Preventing intrauterine growth restriction and improving infant growth outcomes in Bangladesh

Stevens, Briony Jayne (2017) Preventing intrauterine growth restriction and improving infant growth outcomes in Bangladesh. Professional Doctorate (Research) thesis, James Cook University.

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Background Insufficient food intake during pregnancy is a major problem in many developing countries. The pregnancy period presents a key phase for ensuring the survival, growth and development of the offspring. When pregnant women are undernourished, extra food during pregnancy can improve birth outcomes and has the potential to improve the nutritional status of pregnant women. Bangladesh has among the highest rates of maternal and child undernutrition globally. Despite some improvement in maternal and child nutrition status, the World Health Organisation considers stunting and wasting rates high in terms of severity. While a number of studies have considered food-based supplements using locally available and preferred foods, evidence for effective community-based approaches for the treatment of maternal acute malnutrition is limited, particularly among rural population groups.

Objectives The aim of this research was to develop an effective locally produced food-based supplement for undernourished pregnant women that prevents low birth weight (LBW). The research has a focus on undernourished pregnant women living in northern Bangladesh, a rural context. Bangladesh was selected due to continued high levels of maternal and child undernutrition. Consequently there is a public health imperative to address maternal and child undernutrition, and for new knowledge in this area to inform practice and policy. The overarching research question was: can locally produced foodbased supplementation reduce LBW and improve infant growth outcomes when consumed by undernourished pregnant women?

Methods This research was conducted in northern Bangladesh from 2013 until 2015. A multiphase design was used, while ensuring commitment to local-level applied research. This thesis comprises three phases and six sub-studies, encompassing six manuscripts (five published, and one under review). Phase 1 consists of four sub-studies. Study 1 was a systematic review of the effect of balanced protein energy supplementation in undernourished pregnant women from low- and middle- income countries on child growth. Study 2 was a modified Photovoice study designed to explore perceptions on maternal diet of undernourished pregnant women in northern Bangladesh. Women were trained in Photovoice, and equipped with a digital camera. Photographs were used to evoke a narrative through an in-depth interview process. Reflexive, thematic analysis was used. In Study 3, undernourished pregnant women in northern Bangladesh completed a questionnaire to identify women's dietary diversity (women's dietary diversity questionnaire) and household food security (an adaptation of the Household Food Insecurity Access Scale [HFIAS]). In Study 4, all pregnant women from targeted villages in northern Bangladesh were invited to participate in a survey to investigate the role of seasonality on maternal diet and household food security. Women were recruited over a two-year period, thus taking into consideration seasonal variances across the year. Phase 2 was designed to assess the acceptability of a dietary supplement in undernourished pregnant women in Northern Bangladesh via a 30-day acceptability study (Study 5). An assessment and focus group at day 15 allowed for modifications to the initial supplement, and then a further assessment at day 30 allowed for testing acceptance of these modifications. The supplement developed in this study was used in Study 6. Phase 3 (Study 6) was a cluster randomised controlled trial of undernourished pregnant women in Northern Bangladesh that was conducted to identify whether a locally produced prenatal food-based supplement improved anthropometric measures at birth and during early infancy. The intervention group received a locally produced balanced protein energy supplement (designed in Study 5). Intervention and control groups received basic nutrition education, antenatal and postnatal services.

Results Phase 1 Study 1: The systematic review revealed that balanced protein energy supplementation significantly improved birth weight in babies of undernourished pregnant women from low and middle income countries. No significant benefit was observed on birth length or head circumference. The impact of intervention could not be determined for longer-term physical growth due to limited evidence. Additional research is required in low- and middle-income countries to identify impacts on longer-term infant growth.

Study 2: Eight major themes emerged from the Photovoice study: everyday foods consumed during pregnancy; liked foods influence on dietary consumption; household food production influences on dietary consumption; household food production providing both sustenance and income; need for a cash income in a subsistence community; family structure influences on dietary intake; understanding that nutrition is important though not sure why; and support provided by non-governmental organisations. Study findings complemented the information obtained from Studies 1, 3 and 4, to better inform Studies 5 and 6.

Study 3: Half of the households in this survey were identified as food insecure, and two-thirds of women had inadequate dietary diversity, which may contribute to the burden of undernutrition and micronutrient deficiencies. The results of this study helped identify foods typically consumed by pregnant women, and informed the design of the supplement developed, tested and evaluated in Studies 5 and 6.

Study 4: The results of this study showed that seasonality was significantly associated with maternal dietary diversity and household food security. However, no significant differences in maternal nutrition status based on season were observed. The results of this study informed the design of the supplement used in Study 6, and supported the need for a locally developed food-based supplement in order to lessen the shock of lean seasons on household food security and maternal dietary diversity.

Phase 2 Study 5: A small business enterprise consisting of women from the targeted villages was established and women were trained to develop a balanced protein energy supplement using locally available, affordable and preferred foods as identified in Studies 2 and 3. The supplement developed in this study was used in Study 6. The establishment of a local business enterprise to produce the supplement built on local capacity and provided an income generation opportunity to the community.

Phase 3 Study 6: A randomised controlled trial of undernourished pregnant women revealed that a locally produced prenatal food-based supplement improved mid-upper arm circumference in early infancy. Thus, the proportion of wasting was lower in infants of supplemented mothers. Further, the supplement improved birth weight. While not significant, this was likely due to the sample size (type 2 error). The intervention reduced the risk of wasting at 6 months by 63.38%, and of LBW by 88·58%. Only three pregnant women require this intervention in order to prevent wasting at 6 months in one child, and seven need the intervention to prevent LBW of one child.

Conclusion Bangladeshi pregnant women and children are urgently in need of sustainable community-led approaches to addressing undernutrition. This research has explored a new approach to addressing undernutrition through the development of a locally produced food-based supplement. Findings from this research have the potential to influence practice and policy in Bangladesh. Program decision-makers have cheaper and more sustainable alternatives for the treatment of maternal acute malnutrition rather than using imported ready-to-use foods. Further research is required to confirm whether the approach presented in this thesis can be applied in other country contexts.

Item ID: 53005
Item Type: Thesis (Professional Doctorate (Research))
Keywords: Bangladesh; child growth; developing countries; dietary supplements; food supplements; infant growth; low birth weight; low birthweight; low-income countries; pregnancy; prenatal nutrition; supplementation; underdeveloped countries; undernourished mothers; undernutrition
Date Deposited: 29 Mar 2018 04:47
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111716 Preventive Medicine @ 50%
11 MEDICAL AND HEALTH SCIENCES > 1114 Paediatrics and Reproductive Medicine > 111403 Paediatrics @ 50%
SEO Codes: 92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920411 Nutrition @ 50%
92 HEALTH > 9205 Specific Population Health (excl. Indigenous Health) > 920501 Child Health @ 25%
92 HEALTH > 9202 Health and Support Services > 920204 Evaluation of Health Outcomes @ 25%
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