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Prenatal food and micronutrient supplementation to malnourished women in Bangladesh: Effects, Equity, and Cost-effectiveness
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).
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Maternal nutrition is closely linked to child health and survival. In Bangladesh there is a high prevalence of undernutrition in the form of chronic energy deficiency [CED, Body Mass Index <18.5 (kg/m2)] in women and low birth weight. The aims of this thesis are to explore women’s perceptions of maternal undernutrition, to analyse the association between prenatal food supplementation and birth weight (BW), to analyse whether food- and multiple micronutrient interventions generate pro-disadvantaged equity in child survival, and to examine whether an early prenatal invitation to food supplementation and multiple micronutrient supplements (MMS) represents value for money in infant survival compared to invitation to food supplementation at usual time combined with 60 mg iron and 400 µg folic acid (standard practice).

The study on women’s perceptions (n=236) was nested into the MINIMat randomized trial where women (n=4436) were allocated to early (E), or usual (U) time of invitation to prenatal food supplementation and 30 mg iron with 400 µg folic acid, or 60 mg iron with 400 µg folic acid, or MMS. Live births (n=3625) were followed-up. The analyses of equity and cost-effectiveness were based on this trial. A cohort design (n=619) was employed for the analysis of food supplements and BW.

Women perceived maternal undernutrition as a serious health problem and attached very low scores to CED in pregnancy. An average of four months of prenatal food supplementation increased BW by 118 g. An early invitation to prenatal food supplementation and MMS lowered mortality in children before the age of five years and reduced social disparity in child survival chances. An increment from standard practice to E-MMS averted one extra infant death at a cost of US$797 to US$907, and saved one extra life year at a cost of US$27 to US$30.

High priority should be given to the nutritional status of pregnant women in societies where undernutrition and food insecurity occurs. Prenatal food supplementation has the potential to significantly increase BW, and an early initiation of prenatal food supplementation combined with MMS was considered cost-effective in lowering infant mortality and increase social equity in child survival chances.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. , 68 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1165
Keyword [en]
malnutrition, pregnancy, food supplement, micronutrient supplement, birth weight, infant mortality, effectiveness, economic evaluation, equity, Bangladesh
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-267601ISBN: 978-91-554-9426-1 (print)OAI: oai:DiVA.org:uu-267601DiVA: diva2:873797
Public defence
2016-01-27, Rosénsalen, Paediatric Hospital, Akademiska sjukhuset, Entrance 95/96, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2015-12-21 Created: 2015-11-25 Last updated: 2016-01-13
List of papers
1. Quality of life among pregnant women with chronic energy deficiency in rural Bangladesh.
Open this publication in new window or tab >>Quality of life among pregnant women with chronic energy deficiency in rural Bangladesh.
2006 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 78, no 2-3Article in journal (Refereed) Published
Abstract [en]

Quality of life scores of health conditions are needed for measuring quality adjusted life years (QALY), the most common outcome measure in cost-utility analysis. To measure QALY scores we used EQ-5D and a visual analogue scales (VIS). EQ-5D is a standardised instrument for measuring quality of life using five dimensions applicable to a wide range of health conditions. VAS had the endpoints "full health" and "death". We assessed the scores for chronic energy deficiency (CED) characterised by low body mass index (BMI<18.5), a condition highly prevalent among rural Bangladeshi women. EuroQol (EQ)-5D and VAS were used to measure when the condition was worst and VAS measured the current health status. We interviewed 285 pregnant and postpartum women, with 236 (83%) having complete information. Mean scores for CED when perceived to be most severe were 0.30 (EQ-5D, interquartile range -0.02 to 0.52) and 0.27 (visual analogue scale, interquartile range 0.12-0.39) in scales with scores ranging from -0.54 to 1.00 and from 0 to 1.00, respectively. The mean score for current health status derived from the visual analogue scale was 0.49 (95% CI for mean 0.45-0.52) in a scale with scores ranging from 0 to 1.00. Rural Bangladeshi women attached very low quality of life scores to CED. The scores are comparable to scores attached to severe debilitating conditions like cancer in western countries. If considered in the global perspective, prevention of chronic energy deficiency among women in developing countries should be given high priority.

National Category
Health Sciences
Identifiers
urn:nbn:se:uu:diva-267576 (URN)10.1016/j.healthpol.2005.11.008 (DOI)16388875 (PubMedID)
Available from: 2015-11-24 Created: 2015-11-24 Last updated: 2017-12-01
2. Effect of prenatal food supplementation on birth weight: an observational study from Bangladesh.
Open this publication in new window or tab >>Effect of prenatal food supplementation on birth weight: an observational study from Bangladesh.
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2006 (English)In: Am J Clin Nutr, ISSN 0002-9165, Vol. 83, no 6, 1355-61 p.Article in journal (Refereed) Published
Keyword
Adult, Bangladesh, Birth Weight, Dietary Supplements, Female, Humans, Infant; Newborn, Maternal Nutrition, Nutritional Status, Pregnancy, Regression Analysis, Research Support; Non-U.S. Gov't, Seasons
Identifiers
urn:nbn:se:uu:diva-81265 (URN)16762947 (PubMedID)
Available from: 2006-12-05 Created: 2006-12-05 Last updated: 2016-01-13
3. Equity in adherence to and effect of prenatal food and micronutrient supplementation on child mortality: results from the MINIMat randomized trial, Bangladesh
Open this publication in new window or tab >>Equity in adherence to and effect of prenatal food and micronutrient supplementation on child mortality: results from the MINIMat randomized trial, Bangladesh
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2014 (English)In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 14, no 1, 5- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Evidence is often missing on social differentials in effects of nutrition interventions. We evaluated the adherence to and effect of prenatal food and micronutrient supplementations on mortality before the age of five years in different social groups as defined by maternal schooling.

