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

Abstract

Anaemia is one of the most resilient global public health problems and affects a staggering 1.62 billion of the world's population, largely concentrated in Asia and Africa. Anaemia contributes to almost 120 000 maternal deaths globally and indirectly to almost a fifth (18%) of the burden of maternal mortality. Given 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. This review evaluates the evidence of the impact of multiple micronutrient supplements during pregnancy, in comparison with standard iron folate supplements, on maternal anaemia. A systematic review of randomised controlled trials was conducted using search engines like PubMed, the Cochrane Library and World Health Organization Regional Databases. Primary outcomes were 'maternal anaemia' and 'haemoglobin level'. We included seven studies for detailed data abstraction. There was no differential benefit of multiple micronutrients as compared with iron folate on maternal anaemia in the third trimester (relative risk = 1.03 [95% confidence interval 0.94, 1.12]). Results were similar for haemoglobin levels. In summary, multiple micronutrients have a similar effect on maternal anaemia compared with iron folate supplementation. These findings have to be interpreted in the context of other benefits of multiple micronutrient supplementation such as promoting better fetal growth and the possible increased risk of neonatal and perinatal mortality that are best resolved through large-scale effectiveness trials. Keywords: multiple micronutrients, pregnancy, anaemia, haemoglobin.Anaemia is one of the most intractable global public health problems and affects a staggering 1.62 billion of the world's population, largely concentrated in Asia and Africa.1 Anaemia contributes to almost 120 000 maternal deaths globally and indirectly to almost a fifth (18%) of the burden of maternal mortality.2 In addition to maternal deaths, there are several adverse health outcomes associated with anaemia including maternal morbidity, stillbirths and neonatal mortality, low birthweight (LBW) and poor cognitive development in the offspring. 3 In terms of risks, women of reproductive age are more vulnerable to anaemia because of recurrent menstrual loss and the demands of pregnancy and repeated childbearing but corresponding estimates from adolescents and young women are lacking. The most recent global estimates suggest that the prevalence of anaemia is 41.8% among pregnant women and 30.2% among nonpregnant women. [1][2][3][4] Anaemia, as defined by low haemoglobin or haematocrit, is commonly used to assess the severity of iron deficiency in populations without high rates of malaria. The aetiology of anaemia is multi-factorial including genetic factors, dietary deficiencies, repeated pregnancies and high burden of infectious diseases.5 A multi-pronged approach is needed for its prevention and treatment. Although iron...

Effect of Multiple Micronutrient versus Iron-Folate Supplementation during Pregnancy on Intrauterine Growth

“…As reported in earlier publications, the included trials were of high quality and the overall quality of evidence for our outcomes were from moderate to high [6,7]. One major concern is the definition of the intervention and control group.…”

“…We identified published studies through October 2011 from PubMed and EMBASE databases using search strategies that have been published elsewhere [6,7]. Additional studies were identified through hand search of references from previous review articles and from personal communications.…”

“…Several intervention trials have also demonstrated the benefits of providing food supplements during pregnancy especially to undernourished women, but this approach remains both logistically and economically challenging in resource-poor settings [5]. It is in this context that several studies were undertaken to examine the potential benefit of providing supplements containing several micronutrients in addition to IFA [6][7][8]. The objective of this paper is to conduct a systematic review of the evidence on the effects of prenatal multiple micronutrient (MM) supplements on intrauterine growth.…”

Maternal Nutrition Interventions to Improve Maternal, Newborn, and Child Health Outcomes

“…Although the meta-analyses primarily focused on nutrition interventions during pregnancy, the topics of antihelminthics in pregnancy, nutrition education and counseling, household food production, short interpregnancy interval, early age at first childbirth, nutrition before and during pregnancy, and intergenerational influences on child growth and undernutrition were included because of their potential impact on maternal and child health outcomes [10][11][12][13][14][15][16]. We reviewed meta-analyses of the following specific supplementation trials during pregnancy: iron or iron + folic acid (IFA), vitamin A, select B vitamins, vitamin D, n-3 long-chain polyunsaturated fatty acids (n-3 PUFA), iodine, zinc, calcium, multiple micronutrient (MMN), balanced protein-energy, and antihelminthics [10,[17][18][19][20][21][22][23][24][25][26][27]. For all reviews, authors abstracted study data using a standardized Excel-based tool that captured information on 49 potential variables, for example sample size, study design, study context, and estimated effect [9].…”

“…Of note, calcium supplementation decreased the risk of preeclampsia, pregnancy-induced hypertension, and maternal mortality/ severe morbidity [24]. Iron or IFA and vitamin A significantly decreased the risk of maternal anemia [17,18], but MMN interventions did not further reduce the risk of anemia compared to IFA [27]. We did not find any evidence of benefit for maternal mortality that was based on fewer trials (n = 5) that examined the effects of vitamin A (RR: 0.86, 95% CI: 0.6-1.24; 3 trials) and MMN interventions (RR: 0.96, 95% CI: 0.64-1.45; 2 trials) [18,25].…”