Changing the Standard

Why Multiple Micronutrient Supplements in Pregnancy Are an Ethical Issue

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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
 
 
 
 

Cracking the Egg Potential

Working to Reduce Child Stunting and Improve Rural Livelihoods

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Eggs are among “nature’s first foods”, designed to holistically support early life and development. They are among the richest sources of essential amino acids, protein, choline, and long- chain fatty acids (DHA).  They are also an important source of some vitamins and minerals, including vitamin A, B2, B5, B12, selenium, phosphorous and zinc, and contain other bioactive factors. In a symposium chaired by Chessa Lutter from RTI International and the University of Maryland School of Public Health and Saul Morris from the Global Alliance for Improved Nutrition (GAIN), and sponsored by the Child Investment Fund Foundation (CIFF) at the International Congress of Nutrition (ICN 2017) in Buenos Aires, the potential of eggs to improve child nutrition and rural livelihoods was debated. 

Eggs

The Science Behind the Egg

For a full-packed symposium hall, Lora Iannotti from Washington University, presented findings from the Lulun Project, a randomized controlled trial in Ecuador, where eggs were given to children 6 to 9 months of age.  After only 6 months, linear growth was improved and stunting was reduced by 47% in the group receiving eggs –  an effect larger than those of any other complementary feeding interventions to date. The trial also showed significant  improvements in concentrations of biomarkers associated with cognitive development including  choline, betaine, methionine and DHA.  Currently, a replication study is on its way in Malawi that also includes assessments of child development.

In rural Ghana, poultry-based income generation activities embedded in an integrated agricultural and nutrition education intervention also led to improved egg consumption, dietary diversity and linear growth among young children. Dr Grace Marquis from McGill University presented the preliminary results of this intervention, in which households with infants up to 12 months of age received multiple agricultural and infant feeding interventions, including education and training on poultry, home gardens and beekeeping. Dr Marquis and her team are currently working with district partners on the sustainability of the intervention by helping women form farmer associations, opening opportunities for access to credit from the local rural bank, and strengthening technical assistance from government health and agriculture extension services.

Creation of demand and overcoming social and cultural taboos preventing mothers and caregivers from giving eggs can be major barriers to overcome when promoting the use of eggs for young child feeding. A key element of the previously described RCT in Ecuador — an intensive social marketing strategy — was described by Carlos Andres Gallegos Riofrío of Washington University. The project was branded as “Lulun”, which translates into ‘egg’ in the local indigenous language, and symbolically tied the practice of giving eggs to young children with indigenous worldviews. The strategy followed a structured process targeting all the six P’s in successful marketing: people, product, place, price, promotion and policy change. Creating a successful brand, brand loyalty and empowerment of mothers and caregivers to take decisions on their child feeding were critical for the successful and continued behavior change and central to the success of the study in improving egg consumption and child growth.

Availability of Eggs

To make eggs available and affordable to low-income households, small holder poultry business models need to be viable. Klaus Kraemer of Sight and Life presented the findings from a scoping study in Kenya, Ethiopia, Malawi and India demonstrating the potential of four types of business models to be viable at-scale:  

(1)  Micro-Financing institutions that provide a small credit to underserved poultry entrepreneurs coupled with peer group support, technical, and business skill training. Such credit helps backyard poultry farmers set-up and operate micro-enterprises.

(2)  The Out-Grower Model: a partnership between smallholder poultry farmers and commercial players to improve the productivity of hens.  

(3)  In the Enterprise Development Model, an established local input supplier organizes smallholder farmers into groups and helps them invest in mid-size poultry enterprises. With relevant training, market support and funding, they manage businesses that not only generate profits, but also succeed in improving the availability of high quality eggs in their community.

(4)  The One-Stop Hub Model is a distribution and aggregation platform tailored for a rural environment. It is a combination of the above three models, and goes one-step further by providing a marketing channel for eggs to be accessible even in hard-to-reach rural areas.

All of these models were successful and in some contexts even hugely profitable. In Malawi, for instance, women farmers in the Enterprise Development Model, can each earn an average income of US$1130 per year!

Chicken

Finally, Emily Lloyd of the One Acre Fund demonstrated the importance of rigorous piloting before moving to scale to tackle issues with selection of the most appropriate chicken-breed in a particular setting, appropriate housing and vaccinations of chickens to prevent spread of poultry-related infectious diseases in the participating households, as well as distribution and financing challenges.

The Challenges

In a lively discussion, some important suggestions were raised by the audience. These included the potential to improve egg consumption in other vulnerable target-groups, in particular pregnant and lactating women, the need for behavioral change strategies and other interventions to prevent the spread of poultry-related infectious disease to the household, concerns about allergies, considerations of equity when rolling-out poultry business models and how to improve sustainability when these programs and interventions are further scaled-up.

Saul Morris, GAIN’s Director for Policy and Planning, concluded that the potential of egg and poultry interventions to impact child’s nutrition and improve rural livelihoods is ‘egg-citing’ and has been underexplored and appreciated. The symposium clearly demonstrated that together, interventions to improve young child egg intake and household and community egg production could radically reduce the global prevalence of stunting and improve livelihoods of the rural poor. The next challenge will be to bring these interventions to scale, and fulfill the promise that by 2020, 10 million eggs will be delivered to young children annually, as a key component of complementary feeding.

Watch the complete ‘Cracking the Egg’s Potential to Improve Child Growth and Development’ presentation from the 2017 ICN IUNS and access the linked research here on SecureNutrition’s website. For additional information on eggs read ‘Cracking the Egg Potential During Pregnancy and Lactation‘ featured in the Sight and Life magazine on Women’s Nutrition and ‘Eggciting Innovations‘ on our blog. 

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