Child Health Services. Fifth Report
of the World Health Organization Expert Committee on
Maternal and Child Care, WHO Tech. Rep. Ser. No. 428,
Geneva. 1969.

MATERNAL 63