Maternal undernutrition: consequences and implications for practice

Sabeera Dar | Year 6 Medical Student | Maa Academics Officer

Maternal undernutrition: consequences and implications for practice

Maternal undernutrition: consequences and implications for practice.

By Sabeera Dar

The aspiration to end all forms of malnutrition is a critical message in the Sustainable Development Goals agenda. We are seeing a rising political commitment to this goal in increased participation from lower/middle income countries, donor funding and civil society. However, such engagement has not yet yielded large scale outcomes. To break out of brutal cycles of poverty, over 149 million children worldwide need access to adequate nutrition.1 Currently, those suffering from malnutrition experience stunted growth, compromised cognitive development, and reduced physical capability.

Unsurprisingly, the burden of global malnutrition is not evenly spread, nor is the form of malnutrition. Eastern and western Africa and south-central Asia have the highest prevalence of growth stunting. Over 60 million young people affected by stunting reside in south central Asia.2 No country is on course to meet targets on anaemia or adult obesity either. This hints at the “double burden” of malnutrition. The so-called double burden is characterised by the coexistence of undernutrition alongside obesity. Rapid economic transition in countries like India and Nepal, on the background of persistent infectious diseases, is actually crippling health systems as they struggle to battle both types of malnutrition.3

This blog post, however, will focus on undernutrition, more specifically maternal undernutrition in Bangladesh. I will also explore some of the obstacles in improving maternal malnutrition and suggest ways to mitigate them.

The significance of early intervention

Whilst much attention has been paid to reducing vitamin A deficiency, the same focus has not been given to diets lacking in zinc, iodine, and iron.4 Vitamin A supports healthy eyesight and immune system function however deficiencies still affect up to 50% of preschool children in some regions and remains the single most prominent cause of childhood blindness.5

With such bleak statistics, how do we even begin to tackle the issue? Whilst the first 24 months of life are the critical window for intervention, gestation is also profoundly influential on long term health. Poor maternal nutrition is a principal cause of intrauterine growth retardation, causing more than 800,000 neonatal deaths each year. 6 Infants who do survive remain at greater risk of developing non-communicable diseases such as metabolic syndrome and cancer in later adulthood.

Rising evidence reinforces the role of the nutritional status of women at the time of conception and during pregnancy.7 The correlation works both ways; a malnourished mother may have developed a smaller pelvis, potentially obstructing labour and risking increased maternal mortality. Thus, faltering growth and maternal outcomes are matters of prevention as poor health is remarkably inter-generational.

Maternal undernutrition in Bangladesh – existing data

Levels of low birth weight and maternal malnutrition in rural Bangladesh are among the highest in the world. The challenge in Bangladesh remains to tackle the multiple micronutrient deficiencies in young women of childbearing age in combination with increasing levels of breastfeeding amongst mothers. Whilst both breastfeeding and micronutrient deficiencies are addressed at Maa Maternal Health camps and Maa Educational Seminars, we are not the first to grapple with the dilemma. 8,9 The Bangladesh Nutrition Program, supported by the government of Bangladesh, the World Bank and UNICEF has been established since 1995. Over a decade of ‘information, education, and communication’ later, high levels of maternal undernutrition persist in rural Bangladesh. 10

A recent exploratory study conducted across 4 regions of Bangladesh looked at how nutrition counselling and micronutrient supplement intervention could impact antepartum, intra-partum and post-partum complications.11 The most significant findings were that reported postpartum complications were significantly lower among women in the intervention group than in the control group. Indeed, conditions such as retained placenta, postpartum infection, fever and postpartum bleeding were markedly lowered in the intervention group. This conveys that counselling women on nutritional deficiencies may have the additional benefit of enhancing their ability to recognise pregnancy complications.

Another study delved into the relationship between women’s empowerment, nutrition, and low birth weight.12 A women’s empowerment index (WEI) was constructed, incorporating the following key indicators: education, access to socio-familial decision making, attitudes towards domestic violence and mobility. The main findings include that the adjusted odds of having a low-birth-weight baby was 32% lower in the highest quartile of the WEI relative to the lowest quartile. Additional findings showed that household wealth massively modified the effect of WEI on maternal nutrition.

