Narrator: Welcome to ENN's Field exchange podcast. In this episode, our hosts Eilise Brennan and Stephanie Wrottesley speak with Mija Ververs and Sonia Kapil. Mija is a senior associate at the Centre for Humanitarian Health at Johns Hopkins Bloomberg School of Public Health and Sonia is a former graduate researcher at the Emory University in the Rollins School of Public Health. They will be discussing the relevance of using maternal mid upper arm circumference to detect risk of adverse birth outcomes in humanitarian contexts.

Eilise: Hi everyone. Welcome to this podcast. My name is Eilise Brennan and I am a nutritionist at the Emergency Nutrition Network. Today I'm really excited to have a co-host for this podcast: my colleague Steph.

Stephanie: Hi all. And thank you, Eilise, for inviting me to co-host this. My name is Stephanie Wrottesley and I am one of the senior nutritionists at the Emergency Nutrition Network.

Eilise: Today we have a really exciting podcast for everybody and we're both really excited for the conversation to come because we are chatting to both Sonya and Mija about the article that they recently published in FEX. It was a scoping review that they conducted on maternal mid upper arm circumference or MUAC. As I'm sure many of you are aware, MUAC is often used to screen for and assess the risk of undernutrition in children, pregnant and breastfeeding women, and more recently infants. So a very warm welcome to you both and thank you so much for taking the time to come and chat to us today. To start us off, would you mind just introducing yourself to our audience?

Sonia: Hi everyone. I'm Sonia Kapil. I'm a former graduate researcher at the Rollins School of Public Health, where I had the opportunity to work within the emergency response and Recovery branch at the CDC. Thank you, Eilise and Steph, for having us join you today.

Mija: Hi there. My name is Mija Ververs. I am senior associate at the Centre for Humanitarian Health, Johns Hopkins Bloomberg School of Public Health, and I'm based in the US. I'm also a visiting health scientist at the Centres for Disease Control and Prevention but I'm here as Hopkins.

Stephanie: It's such a pleasure to have you both here. Your scoping review looked at maternal MUAC and specifically at the cut offs for identifying and with birth and maternal outcomes. In 2013, MSF undertook an extensive literature review exploring anthropometric indicators, including maternal MUAC and their ability to identify pregnant women at risk of adverse outcomes. Can you give our audience an idea of why you decided to conduct your review and what it adds a decade on?

Sonia: Certainly. So the 2013 MSF review really laid a foundation, however, with advancements in research and the data available, there is the need to revisit and update this information through a comprehensive reassessment of the new research out there. So our review aimed to analyse the evidence after 2012 to determine if recent data sheds further light on optimal MUAC cutoff thresholds, so we specifically focused on identifying pregnant women as at risk for adverse birth outcomes and we were addressing a gap in the Sphere Association Handbook from 2018. Here it states to consider MUAC of less than 21 centimetres as an appropriate cutoff for the selection of pregnant women at risk during emergencies. And it also mentions here that a MUAC of less than 23 centimetres indicates moderate risk among pregnant women. However, the definition of moderate risk is not provided, so overall, our approach years to provide more recent and new insights. So I'll pass it off to Mija to expand a little bit on the work she did in 2013 with MSF.

Mija: Well, we all know that pregnant women are a nutritionally vulnerable group, and they need our full attention during humanitarian emergencies so malnutrition in that group affects the woman's well-being of herself, the foetus and the newborn. The same applies for lactating women. But OK, let's focus now on pregnant women. So currently there is no consensus on which anthropometric measurement should be used to identify acute malnutrition during pregnancy. There's also not consensus over what cut off value would be used or should be used in emergencies or in protected crisis. But pregnant women are often included in nutritional programmes and most frequently supplementary feeding programmes. But the criteria for inclusion varied. They can be enrolment based on gestational age, very often it's the third trimester, and that's regardless of any anthropometric measurement. So at the time when I did this review in 2012 for MSF, we came to the conclusion that MUAC was identified as the best indicator of choice because of its relatively strong association with low birth weight. It is a simple measurement, the simplicity of the measurement is important in humanitarian settings. It also does not require prior knowledge of the gestational age, which can be very important in new humanitarian settings. The MUAC values which we found at the time was 23 centimetres that was recommended for pregnant women at risk flow, birth weight. When I met Sonia more recently, we were wondering over the last 10 years, was there more updated research that would question the findings I had at the time and whether we needed a change? Would there be a different indicator or different cut off values? So that's why we did the study together.

Eilise: It's really interesting to hear the results of the study you did with MSF in 2012, especially because both studies found that maternal MUAC is an appropriate anthropometric measurement and rapid screening tool for identifying at risk pregnant women and both yours and the MSF study suggested using a MUAC cut off of less than 22 centimetres as an indicator of risk of adverse birth outcomes. Given the similarity in findings between these two studies, my question is, was there anything that surprised you or anything that you didn't expect to find?

