Changing the Standard

Why Multiple Micronutrient Supplements in Pregnancy Are an Ethical Issue

Back to Overview

On 9 July 1999, the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO) and the United Nations University (UNU) held a technical workshop at the UNICEF headquarters in New York to address widespread micronutrient deficiencies and high rates of anemia among pregnant women. Looking beyond iron and folic acid (IFA), the workshop designed a comprehensive prenatal supplement – or multiple micronutrient supplement (MMS) –that would be tested in effectiveness trials among pregnant women in low- and middle-income countries (LMICs). Thus, the United Nations International Multiple Micronutrient Antenatal Preparation – now commonly known by its acronym, UNIMMAP – was born.

Women, Family, children

The group at the workshop was, in many ways, before its time. They identified access to MMS as an inequity issue as stated in a report the group published after the workshop: “The high [micronutrient] needs of pregnancy are almost impossible to cover through dietary intake [alone] – in most industrialized countries, it is common for women to take multiple micronutrient supplements during pregnancy and lactation.” And the group discussed how MMS could impact other at-risk groups, particularly adolescent girls.
 
They also considered the needs of the women most in need – and reflected on the information at their fingertips. The UNIMMAP formulation consisted of1 RDA (Recommended Dietary Allowance for women 19-50 years during pregnancy and lactation) for 15 essential vitamins and minerals. But they correctly predicted that 1 RDA underestimated the requirements for populations in LMICs because they were based on dietary reference intakes from populations in the US and Canada, where nutritional statuses are stronger. In April, results from the JiVitA-3 study in rural Bangladesh (the largest ever trial comparing prenatal MMS to IFA) showed that 1 RDA, while reducing risks of preterm birth, low birth weight and still birth, and while improving micronutrient status, failed to eliminate deficiencies. Might 2 RDAs have had a greater effect on birth outcomes in an environment where poverty, poor diets and frequent infections prevail?

The bigger picture

Malnutrition – undernutrition, overweight, obesity, and micronutrient deficiencies – is a driver of intergenerational inequity, poverty, and poor health. It represents a significant barrier to equitable and sustainable social and economic development, in high- and low-income countries alike. However, many women and girls lack access to essential antenatal and postnatal care services, including micronutrient supplementation. This is especially true for women living in LMICs. While 62% of pregnant women globally receive at least four antenatal care visits, in regions with the highest rates of maternal mortality – such as sub-Saharan Africa and South Asia – only 52% and 46% of women in the respective regions receive the same services. Further coverage disparities exist between poor and rich, and rural and urban households. In South Asia and sub-Saharan Africa, the urban-rural gap in coverage of antenatal care visits exceeds 20 percentage points in favor of urban areas, and the richest 20% of the population are more likely to receive antenatal care than poorer women. Good nutrition and equitable rights for all women are mutually reinforcing, and with improved gender equality leading in turn to improved nutrition.

We see this uneven and sub-optimal maternal care reflected in infant birthweight. A new study by the London School of Hygiene & Tropical Medicine (LSHTM), the WHO, and UNICEF finds that there has been minimal progress on reducing the number of babies born low birthweight (LBW), meaning they weigh less than 2,500 grams (5.5 pounds) at birth – a cause for alarm given that LBW increases the risk of newborn death, stunted growth, developmental delays, and conditions such as heart disease and diabetes later in life. As the mother’s micronutrient requirement increases during pregnancy in order to support the growth of the fetus, maternal undernutrition during pregnancy is closely linked with LBW.In 2015, 14.6% of all births worldwide, or 20.5 million babies, were born with LBW, the majority in sub-Saharan Africa and South Asia. Urgent action is needed to get the world on track to meet global goals on LBW, and maternal nutrition must be at the center of this effort.

Time for a change

To help meet women’s increased nutritional demands during pregnancy, the WHO recommends IFA as the current standard of care for pregnant women – but the policy has not changed in 50 years. The most recent 2016 WHO Antenatal Care (ANC) Guidelines, however, opened a window for MMS. The guidelines counsel against the use of MMS due to “some evidence of risk, and some important gaps in evidence,” but stipulate that “policymakers in populations with a high prevalence of nutritional deficiencies might consider the benefits to outweigh the disadvantages [such as cost], and may choose to give multiple micronutrient supplements that include iron and folic acid.”
 
Since 2016, the scientific community has met all the WHO’s concerns regarding risk and evidence. Compelling scientific evidence shows that taking MMS during pregnancy reduces the risk of maternal anemia and reduces the likelihood of a child being born LBW and too small. Anemic and underweight women benefit even more from MMS and have reduced risk of infant mortality and preterm births compared with mothers taking only IFA. Furthermore, recent research shows that MMS can reduce the gender imbalance in terms of the survival of female neonates compared with IFA supplementation alone, and that it represents an opportunity to invigorate maternal nutrition by putting women at the center of antenatal care.

