targeted food supplementation and its effect on birth-weight and pregnancy weight gain
TRANSCRIPT
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1 Introduction
1.1 Background
In May 2004 a panel of economists, including four Nobel laureates, was asked to rank; 40potential interventions designed to tackle some of the worlds most ve!ing development
problems named the "openhagen "onsensus, and they suggested that the interventions; such as
those designed to address micronutrient deficiencies and other dimensions of hunger and
malnutrition were e!cellent investments#
$he often held belief, that all nutrition programs are welfare interventions that divert resources
that could be better used in other ways to raise national incomes, is incorrect; many investments
in nutrition are in fact very good economic investments# $he "openhagen "onsensus also
disclosed the value of e!panding the nascent interface between economics and nutrition#
More than 20 million infants worldwide, representing %& per cent of all births, are born with
low birth'weight, () per cent of them in developing countries# $he level of low birth'weight in
developing countries *%)#& per cent+ is more than double the level in developed regions * per
cent+# -alf of all low birth'weight babies are born in .outh'central /sia, where more than
uarters *2 per cent+ of all infants weigh less than 2,&00 g at birth# 1revalence of low birth
weight in angladesh is 403 according to 5-. report in 6angladesh country health system
profile#
Maternal under'nutrition and malnutrition are ma7or problems in especially the poorest
developing countries and are generally considered to be of importance for the high prevalence of
low birth weight and fetal growth retardation# 8imited access to high uality foods is the ma7or
reason for under'nutrition, but traditional food habits, food taboos and limited knowledge may
also contribute to under'nutrition#
$he important role of low birth weight and prematurity for perinatal mortality and morbidity in
developing countries and its association with under'nutrition and malnutrition in the mothers,
has motivated various attempts to improve pregnancy outcome through food supplementation#
%
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.ubstrate supply to the fetus is a ma7or regulator of prenatal growth# Maternal nutrition
influences the availability of nutrients for transfer to the fetus# observational and intervention
studies in humans provide limited support for a ma7or role of maternal nutrition in determining
birth si9e, e!cept where women are uite malnourished #
uring pregnancy, the foetus is solely dependent on maternal intake and nutritional stores,
mostly fat, for its energy# 1oor maternal nutrition during pregnancy in turn implies a risk of poor
nutritional availability to the foetus# $he best methodological approach for assessing the effect of
this factor on birth'weight and more specifically on I:5 or prematurity is thus supplementation
aiming that an increase in food intake may increase birth'weight and thus the prevalence of 8ven if it is consumed, it may
replace some of the usual diet# .upplementation trials must take this into account in order to
evaluate the actual e!tra amount ingested# Many such trials have been carried out# :ntil recently
most of the evidence seemed to indicate that maternal caloric intake during pregnancy had no
effect on prematurity; however supplementation had a positive effect on birth'weight and I:5#
$he effect was greater among the mothers, who were malnourished before their conception#
Nutritional supplementation during pregnancy was also shown to be associated with a reduction
in the incidence of 8< in developing and developed populations%
#
?or at least )& years, nutritionists, physicians, and public'health policy'makers have studied the
impact of food supplementation to pregnant women who are under'nourished or otherwise at risk
for adverse pregnancy outcomes 2# Most of these studies on feeding supplementation have
targeted an increase in the birth'weight of the offspring, based on the well'established
relationship between higher birth'weight *at least up to an optimal birth'weight rarely attained in
developing countries+ and increased survival, reduced morbidity, and more recently, even
perhaps a lower risk of long'term chronic diseases of adults, such as hypertension, type 2diabetes, and coronary heart disease @, 4 Aarkers hypothesisB#
5estational maturity is a far more important predictor of infant *and especially neonatal+
mortality and severe morbidity than is si9e for gestational age, and thus, the relationship between
birth'weight and these outcomes is primarily due to the close correlation between birth'weight
2
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and gestational age .ince food supplementation during pregnancy has not been shown to
prolong gestation, most of the presumed benefit arises from an increase in the si9e of infants
born at term )# $he 5ambian supplementation trial, which succeeded in reducing both stillbirth
and neonatal death by providing a much higher net increase in energy intake than any other of
such trials #
/lthough an increase in si9e of term infants may be beneficial, randomi9ed trials have not shown
a benefit of maternal food supplementation on long'term growth or functional outcomes in
children )# Moreover, recent data from Ca7nik et al. suggest that Indian newborns that are growth'
restricted compared to newborns in the :D have a relatively normal fat mass E# $hese data raise
the warning that increasing the si9e of .outh /sian infants might increase fat mass without
adding substantially to bone, muscle, or other lean body tissue, with potentially adverse long'
term conseuences *insulin resistance and type II diabetes+ in later childhood and adulthood# /ll
this is to say that the goals of providing food supplementation, even if targeted to thin women in
countries like angladesh and India, must clearly consider medium' and long'term functional
outcomes in the offspring, not merely an increase in birth'weight (#
8ow birth weight is a ma7or contributor to neonatal and post neonatal mortality# $wenty five
million babies a year are born below 2&00 g, the
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.uch results lend support to the theory that fat deposited early in pregnancy acts as a reserve for
the last trimesters caloric demands# /s most nutritional interventions were implemented in the
third trimester of pregnancy, this could e!plain the lack of a large effect on birth'weight and
I:5, rather than the recently suggested lack of association %2# .upplementing in the last
trimester *after 20 weeks+ may indeed e!clude from the benefits of stunting#
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remain undernourished, with reduced muscle strength, throughout their lives, and to suffer a
higher incidence of diabetes and heart disease %# "hildren born underweight also tend to have
cognitive disabilities and a lower IH, affecting their performance in school and their 7ob
opportunities as adults#
1revious studies have also linked infant mortality with motherGs education, age at childbirth,
delivery status, health status, parity and marital union; fatherGs education and employment;
household income and consumer goods, household safe source of drinking water and sanitation;
and slum and rural residence %E,%(,20# emographic characteristics such as childGs se!, ethnicity,
preceding and succeeding birth interval, and birth order are also known to be associated with
infant mortality 2%#
&
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1.2 Justification of the study
In developing countries chronic maternal undernutrition is a prime contributor to the birth of
over 2& million low birthweight babies annually and to high rates of neonatal mortality# /n
absence of well designed field trials has created uncertainty about the potential efficacy of
maternal feeding programmes# $his small scale operational research was aimed to show that
dietary supplementation in pregnancy can be effective in reducing the proportion of low
birthweight babies# $his research also had the notion that supplementary feeding program can be
installed efficiently into a rural primary healthcare system, middle and late pregnancy is the
period most amenable to intervention#
8< infants have less chance of survival; when they do survive, they are more prone to disease,
growth retardation and impaired mental development# / good start in life is important and
maternal nutritional status during pregnancy has repeatedly been demonstrated to be associated
with pregnancy outcomes for the infant 22#
In developing countries intrauterine growth retardation *I:5+ accounts for the ma7ority of low
birth weights whereas in developed countries most 8< babies are premature as opposed to
growth retarded 2@#
$he most sensitive measure of acute nutritional stresses during pregnancy is indeed maternal
weight gain# $here is strong epidemiological evidence of an association between maternal weight
gain during pregnancy and 8
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morbidity# Fther environmental factors may indeed directly affect these outcomes independently
of birth weight 22#
$he magnitude of the immediate conseuences as well as the generational and inter'generational
