Supplementation Programmes for Pregnant and Lactating Women.

In emergencies, a marginal or deficient diet for a pregnant or lactating woman has repercussions not only for her own health, but also for the health of the unborn, and the young infant.

Various international non-governmental organisations have a specific policy to address the needs of pregnant and lactating women in relief situations.

Oxfam and Save The Children Fund focus upon food security at household level as a criteria for selecting beneficiaries for supplementation programmes. The basic assumption is that the economically vulnerable should be targeted and that intra-household distribution will benefit pregnant and lactating women. In contrast, Médecins Sans Frontières approaches the assessment of needs for nutrition intervention in an 'individual' way e.g. all women in their 3rd trimester of pregnancy are included in a feeding programme as well as (depending on available resources):

• lactating mothers of malnourished infants younger than 6 months;
• lactating mothers with young infants whose breast-milk production has stopped, or is reduced;
• all lactating mothers up to 6 months after delivery.

However, the efficacy and impact of these programmes are frequently unclear due to lack of consensus on admission criteria, lack of monitoring of the admitted women, and absence of criteria to assess the impact of the supplementation programme. Dr Mija Tesse Ververs investigated the appropriateness of various anthropometric indicators for use in supplementation programmes for pregnant and lactating women in her thesis for an MSc course in Public Health in Developing Countries at the London School of Hygiene and Tropical Medicine.

The following is a summary of her findings.

Pregnancy

Mid Upper Arm Circumference (MUAC) is the most useful measurement for identifying pregnant women with increased risk of Low Birth Weight (LBW), Intra Uterine Growth Retardation (IUGR) or foetal/ infant mortality compared to all other anthropometric indicators investigated (weight-for-gestational-age, weight gain, absolute weight, pre- or early pregnancy weight, BMI, pre- or early pregnancy BMI).

MUAC is relatively stable throughout pregnancy and independent of gestational age and can therefore be used in all stages of pregnancy. The measurement is simple and no other information is required.

The following intervention model is proposed by M.T. Ververs, the author of the thesis:

Suggested cut-off points for risk vary by country and range from 21 to 23 cm. However, these cut-off points are based on the average MUAC of women in these countries and therefore may not be relevant to emergency situations. A more appropriate cut-off point for selection of women at risk during emergencies might therefore be closer to 21 cm.

One disadvantage of MUAC is that weight increase, (accumulation of fat) is not directly reflected in an increased MUAC. MUAC is therefore not suitable for monitoring the nutritional status of the individual pregnant women during the intervention or for evaluating the impact of the nutritional intervention. The most suitable indicator for monitoring nutritional status of pregnant women is weight gain during pregnancy. This however requires an efficient antenatal care system. Other indicators like weight-for-gestational age, weight gain and BMI are also valid for identifying pregnant women at risk, but these indicators have no particular advantages above MUAC. Moreover, several of these measurements are not easily made in emergencies, e.g. pre-pregnancy weight, age of the woman, and require two sets of measurement.

Teenage pregnant girls require a different approach for risk determination as the girls are still growing themselves. Their metabolism gives priority to the growth of the tissues involved in the pregnancy. These girls are therefore at risk of impaired physical development and, as a consequence, subsequent pregnancy risks. Height may be an appropriate measure for selecting at risk teenage girls and subsequent monitoring. The intended effect of supplementation during pregnancy is to increase birthweight via an increase of maternal weight. Various researchers suggest that in famine conditions, a direct relationship exists between maternal dietary intake and birthweight, without the intermediary step of increasing maternal weight. This shortcut seems to take place below a threshold in dietary intake of 1600 - 1750 kcal per day. The implication is that in famine situations all pregnant women should be supplemented regardless of their anthropometric status. The supplementation should be started as soon as possible, in order to facilitate the growth of breast, uterus, blood volume, and fat stores.

Lactation

Studies on the effect of nutritional supplementation on lactation performance have yielded inconsistent results. Milk volume is less subject to change than the milk composition as a result of supplementation.

Various researchers have suggested that increased dietary intake could improve lactation performance with an initial effect on maternal nutritional status (weight gain or limited weight loss).

The mother therefore benefits directly from supplementation through reduced weight loss or an increased physical activity or work output capacity.

There is no conclusive evidence to indicate which anthropometric indicator best identifies lactating women at risk of poor lactational performance in terms of quantity, or lactating women who might benefit from a supplementation programme. However, it appears that MUAC measurements have the greatest potential for this role.

Weight loss (more then 600-700 grams/month) during lactation can also be used as an indicator for selection of lactating women who might benefit from a supplementation programme. BMI could have a similar role (a monthly reduction of 0.3 would indicate the need for selection) but has no particular advantage over weight loss.

Summary of implications for supplementation programmes

MUAC is currently the best tool for screening and identification of pregnant and lactating women eligible for supplementation programmes. Weight gain (or loss) is the best indicator to monitor the individual pregnant and lactating women enrolled in a supplementation programme. The impact of a supplementation programme can be measured by average weight gain during pregnancy or weight loss during lactation;

Areas for future research

Research is needed to establish appropriate MUAC cut off points for identifying pregnant and lactating women eligible for supplementation programmes.

There is also a need for more information on the impact and importance of improved composition of breastmilk after supplementation as well as the importance of an improved nutritional status of the lactating mother. This will help ascertain the appropriate priority that should be given to supplementation programmes for pregnant and lactating women in emergencies.

Source: Dr. Mija Tesse Ververs. - "Nutrition interventions for pregnant and lactating women in relief situations: the assessment of need and impact", November 1997. For more information contact: Saskia van der Kam, Nutritionist MSF-Holland. Email: Saskia_vd_Kam@amsterdam.msf.org