Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries

Megan W Bourassa, Saskia J M Osendarp, Seth Adu-Afarwuah, Saima Ahmed, Clayton Ajello, Gilles Bergeron, Robert Black, Parul Christian, Simon Cousens, Saskia de Pee, Kathryn G Dewey, Shams El Arifeen, Reina Engle-Stone, Alison Fleet, Alison D Gernand, John Hoddinott, Rolf Klemm, Klaus Kraemer, Roland Kupka, Erin McLean, Sophie E Moore, Lynnette M Neufeld, Lars-Åke Persson, Kathleen M Rasmussen, Anuraj H Shankar, Emily Smith, Christopher R Sudfeld, Emorn Udomkesmalee, Stephen A Vosti, Megan W Bourassa, Saskia J M Osendarp, Seth Adu-Afarwuah, Saima Ahmed, Clayton Ajello, Gilles Bergeron, Robert Black, Parul Christian, Simon Cousens, Saskia de Pee, Kathryn G Dewey, Shams El Arifeen, Reina Engle-Stone, Alison Fleet, Alison D Gernand, John Hoddinott, Rolf Klemm, Klaus Kraemer, Roland Kupka, Erin McLean, Sophie E Moore, Lynnette M Neufeld, Lars-Åke Persson, Kathleen M Rasmussen, Anuraj H Shankar, Emily Smith, Christopher R Sudfeld, Emorn Udomkesmalee, Stephen A Vosti

Abstract

Inadequate micronutrient intakes are relatively common in low- and middle-income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost-effectiveness of MMS compared with IFA. Recent meta-analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual-participant data meta-analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost-effective method to reduce the risk of adverse birth outcomes.

Keywords: LMICs; micronutrient; pregnancy; supplements.

© 2019 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals, Inc. on behalf of New York Academy of Sciences.

Figures

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Figure 1
Regional estimates of micronutrient deficiencies and anemia as reported in women of reproductive age. Black circles are not representative (

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Prevalence of anemia (Hb

Figure 2

Prevalence of anemia (Hb

Figure 2
Prevalence of anemia (Hb

Figure 3

Prevalence of anemia (Hb

Figure 3

Prevalence of anemia (Hb

Figure 3
Prevalence of anemia (Hb

Figure 4

Forest plot for the effect…

Figure 4

Forest plot for the effect of MMS versus IFA (with 60 mg of…

Figure 4
Forest plot for the effect of MMS versus IFA (with 60 mg of iron and any dose of folic acid) in the control group on neonatal mortality. This includes all available trials that included a 60 mg iron control group. Reproduced from Sudfeld and Smith.44
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References
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    1. Smith, E.R. , Shankar A.H., Wu L.S.‐F., et al 2017. Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta‐analysis of individual patient data from 17 randomised trials in low‐income and middle‐income countries. Lancet Glob. Health 5: e1090–e1100. - PubMed
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Figure 2
Figure 2
Prevalence of anemia (Hb

Figure 3

Prevalence of anemia (Hb

Figure 3

Prevalence of anemia (Hb

Figure 3
Prevalence of anemia (Hb

Figure 4

Forest plot for the effect…

Figure 4

Forest plot for the effect of MMS versus IFA (with 60 mg of…

Figure 4
Forest plot for the effect of MMS versus IFA (with 60 mg of iron and any dose of folic acid) in the control group on neonatal mortality. This includes all available trials that included a 60 mg iron control group. Reproduced from Sudfeld and Smith.44
Similar articles
Cited by
References
    1. Berti, C. , Gaffey M.F., Bhutta Z.A. & Cetin I.. 2018. Multiple‐micronutrient supplementation: evidence from large‐scale prenatal programmes on coverage, compliance and impact. Matern. Child Nutr. 14(Suppl. 5): e12531. - PMC - PubMed
    1. United States Department of Agriculture . 2019. Pregnancy. Accessed April 24, 2019. https://www.nutrition.gov/subject/life-stages/women/pregnancy.
    1. Keats, E.C. , Haider B.A., Tam E., et al 2019. Multiple‐micronutrient supplementation for women during pregnancy. Cochrane Database Syst. Rev. 3: CD004905. - PMC - PubMed
    1. Smith, E.R. , Shankar A.H., Wu L.S.‐F., et al 2017. Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta‐analysis of individual patient data from 17 randomised trials in low‐income and middle‐income countries. Lancet Glob. Health 5: e1090–e1100. - PubMed
    1. World Health Organization . 2016. World Health Organization recommendations on antenatal care for a positive pregnancy experience. Geneva: WHO.
Show all 68 references
Publication types
Related information
Full text links [x]
[x]
Cite
Copy Download .nbib
Format: AMA APA MLA NLM
Figure 3
Figure 3
Prevalence of anemia (Hb

Figure 4

Forest plot for the effect…

Figure 4

Forest plot for the effect of MMS versus IFA (with 60 mg of…

Figure 4
Forest plot for the effect of MMS versus IFA (with 60 mg of iron and any dose of folic acid) in the control group on neonatal mortality. This includes all available trials that included a 60 mg iron control group. Reproduced from Sudfeld and Smith.44
Figure 4
Figure 4
Forest plot for the effect of MMS versus IFA (with 60 mg of iron and any dose of folic acid) in the control group on neonatal mortality. This includes all available trials that included a 60 mg iron control group. Reproduced from Sudfeld and Smith.44

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