The push for progress

The Women Deliver Conference (Vancouver, 3–6 June 2019) will be the world’s largest conference on gender equality, so Sight and Life and other leading organizations are working to elevate MMS. At Women Deliver, Sight and Life has partnered with the Children Investment Fund Foundation (CIFF), Kirk Humanitarian, 1,000 Days, Vitamin Angels, and the Multiple Micronutrient Supplement Technical Advisory Group (MMS TAG) – to host a side-event to make the case for MMS and build support behind the movement to update the global recommendations on MMS. This event, named Power for Mothers, will capitalize on the gathering of global leaders, key influencers, decision-makers, civil society and donors as part of the Women Deliver conference.

I firmly believe that, after 20 years of research and some 20 studies and meta-analyses comparing IFA and MMS on birth outcomes, it is unethical to further withhold MMS from pregnant women in low-resource settings. The MMS TAG (to which I belong) has documented the clear scientific advantage of MMS over IFA and the safety of MMS for mothers and their children, and has shown that the provision of prenatal MMS is a cost-effective intervention. Not only is MMS cost-effective, but it has also achieved cost parity.
 
It is no wonder why some early-riser countries with widespread micronutrient deficiencies have requested implementation research and donations of MMS for the successful replacement of IFA in their health sector. The time is now to adapt global and national guidelines to the overwhelming evidence. Disparities in antenatal care including the provision of MMS are no longer acceptable.

Email: klaus.kraemer@sightandlife.org
 
 
 
 

Introducing Vitamin B9

An Important Nutrient for Conception and Pregnancy

Back to Overview

Many women who are planning or have already had a baby will have heard about the importance of folic acid before conception and in the first 12 weeks of pregnancy. Vitamin B9, as known as folate, describes a group of derivatives of pteryl glutamic acid and folic acid is the synthetic form of folate used in supplements and for food fortification.

There is conclusive evidence that adequate folic acid intake helps to prevent neural tube defects (e.g. spina bifida) in babies. It is recommended that all women of childbearing age who are planning a pregnancy take a daily supplement as it is difficult to achieve through diet alone.

Folate works together with vitamin B12 to form healthy red blood cells. It is also necessary for normal cell division, the normal structure of the nervous system and specifically in the development of the neural tube (which develops into the spinal cord and skull) in the embryo. Vitamins B6, B12, and folate are involved with the maintenance of normal blood homocysteine levels. The amino acid homocysteine is an intermediate in folate metabolism and evidence suggests that raised blood homocysteine (hyperhomocysteinemia) is an independent risk factor for cardiovascular disease.

The Primary Sources of Folate

The most common sources of vitamin B9 is dark green leafy vegetables, beans, lentils, asparagus, wheat germ, yeast, peanuts, oranges, and strawberries. Animal products such as eggs, milk, cheese and liver also contain vitamin B. 

Bioavailability of Folate

Folic acid from supplements is 100% bioavailable, if taken without food, and 85% bioavailable when taken with food. Naturally occurring folates in food are 50% bioavailable, but the natural forms are highly unstable. Folate is easily destroyed by heat and oxygen.

Risks Related to Inadequate Intake of Folate

Individuals with diets that lack sufficient quantity and variety of green leafy vegetables and legumes are at risk for inadequate folate intake. Folate requirements are increased during pregnancy, especially in the first couple of weeks of gestation. Folate deficiency is highly associated with the risk for neural tube defects in the growing fetus. Women of child-bearing age and pregnant women are advised to meet folate requirements using a combination of natural foods (folate forms) and fortified foods or supplements (folic acid). In many western countries, governments have mandated flours to be fortified with folate. Because folate is critical for cell growth and repair, especially for cells with a short life span, such as cells in the mouth and digestive tract, visible signs of folate deficiency include digestive problems. Other symptoms are tiredness, loss of appetite, fewer but larger red blood cells (megaloblastic or macrocytic anemia), and neurological problems.

Find more information on vitamins and micronutrient deficiencies though our partner, Vitamin Angels or download our complete vitamin and mineral guide here.

To increase your vitamin B9 intake in your next meal, try this delicious recipe:

Red Lentil and Chorizo Soup*

Ingredients
1 tbsp, olive oil , plus extra for drizzling
200g cooking chorizo, peeled and diced
1 large onion, chopped
2 carrots, chopped
pinch of cumin seeds
3 garlic cloves, chopped
1 tsp smoked paprika, plus extra for sprinkling
pinch of golden caster sugar
small splash red wine vinegar
250g red lentil
2 x 400g cans chopped tomato
850ml chicken stock
plain yogurt, to serve

Method

Heat the oil in a large pan. Add the chorizo and cook until crisp and it has released its oils. Remove with a slotted spoon into a bowl, leaving the fat in the pan. Fry the onion, carrots and cumin seeds for 10 mins until soft and glistening, then add the garlic and fry for 1 min more. Scatter over the paprika and sugar, cook for 1 min, then splash in the vinegar. Simmer for a moment, then stir in the lentils, and pour over the tomatoes and chicken stock.

Give it a good stir, then simmer for 30 mins or until the lentils are tender. Blitz with a hand blender until smooth-ish but still chunky. Can be made several days ahead or frozen for 6 months at this point. Serve in bowls, drizzled with yogurt and olive oil, scattered with the chorizo and a sprinkling of paprika.

*Adapted from BBC Good Food

SaveSave

SaveSave

SaveSave

SaveSave