Socio-cultural obstacles

This is all quite logical; women’s empowerment and opportunity to access nutritional supplements leads to fewer adverse outcomes. Paradoxically though, qualitative research shows that sometimes, despite having high levels of awareness of dietary requirements, many women report unchanged or even reduced food intake during pregnancy. Survey data from JourneyMaa 2019 corroborates these findings.13 Indeed, the persistence of dietary taboos and food aversions are still widely practised and stem from oral traditions passed down from indigenous communities. These are nuanced models created around pregnancy and childbirth that women have developed detailed explanations of. Biomedical health-based programs must be executed in a way that is framed around existing belief systems. Such a venture is certainly challenging as some research points to blatant conflicts in local explanatory models and biomedical knowledge, such as the local custom to avoid highly nutritious foods like fish and lentils. 10

Religious practices such as fasting during the month of Ramadhan, despite existing Islamic exemptions for pregnant women, further complicate the matter. Healthy pregnant women are exempted from fasting if they believe that their health or their foetus’s health could negatively impacted; such conflicting guidance means some women still take fasting whilst pregnant as an obligation.14 Clearly, this emerges as an area for possible collaboration between health workers and religious authorities.

Gender relations and maternal nutrition

Furthermore, gender bias defines decisions making and intrahousehold allocation. In the hierarchal family setting, women often receive the last and smallest food shares during mealtimes.15 In one study, all participants reported being aware of increased dietary demands during pregnancy.10 Despite this awareness, just under half were practically able to increase their food intake during their pregnancy. This reflection of low social status is a consequence of biased treatment that is deeply embedded in Bangladeshi culture and thus may takes years to undo. A more immediate remedy could centre the involvement of males in the family and new fathers as well as mothers-in-law. Transplanting the discussion from women’s groups to the wider family could have an enabling effect.

Evaluating existing interventions

Finally, in the context of the Bangladesh Rural Advancement committee, it was found that women taking supplements during pregnancy remained undernourished in the postpartum period. Moreover, those who did not present as severely malnourished in the first antenatal contact, were found to become so during the gruelling lactation period. And to make matters worse, there are many cases of women taking supplements as replacements for meals, which has a deleterious effect and does little in the way of increasing overall calorie intake.

Conclusion

Such findings call for an urgent need to adopt a holistic approach to solving the issue of maternal undernutrition. Doing so will allow for a greater uptake of positive health behaviours, possibly transforming the lives of mothers and infants. For interventions in maternal nutrition to be impactful, organisers need to ensure their plans utilise social, anthropological, and political strategies to address each influential layer of the issue.  

