Integrating nutrition and antenatal care: a reproductive health perspective

Sarah Neusy is an Obstetrician-Gynecologist and Reproductive Health Advisor with Save the Children UK.

I read with a great interest Mike Golden’s article.¹ His view makes a lot of sense and it is refreshing and somehow hopeful to see this kind of global understanding of (reproductive) health coming from the nutrition world.

Indeed, I am concerned by the segregation between health and nutrition sectors that can exist in the field during emergency responses. Without having real expertise in nutrition myself, it is clear that it is impossible to be in good health without being well-nourished, and no improvement of a patient’s nutritional status will be reached if  the associated disease is not taken care of too.  The nutritional status and micronutrient deficiencies of the pregnant woman affect directly the foetus, and therefore the newborn birth weight and child health, as well as the mother’s own chances of survival. Antenatal care consultation (ANC) provided to the pregnant woman by a skilled staff, starting during the first trimester, and continued through the nine months of pregnancy, is of paramount importance to prevent maternal mortality and morbidity. This will allow skilled health staff to identify early danger signs related to pregnancy and to refer or follow the woman accordingly.

Some aspects of the nutritional status of the pregnant woman are already taken into account by the midwife during an ANC visit. Anthropometric measurements of the pregnant woman are indeed part of the midwife’s tasks during the first visit. Weight and height will be measured and followed during pregnancy; through the mother’s weight gain, midwives will follow the mother’s health and foetal growth. From these measures, they will also be able to predict any foetopelvic disproportion leading to potential life threatening situations for both and refer the woman, as appropriate, for caesarean section. The mid-upper arm circumference (MUAC) measure could be taken too during the first ANC visit.

Each pregnant woman will also be dewormed and supplemented with oral iron (Fe) to fight anaemia (low haemoglobin level (Hb)); 1 month Fe supply is usually provided, to encourage the woman to attend ANC the following month and take more supplies. In 80% of cases where mortality occurs, pregnant women will die around delivery time and mostly from haemorrhage. In Niger,² for example, the average number of children per woman is seven, and many girls are married at 12 years old with the prospect of a multitude of potentially life threatening obstetric complications. Chronic anaemia, and chronic severe anaemia (Hb<7g/dl), are very common, resulting from this high number of pregnancies (acute blood losses) as well as infectious diseases (malaria) and a poor quality diet. The most serious complication arising from chronic anaemia is tissue hypoxia, which can lead, with the next blood loss or the next malaria crisis, to decompensation, multiple organ failure, shock and death of the woman.

Here are some examples to illustrate the importance of ANC during pregnancy as a mean to decrease maternal mortality and morbidity, as well as nutrition aspects already integrated within sexual and reproductive health activities. So advocating for women’s nutrition to be further integrated into sexual and reproductive health (SRH) clinics makes perfect sense to me. The need for a multidisciplinary approach is already a concept that should be part and parcel of every SRH team; the midwife, the obstetrician-gynaecologist or the doctor with obstetrical skills, the psychosocial worker or psychologist (for sexual and gender based violence cases, for instance), all working together to offer a full spectrum of care to the woman… a nutritionist could easily supplement this core team, overseeing maternal nutrition and ensuring the communication and referral mechanisms with the co-existing nutrition programme if needed.

It is also clear that in resource-poor settings, in order to increase the uptake of ANC services by women, it is important to think about how to make the service more accessible. The distances to the clinics or hospitals may be large and the roads very difficult to walk. Going to a supplementary feeding programme (SFP) one day and to the ANC clinic the day after might prove too time-consuming, forcing women to choose one over the other.

Combining feeding programmes with SRH programmes during emergencies, allowing mothers to be cared for at the same time and same place as their malnourished children even if taken care of by different teams, will lead to a comprehensive package of care and will improve both mother and child health.

For programmes on infant and young child feeding in emergencies (IYCF-E) especially, combining IYCF-E activities with basic SRH activities, in one package of care, and within the same team and location is feasible and should be the way forward. Mothers will prioritise their child over their needs if time is scarce. This situation is evident in the current European refugee crisis where rapid transit schemes were established up until March 2016, all along the refugee’s route from the Greek islands to Germany. In these centres, refugees had only a few hours to access services. Implementing basic SRH activities³ inside the ‘baby corner’ area where the IYCF-E activities were taking place, would allow the woman to care for her child, receive counselling for feeding practices and undergo ANC or post-natal visits. She could also seek family planning support and report any worrying acute symptoms like blood loss.

In order to enable this, one trained midwife would need to be included in each IYCF-E counsellor’s shift; she would be part of the nutrition counselling team. Indeed, midwives are already trained to answer questions about breastfeeding and would only need one training about IYCFE specificities to have this dual role. Medical and non-medical supplies required are relatively limited and the budget needed to implement the SRH component would be very small. I recently attempted, with my nutrition colleagues at Save the Children, to secure support for such a combined programme during the European migrant crisis; it proved unsuccessful as the RH component was not considered a priority for support in a nutrition-orientated programme.

I really believe that the way we tend to separate (reproductive) health and nutrition programmes make no sense from a medical and humanitarian point of view. Large agencies and donors should be more flexible and adaptable when it comes to complex humanitarian situations. Although, to be fair, it is my experience that it is also difficult to implement integrated programmes in relatively small organisations. There are operational challenges to implementing integrated programming but they can be overcome with easy solutions; the more examples of successful integrated programming we can share, the more likely it is that agencies will begin adopting this more common sense approach.

For more information, contact: Sarah Neusy