effects of foetal growth retardation are enormous in .outh /sia, and especially in angladesh,where reportedly 4&3 of infants are born with a weight below 2,&00 g# -alf of the worlds
malnourished children live in three countries on the subcontinentK angladesh, India, and
1akistan# $his forms the background to launch ambitious nutrition programmes in the region,
where large investments have been made to break the cycle of malnutrition through food and
micronutrient supplementation *and related activities+ to pregnant women and infants24#
In angladesh, every second woman becoming pregnant has a body mass inde! consistent with
chronic energy deficiency# .paring supplementary calorie support of about )00 kcal consisting
about %E gm of vegetable protein; one of the ma7or determinant for the distribution of the effect
seems to be the mothers pre'pregnancy weight AMIB# Fther important factors for the si9e of the
effect are her basic dietary intake during this period, the energy and nutrient composition of the
supplement, the timing and total duration of supplementation, the replacement level of the
supplement, her level of physical activity, and her general health, especially the presence of
infectious diseases# "hronic psychological stress may probably also contribute significantly to
the problem of pre'term delivery and low birth'weight or modify the effect of nutritioninterventions 2
$here is a need to determine the nature of factors that contribute to poor growth and development
before birth, within, and between populations# $he possible adverse effects of interventions also
reuire further e!ploration# $he researchers failed to provide concrete conclusion e!plaining the
/sian enigma of low birth weight reduction by nutritional intervention programs adopted by
different population# $hey even could not advice us to accept any of the philosophies regarding
these interventions through logically evaluated publication# $hus the basis of our knowledgeabout supplementary food is so far weak, with seemingly contradictory results#
Many of the basic uestions still remain unanswered#
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1.3 Conceptual framework of low birth weight
E
Insufficient accessto food, 5enderdiscrimination
Inadeuate carefor children andwoman
1oor water sanitationand inadeuate health
service
Low pregnancy weight
gain
isease ; chronic disease, -$N,diabetes, renal disease, "F1,vulvular heart disease
Inadeuate ietary Intake, lifestyle, normal dietary habit,social=cultural beliefs,religion
rug abuse, otherhabits, $obacco,alcohol
Inadeuate est,working status,stress= an!iety
Low birth weight
/ge at conception8iving condition , shortstature, unplannedpregnancy
.e! of child ,seuence, multiplepregnancy, ?e, vit#"folic acid, I ,n,vit /
nderlyingcause
household
le!el
"redisposing
cause
Immediatecause
#utcome
$uantity and %uality of actual resource &
human' economic and organi(ational and
the way they are controlled
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1.) *ypothesis
$argeted food supplementation of National Nutrition 1rogram has influence on pregnancy weight
gain and birth weight of the newborn#
1.+ #b,ecti!es
-eneral ob,ecti!e
$o find out the effect of targeted food supplementation of National Nutrition 1rogram onpregnancy weight gain and birth weight of the newborn in the mothers among intervention area
and nonintervention area in the selected :pa9ilas#
pecific ob,ecti!es
%# $o compare the pregnancy weight gain of the selected mothers among NN1 intervention
and nonintervention areas#
2# $o compare the birth weight of the newborn between two areas#
@# $o find out the socio'demographic status of the selected mothers#
(
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1./ 0ariables in the study
ocio demographic !ariables
%# /ge2# /ge at marriage@# eligion4# >ducational status of the sample Fccupation of the sample)# /ge of the samples husband# >ducation of the samples husbandE# .tudy sample husbands occupation(# .ocioeconomic status of the sample%0# O5 card
0ariables related to pregnancy deli!ery
%# $ime of pregnancy registration2# 8ast menstrual period@# >!pected date of delivery4# ate of delivery -eight of the respondent)# 5ravid# /N" .tatusE#
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4# "olostrums giving to the new born
1.4 5ey !ariables and scales of measurement
pecific ob,ecti!e 0ariables cales of
measurement
%%
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%#$o compare the
pregnancy weight gain of
the selected pregnant
mothers between NN1
intervention P non'
intervention areas#
%# 1regnancy duration in daysa. Last menstrual period
b. Date of delivery
2# $ime of pregnancy registrationa. Last menstrual period
b. Date of pregnancy registration
@# 1arity
4# No# of /N" taken
-eight in centimeters
)#
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%4# .e! of the child
"o = 0
#es = 1
$ntrained %&' = 0
%rained %&' = 1
"urses and
paramedics = !
Doctors = (
)emale child = 0
*ale child =1
2# $o compare the birth
weight of the newborn
babies of the respondents
between two areas#
% irth weight of the new born in grams%)# $ime at which birth weight is taken%# "olostrums giving to the new born
.cale
.cale
.cale
@# $o determine the socio'
demographic status of the
respondents
%E# /ge%(# -ow long being married20# eligion
2%# >ducation of the respondent
22# Fccupation of the mothers
.cale
.cale
+slam = 0
Hindu and others = 1
"o education = 0
,re-primary =1
-/ class = !
and above = (
%@
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2@# /ge of the sample husband
24# >ducation of the samples husband
2 .amples husband occupation
2)# .ocioeconomic status
2# O5 card
Houseife = 0
ervice = 1
.cale
"o education = 0
,re-primary =1
-/ class = !
and above = (
$nemployed =0
Heavy orker = 1
killed orker = !
&usinessman = (
erviceman = 2
Destitute = 0
,oor = 1
"o = 0
#es = 1
%4
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1.6 #perational 7efinition
ocio demographic !ariables
1. 8ge
/ge was taken as completed years, preferably from the Ooter I card#
2. 8ge at marriage
/ge at marriage was taken in completed years# It was computed by deducting the duration
of marriage from their current age#
3. 9eligion
$he religion of the mothers was classified as Islam, -indu, "hristian, uddhist# It was
further classified as Islam and Fthers for easy applicability of the statistical procedure#
). :ducation of the samples
>ducation was taken as a continuous variable during data collection then it was further
classified as, no education, pre primary Q non'formal education,&'( years of education and
above secondary education#
+. #ccupation of the mothers
Fccupation was categori9ed into housewife, service and others# $hose who involved
themselves in income generating professions were included into service category#
Fccasional 7ob holders or those who generate income inconsistently were distributed in the
others category#
/. 8ge of their husband
/ge in completed years
4. :ducation of the respondent;s husband
.ame as mothers education6. 9espondent;s husband occupation
1rimarily it was categori9ed as farmer, fisherman, rickshaw and other manual three
wheelers puller, daily laborers, weaver, businessman including small business, teacher,
service holder and others but finally they were grouped as no employment, heavy workers,
.killed workers, businessman and service holder; permanent occupation of the participants#
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In this study all the samples were taken from the poor socioeconomic group designated by
the respective organi9ation#
1=. 0-7 card
$hose were given economic support through vulnerable group funding program#
0ariables related to pregnancy deli!ery
11. >ime of pregnancy registration
ate of first registration# $his time should not e!ceed %20 days from her last menstrual
period#
12. Last menstrual period
ate of onset of her last regular menstrual bleeding#
13. :?pected date of deli!ery
It was counted by adding 20R%0 days with the 8M1
1). 7ate of deli!ery
/ babys low weight at birth is either the result of preterm birth *before @ weeks of
gestation+ or due to restricted foetal *intrauterine+ growth .o Mothers conceived for @
completed weeks were taken into count, the date of delivery of the baby#
1+. *eight of the mothers-eight in centimeters was taken as continuous variable#
1/. -ra!id
$he no of times she became pregnant includes M, abortion, miscarriage, still birth, live
birth#
14. 8@C tatus
$he freuency of antenatal care she was provided#
16. Aeight of the respondent at booking first !isit
$he weight of the mother in kilograms during registration
1
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Iron and folic acid supplementation in completed months
21. >otal weight gain during pregnancy
$his measurement was computed by subtracting last weight and first weight
22. "lace of deli!ery1lace where she completely delivered her baby with the delivery of placenta# 1lace of
delivery were categori9ed as home delivery, delivery at 5overnment health facilities and at
clinics or at other similar services#
23. Birth attendant
Fne who assisted as well as completed the total delivery process and professionally
designated as any of the category mentioned in the uestionnaire#2). 7eli!ery complication
/ny untoward event during birth process that might cause threat to mother or her baby that
reuires special medical support#
2+. Body Dass Inde?