References

  1. Levels and trends in child malnutrition: Key findings of the 2019 edition [Internet]. Unicef.org. 2019 [cited 3 April 2021]. Available from: https://www.unicef.org/reports/joint-child-malnutrition-estimates-levels-and-trends-child-malnutrition-2019
  2. Stunting is holding back the development of South Asian children and nations [Internet]. Unicef.org. 2021 [cited 3 April 2021]. Available from: https://www.unicef.org/rosa/press-releases/stunting-holding-back-development-south-asian-children-and-nations#:~:text=Stunting%20is%20holding%20back%20the%20development%20of%20South%20Asian%20children%20and%20nations,-18%20May%202016&text=The%20latest%20data%20indicate%20that,due%20to%20chronic%20nutritional%20deprivation.
  3. Gao L, Bhurtyal A, Wei J, Akhtar P, Wang L, Wang Y. Double Burden of Malnutrition and Nutrition Transition in Asia: A Case Study of 4 Selected Countries with Different Socioeconomic Development. Advances in Nutrition. 2020;11(6):1663-1670.
  4. Imdad A, Bhutta Z. Global Micronutrient Deficiencies in Childhood and Impact on Growth and Survival: Challenges and Opportunities. Meeting Micronutrient Requirements for Health and Development. 2012;:1-10.
  5. Micronutrient Facts [Internet]. Centers for Disease Control and Prevention. 2021 [cited 3 April 2021]. Available from: https://www.cdc.gov/nutrition/micronutrient-malnutrition/micronutrients/index.html
  6. Bhutta Z, Das J, Rizvi A, Gaffey M, Walker N, Horton S et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?. The Lancet. 2013;382(9890):452-477.
  7. Koletzko B, Godfrey K, Poston L, Szajewska H, van Goudoever J, de Waard M et al. Nutrition During Pregnancy, Lactation and Early Childhood and its Implications for Maternal and Long-Term Child Health: The Early Nutrition Project Recommendations. Annals of Nutrition and Metabolism. 2019;74(2):93-106.
  8. Ash D, Ireen S, Forissier T, Mahmud Z. Delivery of maternal nutrition interventions at scale and mainstreaming into the health system in Bangladesh [Internet]. Ennonline.net. 2020 [cited 3 April 2021]. Available from: https://www.ennonline.net/fex/63/maternalnutritionbangladesh
  9. Action – Nutrition International – Bangladesh – Maternal Nutrition Program – Nutrition counselling – Pregnant women (PW) | Global database on the Implementation of Nutrition Action (GINA) [Internet]. Extranet.who.int. 2018 [cited 3 April 2021]. Available from: https://extranet.who.int/nutrition/gina/en/node/26329
  10. Shannon K, Mahmud Z, Asfia A, Ali M. The Social and Environmental Factors Underlying Maternal Malnutrition in Rural Bangladesh: Implications for Reproductive Health and Nutrition Programs. Health Care For Women International. 2008;29(8):826-840.
  11. Todd C, Chowdhury Z, Mahmud Z, Islam N, Shabnam S, Parvin M et al. Maternal nutrition intervention and maternal complications in 4 districts of Bangladesh: A nested cross-sectional study. PLOS Medicine. 2019;16(10):e1002927.
  12. Kabir A, Rashid M, Hossain K, Khan A, Sikder S, Gidding H. Women’s empowerment is associated with maternal nutrition and low birth weight: evidence from Bangladesh Demographic Health Survey. BMC Women’s Health. 2020;20(1).
  13. JourneyMaa 2019 Report [Internet]. Maacharity.org. 2021 [cited 3 April 2021]. Available from: https://maacharity.org/wp-content/uploads/2020/12/JourneyMaa-2019-Report.pdf
  14. Sultan I, Taha I, Hassanein M. Ramadan Fasting and Maternal Perspectives in Healthy Pregnant Women: Systematic Review. British Journal of Medicine and Medical Research. 2015;6(6):573-586.
  15. Blum L, Khan R, Sultana M, Soltana N, Siddiqua Y, Khondker R et al. Using a gender lens to understand eating behaviours of adolescent females living in low‐income households in Bangladesh. Maternal & Child Nutrition. 2019;15(4).

Maternal undernutrition: consequences and implications for practice.

By Sabeera Dar

 

The aspiration to end all forms of malnutrition is a critical message in the Sustainable Development Goals agenda. We are seeing a rising political commitment to this goal in increased participation from lower/middle income countries, donor funding and civil society. However, such engagement has not yet yielded large scale outcomes. To break out of brutal cycles of poverty, over 149 million children worldwide need access to adequate nutrition.1 Currently, those suffering from malnutrition experience stunted growth, compromised cognitive development, and reduced physical capability.

 

Unsurprisingly, the burden of global malnutrition is not evenly spread, nor is the form of malnutrition. Eastern and western Africa and south-central Asia have the highest prevalence of growth stunting. Over 60 million young people affected by stunting reside in south central Asia.2 No country is on course to meet targets on anaemia or adult obesity either. This hints at the “double burden” of malnutrition. The so-called double burden is characterised by the coexistence of undernutrition alongside obesity. Rapid economic transition in countries like India and Nepal, on the background of persistent infectious diseases, is actually crippling health systems as they struggle to battle both types of malnutrition.3

 

This blog post, however, will focus on undernutrition, more specifically maternal undernutrition in Bangladesh. I will also explore some of the obstacles in improving maternal malnutrition and suggest ways to mitigate them.

 

The significance of early intervention

 

Whilst much attention has been paid to reducing vitamin A deficiency, the same focus has not been given to diets lacking in zinc, iodine, and iron.4 Vitamin A supports healthy eyesight and immune system function however deficiencies still affect up to 50% of preschool children in some regions and remains the single most prominent cause of childhood blindness.5

 

With such bleak statistics, how do we even begin to tackle the issue? Whilst the first 24 months of life are the critical window for intervention, gestation is also profoundly influential on long term health. Poor maternal nutrition is a principal cause of intrauterine growth retardation, causing more than 800,000 neonatal deaths each year. 6 Infants who do survive remain at greater risk of developing non-communicable diseases such as metabolic syndrome and cancer in later adulthood.