METHODS: Data came from the MINIMat study (Maternal and Infant Nutrition Interventions, Matlab), a randomized trial of prenatal food supplementation (invitation early, about 9 weeks [E], or at usual time, about 20 weeks [U] of pregnancy) and 30 mg or 60 mg iron with 400 μgm folic acid, or multiple micronutrients (Fe30F, Fe60F, MMS) resulting in six randomization groups, EFe30F, UFe30F, EFe60F, UFe60F, EMMS, and UMMS (n = 4436). Included in analysis after omissions (fetal loss and out-migration) were 3625 women and 3659 live births of which 3591 had information on maternal schooling. The study site was rural Matlab, Bangladesh. The main stratifying variable was maternal schooling dichotomized as <6 years and ≥6 years. We used Cox proportional hazard model for survival analyses.

RESULTS: Overall, women having <6 years of schooling adhered more to food (81 vs. 69 packets, P=0.0001) but a little less to micronutrient (104 vs. 120 capsules, P = 0.0001) supplementation compared to women having more schooling, adjusted for maternal age (years), parity and body mass index (BMI, kg/m2) at week 8 pregnancy. Children of mothers with ≥6 years of schooling had lower under-five mortality, but the EMMS supplementation reduced the social difference in mortality risk (using standard program and schooling <6 years as reference; standard program and schooling ≥6 years HR 0.54, 95% CI 0.27-1.11; EMMS and schooling ≥6 years HR 0.28, 95% CI 0.12-0.70; EMMS and schooling <6 years HR 0.26, 95% CI 0.11-0.63), adjusted for maternal age (years), parity and body mass index (kg/m2) at week 8 pregnancy.

CONCLUSIONS: The combination of an early invitation to prenatal food supplementation and multiple micronutrient supplementation lowered mortality in children before the age of five years and reduced the gap in child survival chances between social groups. The pattern of adherence to the supplementations was complex; women with less education adhered more to food supplementation while those with more education had higher adherence to micronutrients.

TRIAL REGISTRATION: ISRCTN16581394.

Keyword
Equity, Child mortality, Food supplementation, Micronutrient supplementation, Adherence, Bangladesh
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-219111 (URN)10.1186/1471-2458-14-5 (DOI)000329761900001 ()24393610 (PubMedID)
Available from: 2014-02-21 Created: 2014-02-21 Last updated: 2017-12-05Bibliographically approved
4. Cost-effectiveness of invitation to food supplementation early in pregnancy combined with multiple micronutrients on infant survival: analysis of data from MINIMat randomized trial, Bangladesh
Open this publication in new window or tab >>Cost-effectiveness of invitation to food supplementation early in pregnancy combined with multiple micronutrients on infant survival: analysis of data from MINIMat randomized trial, Bangladesh
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2015 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, 125Article in journal (Refereed) Published
Abstract [en]

Background: Absence of cost-effectiveness (CE) analyses limits the relevance of large-scale nutrition interventions in low-income countries. We analyzed if the effect of invitation to food supplementation early in pregnancy combined with multiple micronutrient supplements (MMS) on infant survival represented value for money compared to invitation to food supplementation at usual time in pregnancy combined with iron-folic acid. Methods: Outcome data, infant mortality (IM) rates, came from MINIMat trial (Maternal and Infant Nutrition Interventions, Matlab, ISRCTN16581394). In MINIMat, women were randomized to early (E around 9 weeks of pregnancy) or usual invitation (U around 20 weeks) to food supplementation and daily doses of 30 mg, or 60 mg iron with 400 mu gm of folic acid, or MMS with 15 micronutrients including 30 mg iron and 400 mu gm of folic acid. In MINIMat, EMMS significantly reduced IM compared to UFe60F (U plus 60 mg iron 400 mu gm Folic acid). We present incremental CE ratios for incrementing UFe60F to EMMS. Costing data came mainly from a published study. Results: By incrementing UFe60F to EMMS, one extra IM could be averted at a cost of US$907 and US$797 for NGO run and government run CNCs, respectively, and at US$1024 for a hypothetical scenario of highest cost. These comparisons generated one extra life year (LY) saved at US$30, US$27, and US$34, respectively. Conclusions: Incrementing UFe60F to EMMS in pregnancy seems worthwhile from health economic and public health standpoints.

Keyword
Cost-effectiveness, Prenatal food supplementation, Micronutrient supplementation, Infant mortality, Bangladesh
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-256224 (URN)10.1186/s12884-015-0551-y (DOI)000355072800001 ()26018633 (PubMedID)
Funder
Swedish Research Council
Available from: 2015-07-06 Created: 2015-06-22 Last updated: 2017-12-04Bibliographically approved

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