$he ody Mass Inde!*MI+ formula was developed by elgium statistician /dolphe
Huetelet*%()'%E4+, and was known as the Huetelet Inde!#$he metric bmi formula
accepts weight measurements in kilograms = height measurements in either cmGs or meters
suare#
2/. Chronic :nergy 7eficiency
New criteria are proposed for classifying chronic energy deficiency *">+ in adults# /
progressively more precise approach to identifying affected individuals involves measuring
body weight and height, then energy intake *or e!penditure+ and finally the basal metabolic
rate *M+# $hree cut'off points for body mass inde! *MI+ were identifiedK %E#&, %#0
and %)#0# / MI above %E#& is classified as normal and below %)#0 as grade III "># /
diagnosis of grades I and II "> depends on finding the combination of a MI of %)#0'%)#( or %#0'%E#4 with a ratio of energy turnover to predicted M of less than %#4#
Measuring the individual M avoids misclassification and confirms the diagnosis# *">+
III *MI %)#0 kg=m2+, "> II *MI+ S %)#0T%)#( kg=m2+ and "> I *MI+ S %#0T%E#&
kg=m2+# -ere researcher found it impossible to measure M for the samples because this
%
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was not recorded in any of the organi9ational report so he took only MI level for
categori9ing "hronic >nergy eficiency status#
24. ood supplementation
?ood supplementation through NN1 *Intervention area+K
:pon disclosure by a woman of her pregnancy *usually during the third month+, weight and
height of the woman are recorded to assess her MI# $hereafter, regardless of MI, she is
weighed monthly until delivery when the birth'weight of child is recorded# / woman whos
MI in early pregnancy is eual to or less than %E#& are enrolled in a daily on'site
supplementary feeding regimen which continues until delivery## $he food supplementation
contains an estimated 23 of a womans daily allowance for calories, using 2,2E0 kcal as
the daily reuirement for pregnant women#
26. 7uration of food supplementation
$hree supplementation groups were constructed comprising low, intermediate and high
number of days of supplementation which euated to %20 and U%)0 days in registration
month @# "onseuently the supplementation groups were defined as %20 *low+ days, %20'
%&( *intermediate+ days and U%)0 *high+ days of supplementation, respectively# In
registration month 4, low, intermediate and high supplementation groups were defined as
%00 days, %00'%@( days and U%40 days, respectively#
0ariables related to the new born
2
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times more likely to die than heavier babies# esearcher took 2&00gm of birth weight as
cut'off value for low birth weight#
31. >ime at measurement taken
$he birth weight should be taken preferably within the first hour of life# In this study the
birth profiles of the newborn were taken from the relevant primary baseline records when
reported within 2 hours of delivery#
32. Colostrums gi!en to the new born
33. @on Inter!ention area
$he area from where the respondents were selected to compare the effects of food
supplementation# $wo areas were chosen by the researcher keeping two priorities in mind#
$he respondents should bear almost similar socio'demographical characteristics and the
primary records of the respondents should be reliable# -ere the area chosen to compare the
NN1 area was 5D *5onosashthaya Dendra + territory hamrai .avar#
%(
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1.< Limitations
It is necessary to discuss the limitations of this study# $he present study was performed in two
up9ilas of almost same demographic characteristics# ata were collected from the baseline
organi9ational reporting of two different organi9ations#
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c+ a tendency of some community nutrition promoters to record birth'weights at or above
2#& kg to avoid the additional responsibilities reuired in low birth'weight cases#
4# 8astly as more than E0 3 of the delivery were conducted at home it was practically
impossible to take birth weight measurement within the first hour of birth# esearcherallowed birth'weight records that were taken within 2 hours of delivery# $ime for the
study was inadeuate and more over there were no fund support for conduction of such
research pro7ect#
In this study, as only one intervention site samples are taken into count to compare the
effect of supplementation, the result of the study may not reflect the e!act effectiveness of
supplementation in the large scale National Nutrition 1ro7ect A
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2 9e!iew of literature
Daternal malnutrition low birth weight
Maternal under'nutrition and malnutrition are ma7or problems in especially the poorest
developing countries and are generally considered to be of importance for the high prevalence of
low birth weight and fetal growth retardation# 8imited access to high uality foods is the ma7or
reason for under'nutrition, but traditional food habits, food taboos and limited knowledge may
also contribute to under'nutrition#
$he important role of low birth weight and prematurity for peri'natal mortality and morbidity in
developing countries and its association with under'nutrition and malnutrition in the mothers, hasmotivated various attempts to improve pregnancy outcome through food supplementation 2)#
$he most recent trial included in the review was published in %((# $his trial was conducted in
rural 5ambia and the beneficial effects of high energy with balanced protein content
supplementation would likely apply to similar settings where a substantial proportion of the
populations are undernourished#
Ideally, rising of the social and economic status of women in developing countries is the bestlong'term solution for improving the nutritional status of undernourished pregnant women#
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8ow birth weight is a ma7or contributor to neonatal and postneonatal mortality# $wenty five
million babies a year are born below2&00 g, the
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each additional %00 kcal ingested daily# .imilarly a significant reduced risk of I:5 in women
who received the supplements was shown# "ollated data sets suggested that if %00 kcal per day
were supplemented throughout pregnancy, the risk of I:5 would be halved in mothers
undernourished prior to pregnancy, but only reduced by %=& in well'nourished mothers 22#
In other conte!ts, birth weight is an inputJ T i#e#, a pro!y for the initial endowment of an
infants health human capitalJ# "onsistent with this view, research has found that 8< infants
tend to have lower educational attainment, poorer self'reported health status, and reduced
employment and earnings as adults, relative to their normal weight counterparts 2#
ood supplementation through @@" Inter!ention area
:pon disclosure by a woman of her pregnancy *usually during the third month+, weight and
height of the woman are recorded to assess her MI# $hereafter, regardless of MI, she is
weighed monthly until delivery when the birth'weight of child is recorded# / woman whos
MI in early pregnancy is eual to or less than %E#& are enrolled in a daily on'site
supplementary feeding regimen which continues until delivery#
$he intent of the new National Nutrition 1rogram is also to enrolled in the supplementary
feeding regimen any pregnant woman failing to gain at least % kg of body'weight during any
month of her pregnancy# $he food supplement is produced at the "ommunity Nutrition "entre
by groups of low'income mothers for whom production of the supplement is an income'
generating activity# Oillage women employed by the program prepared the food supplements
using local products# $he prepared food was provided in plastic packets to be mi!ed with water#
$he daily supplement contained E0 g roasted rice powder, 40 g roasted pulse powder, 20 g
molasses, and %2 m8 *) g+ soybean oil, which provided )0E kcal and %#( g vegetable protein
*%%#&3 of total energy+# $he supplements were usually eaten at the "N", but were often
brought to the participantsG homes# $he food supplementation contains an estimated 23 of awomans daily allowance for calories, using 2,2E0 kcal as the daily reuirement for pregnant
women#
tudy findings in Bangladesh E:ffect of ood supplementationF
24
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Monitoring data on 4&) womenX%(& receiving food supplement and 2)% not
receiving.upplements were collected from % upa9ilas *sub'districts+ in four districts of
angladesh# $he assessment found that, despite lower economic status, the women with low
MI receiving supplementation of food and intensified services were more likely to have
adeuate pregnancy'related weight gain than the more economically'advantaged women with
higher MI# 1rimigravidae receiving supplementation were also more likely to have adeuate
pregnancy'related weight gain than the better'off non'supplemented primigravidae *E vs
&%#(3, pS0#044+# $he mean birth'weights of infants of the supplemented women with low MI
were comparable to those of the better'off, non supplemented women 2E#
1regnant women who had a MI of, %E#&kg=m2 on first presentation should have been selected
for supplementary feeding *2&%2 kY *)00 kcal+=d for si! days per week+ starting at month 4 *%)
weeks+ of pregnancy# -owever, of the &2) "> pregnant mothers only @@& received
supplementation; so the failure rate was @)#@3, among them only %(@ women *@)#3 of &2)
women+ commenced supplementation at the correct time, of whom thirty'two *(#)3 of @@&
women+ received supplementation for the correct number of days *%003 days+# $here were no
significant differences in mean weight gain between MI, %E#& kg=m2 supplemented or non'
supplemented groups# 8ighter women gained relatively more weight during their pregnancy than
heavier women# $he mean birth weight in the supplemented and non'supplemented groups was