Rising evidence reinforces the role of the nutritional status of women at the time of conception and during pregnancy.7 The correlation works both ways; a malnourished mother may have developed a smaller pelvis, potentially obstructing labour and risking increased maternal mortality. Thus, faltering growth and maternal outcomes are matters of prevention as poor health is remarkably inter-generational.

 

Maternal undernutrition in Bangladesh – existing data

 

Levels of low birth weight and maternal malnutrition in rural Bangladesh are among the highest in the world. The challenge in Bangladesh remains to tackle the multiple micronutrient deficiencies in young women of childbearing age in combination with increasing levels of breastfeeding amongst mothers. Whilst both breastfeeding and micronutrient deficiencies are addressed at Maa Maternal Health camps and Maa Educational Seminars, we are not the first to grapple with the dilemma. 8,9 The Bangladesh Nutrition Program, supported by the government of Bangladesh, the World Bank and UNICEF has been established since 1995. Over a decade of ‘information, education, and communication’ later, high levels of maternal undernutrition persist in rural Bangladesh. 10

 

A recent exploratory study conducted across 4 regions of Bangladesh looked at how nutrition counselling and micronutrient supplement intervention could impact antepartum, intra-partum and post-partum complications.11 The most significant findings were that reported postpartum complications were significantly lower among women in the intervention group than in the control group. Indeed, conditions such as retained placenta, postpartum infection, fever and postpartum bleeding were markedly lowered in the intervention group. This conveys that counselling women on nutritional deficiencies may have the additional benefit of enhancing their ability to recognise pregnancy complications.

 

Another study delved into the relationship between women’s empowerment, nutrition, and low birth weight.12 A women’s empowerment index (WEI) was constructed, incorporating the following key indicators: education, access to socio-familial decision making, attitudes towards domestic violence and mobility. The main findings include that the adjusted odds of having a low-birth-weight baby was 32% lower in the highest quartile of the WEI relative to the lowest quartile. Additional findings showed that household wealth massively modified the effect of WEI on maternal nutrition.

 

Socio-cultural obstacles

 

This is all quite logical; women’s empowerment and opportunity to access nutritional supplements leads to fewer adverse outcomes. Paradoxically though, qualitative research shows that sometimes, despite having high levels of awareness of dietary requirements, many women report unchanged or even reduced food intake during pregnancy. Survey data from JourneyMaa 2019 corroborates these findings.13 Indeed, the persistence of dietary taboos and food aversions are still widely practised and stem from oral traditions passed down from indigenous communities. These are nuanced models created around pregnancy and childbirth that women have developed detailed explanations of. Biomedical health-based programs must be executed in a way that is framed around existing belief systems. Such a venture is certainly challenging as some research points to blatant conflicts in local explanatory models and biomedical knowledge, such as the local custom to avoid highly nutritious foods like fish and lentils. 10

 

Religious practices such as fasting during the month of Ramadhan, despite existing Islamic exemptions for pregnant women, further complicate the matter. Healthy pregnant women are exempted from fasting if they believe that their health or their foetus’s health could negatively impacted; such conflicting guidance means some women still take fasting whilst pregnant as an obligation.14 Clearly, this emerges as an area for possible collaboration between health workers and religious authorities.

 

Gender relations and maternal nutrition

 

Furthermore, gender bias defines decisions making and intrahousehold allocation. In the hierarchal family setting, women often receive the last and smallest food shares during mealtimes.15 In one study, all participants reported being aware of increased dietary demands during pregnancy.10 Despite this awareness, just under half were practically able to increase their food intake during their pregnancy. This reflection of low social status is a consequence of biased treatment that is deeply embedded in Bangladeshi culture and thus may takes years to undo. A more immediate remedy could centre the involvement of males in the family and new fathers as well as mothers-in-law. Transplanting the discussion from women’s groups to the wider family could have an enabling effect.

 

Evaluating existing interventions

Finally, in the context of the Bangladesh Rural Advancement committee, it was found that women taking supplements during pregnancy remained undernourished in the postpartum period. Moreover, those who did not present as severely malnourished in the first antenatal contact, were found to become so during the gruelling lactation period. And to make matters worse, there are many cases of women taking supplements as replacements for meals, which has a deleterious effect and does little in the way of increasing overall calorie intake.

 

Conclusion

Such findings call for an urgent need to adopt a holistic approach to solving the issue of maternal undernutrition. Doing so will allow for a greater uptake of positive health behaviours, possibly transforming the lives of mothers and infants. For interventions in maternal nutrition to be impactful, organisers need to ensure their plans utilise social, anthropological, and political strategies to address each influential layer of the issue.  

