Food for thought: Supplementary feeding programme or ‘antenatal feeding programme’ for pregnant women

By Michael H Golden

Michael Golden is Emeritus Professor at the University of Aberdeen, Scotland. An independent physician and researcher, he has over 40 years of experience in international nutrition, specialising in all aspects of malnutrition.

Thanks to Jane Hirst for reviewing this article and contributing valuable insights and supporting data from an obstetrics perspective. Jane is a Senior Fellow in Perinatal Health and Locum Consultant in Obstetrics & Gynaecology, Nuffield Department of Obstetrics & Gynaecology, University of Oxford. Her area of research is global perinatal health. She is the UK principal investigator in the Interbio21st.

In emergencies, where a functioning health system does not exist or is overwhelmed, pregnant and lactating women who are thin (generally a mid upper arm circumference (MUAC) below 21cm) are admitted to a supplementary feeding programme (SFP), along with malnourished children. This practice has now become routine and has spread to countries without an acute emergency where a health system exists. In some countries, this programme only functions during the ‘hungry season’, leading to pregnant women in other seasons of the year being denied additional nutrition.

Arguably the most distressing statistic is the percentage of mothers that die during and due to pregnancy. In west and central Africa, it is estimated that 590 mothers die for each 100,000 live births (i.e. at least 0.59% of pregnancies end in the death of the mother), though the nationally reported figures are higher than the estimates. In Sierra Leone more than 1%  of pregnancies end in the mother’s death and 5% of fertile women die due to their pregnancy (UNICEF, 2015). Such loss deprives a family of a mother and wife who cannot care for the other children or engage in economic activity to support her family. There are estimated to be 2.6 million stillbirths per year globally (Blencowe et al, 2016); nine of the ten countries with the highest rates are in sub-Saharan and west Africa. I cannot find reliable statistics on spontaneous abortion or other pregnancy-related complications for these countries. The low birth weight rate is reported as 14% for west Africa and all “least-developed” countries (UNICEF, 2015) (the rate is 27% in Niger).

Consider two pregnant women in a village 5km from the health centre. The woman with a MUAC of 24cm should go to the antenatal clinic on Thursday, but such women often fail to go or only attend very late in pregnancy. The other woman has been screened and found to have a MUAC of 20cm; she is now told to go to the SFP to collect a ration of blended food on Wednesday. Of course, she should also go to the antenatal clinic on Thursday – but a 10km round trip and a lengthy wait two days in a row is a major challenge for an overworked, pregnant woman; she is much less likely to attend the antenatal clinic than the woman with a normal MUAC. So, which clinic will she choose to go to? She does not get any substantive help at the antenatal clinic, but does get a valuable ration at the SFP, so she is much more likely to omit to go to the antenatal clinic. In the least-developed countries, only 74% of women attend an antenatal clinic and only 38% attend four or more times.  It is unclear what percentage of pregnant women who are referred to SFPs actually attend, but we can speculate that it is higher than the attendance at antenatal clinics. If access to the clinics is difficult or there are major seasonal demands for labour, the difference between attending for an antenatal check-up or receiving supplementary food is likely to increase, to the added detriment of obstetric care.

If we hope to reduce maternal mortality and improve the outcome of pregnancy, antenatal care is critical. Not only does it require attention to the quality and content of care throughout pregnancy and delivery, but we need women to attend the antenatal clinics in the first place.  For this reason, I consider that enrolment of pregnant women into SFPs, as currently organised alongside malnourished children and based solely on a MUAC measurement, as likely to increase maternal mortality and result in a poorer outcome of pregnancy. I voiced this opinion to one United Nations representative in west Africa only to be told: “Our mandate is to treat malnutrition, not to save lives.” This left me speechless, but is typical of focused programmes that lose sight of the bigger picture, reinforce the notion that nutritional help should be left solely in the hands of nutritionists, ensure that obstetric services and nutritional services do not communicate, and question the way we consider priorities in apportioning services and effort.

Pregnant women and their foetuses are clearly at very high risk; indeed, maternal death may be more common that death due to severe malnutrition in some least-developed countries. I maintain that all pregnant women, but particularly those with high-risk pregnancies, should have facilitated access to adequate antenatal care; provision of high-quality nutrition (including but by no means limited to iron and folic acid that is typically provided as part of ANC) to support the pregnancy should be part of this care. The dispensing of the supplementary food should therefore NOT be in an SFP alongside the malnourished children, but should be run by the obstetric services themselves, independent of the services for malnourished children. At a minimum, the supplement should be given to ALL high-risk pregnant women. However, just as the school feeding programme was instituted mainly to encourage children to attend school as well as improving their nutrition, supplementary food should be used to encourage all pregnant women to attend antenatal clinic and to attend early and regularly. Indeed, the sections on pregnancy (preventive) should be removed from guidelines aimed at treatment for the malnourished and instead transferred to, and emphasised in, obstetric (and follow-up) guidelines.