2#)@ kg and 2#2 kg, respectively# Mothers with MI, %E#& kg=m2 who were or were not
supplemented had almost eual percentages of low'birth'weight babies *2%3 and 22 3,
respectively+# $he study raises doubt about the efficiency of the IN1 to correctly target food
supplementation to pregnant women# It also shows that food supplementation does not lead to
enhanced pregnancy weight gain nor does it provide any evidence of a reduction in prevalence of
low birth weight 2(#
In early first trimester, @&0 women were followed for duration of pregnancy and data gathered on
maternal factors such as social, demographic, anthropometric, biochemical measures and
newbornGs birth weight within 4E hours of birth# /lmost a uarter of babies *243+ were born
with 8< and mean birth weight was 2()% g# ivariate analysis found associations between
8< and motherGs age, parity, weight and hemoglobin level at booking, weight gain and health
problems during pregnancy, tobacco consumption, and gestational age# ut no such association
2&
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was seen for birth spacing, motherGs height, economic status, educational level, body mass inde!,
mid upper arm circumference and number of /N" visits @0#
Fver @)3 of mothers were malnourished *MI %E#&+ while %@#43 and 4E#&3 of their children
were wasted and stunted respectively# "hildren at risk of wasting and stunting were @%#&3 and))#&3 respectively# Mothers from better'off households tended to be taller, heavier and have
higher MIs# $here were mainly low'to'moderate positive correlations between mothers MI
and childs 'scores# /fter taking into account variation in socio'economic variables, the
distribution of households on the combined basis of maternal MI and child nutritional status did
not suggest that low maternal MI was associated with increased levels of childhood wasting,
stunting or underweight @%#
In another study cohort of undernourished pregnant women *nS +who received prenatal food
supplementation *)0E kcal=d+ was followed# $he association between the uptake of food
supplements and < was analy9ed after ad7ustment for potential confounders *nS )%( with
complete information+# ifferential effects in lower and higher maternal postpartum weight
groups were e!amined# $he average < was 2&2% g# Fn average, the women received daily
supplements for 4 months, which resulted in an increase in < of %%E g *%#0 g=d+# $he strongest
effect was found for births occurring in Yanuary and ?ebruary# $here was a linear dose'response
relation between duration of supplementation and < for women
with higher postpartumweights *42 kg, above the median+# In women with lower weights *42 kg, below median+, a
shorter duration of supplementation *4 mo+ had no such dose'response relation with
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demonstrated effects of food supplementation would not also have a positive impact on foetal
growth among angladeshi pregnant women#
$he research design used in this study is highly unusual, however# $he intervention was not
randomi9ed, nor was the intervention group compared with a similar group of women neitherelsewhere in the country or region who did not receive the supplement, nor even with a
historical group of similar women who gave birth prior to the intervention# Instead, the authors
elected to feed all women who met their eligibility criterion *body mass inde! AMIB %E#&
kg=m2 at the time of registration+ and compared weight gain and birth'weight *without respect
to gestational age, presumably because the latter was unavailable or felt to be inaccurate+ with
those outcomes in women with higher baseline MIs *and therefore not eligible for the
supplement+, who generally came from more socioeconomically favourable households#
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1rovision of food does not necessarily lead to its consumption# >ven if it is consumed, it may
replace some of the usual diet# .upplementation trials must take this into account in order to
evaluate the actual e!tra amount ingested# Many such trials have been carried out# :ntil recently
most of the evidence seemed to indicate that maternal caloric intake during pregnancy had no
effect on prematurity; however supplementation had a positive effect on birthweight and I:5#
$he effect was greater the more malnourished the mother was before pregnancy# Nutritional
supplementation during pregnancy was also shown to be associated with a reduction in the
incidence of 8< in developing and developed populations#
.urprisingly, and regardless of methodological and practical differences, the effect of nutritional
supplementation during pregnancy on birthweight has generally been modest, with an average
increase of about %00g %#
International study finding E:ffect of supplementationF
Fne study showing a substantial effect was in the 5ambia where daily supplements of groundnut
based biscuits and vitamin fortified tea was distributed to pregnant women# $he mean net
increase of energy intake was 4@% kcal per day# $he resulting significant increase in birthweight
was on average %20g and the overall prevalence of 8< babies decreased significantly from 20
to )3# $here were however marked seasonal differences# .upplementation during the wet season*hungryJ season+ led to a significant increase in birthweight of about 200g and a decrease in the
proportion of 8< from 2@#3 to #&3; in the dry season supplementation had no effect
*average increase of 2g only+ %@#
/s stated by Oillar women without overt malnutrition or in positive energy balance *5ambia dry
season+ obtain a limited benefit from nutritional supplementation during one pregnancy#
"hronically malnourished mothers also supplemented during one pregnancy e!perience only a
modest impact on birthweight of about %00g#
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/ recent meta'analysis of controlled clinical trials on the effect of supplementation during
pregnancy on the outcome of pregnancy confirmed that trials of nutritional advice to increase
energy and protein intakes and of balanced energy and protein supplementation, have
demonstrated only a modest increase in maternal weight gain and fetal growth, even in
undernourished women, and no long term benefits to the child in terms of growth of neuro'
cognitive development %4# $hat is, the clinical e!perimental evidence reviewed showed that
modest increases in fetal growth in the absence of effects on gestational duration do not appear to
confer long lasting benefits on infant and child survival, health and performance#J
Fnly trials using controls or random or uasi random methods of treatment allocation were
included in the overview *the 5uatemalan and 5ambian trials were e!cluded+# $he author
concluded that unless future trials of energy and protein supplementation demonstrate clear
reductions in risk for preterm birth, stillbirth, or neonatal death, or improvements in maternal
health, clinicians and politicians should avoid high e!pectations from this type of nutritional
intervention and should perhaps shift their focus towards potentially more fruitful avenues for
improving maternal and child health %4#
$he contrasts between the findings of this overview and the results of observational studies
suggest that the latter may have overestimated the effects of supplementation on pregnancy
outcome# $he robust findings of a strong association between maternal weight gain and fetalgrowth and of an even stronger association in undernourished women may partly reflect a non'
nutritional effect mediated by such factors as e!panded maternal plasma volume and increased
placental blood flow %4#
Most of the dietary intervention studies addressed only birthweight as the outcome variable# Fne
study in >ast Yava however showed that maternal nutrition during pregnancy influenced growth
of the offspring beyond the intrauterine period# .upplements were distributed during the last
trimester of pregnancy#
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$hese children were significantly heavier up to the age of 24 months and taller throughout the
first & years# .tunting was less prevalent among children whose mothers had received the high
energy supplement# Mothers may have had an improved breastmilk output and their better'
nourished children were less likely to become sick @)#
$he ability of supplementation to reverse the retardation of fetal growth in the hungry season
when provided for an averageof only E2 days in the second half of pregnancy is consistent with
findings from the utch Zhunger winterZ of %(44'& @#
#ther contributors effecting pregnancy outcome
If indeed this improved pregnancy performance among the younger women is due to early and
adeuate antenatal care then it follows that all adolescent girls should be encouraged to seekearly and appropriate antenatal care to decrease the morbidity and mortality associated with
pregnancy as previously reported# "hang et alhave shown that there is a relationship between
inadeuate prenatal care and an increase rate of preterm birth @E# In this study, the high rate of
antenatal care e!perienced in each group suggests that the similar pregnancy performance
between the mature women and the adolescent girls may in fact be linked to adeuate antenatal
care and this adeuacy of care has a positive effect on pregnancy outcome in adolescent girls#
?indings by .choll et aland ?raser et alalso support this as they have shown a strong association
between inadeuate prenatal care and adverse outcomes @(, 40# $his study therefore concurs with
studies which suggest that improved antenatal care may improve outcome in the adolescents#
$he :#. Institute of Medicine recommendations for weight gain during pregnancy are based on
pregnancy MI and uphold a slightly different range of weight gain for each MI category#