Sonia: I would say that while the overall affirmation of MUAC as a reliable indicator wasn't too surprising to us, however, the specific cut off point of less than 23 centimetres consistently being associated with the adverse birth outcomes across studies was fairly notable. It reinforced that importance of this threshold in identifying at risk pregnant women, and I would say the discrepancy in the sphere handbook, for that recommendation raised some questions so our findings underscore the need for that standardised approach to MUAC cut off.

Mija: I wasn't really surprised either. The studies were done well also after 2012, though mostly not in humanitarian settings, but still relevant. My surprise is more on how the humanitarian actors, how slow they are to acknowledge these repetitive findings in that the sphere standard still states 21. My other surprise also, or I should say more disappointment, is that so few studies still look predominantly at adverse birth outcomes and not the outcomes that directly affect the women themselves. In other words, maternal morbidity or maternal mortality.

Eilise: Yes, it is disappointing to hear that still continues to be the case. Given your findings and the findings from the study in 2012 and the fact that the Sphere Handbook still considers a MUAC of 21 centimetres as an appropriate cut off, what do you hope to achieve going forwards?

Sonia: Yeah, that's a great question. I would say the divergences in MUAC cut off recommendations emphasises the need for, as I previously said, consensus and standardisation across the board. So going forward we would hope to, of course, influence guidelines and policies and encourage that shift towards the less than 23 centimetre threshold. This alignment could improve the identification of pregnant women at risk during emergencies and it could also enhance the effectiveness of nutritional intervention, ultimately leading to that reduction in adverse birth outcomes. Essentially, it's about ensuring that the recommendations are not just evidence based, but they can be universally applicable.

Mija: I hope NGOs will reconsider the findings of the research done over the last 20 years on this issue. I also hope that the sphere handbook will be adjusted as at the moment their recommendations are a bit confusing and I can illustrate that there is an interactive handbook online and in the Sphere handbook, or see in the Appendix 4 it says that a MUAC can be considered less than 21 centimetres as an appropriate cut off for selection of women at risk during emergencies but in the table in that same appendix sphere outlines the differences between global acute malnutrition for pregnant women, moderate acute malnutrition, and severe. They used for severe malnutrition MUAC below 18 1/2 centimetres and I'm not sure whether it's wise at this stage, or even whether you have enough evidence to distinguish between moderate and severe acute malnutrition, we just simply know that below 23 centimetres there's a high risk of low birth weight and I'm not sure what we should distinguish between this and 18 1/2. I think it's really very low, so perhaps we can reconsider that as a humanitarian nutrition community.

Stephanie: I understand that this work will continue to contribute to the work being done conducted by the Women's Nutrition Task Force established within the Global Nutrition Cluster Technical Alliance. Can you explain a little bit more about that.

Mija: Yes, I am also a Member of this task force and it's a very competent group, but with very difficult objectives, I must say, it's not easy. One of the objectives is to develop an interim guidance for MUAC wasting cut offs for pregnant and breastfeeding women and also adolescent girls possibly, so it's a bit wider than the topic we're discussing now. The task force also is looking at the development of guidance on strengthening women and adolescent nutrition assessments and also it will look at the development of implementation guidance for pregnant and lactating women's nutrition in new material setting. So that means as a task force, we will look at what programming approaches should be considered and also when and how to programme balanced energy, protein and other nutritional supplementation.

Eilise: That is a massive mandate that the group has on their hands, so everyone's going to be very excited to hear about all the work on going in this task force. And I'm sure we'll be eagerly awaiting it as well. Just thinking about the number of programmes that may be potentially adopting this 23 centimetres cut off, I was wondering could you speak a little bit about the implications that this might have?

Sonia: Sure. Adopting a MUAC cut off of less than 23 centimetres and more programmes, could lead essentially to the improved identification of at risk pregnant women and facilitate targeted nutritional interventions. I think this alignment could enhance the programme effectiveness and it could streamline the training efforts and overall contribute to a standardised approach within the humanitarian context. However, I think as work is being done in this field, it's important to have careful consideration in monitoring to ensure that the impact and appropriateness of this threshold across diverse settings is of course relevant.

