A six-year study of nearly 100,000 women in Botswana has provided new evidence that relatively inexpensive daily dietary supplementation of iron, folic acid and vitamins during pregnancy can reduce birth complications. Researchers have found that iron and folic acid supplementation (IFAS), as well as iron and folic acid plus essential vitamins and trace minerals (multiple micronutrient supplementation, or MMS), are associated with increased levels significantly lower of babies born with low birth weight and other birth complications, compared to iron or folic acid alone. For example, the birth rate with low birth weight was less than 10.5% for women supplementing their diets with multiple micronutrients, the lowest rate of all comparison groups.
Published in Lancet Global Health, the study was led by Ellen Caniglia, ScD, assistant professor of epidemiology in the Department of Biostatistics, Epidemiology, and Informatics at the University of Pennsylvania’s Perelman School of Medicine, along with by researchers from Botswana -Harvard AIDS Institute Partnership and Harvard TH Chan School of Public Health. The results represent broad and real confirmation of the results of previous clinical trials. The study, the largest ever of its kind, also included a substantial cohort of HIV-positive pregnant women and found that IFAS and MMS appeared to have even greater benefits in this group.
“Our results support the current World Health Organization recommendation that pregnant women should take daily iron and folic acid supplements, but also provide compelling evidence that multiple micronutrient supplementation has other benefits. compared to IFAS,” Caniglia said.
About 15-20% of children born each year worldwide have low birth weight, defined as birth weight of less than 2.5 kg. Commonly occurring in preterm birth, low birth weight is associated with significantly increased risks of childhood illnesses and death, as well as illnesses later in life, such as diabetes and cardiovascular disease. The highest rates of low birth weight births occur in South Asia and sub-Saharan Africa.
To help reduce the rate of babies born with low birth weight and complications associated with birth, the World Health Organization (WHO) recommends daily IFAS throughout pregnancy, in all settings. , based on substantial clinical evidence. There is also evidence from clinical trials that daily prenatal MMS, which includes iron and folic acid plus vitamins (A, C, D, E, B1, B2, B3, B6, B12) and minerals /metals (iodine, selenium, zinc, copper), may be higher than IFAS.
However, there has been a need for more evidence on the benefits of MMS, particularly with respect to IFAS, in real-world settings and in high-risk women such as women living with HIV. The new study provides evidence that the approach can help.
Caniglia and colleagues looked at supplement use and birth outcomes among 96,341 women who were seen between 2014 and 2020 at a group of public hospitals in Botswana. The sample of patients studied represents a large proportion of all births in Botswana during the period. Initiation to supplementation was relatively easy to follow in the sample because the pills were prescribed and provided free of charge by participating hospitals. Researchers analyzed how rates of low birth weight and other birth complications, such as preterm or very preterm birth, stillbirth and neonatal death, varied depending on the supplements each woman was started on. take during pregnancy.
Women who started IFAS had significantly lower rates of worst pregnancy outcomes, compared to women who took only iron or folic acid. Rates of births with low birth weight, for example, were 16.92% in the folic acid-only group and 12.70% in the iron-only group, but only 11. 46% in the IFAS group.
Compared to IFAS, women who started using MMS saw significantly lower rates of preterm birth, very preterm birth, low birth weight, very low birth weight, and ‘cesarean delivery. The birth rate with low birth weight, for example, was 10.48% for women on MMS. Similarly, the preterm delivery rate was 12.68% for women taking IFAS and 11.63% for those taking MMS.
HIV infection is exceptionally widespread in Botswana, and almost a quarter of the pregnant women in the study were living with the virus. The analysis revealed that among these women, the differences in adverse event rates between MMS and IFAS, and between IFAS and folic acid or iron alone, were generally greater than those seen in HIV-negative women, suggesting that supplementation has greater benefits for this disease. population.
“We don’t really know why that is – it’s possible that HIV-positive pregnant women are more susceptible to micronutrient deficiency,” Caniglia said.
The data suggests that women over 35 also appear to benefit more from IFAS or MMS, compared to younger women.
While the study shed light on the comparative advantages of prenatal supplements, it also highlighted the problem of supplement shortages or “stock-outs.” Throughout the study period, IFAS was universally recommended by WHO for pregnant women, but more than 43% of women in the study received iron alone, folic acid alone, or no extras at all, apparently due to these stock shortages.
“This highlights the need for new strategies to improve antenatal supplementation coverage among pregnant women,” Caniglia said.
She and her colleagues plan to conduct further studies in Botswana, aimed at understanding barriers to prenatal supplement use and demonstrating the value of these supplements in improving birth outcomes.