Effect of multiple micronutrient supplementation during pregnancy on maternal and birth outcomes

Abstract

Objectives/backgroundGiven the widespread prevalence of micronutrient deficiencies in developing countries, supplementation with multiple micronutrients rather than iron-folate alone, could be of potential benefit to the mother and the fetus. These benefits could relate to prevention of maternal complications and reduction in other adverse pregnancy outcomes such as small-for-gestational age (SGA) births, low birth weight, stillbirths, perinatal and neonatal mortality. This review evaluates the evidence of the impact of multiple micronutrient supplements during pregnancy, in comparison with standard iron-folate supplements, on specific maternal and pregnancy outcomes of relevance to the Lives Saved Tool (LiST).Data sources/review methodsA systematic review of randomized controlled trials was conducted. Search engines used were PubMed, the Cochrane Library, the WHO regional databases and hand search of bibliographies. A standardized data abstraction and Child Health Epidemiology Reference (CHERG) adaptation of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) technique were used for data abstraction and overall quality of evidence. Meta-analyses were performed to calculate summary estimates of utility to the LiST model for the specified outcome of incidence of SGA births. We also evaluated the potential impact of multiple micronutrients on neonatal mortality according to the proportion of deliveries occurring in facilities (using a threshold of 60% to indicate functionality of health systems for skilled births).ResultsWe included 17 studies for detailed data abstraction. There was no significant benefit of multiple micronutrients as compared to iron folate on maternal anemia in third trimester [Relative risk (RR) = 1.03; 95% confidence interval (CI): 0.87 – 1.22 (random model)]. Our analysis, however, showed a significant reduction in SGA by 9% [RR = 0.91; 95% CI: 0.86 – 0.96 (fixed model)]. In the fixed model, the SGA outcome remained significant only in women with mean body mass index (BMI) ≥ 22 kg/m2. There was an increased risk of neonatal mortality in studies with majority of births at home [RR = 1.47, 95% CI: 1.13-1.92]; such an effect was not evident where ≥ 60% of births occurred in facility settings [RR = 0.94, 95% CI: 0.81-1.09]. Overall there was no increase in the risk of neonatal mortality [RR = 1.05, 95% CI: 0.92 – 1.19 (fixed model)].ConclusionThis review provides evidence of a significant benefit of MMN supplementation during pregnancy on reducing SGA births as compared to iron-folate, with no significant increase in the risk of neonatal mortality in populations where skilled birth care is available and majority of births take place in facilities. Given comparability of impacts on maternal anemia, the decision to replace iron-folate with multiple micronutrients during pregnancy may be taken in the context of available services in health systems and birth outcomes monitored.

Prenatal Nutrient Supplementation and Postnatal Growth in a Developing Nation: An RCT

“…5 In 2011, an estimated 165 million children aged ,5 years worldwide had stunted growth, with the majority residing in Asia and sub-Saharan Africa. 6 Prenatal multiple micronutrient (MMN) 7 and balanced energy and protein 8 supplementation result in a significant reduction in small-for-gestational age births (9% and 31%, respectively). However, the results of such interventions on postnatal growth yielded more dispersed results.…”

The interconnections between maternal and newborn health – evidence and implications for policy

“…The impact of this intervention in another review by Imdad et al, showed no impact on stillbirths (RR 0.98; 95% CI: 0.88 to 1.10) [135] or on perinatal mortality (RR 1.07; 95% CI: 0.92 to 1.25) [135]. There was also no evident reduction in the risk of neonatal mortality (RR 1.05; 95% CI: 0.92 to 1.19) [134].…”

“…However, the same review showed a significant reduction in the risk of SGA infants with the use of multiple micronutrient supplements (RR 0.91; 95% CI: 0.86 to 0.96) compared to iron-folate supplementation [134]. The impact of this intervention in another review by Imdad et al, showed no impact on stillbirths (RR 0.98; 95% CI: 0.88 to 1.10) [135] or on perinatal mortality (RR 1.07; 95% CI: 0.92 to 1.25) [135].…”

“…Impact estimates: A review by Haider et al [134] showed that multiple micronutrient supplementation during pregnancy had no significant effect on maternal anemia in the third trimester compared to iron-folate (RR 1.03; 95% CI: 0.87 to 1.22). However, the same review showed a significant reduction in the risk of SGA infants with the use of multiple micronutrient supplements (RR 0.91; 95% CI: 0.86 to 0.96) compared to iron-folate supplementation [134].…”

Is it Time to Replace Iron Folate Supplements in Pregnancy with Multiple Micronutrients?

“…13,14 In recent years in addition to the aforementioned issues of poor uptake and reach of IFA supplementation programmes, two factors have emerged, which suggest that the policy for isolated IFA supplementation in pregnancy ought to be reviewed. The first is the recognition that many women of reproductive age and pregnant women have multiple micronutrient (MMN) deficiencies [15][16][17][18] and the other is that in addition to anaemia, important birth outcomes such as LBW should be considered.Although an earlier meta-analysis of iron folate supplementation in pregnancy did not suggest a significant improvement in birthweight, 19 21 Others have indicated that IFA supplementation was associated with a significant reduction in early neonatal mortality by 47% in Indonesia 22 and that the combination of iron folate supplementation and IFA and IPTp (intermittent preventive treatment of plasmodium malaria) was associated with 24% reduction on neonatal mortality in 19 sub-Saharan African countries. …”