Targeted food supplementation and its effect on birth-weight and pregnancy weight gain

8/12/2019 Targeted food supplementation and its effect on birth-weight and pregnancy weight gain

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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#


29/103

/ 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#


30/103

$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#


31/103

$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

@%


32/103

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


33/103

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

@@


34/103

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


35/103

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+#

@&


36/103

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#&


37/103

/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,


38/103

).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


39/103

>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/


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


40/103

).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/


41/103

).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


42/103

).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


43/103

>able ).+ 7eli!ery related !ariables among the study samples E@H+/+F

4@

7eli!ery characteristics

ample category

_2 p !aluea!ar

@ H 12/


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 @& %)#)


44/103

).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


45/103

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/


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


46/103

.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)


47/103

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


48/103

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


49/103

).).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


50/103


51/103

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#

&%


52/103

>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


53/103

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


54/103

igure+.2


55/103

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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&)


57/103

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


59/103

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


62/103

)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


66/103

))

>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


67/103

)

>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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C:7 II E1/1/.


70/103


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


71/103

)./ 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#

%


72/103

>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/


73/103

)./.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


74/103

)./.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 "


78/103

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


79/103

>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#)


80/103

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#


81/103

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 "


82/103

+ 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

Documents

Targeted food supplementation and its effect on birth-weight and pregnancy weight gain