Who should be given what ration? There are well established and universal obstetric factors that increase the risks of pregnancy. Infections during pregnancy, such as malaria, have a profound effect on birth weight. There is indeed some evidence that a low MUAC is associated with a slight reduction in birth weight, although most studies did not undertake multivariate analyses (Ververs et al, 2013) and there are a number of studies that found no effect of moderate deficits in anthropometry on pregnancy outcome; short maternal height was a risk factor. Table 1 lists the criteria that I think should be used by the obstetric services to entitle at-risk mothers to receive highly fortified blended food throughout pregnancy; Table 2 outlines suggested criteria for supplementation during lactation. However, a strong argument could be made for giving a simpler (cheaper) ration to all pregnant women, along with micronutrient supplements. This could, at least, help reduce low birth weight, anaemia and pre-eclampsia in the mother (Bhutta et al, 2014). However, antenatal care attendance also has the benefits that conditions such as pre-eclampsia, gestational hypertension, polyhydramnios, malaria, HIV, syphilis, multiple foetus, cephalo-pelvic disproportion, antenatal bleeding (e.g. placenta previa), breech presentation, etc. could be diagnosed and managed appropriately. These complications in pregnancy are much more dangerous for the mother and foetus/infant than a mild anthropometric deficit; moreover, type I nutrient deficiencies, which are particularly prevalent and damaging to the foetus, do not result in an anthropometric deficit (Golden, 1991). There may well be a role for additional anthropometric criteria, like MUAC, that could be undertaken by midwives (who already measure weight) to triage different nutritional interventions; however, the key development needed is for the organisation of services to be located within obstetric services.

Those who have received supplementation during pregnancy and all those with a low birth weight infant or have had such complications as an excessive blood loss during delivery or have signs of micronutrient deficiency should continue to be supplemented during lactation.

Many deaths of mothers actually occur in the post-natal period secondary to infection, eclampsia and secondary haemorrhage, which is usually due to retained infected placental tissue or endometritis. Nutrition support in the postnatal period would provide an opportunity for postnatal care (for a minimum of six weeks) and assessment of the nutritional state and growth of the baby with hopefully early detection of nutritionally vulnerable infants. 

It is likely that much of the damage done to the foetus through maternal malnutrition has its greatest effect in the peri-conception period and during the first trimester (e.g. as reflected in the follow-up data from the Dutch famine during the latter part of the Second World War), and supplementation during this period has a major effect upon the foetal epigenome (Khulan et al, 2012). This indicates that an additional major focus of nutritional support should at least include pre-pregnant adolescent females. Attendance and supplementation through the antenatal clinic should be as early in pregnancy as possible.

In summary, UNICEF, WFP and WHO – the international agencies already involved in support of nutrition for pregnant women in least-developed countries – should work closely with the United Nations Population Fund (UNFPA) and national obstetric services to develop an entirely new (preventive) Antenatal-Nutrition Programme (ANP), with appropriate protocols, training, staff and products (including adequate amounts of all type I and type II nutrients). Such a programme should be incorporated into the obstetric protocols and guidelines and removed from the standard nutrition protocols and health-related protocols derived from disaster/emergency response documents. To fail to prepare is to prepare to fail...

Table 1: Suggested indications for fortified blended food supplementation during pregnancy

• Primigravida / primipara (1st pregnancy)
• Grand-multipara (≥5children) (from 2nd trimester) 
• Teenagers (puberty to <18yr)
• Twin pregnancy
• Previous abortion/stillbirth/low birth weight infant/caesarean/prolonged labour (>24h primipara, >12h multipara) /serious infection
• Any other complication of this or the last pregnancy, e.g. severe anaemia, malaria, pre-eclampsia (hypertension, proteinuria), hyperemesis gravidarum, night blindness
• HIV positive – or any sign of immuno-incompetence (e.g. candidiasis)
• Interpregnancy interval < 18 months
• Goitre
• Any other sign of micronutrient deficiency Underweight/thin mothers – MUAC <21cm or <23cm (criteria not established). Note that severely malnourished mothers (MUAC < 16cm) should be referred and receive the same treatment as for all adults with severe acute malnutrition.
• Short mothers (<150cm)
• Poor weight gain during pregnancy (only 2nd/3rd trimester)

Table 2: Suggested indications for fortified blended food supplementation during lactation

• ALL mothers who qualified for supplements during pregnancy (see Table 1)
• Mothers whose infant was low birth weight (<2.5kg = premature or intrauterine growth retardation IUGR)
• Any complication of the delivery, e.g. excess bleeding (>500ml)
• Any sign of micronutrient deficiency
• Mothers whose infants have been treated using the supplementary suckling (SS) technique to re-lactate
• Other mothers whose infants are not gaining weight adequately
• Mothers who are specifically referred for additional supplements by an infant and young child feeding (IYCF) programme

For more information, contact: Michael Golden, Pollgorm, Ardbane, Downings, Co Donegal, Ireland 

If you’d like to share your views on this topic, we welcome letters to Field Exchange or post your comments on en-net; any en-net discussions will be summarised in a future Field Exchange edition.

References

Blencowe H, Cousens S, Jassi FB, et al. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis Lancet Global Health 2016;4: e98–108 

Ververs M, Antierens A, Sack A, et al. Which Anthropometric Indicators Identify a Pregnant Woman as Acutely Malnourished and Predict Adverse Birth Outcomes in the Humanitarian Context?. PLOS Currents Disasters. 2013. Edition 1. doi:10.1371/currents.dis.54a8b618c1bc031ea140e3f2934599c8

Bhutta ZA, Das JK, Bahl R, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet 2014; 384: 347–70  

Golden MH. The nature of nutritional deficiency in relation to growth failure and poverty.  Acta Paediatr.Scand.Suppl. 374, 95. 1991 

Khulan B, Cooper WN, Skinner BM, et al. Periconceptional maternal micronutrient supplementation is associated with widespread gender related changes in the epigenome: a study of a unique resource in the Gambia. Human Molecular Genetics, 2012, Vol. 21, No. 9 2086–2101 doi:10.1093/hmg/dds026

UNICEF 2015. The State of the World’s Children 2015: Reimagine the Future.