Mija: Yeah. And I would add to that, that of course it would be very good to see what the scale is of the problem, how many pregnant women do actually have a low MUAC are we talking about? Is it something hypothetical or is it something that is really widespread? NGOs might actually find pregnant women with MUAC below 23 centimetres, and in some contexts those NGO workers might say perhaps we do not have enough resources to enrol all of these women and they might change the threshold for that reason, and they might choose 21 centimetres or lower or something similar. This means that NGOs might make these decisions driven by limited resources. That is a programmatic choice, and there are consequences, of course, because we just know from research that it is clear, at least for low birth rate. We can say there is an association between MUAC below 23 centimetres and low birth weight so we need to be careful here if we have limited resources where will you allocate your resources to and a pregnant woman is who is adequately nourished and healthy, and then gives birth is much better equipped physically to go through the next demanding journey, and that's the one of breastfeeding. Keeping her well-nourished is an investment that is so worthwhile and so many lives at stake, her own life first of all, as a pregnant woman, but also as a mother of a newborn and a mother for her other children. So if people change the thresholds, there might be good reasons, but we have to be careful there and consider this wisely.

Stephanie: In that article you mentioned several limitations to this review, such as the small number of available studies, the lack of comparability between studies, and the lack of research on maternal outcomes. Given these limitations, can you speak to future research needs in this area?

Sonia: Absolutely. So the limitations highlight the need for further research. I believe future studies should really delve into looking at maternal outcomes as well as expanding the focus to include humanitarian emergencies and conflict settings. Of course, it's going to be harder to get data from these emergency settings, but that could be a way forward, looking into future research. I would say larger and more comparable studies across diverse populations would be essential to really strengthen that evidence base. I really think the next step would be exploring the potential benefits of nutritional interventions using the enrolment criteria of a MUAC of less than 23 centimetres for a pregnant woman, and understanding those longer term impacts on both maternal and birth outcomes could be really valuable for future investigation.

Mija: So both the previous study with MSF from 2013 and this scoping review also saying MUAC 23 for pregnant women as an indicator of risk for adverse birth outcome in humanitarian context. But it's for risk for adverse risk outcomes. We do not have sufficient information to determine if MUAC also can be used as an indicator predicting the potential benefit, for instance, improved foetal growth of a certain nutritional intervention. So we certainly need more prospective research, we need to identify women with MUAC early on and roll them in a nutritional programme and see if we can avert the adverse outcomes, low birth weight and also others. But also, we should look more at keeping the pregnant women healthy and look at other outcomes and not only the foetal and birth, and I can't stress that enough. I think also we should relook a little bit more in detail to define what maternal malnutrition or undernutrition exactly is. Looking at lactating women, that's a whole other area. They are not on any radar screen at the moment so that would be an additional part after this.

Stephanie: Building on what you just mentioned around the lack of focus on maternal nutrition and health outcomes, this is a narrative we're continually hearing. Why do you think maternal nutrition and health have been so overlooked, and how do you think we can change that?

Sonia: Thanks, Steph. That's a great question. As you said, based on the extensive literature search that we conducted, we did find that maternal nutrition and health is often overlooked as the focus has really been on adverse birth outcomes for the child. I think this can be changed by not just shifting our focus, but rather just adjusting it to include the focus on the outcomes for both the child and the mother. So, for example, it would be important to have more data on factors influencing maternal mortality and other maternal outcomes as well. I think integrating maternal health into the broader health and nutrition agendas and backing it with supportive policies can contribute to a more comprehensive understanding for maternal nutritional needs to improve outcomes for both mother and child.

Mija: Yeah. And as I said earlier, maternal malnutrition is not so easy to define. Are we looking at anthropometrics only, or micronutrients or both? Or are we looking through the lengths of birth outcomes mostly. Also, I feel that there are many different professionals include different subgroups if we speak about ‘maternal nutrition’, do we talk about pregnant women? Do we talk about adult women in general, so women of reproductive age are we including adolescent girls? I'm still a bit confused and see that ‘maternal’ refers for some to different groups. Pregnant women is also a group and it's not so easy to get access for people like us working a lot on nutrition. In the best scenarios, they come a few times to the health clinic for prenatal follow-up, maybe for iron, folate and multi-micronutrients and sometimes they get calcium depending on the context. But many come in late in their pregnancy, and there might only be a limited impact if the nutrition support starts late, so we have to be realistic there as well, and the earlier of course the better. But I'm optimistic and more and more studies are actually commissioned on this topic so let's be hopeful.

Eilise: I like ending on the optimistic note and I'm with you as well. I am optimistic that we are not changing, but as you said, increasing our focus to also include those maternal health and nutrition outcomes in all we do. Thank you both for taking the time to chat to us today. We really, really appreciate it, especially as we know you both have really busy schedules and it really has been a fascinating conversation. For everyone who would like to hear more about the scoping review that was done, please do go and check out the article. It is entitled ‘maternal mid upper arm circumference, still relevant to identify adverse birth outcomes in humanitarian contexts?’ and it can be found in Field Exchange 70 which is available on ENN's website. Thank you and goodbye.

Narrator: Thanks for listening to ENN’s Field Exchange podcast. For more background on this story and for more nutrition stories from around the world, please go to ennonline.net/fex.