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$he highest prevalence of low iron stores, iron deficiency and iron deficiency anaemia is among
New ealand Maori women, particularly aged from %&'24 years 4@# Maternal anemia is associated
with infant mortality and premature delivery 44#In addition to reducing neural tube defects, lack
of folate during pregnancy is associated with increased risk of pre term delivery, low birth weight
and poor fetal growth 4@#
3 Daterials and methods
Dethodology
3.1 tudy design$his is an operational research aiming to evaluate the outcome of the targeted food
supplementation program by NN1 angladesh#
3.2 tudy period
$he total study lasted for a period of ) months commencing from Yanuary 200( to Yune
200(# $o complete the study in time, a work schedule was prepared including all the tasks in
a seuence# $he first three months were spent for literature review, topic selection,
development and approval of the protocol# $he subseuent three months were spent for
uestionnaire development, pretesting, data collection, compilation and analysis, report
writing, printing and submission of the thesis# 8iterature review was simultaneously going
on till the final report was written#
3.3 "lace of the study
$his study was conducted in Dapasia :pa9ila * NN1 intervention area + of 5a9ipur district
P .avar hamrai * nonintervention area + haka disttrict # Dapasia
3.) tudy population
$he samples were taken from two different population served by two different N5Fs
*O/ P 5D+# O/ is implementing the maternal and child nutritional supportive
programme following National Nutrition 1rogram guidelines in one study area *Dapasia+ P
@%
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5D *5onosashthaya Dendra+ is delivering maternal P "hild health "are services through
primary health care in another area *.avar+#
/t first %%(@ sample information were collected, )&E from 5onosasthaya Dendra P &@& from
O/ NN1 area# ut only &)& of them e!clusively meet the selection criteria #/lthoughaccording to NN1 all pregnancies with MI S%E#& are eligible to get daily on'site
supplementary feeding regimen until delivery but records reveal only 2@E out of &@& chronic
energy deficient mother were inconsistently supplemented # In this situation a good number
pregnant mothers who resides in the O/ NN1 area and are entitled to have food
supplementation become non'supplemented #$hus a third group evolves naturally that is
Dapasia non'supplemented group#
It was obvious that the researcher should conduct P compare the analysis between two
samples but instead he took the opportunity to compare the results of the study between three
groups to make it more e!haustive# .o the results presented in this section are based on three
category of respondents comprising &)& mothers#
5onoshasthaya Dendra .avarAhamraiB * n S %2) +
Dapasia non supplemented * n S 22E+
Dapasia supplemented * n S 2%%+
/ll pregnant women with MI %E#4( Dg=m2
of the selected :p9ilas#
@2
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election criteriaG
Inclusion criteria
1regnant women have MI %E#& P
egistered at not more than 4th month of pregnancy
etween age %@ to @& years
$he birth profiles of the newborn are only taken when reported within 2 hours of delivery
:?clusion criteria
Multiple pregnancies
1regnancy with chronic diseases
1regnancy with metabolic diseases
.mokers
1re termed delivery P post'dated or prolonged pregnancy
3.+ ample si(eG
$he sample si9e was determined by following formula
>stimating the difference between two population proportion with specified absolute
precision
n H (212E"11 "1 K "21"2F d2
or n H (212! d2 where' E0 H "11 "1 K "2 1 "2F
@@
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1opulation proportion 1% and 12
1roportion of low birth weight in non'intervention area 1% S @E#E 3
1roportion of low birth weight in NN1 area 12 S 2& 3
"onfidence level (& 3 * 9 S %#() +
/bsolute precision d S & 3 *#0& +
Intermediate value O S 1%*%' 1%+ Q 12*%'12+
O S #@EE*#)%2+ Q #2&*#&+ v S #424(
Now, n S 92 %'[=2v= d2
S %#()2#424( = #0&2
S )&@#0044
S )&@
/ sample si9e of )&@ would be needed
*for "I S(&3, d S 0#0& P OS #424(+
3./ ampling techni%ue
$he study was conducted by sample survey# .amples were taken from the pregnancy P birth
registers P cards of the corresponding organi9ation# $hen he selected the participants
according to the inclusion criteria# /ll samples of randomly selected unions were taken in the
study#
3.4 7ata collection method
/ format was made as data collection instrument to collect data from the past P present
records of NN1 intervention area *O/ conducted+ P non NN1 intervention area *5D
;5onoshasthaya Dendra working territory+# It was used to collect information from primary
@4
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records regarding socio'demographic, reproductive, delivery, food supplementation and
pregnancy outcome profile#
$he draft format was trialed and modified for several times to make it synchroni9ed, easy and
informative# $he necessary modification was done after consultation with an epidemiologistand a statistician# It was finali9ed in a way so that it could collect all the relevant information
to meet the ob7ectives of the study#
3.6 tatistical analysis
7ata management
\ .orting the data
\ 1erforming uality control check
\ ata processing
] "ategori9ing
] "oding
] summari9ing
\ 7ata presentation
ata will be presented by tables P graphs
\ 7ata analysis
ata were cleaned, edited, coded and computed with the help of the computer by .1..
%)#0 for windows#
ata collected were of ualitative P Huantitative type#
Huantitative data were analy9ed to find out the mean P standard deviation P were tested
by .tudents 6t test and one way analysis of variance# */ssuming (&3 confidence interval
P &3 precision+#
@&
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Hualitative data were analy9ed to estimate the proportion and will be tested by 2 tests# $o
remove the effects of confounders, binary and multinomial logistic regression, 5eneral
8inear Model *epeated measure+ and linear regression were performed#
3.< :thical consideration
1rior to commencement of the study, the research protocol was approved by the ethical
committee *local ethical committee+ of the NI1.FM, haka, angladesh# Frgani9ational
approval was taken and detailed information regarding the study was acknowledged#
) 9esults of the study
$his record'based study was carried out in Dapasia and .avar upa9ila to e!plore the effect of
targeted food supplementation by comparing the pregnancy weight gain and birth weight# ata
on %%(@ samples *)&E from .avar and &@& from Dapasia+ were collected# ut only &)& of them
met the selection criteria, therefore detailed analysis were done on those data only# $his chapter
presents those data through tables and graphs under following headings#
4#% .ocio'demographic characteristics
4#2 eproductive health
4#@ "hronic energy deficiency status
4#4 ?ood supplementation
4#&
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/mong the mothers selected from Dapasia upa9illa 2%% received food supplementation, rest did
not *22E+# In addition to 6.avar non'supplemented and 6Dapasia supplemented a new group
6Dapasia non'supplemented was formed# $he researcher e!plored the social P demographic
status of the mothers of different categories# $he aim of the analysis was to compare their
background characteristics including age, education, and occupation between these groups of
pregnant women#
).1.1 8ge of the mother
$he study included samples having their age at pregnancy between %4 and 44 years #$he mean
age at pregnancy were almost same among all three categories *? S 0#@4, pV0#0&+#$he
distribution of age categories showed that only )#@3 of the .avar group were under 20 years
which was double and triple in Dapasia non'supplemented and Dapasia supplemented group,
respectively# Fn the other hand 403 of the mothers in .avar area were in 2&'2( years category
which was %03 higher than that of both non'supplemented and supplemented mothers in
Dapasia area# 8ess than &3 of the study population had their age over @& years# $hesedifferences were statistically significant * p S 0#00)+#Atable 4#%B
>able ).1 8ge distribution of the samplesE@H+/+F
@
8ge of mothers in years
ample category
2 p !aluea!ar @ H 12/
kapasia nonsupplemented
n H 226
kapasiasupplemented
n H 211
N 3 N 3 N 331/ E )#@ 2( %2# @E %E
#00)!0-!2 &4 42#( (E 4@ E4 @(#E!-!/ &0 @(# &E 2 &% 24#2 2%#2E(0-(2 %0 #( 24 %0#& 2) %2#@4( 4 @#2 %( E#@ %2
Dean M7 2@#(ER4#@ 24#%@R&& 2@#&R@4 #@4 ns^? ratio for one way analysis of variance,
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).1.2 Dothers; education
.ignificant differences were observed in the educational status between the mothers of the threegroups *2S 4@#4&, df S ) , p 0#00%+# Illiteracy was three times higher in .avar area mothers
*2% 3+ than those of Dapasia area *)#%3 among non'supplemented and #%3 in supplemented
mothers+# $he proportion of 1rimary education was least among mothers of .avar which is three
and four times higher in Dapsia non'supplemented and supplemented mothers, respectively#
esearcher wanted to find out the relationship of education and supplementation status only
among Dapasia categories and it was found not significant, A$able 4#2B#
).1.3 athers; education
Illiteracy among fathers of .avar group was higher *%(#E 3+ than that of Dapasia groups; it was
%23 in supplemented and %43 in non'supplemented and primary education was two times more
common in non'supplemented and three times among supplemented mothers in Dapsia, than $he
mothers of .avar# $he difference was tested by 2 test **2S 2%+ and found significant *p
0#00%+, A$able 4#2B#
).1.) Dothers; occupation
/lmost all the mothers were housewife e!cept %0 who were mainly N5F workers5A$able 4#2B#
).1.+ athers; occupation
/bout &(3 of the husbands of Dapasia supplementation group were heavy workers in
comparison to the .avar group where it was only @)#&3# .killed labour category was larger in