 

References

  1. Levels and trends in child malnutrition: Key findings of the 2019 edition [Internet]. Unicef.org. 2019 [cited 3 April 2021]. Available from: https://www.unicef.org/reports/joint-child-malnutrition-estimates-levels-and-trends-child-malnutrition-2019
  2. Stunting is holding back the development of South Asian children and nations [Internet]. Unicef.org. 2021 [cited 3 April 2021]. Available from: https://www.unicef.org/rosa/press-releases/stunting-holding-back-development-south-asian-children-and-nations#:~:text=Stunting%20is%20holding%20back%20the%20development%20of%20South%20Asian%20children%20and%20nations,-18%20May%202016&text=The%20latest%20data%20indicate%20that,due%20to%20chronic%20nutritional%20deprivation.
  3. Gao L, Bhurtyal A, Wei J, Akhtar P, Wang L, Wang Y. Double Burden of Malnutrition and Nutrition Transition in Asia: A Case Study of 4 Selected Countries with Different Socioeconomic Development. Advances in Nutrition. 2020;11(6):1663-1670.
  4. Imdad A, Bhutta Z. Global Micronutrient Deficiencies in Childhood and Impact on Growth and Survival: Challenges and Opportunities. Meeting Micronutrient Requirements for Health and Development. 2012;:1-10.
  5. Micronutrient Facts [Internet]. Centers for Disease Control and Prevention. 2021 [cited 3 April 2021]. Available from: https://www.cdc.gov/nutrition/micronutrient-malnutrition/micronutrients/index.html
  6. Bhutta Z, Das J, Rizvi A, Gaffey M, Walker N, Horton S et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?. The Lancet. 2013;382(9890):452-477.
  7. Koletzko B, Godfrey K, Poston L, Szajewska H, van Goudoever J, de Waard M et al. Nutrition During Pregnancy, Lactation and Early Childhood and its Implications for Maternal and Long-Term Child Health: The Early Nutrition Project Recommendations. Annals of Nutrition and Metabolism. 2019;74(2):93-106.
  8. Ash D, Ireen S, Forissier T, Mahmud Z. Delivery of maternal nutrition interventions at scale and mainstreaming into the health system in Bangladesh [Internet]. Ennonline.net. 2020 [cited 3 April 2021]. Available from: https://www.ennonline.net/fex/63/maternalnutritionbangladesh
  9. Action – Nutrition International – Bangladesh – Maternal Nutrition Program – Nutrition counselling – Pregnant women (PW) | Global database on the Implementation of Nutrition Action (GINA) [Internet]. Extranet.who.int. 2018 [cited 3 April 2021]. Available from: https://extranet.who.int/nutrition/gina/en/node/26329
  10. Shannon K, Mahmud Z, Asfia A, Ali M. The Social and Environmental Factors Underlying Maternal Malnutrition in Rural Bangladesh: Implications for Reproductive Health and Nutrition Programs. Health Care For Women International. 2008;29(8):826-840.
  11. Todd C, Chowdhury Z, Mahmud Z, Islam N, Shabnam S, Parvin M et al. Maternal nutrition intervention and maternal complications in 4 districts of Bangladesh: A nested cross-sectional study. PLOS Medicine. 2019;16(10):e1002927.
  12. Kabir A, Rashid M, Hossain K, Khan A, Sikder S, Gidding H. Women’s empowerment is associated with maternal nutrition and low birth weight: evidence from Bangladesh Demographic Health Survey. BMC Women’s Health. 2020;20(1).
  13. JourneyMaa 2019 Report [Internet]. Maacharity.org. 2021 [cited 3 April 2021]. Available from: https://maacharity.org/wp-content/uploads/2020/12/JourneyMaa-2019-Report.pdf
  14. Sultan I, Taha I, Hassanein M. Ramadan Fasting and Maternal Perspectives in Healthy Pregnant Women: Systematic Review. British Journal of Medicine and Medical Research. 2015;6(6):573-586.
  15. Blum L, Khan R, Sultana M, Soltana N, Siddiqua Y, Khondker R et al. Using a gender lens to understand eating behaviours of adolescent females living in low‐income households in Bangladesh. Maternal & Child Nutrition. 2019;15(4).

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