UNICEF/HQ97-0317/ Noorani
Major Issues
in Maternal Nutrition
• 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)
Percent
30 28
21
20 18
10
0
Asia LAC Africa
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
Short stature
Kramer, 1989
10
The Intergenerational
Cycle of Malnutrition
ACC/SCN, 1992
11
Dietary Iron Requirements
Throughout the Life Cycle
Required iron intake
(mg Fe/1000 kcal)
12
Pregnancy
10 Men
Women
8
0
0 10 20 30 40 50 60 70
Age (years)
12 Stoltzfus, 1997
Iron Deficiency
14
Parasitic Infection
15
Malaria
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
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)
10
3.5
0
< 65 > 65
Pregnancy hemoglobin concentration (g/L)
Llewellyn-Jones, 1985
22
Pregnancy Hemoglobin
and Low Birth Weight
15 13.8
11.5
% Low birth weight
11.4 11
9.7 9
10 8.9
0
80 90 100 110 120 130 140
Lowest pregnancy hemoglobin concentration (g/L)
UNICEF/HQ95-0974 /Noorani
Reduced productivity
24
Consequences of Anemia
on Children’s Education
UNICEF/C-79-45/Goodsmith
Reduced learning capacity
25
Causes of Maternal
Vitamin A Deficiency
• Inadequate intake
• Recurrent infections
UNICEF/DOI93-1879/Zamman
• Reproductive cycles
26
Consequences of Vitamin A
Deficiency in Pregnancy (1)
• Miscarriage
• Stillbirth
28
Consequences of Maternal
Vitamin A Deficiency on Lactation
Low vitamin A
concentration
UNICEF/81-105/John Isaac
in breastmilk
29
Consequences of Vitamin A
Deficiency in Childhood
• Anemia
30
Iodine Deficiency in Women
• 3% cretins
UNICEF/C-92/Sprague
• 87% mildly mentally impaired
32
Consequences of Iodine
Deficiency on Education
• Educability
UNICEF/C-56-19/Murray-Lee
• Drop-out rates
• 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
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
UNICEF/HQ97-0317/ Noorani
Interventions
Major Interventions
in Maternal Nutrition
39
Improving Maternal Weight
40
Improving Maternal Height
Early Infancy:
Exclusive
breastfeeding
UNICEF/92-070/John Isaac
to six months
of age
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/HQ96-0304/Charton
breastfeeding
to 24 months
and beyond
44
Optimal Behaviors
to Improve Women’s Nutrition
Pregnancy:
• Increase food intake
• Take iron+folic acid
UNICEF/90-196/J. Schytte
supplements daily
• Reduce workload
45
Optimal Behaviors
to Improve Women’s Nutrition
Lactation:
• Increase food intake
• Take a high dose
UNICEF/C-88-15/Goodsmith
vitamin A at delivery
• Reduce workload
46
Vit A Postpartum
Supplementation (Indonesia)
Jan-June 96 18.8
July-Dec 95 12.5
0 10 20
Percentage of mothers receiving postpartum Vitamin A supplements
UNICEF/HQ97-0934/Noorani
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
51
Parasite Control to Improve
Women’s Micronutrient Status
• Improve hygiene
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
or
• Daily supplementation
• Start as soon as possible
• Continue for six 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
60
Supplement Delivery System
• Appropriate Staff:
− Motivated
− Approachable
− Supportive
− Adequately trained
61
Women’s Demand and Compliance
• Communications component
− Community awareness
62
Monitoring and Evaluation