.avar group# 2
S @)#), *p S 0#00%+, A$able 4#2B#
@E
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>able ).2 :ducation and occupational status of the study samples E@H+/+F
@(
:ducation and
occupational status
ample category
2 p !aluea!ar
@ H 12/
kapasia nonsupplemented
n H 226
kapasiasupplemented
n H 211
@ N @ N @ N
Dothers education
"o education 2 2%#4 %4 )#% %& #%
0#00%6 ,rimary %0 #( 4E 2%#% )% 2E#( 4@#4&
-/ years E )%#( %2( &)#) %0E &%#2 and above %% E# @ %)#2 2 %2#E
athers; education
"o education 2& %(#E 2 %%#E @0 %4#2
0#00%6 ,rimary %4 %%#% )( 2( 2 @4#% 2%-/ years )E &4 %0& 4)#% E0 @#( and above %( %% @ %)#2 2( %@#
athers; occupation
$nemployed @ 2#4 @#% ( 4#@
0#00%Heavy orker 4) @)#& %0@ 4 %24 &E#E
killed labour @0 2@#E 2% (#2 % E#% @)#)&usinessman 2& %(#E )4 2E#% @( %E#&
erviceman 22 %#& @@ %4#& 22 %0#4
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).2 9eproducti!e health characteristics
).2.1 8ge at marriage
$he age at marriage ranged from %@ years to 2& years# $he mean *R.+ age was lowest %#(
*R%#&E+ years for .avar population and was highest %E#@) *R2#4)+ years for Dapasia non'
supplemented group# /ge class was formed as two subsets; 6 17 years and 417 years *pS #(@ +,
Atable 4#@B# More than one third of the participants were married at an earlier age# $he age of
marriage was not associated to either pregnancy weight gain category or birth weight category
when "hi suare test was run, A$able not shownB#
$he age at marriage of the husbands ranged from %& to 2 years# / good number of them got
married at or below the age of 20 years# $he mean *R.+ age of marriage of the husbands were
2@#(0 *R@+ years for .avar group and 2)4 *R4#)+, 24#&*R4#(+ years for Dapasia non
supplemented and supplemented group, respectively# $he difference between the age at marriage
of husbands three groups is statistically significant #? value &2 with a p value of 0#004#
>able ).3 Darital and gra!id status of the samples E@H+/+F
40
8ge at marriage
ample category
2 p !aluea!ar
@ H 12/
kapasia non
supplemented n H 226
kapasia
supplemented n H 211
@ N @ N @ N
6 17 years 4@ @4#% E% @& E% @E#4 % 0#0,ns417 years E@ )( %4 )4#& %@0 )%#)meanM7
*other %#( Q %#&E %E#@) Q2#4) %E#%)Q%#&E %#@2^ ns)ather 2@#(0 Q @ 2)4 Q4#)0 24#&Q4#( &2^ #004-ra!ida
6 ! (% 2#2 %)E 2#2 %&& @#& #0( ns4! @& 2#E )0 2)#@ &) 2)#&^? ratio for one way /NFO/
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).2.2 -ra!id
$here were no significant differences in number of gravid among the mothers between the study
areas# $hree uarters of the sample mothers conceived at least twice in their reproductive life, *p
S #(&+, A$able 4#@B#
).2.3 8ntenatal care
/nti'natal care status was classified following
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).2.) Iron and olic acid supplementation
More than E2 3 of the respondents from .avar got iron and folic acid supplementation for @
months or more and the percentage were 42#&3 and 4 3 in Dapasia non'supplemented and
supplemented respectively# $he differences were statistically significant with a 2value of &4#(2
*p 0#00%+, A$able 4#4B#
).2.+ "lace of deli!eryIn .avar area E%# 3 of the deliveries were conducted at home and in Dapasia those were E0# 3
to EE 3 among non'supplemented and supplemented group, respectively# 5overnment
hospitals conducted only 2#&3 of the delivery in .avar and E#E 3 and 3 delivery in Dapasia#
$he variation was noticeable and had a 2 value of %%#% *pS0#0@+, A$able 4#&B#
).2./ Birth attendant
$raditional birth attendant conducted more than E03 of the delivery in all three groups of bothareas# ut in .avar area most of the delivery attended by the trained $/ E#)3 and only @3 of
the birth events involved the untrained personnel# $he proportion of delivery conducted by the
untrained $/ is relatively higher in Dapasia ranged %43 to %3 in Dapasia non'supplemented
and supplemented category respectively# $he variation was tested statistically and found
significant, 2 value %4#)( *p S 0#02+# $he proportion of delivery conducted by doctors was
mostly of caesarian type, A$able 4#&B#
).2.4 Complication at deli!ery
"omplication during delivery was %2#3 in .avar and the proportion was almost same for
Dapasia non supplemented group# $he proportion of complication was highest in the
supplemented Dapasia group *%)#)3+ although not statistically significant, A$able 4#&B#
42
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>able ).+ 7eli!ery related !ariables among the study samples E@H+/+F
4@
7eli!ery characteristics
ample category
_2 p !aluea!ar
@ H 12/
kapasia nonsupplemented
n H 226
kapasiasupplemented
n H 211
@ N @ N @ N
"lace
Home %0@ E%# %E4 E0# %E% EE%%#% #0@Government Hospitals @ 2#4 20 E#E %& #%
linics 20 %( 24 %0#& %& #%
Birth attendant$ntrained %&' 4 @#2 @2 %4 @) %#%%4#)( #02%rained %&' (( E#) %&) )E#4 %@ )4#(
"urses 8 paramedics %2 (#& 22 (#) 20 (#&Doctors %% E# %E #( %E E#&Complication
"o %%0 E#@ 202 EE#) %) E@#4 2#)2 ns#es %) %2# 2) %%#4 @& %)#)
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).3 EChronic energy deficiencyF C:7
/ccording to National Nutrition 1rogram only pregnancies with ody Mass Inde! %E#& were
eligible to get daily on'site supplementary feeding regimen# $o match with the supplemented
samples, mothers with MI %E#&3 were selected from .avar area also#
).3.1 7istribution of BDI among the Chronically :nergy 7eficient mothers
7istribution of BDI among the participants
44
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igure1
5raph shows the mean *M. MI was %)# *M.(( below "> II level# MI ranged
from%@#4 to%E#4(# -ighest freuency of MI was at or around %#
>able )./ 7istribution of C:7 among the supplement categories E@H+/+F
4&
C:7 categories
upplement category
p &!aluea!ar @ H 12/
kapasia nonsupplemented
n H 226
kapasiasupplemented
n H 211
@ N @ N @ N
9D + E )%#( %40 )%#4 %4 )#)9D ++ 2) 20#) 2 @%#) %@2 )2#) %@#%) 0#00%9D +++ 22 %#& %) )& @0#E
*ean :D %#0@ R %#%( %#%4 R#E2 %)#2% R# ))#@E^ 0#00%^? ratio for one way analysis of variance
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.upplemented mothers from Dapasia area had, on average, lower MI *%)#2%R0#+ than non
supplemented mothers in Dapasia *%#%4R#E2+ and .avar %#0@R%#%(+ area# Fneway /NFO/showed the difference significant and by performing posthoc -ochbergs 5$2 test it was further
noticed that the mean MI level of the supplemented group differed highly significantly from
other two groups, *? value ))#@E, p 0#00%+, A$able 4#)B#
$able 4#) shows that more than )0 3 of the non'supplemented mothers both from Dapasia and
.avar were with "> I while only )#)3 supplemented mothers were in this category# More than
(03 of Dapasia supplemented category were at or below "> II level of malnutrition # $he
variation was highly significant *_2S %@#%), p0#00%+#
).) ood supplementation
7uration of supplementation among the sample categories
4)
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igure2
$hree supplementation groups were constructed comprising low, intermediate and high number
of days of supplementation and were defined as no or 0 days, %20 *low+ days, %20'%&(*intermediate+ days and U%)0 *high+ days of supplementation, respectively# In registration month
4; no, low, intermediate and high supplementation groups were defined as 0 days, %00 days,
%00'%@( days and U%40 days, respectively# esearcher try to segregate the classification only for
Dapasia respondents as .avar population are normally destitute of supplementation# .o the
classification for Dapasia was no supplementation, poor supplementation, moderate
supplementation, 6good=adeuate supplementation
4
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igure3
?igure @ shows only about E3 of the Dapasia participants got full supplementation# More than
&03 were not supplemented at all though all of them were eligible for on'site food support#
4E
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).).1 Chronic energy deficiency status in !arious supplementation Categories
$he non'supplemented group of Dapasia were mostly of "> I category respondents#Fn the
other hand those who got either poor, moderate or adeuate supplementation in Dapasia are
mostly of ">II P "> III category# $he results show NN1 targeted food supplementation tried
to ensure supplementation for most vulnerable ones though the enthusiasm was very much
inconsistent, A$able 4#B#
>able ).4 Chronic :nergy 7eficiency status among different supplement
categories Ebased on duration of supplementationF @H+/+
ut after starting supplementation at early pregnancy they were incapable to manage the on site
food support consistently to all upto delivery# >ven among E% of the severely malnourishedmothers only %& were managed to complete the full supplementation# $hus only @4 out of 2%%
supplemented mothers got supplementary food support upto the term#
$he relationship between the supplement category and "> status were found highly significant
in 2test# *2%(#2, p S 0#00%+# $he mean *R.+ MI of the good supplementation group were
lowest %)#0) *R#(+ and for Dapasia non supplement group it was highest %#%4*R#E2+# /fter
performing univariate analysis 1osthoc 5ames -owell test was done assuming the varianceswere not eual * as levene statistic was significant )#%@ df%S 4, df2 S&)0 sig#0#000+# /nalysis
showed .avar and Dapasia non supplement categories possessed almost similar MI level
although there were significant differences of the mean MI between these categories and other
groups# ? ratio @@, dfS4, pS0#00%, A$able 4#B#
4(
C:7
upplement category
2 p!aluea!ar 5apasia
@o
supplement
@H12/
@o
supplement
@H226
"oor
supplement
@H112
Doderate
supplement
@H/+
8de%uate
supplement
@H3)
n N n N n N n N n N
9D+ E )%#( %40 )%#4 ( E#0 @ 4#) 2 (0#00%9D++ 2) 20#) 2 @%#) @ ) 42 )4#) % &0 %(#2
9D +++ 22 %#& %) #0 @0 2)#E 20 @0#E %& 44#%BDI
mean:D; %#0&R%#%2 %#%4R#E2 %)#2ER#) %)#%)R# %)#0)R#( @@ 0#00% ^? ratio for one way analysis of variance
