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Cost-effectiveness of prenatal food and micronutrient interventions on under-five mortality and stunting: Analysis of data from the MINIMat randomized trial, Bangladesh.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health. (Global barnhälsa och nutrition)
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.ORCID iD: 0000-0001-8036-168x
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh .
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2018 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 13, no 2, article id e0191260Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Nutrition interventions may have favourable as well as unfavourable effects. The Maternal and Infant Nutrition Interventions in Matlab (MINIMat), with early prenatal food and micronutrient supplementation, reduced infant mortality and were reported to be very cost-effective. However, the multiple micronutrients (MMS) supplement was associated with an increased risk of stunted growth in infancy and early childhood. This unfavourable outcome was not included in the previous cost-effectiveness analysis. The aim of this study is to evaluate whether the MINIMat interventions remain cost-effective in view of both favourable (decreased under-five-years mortality) and unfavourable (increased stunting) outcomes.

METHOD: Pregnant women in rural Bangladesh, where food insecurity still is prevalent, were randomized to early (E) or usual (U) invitation to be given food supplementation and daily doses of 30 mg, or 60 mg iron with 400 μg of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 μg of folic acid. E reduced stunting at 4.5 years compared with U, MMS increased stunting at 4.5 years compared with Fe60, while the combination EMMS reduced infant mortality compared with UFe60. The outcome measure used was disability adjusted life years (DALYs), a measure of overall disease burden that combines years of life lost due to premature mortality (under five-year mortality) and years lived with disability (stunting). Incremental cost effectiveness ratios were calculated using cost data from already published studies.

RESULTS: By incrementing UFe60 (standard practice) to EMMS, one DALY could be averted at a cost of US$24.

CONCLUSION: When both favourable and unfavourable outcomes were included in the analysis, early prenatal food and multiple micronutrient interventions remained highly cost effective and seem to be meaningful from a public health perspective.

Place, publisher, year, edition, pages
2018. Vol. 13, no 2, article id e0191260
Keywords [en]
cost-effectiveness, stunting, nutrition intervention, DALY, child mortality, nutrition, Bangladesh
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-347520DOI: 10.1371/journal.pone.0191260PubMedID: 29447176OAI: oai:DiVA.org:uu-347520DiVA, id: diva2:1194855
Available from: 2018-04-04 Created: 2018-04-04 Last updated: 2018-11-28Bibliographically approved
In thesis
1. Stunted growth in children from fetal life to adolescence: Risk factors, consequences and entry points for prevention - Cohort studies in rural Bangladesh
Open this publication in new window or tab >>Stunted growth in children from fetal life to adolescence: Risk factors, consequences and entry points for prevention - Cohort studies in rural Bangladesh
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Stunted growth affects one in four children under the age of five years and comes with great costs for the child and society. With an increased understanding of the long-term consequences of chronic undernutrition the reduction of stunted growth has become an important priority on the global health agenda. WHO has adopted a resolution to reduce stunting by 40% by the year 2025 and to reduce stunting is one of the targets under the Sustainable Development Goals.

The aim of this thesis was to study linear growth trajectories, risk factors and consequences of stunting and recovery of stunting from fetal life to adolescence in a rural Bangladeshi setting and to assess the cost-effectiveness of a prenatal nutrition intervention for under-five survival and stunting.

A birth cohort of children of women participating in the Maternal and Infant Nutrition Interventions trial (MINIMat), a randomized prenatal food and multiple micronutrient (MMS) trial, was followed from birth to adolescence. Information about socioeconomic and nutritional characteristics of the mother and father was collected, and frequent anthropometry assessments of the child were done at birth, in infancy, and during childhood and adolescence. At puberty, pubertal stages according to Tanner, age at menarche and start of the pubertal growth spurt in boys were assessed. Calculations were made regarding the cost-effectiveness of prenatal food and micronutrient intervention related to the disability adjusted life years (DALYs) lost by death and stunting.

At birth, the children were on average short compared the WHO growth reference and more than half of the children were Small-for-Gestational-Age. Linear growth faltered dramatically up to 2 years, after which height-for-age Z-score increased up to adolescence. The prevalence of stunting was highest at 2 years (50%) and thereafter decreasing to 25% in adolescence. Birth size, maternal anthropometry and parental education were the most influential factors for linear growth up to and stunting at 2 years. Conditions after birth, such as feeding practices and morbidity, were less important. At 10 years, children born to short mothers (<147.5 cm), mothers with no education, or those conceived in the pre-monsoon season had an increased probability to be stunted. The median age at menarche was 13.0 years. Children that were stunted in infancy and childhood had later pubertal development as compared to non-stunted children. Children that recovered from stunting had a similar timing of puberty as their peers who had never been stunted. Supplementation with combined early prenatal food and multiple micronutrients was highly cost-effective in averting DALYs from under-five deaths and stunting.

The results from this thesis support the conclusion that a lifecycle approach is needed for the prevention of stunting. The gaps between current knowledge, policy and practice needs to be closed, with more emphasis given to prenatal interventions.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 73
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1453
Keywords
stunting, linear growth, child health, undernutrition, Bangladesh, cost-effectiveness, data mining, puberty, prenatal interventions, global health
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-347524 (URN)978-91-513-0305-5 (ISBN)
Public defence
2018-05-25, Gustavianum, Akademigatan 3, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2018-05-03 Created: 2018-04-04 Last updated: 2018-10-08

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Svefors, PernillaEkholm Selling, KatarinaShaheen, RubinaKhan, Ashraful IslamPersson, LA

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