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7istribution of pregnancy weight gain among the samples
igure)
?igure 4 shows the average pregnancy weight gain and the distribution of weight gain in study
population# $he weight gain ranged from 2#2 kg to %2#@ kg# with a meanR. of #& R2#% kg#
&%
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>able ).6 "regnancy weight gain in supplement categories E@H+/+F
).+.2Aeight gain among supplement category
$able shows there was significant relationship between food supplementation and pregnancy
weight gain in one way /NFO/ *p S 0#00%+# ut post hoc 5ames -owell test was done to
specify the variant categories and it was found that .avar group with a meanR. )#&0R%#&@
deferred significantly from other groups# $he 6no supplementation and poor supplementation
group gained almost same average weight during pregnancy# ut those who were adeuately
supplemented gained better weight than all other groups as they gained E#&0 *R%#&(+ kg at their
prenatal period, A$able 4#EB#
$hen analysis was repeated e!cluding the .avar group *as Dapasia had de novo non'supplement
group for better and logical comparison+ from the analysis to find out more specific relationship
between food supplementation and weight gain# /fter performing one way analysis of variance
no association was found *? S %#0@ df S@, pS0#@E ns+, A$able not shownB#
&2
upplementation category "regnancy weight gain p!alue
@ DeanM7 Din Da?"o supplement 22E #E2R2#2E 2#20 %2#@0,oor supplement %%2 #E%R2#%@ 2#)0 %%#)0*oderate supplement )& #E)R%#EE 4#00 %2#00 %2#%( 0#00%Good supplement @4 E#&R%#) @#E0 %%#%0avar no supplementation %2) )#&0R%#&@ @#00 %%#00^ ? ratio for one way analysis of variance
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igure +.1
epeated measure analysis shows significant variation in weight gain between .avar and all
other Dapasia categories# ? S%2#%( *p 0#00%+
&@
"regnancy weight gain pattern in different supplement categories
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igure+.2
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supplement line Aut we found earlier that all supplemented category had almost similar early
pregnancy MIB# $his might suggest that supplementation might have effect on pregnancy
weight gain in severe malnourished woman but the effects of other factors related to pregnancy
weight should be ruled out#
).+.3 Aeight gain at different le!el of C:7
>able ).< "regnancy weight gain according to C:7 le!el of the samples
$he weight gain ranged from 2#20 kg to %2#@0 kg# $able shows .everely malnourished mothers
gained better weight than those of mild P moderately malnourished category# Fne way analysis
of variance reveals significant variation in gaining weight between the categories# 1ost -oc
analysis was done assuming euality of variances * 8evene statistic not significant+ among the
groups and the method showed average weight gain in "> III category mothers significantly
differs from other two "> categories, * ? S (#& and p S 0#00%+, A$able 4#(B#
&&
C:7 "regnancy weight gain p!alue
@ DeanMsd Din Da?
9D + 2@2 #%@R2#00 2#20 %%#)09D ++ 2@0 #)R2#0( 2#)0 %2#20 (#&^ 0#00%9D +++ %0@ E#%@R2#%E @#00 %2#@0^? ratio for one wa anal sis of variance
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&)
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igure/.1
&
"regnancy weight gain pattern in sample categories considering C:7
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?igure shows no variation in weight gain among different supplement group considering the
effect of "> status of the mothers# ?S#(@ ns#
&E
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igure/.2
>!luding savar category from the analysis 5raph shows no variation in weight gain among
different supplement group considering the "> status of the mothers# ?S #@4 ns#
&(
"regnancy weight gain pattern in sample categories considering C:7
E:?luding a!ar samplesF
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)0
>able ).1= :ffect of food supplementation on pregnancy weight gain ad,usting
C:7 status of the sample mothers E@H+/+F
Supplementation Beta t "
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)%
able).1=.1 9egression analysise?cluding a!ar category E@H )3
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)2
>able ).11:ffect of Chronic :nergy 7eficiency on pregnancy weight gain
ad,usting food supplementation status E@H+/+F
Chronic Energy
Deficiency
Beta t " I A MI SV % B eta S standardi9ed co'efficient t S t statistic "I S confidence interval for un'standardi9ed regression co'efficient
/s previously it was noted that the average E#%@ kg pregnancy weight gain in "> III category
significantly differ from #%@ kg of "> I mothers with a ? ratio (#&, researcher tried to analy9e
the situation more specifically, A$able 4#(B#
.o 8inear regression analysis was performed to find out the association of level "> on pregnancy
weight gain removing other effects that might contribute to the significance observed in earlier
analysis# ? ratio for this model was )#@4 at 0#002 significance level# $he /d7usted suare for this
model was #0E( can e!plain the proportion of variation in pregnancy weight gain by ">#
/ssuming "> I as reference; only "> III group shows noticeable variation in mean difference##
?or "> III category tS @#&4, p 0#00% and "I S A#@) to %#@%@B, A$able 4#%%B#
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).+.) "regnancy weight gain category
/s National Nutrition 1rogram targeted the "> mothers to supplement them and monitor
regularly ensuring pregnancy weight gain more than % kg per month for ) months, the researcher
took the opportunity to categori9e the respondents based on their total pregnancy weight gain#$he categories were 6`(( Dg and 6U) Dg# Fn the other hand one of the core ob7ective of NN1
program is weight gain during pregnancy increased U ( kg in &0 3 women# .o this classification
was also used in the upcoming analysis# esearcher was not able to find out relevant literature
regarding classification of weight gain# In one way it was very much realistic to categori9e
weight gain taking (kg cut'off value *as it is the program ob7ective+, on the other hand as all the
samples were mild to severely malnourished and they were studied from @ rdto 4 thmonth of their
conception it was practically reasonable to take )kg as a cut off value *one kg per month+#
>able ).12 upplementation status among pregnancy weight gain categories
Cutoff le!el / kg E@H+/+F
$able shows significant relationship between weight gain categories and food supplementation
status when all the categories were included in the analysis# 2H %0#4, dfS4, p S 0#0@4, A$able
4#%2B#
/lmost all the Dapasia good supplemented group gained U ) Dg e!cept two# $he table shows as
the duration of supplementation increased the proportion of 6adeuate weight gain 6status
increased steadily along'with but this variation is statistically significant at #0& level as savar
)@
"regnancy weight gain
upplementation status O / kg P / kg
2 "!alue
@H11/ @H ))able ).1) C:7 among pregnancy weight gain categoriesQ Cut off / kg
E@H+/+F
$able shows no significant association between "> status and pregnancy weight gain
categories, *pS 0#2)+, A$able 4#%4B#
>able ).1+ C:7 among pregnancy weight gain categoriesQ Cut off < kg
E@H+/+F
$able shows a little more than one fifth of the samples managed themselves to gain weight U(kg#
$he less malnourished group 9D + ;gained lesser weight and the severe malnourished group
gained better weight proportionally #* 2S22#0, pS 0#00%+, A$able 4#%&B#
)&
"regnancy weight gain category
C:7 ( kg *NS40@+ U(kg *NS%)2+ 2 "!alue
n N n N
9D + %(0 4#% 42 2(O=.==19D ++ %&0 @#2 E0 4(#4 22#0
9D +++ )@ %) 40 24#
"regnancy weight gain categoryC:7 ) kg *NS%%)+ U )kg *NS44(+ 2 "!alue
n N n N
9D + && 4#4 % @(#40#2)'ns9D ++ 44 @#( %E) 4%#4 2#@
9D +++ % %4# E) %(#2
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))
>able ).1/ :ffect of food supplementation on pregnancy weight gain
category ad,usting C:7 le!el among the sample mothersE@H+/+Food supplementation
2 p!alue #9
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)
>able ).14 :ffect of C:7 on pregnancy weight gain category ad,usting food
supplementation status E@H+/+'assuming status and pregnancy
weight gain ad7usting the food supplementation status of the mothers# $he model correctly classify
()#E3 less weight gained mothers and only %%#% 3 better weight gained mothers ,the overall
classification were 2 3 correct # -osmer 8emeshow goodness'of'fit test were applied which was not
significant A2 @#&(, dfS,ns B and "I for standardi9ed regression co'efficient were noted#
/fter removing the effect of food supplementation status and assuming "> I as reference group; the
variables in the euation showed pregnancy weight gain had significant relationship with "> II A 2 H
%2#%,0#00%B and "> III categories#A 2
H%)#)0,0#00%B# A?or "> II, FS2#& and "> III,
FS@#EB# "> II and "> III mothers were 2 to 4 times more likely to gain adeuate pregnancy
weight considering effect of food supplementation# A$able 4#%B
esearcher was interested to find out the effect of "> within Dapasia samples and the data were
analy9ed accordingly# $he results showed even after e!clusion of .avar group, the level of significance
remained same with a slight increment,A$able shown belowB #
>able ).14.1 9e!iew analysis e?cluding a!ar samplesE@H)3
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"regnancy weight gain in different chronic energy defficient categories
C:7 I EP14 BDIF
igure 4.1
5raph shows the effect of supplementation on pregnancy weight gain in ">I category# $he
variation in weight gain pattern is not significant regarding supplementation pattern#
)E
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"regnancy weight gain in different chronic energy defficient categories
C:7 II E1/1/.
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"regnancy weight gain in different chronic energy defficient categories
C:7 III ES 1+.# A58M# repeated measureB# 5ood supplementation enhanced ma!imum
weight gain in "> III mothers with respect to other supplementation status, A?igure'#@B#
0
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)./ Birth weight
4./.1 7istribution of birth weight among the newborn
igure6
$he histogram with normal curve shows birth weight varies from %&00 grams to 4000 grams#
$he ma!imum freuency is observed around 2&00 gm and also a lesser pick in freuency is
noticeable at @000 gram, A?igure EB#
%
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>able ).16 7istribution of birth weight among supplement categories
$able shows the average birth weight of .avar group is significantly different from all the other
groups of Dapasia# $he mean birth weight of .avar category Mean *R. + 240R@))#0@ were
lower than the cut'off value of 8ow birth weight# *? %0#)4, p S0#00%+, A$able 4#%EB#
$he researcher e!cluded .avar category from the analysis and found no significant difference in
birth weight among the Dapasia categories# $he mean *R.+ birthweight for Dapasia non'
supplemented group 220#%E*R@)E#)@+ grams and in Dapasia good supplemented group it was
2&2#(4 *R@44#E)+ grams# *? S2#0, pS0#%%, ns+, A$able 4#%EB, Atable not shownB#
>able ).1< 7istribution of birth weight among supplement categories in
5apasia E@H+/+F
/ little less than half of the poor supplemented group delivered low birth weight baby whereas
almost all of the good supplemented mothers delivered normal weight babies e!cept five# $he
researcher noticed birth weight increases steadily as the duration of supplementation increased ,
A$able 4#%(B#
2
Birthwt in
grams.
upplement Category5apasia
2 p!alue@o
@H226
"oor
@H112
Doderate
@H/+
8de%uate
@H3)
n N n N n N n N
6!00 @ %)#2 @2 2E#) %2 %E#& & %4#044!00 %(% E@#E E0 %#4 &@ E%#& 2( E@ #(4
Dean M7 220#%ER@)E#)@
2)2)#2%R@E%#
2)E@#0ER@2@#E@
2&2#(4R@44#E)
2#0^ N.
^? ratio for one way analysis of variance
upplementation
category
Birth weight p!alue
@ DeanM7 Din Da?
"o supplement 22E 220#%E R@)E#)@ %&00 @E00,oor supplement %%2 2)2)#2% R@E%# %&00 @&00*oderate supplement )& 2)E@#0E R@2@#E@ 2000 4000 %0#)4 0#00%Good supplement @4 2&2#(4 R@44#E) %(00 @400avar no supplementation %2) 240#44R@))#0@ %00 @&00
? ratio for one way /NFO/
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)./.2 Birth weight at different le!el of C:7
irth weight status improved with the "> status in contrast to pregnancy weight gain which
was inversely related to "> categories# $he severely undernourished group delivered babies
with mean *R .+weight of 2&&4#@ R @)2#(@ grams and the mild under'nutrition mothers gave
birth of better weighted child# $he variation of mean among the groups were significant at *0 #02
level, ?S @#(2+, A$able 4#20B#
>able ).2= 8!erage birth weight in chronic energy deficient categories
@
C:7 Birth weight p!alue
@ DeanMsd Din Da?
9D + 2@2 2)E#%@ @(%E %&00 @E00
9D ++ 2@0 2)4E#)@ R@&E#)@ %&00 @&00 @#(2^ #029D +++ %0@ 2&&4#@R @)2#(@ %&00 4000^? ratio for one way analysis of variance
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)./.3 upplementation status at Birth weightcategory
$able shows there is significant variation in birth weight category between supplemented and
good supplemented respondents when 2test was done #* 2 S #(4 , pS 0#0& + e!cluding .avar
group# ?or all categories the association of supplementation and birth weight became more
evident, *2valueS &0#EE, dfS@, pS 0#00%+, A$able 4#2%B#
>able ).21 upplementation status at Birth weight categories
)./.) 7istribution of C:7 status among birthweight categories
>able ).22 Chronic energy deficiency in birth weight categories
$able shows the proportion of low birth weight varies with various level of "hronic >nergy
eficiency status# More than one third of the ">III mothers delivered low birth weight child
even though most of them were supplemented# $he variation is statistically significant with a 2
value of E#)E at #0%@ level,A$able 4#22B#
4
Birth weight category
C:7 Low O2+== @ormal P2+== 2 "!alue
NS%4E NS 4%
n N n N
9D + &4 @)#& %E 42##0%29D ++ && @#2 %& 42 E#(
9D +++ @( 2)#4 )4 %@
Birth weight
upplementation status O !00 gms P !00 gms
2 "!alue
@H11/ @H ))able ).2+ :ffect of food supplementation on birth weight ad,usting se? of the
newborn and C:7 categories'E@H+/+F
Supplementation Beta t "
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E
>able ).2/ :ffect of food supplementation on birth weight category after
ad,usting for se? of the child C:7 le!el among the sample mothers' E@H+/+F
ood supplementation
2 p!alue #9
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>able ).24 Birth weight status among pregnancy weight gain categories
irth weight increased with the increment of the pregnancy weight gain# .ignificant relationship
was found between the pregnancy weight gain and birth weight of the newborn#2 value was
%2#0( , p S #00%+, A$able 4#2B#
(
1regnancy weight gain irth weight F (&3 "I
2 1 value
2&00gm U2&00gm (kg %22 E2#4 2E% )#4 2#2 %#42 to @#)4 %2#0( #00%U (kg 2) %#) %@) @2#)
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E0
>able ).26 :ffect of pregnancy weight gain on birthweight categories after
ad,usting se? of the baby' food supplementation and C:7 status' E@H+/+F
"regnancy weight gain
2 p!alue #9 status of the mothers#
$he model was ) 3 correctly classified# -osmer 8emeshow goodness'of'fit test were applied
which was not significant A2 &&4, dfSE,ns B and "I for standardi9ed regression co'efficient were
noted#
/fter removing the effect of se! of the baby, food supplementation and "> status of the mothers
/ssuming (kg pregnancy weight gain as reference group; the variables in the euation showed
birth weight had significant relationship with pregnancy weight gain A 2 H )&,pS 0#0%B # A?or U
(kg weight gain FS %#E(B# .o the better pregnancy weight gained category was about 2 times less
likely to deliver low birth weight baby, A$able 4#2EB#
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E%
>able ).26.1 :ffect of pregnancy weight gain on birthweight after ad,usting se? of
the baby' food supplementation and C:7 status of the sample mothers(E@H+/+F
"regnancy weight gain B t "
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+ 7iscussions
/n operational research with two sample sites was carried out in two different up9ilas to e!plore
the effects of food supplementation program by comparing the pregnancy weight gain P birth
weight of the newborn between food supplemented P non'supplemented mothers of those areas#
$his study assessed the effects of pregnancy interventions in nutrition pro7ect, recogni9ing the
importance more generally of using pro7ect'based data in assessing the effectiveness of
interventions# 5iven the recent inclusion of pregnancy related ob7ectives in large'scale
operational pro7ects and the minimal amount of impact data actually collected in such pro7ects in
the past, some attempt to assess the effects of NN1 appears crucial# "learly, the most valuable
data for such purposes would be that from evaluative studies, comparing baseline and mid'point
or end'point data in the pro7ect and control areas#
$his record'based study was carried out in Dapasia and .avar upa9ila to e!plore the effect of
targeted food supplementation by comparing the pregnancy weight gain and birth weight# ata
on %%(@ samples *)&E from .avar and &@& fr