The first 500 days of life: policies to support maternal nutrition

Figures & data

Table 1 Feasible evidence-based interventions for improving women's nutrition and birth outcomes in large-scale programs

	Efficacy, based on meta-analyses	Effectiveness of large-scale programs	Applicability
What works during and before pregnancy
To decrease risk of maternal anemia and intrauterine growth restriction (IUGR)/low birth weight (LBW): a) Iron or IFA or b) multiple micronutrient (MMN) supplementation c) Fortification with iron	Moderate quality evidence for impact on maternal anemia (29). MMNs as good as iron–folate for anemia (30), plus increased birth weight (31). Efficacy not assessed.	Examples: Nicaragua (5), Thailand, Vietnam (32). Supplementation considered successful, although worst off especially in rural areas may be missed. Case studies ^a: iron supply and distribution was a major constraint at all levels; acceptability and awareness less so. Fortification of staples: mixed results.	Supplementation is universally applicable – should be early intervention in all populations in low- and middle-income countries (LMICs). Flour fortification can be expanded to more countries.
Balanced protein energy supplementation: to increase birth weight and reduce risks of IUGR/LBW and stillbirth	Moderate/high quality evidence for impact on birth weight, greater in undernourished women (33).	Examples: Tamil Nadu Integrated Nutrition Project; Madagascar (5). Case studies: used when food insecurity exists, such as periodically in Ethiopia; supplements are mandated in India, although coverage varies.	When substantial resources are available; usually targeted; requires considerable logistics.
Iodine fortification of salt (or supplementation in rare cases): to decrease risk of cretinism and improves cognition	High quality evidence for effects on cognitive development (34).	Examples: Thirty-six African countries have over 70% coverage of iodized salt (5). Case studies: in Ethiopia major supply problems, iodized oil capsules for mothers used; Nigeria high coverage; India varying implementation.	Universally applicable – should be implemented in all populations.
Conditional cash transfers: to provide cash, and a platform for education, supplement provision	Efficacy in terms of access to and use of services, nutritional status and health outcomes; may be attributed to cash or other components (35).	CCTs are implemented in an increasing number of countries, Brazil and Mexico as examples. Evidence in Mexico programme for impact on birth weight. Evidence from Brazil on reduction of infant deaths due to undernutrition. See also (36).	Provide much greater resources than other programs relevant to nutrition: when initiated should be built on.
What works before pregnancy
Increasing age at first pregnancy	Moderate quality evidence that young maternal age is risk for low birth weight and preterm birth; also for maternal anemia (37).	Interventions include legislation preventing marriage before 18 years, cash incentives, outreach programs to prevent harmful traditional practices. Effectiveness not reviewed. Case studies: India has legislation and incentives; Ethiopia also has combatting HTP outreach program	Basic intervention in most LMICs – should have legislation and outreach.
Increasing interpregnancy interval (IPI)	Moderate quality evidence that short IPIs are linked with preterm birth, LBW, and early neonatal mortality (38).	Family planning programs, not reviewed by us.	In family planning programs.

^aCase studies: see text.

Imdad A, Bhutta ZA. Routine iron/folate supplementation during pregnancy: effect on maternal anaemia and birth outcomes. Paediatr Perinat Epidemiol. 2012; 26(Suppl 1): 168–77.

 Google Scholar

Bhutta ZA, Imdad A, Ramakrishnan U, Martorell R. Is it time to replace iron folate supplements in pregnancy with multiple micronutrients?. Paediatr Perinat Epidemiol. 2012; 26(Suppl 1): 27–35.

 Google Scholar

Ramakrishnan U, Grant FK, Goldenberg T, Bui V, Imdad A, Bhutta ZA. Effect of multiple micronutrient supplementation on pregnancy and infant outcomes: a systematic review. Paediatr Perinat Epidemiol. 2012; 26(Suppl 1): 153–67.

 Google Scholar

Victora CG, Barros FC, Assuncao MC, Restrepo-Mendez MC, Matijasevich A, Martorell R. Scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues. Food Nutr Bull. 2012; 33(Suppl 2): S6–26. [PubMed Abstract].

 Google Scholar

Mason J, Deitchler M, Mathys E, Winichagoon P, Tuazon MA. Lessons from successful micronutrient programs. Part III: program impact. Food Nutr Bull. 2004; 25: 53–78. [PubMed Abstract].

 Google Scholar

Imdad A, Bhutta ZA. Maternal nutrition and birth outcomes: effect of balanced protein–energy supplementation. Paediatr Perinat Epidemiol. 2012; 26(Suppl 1): 178–90.

 Google Scholar

Zimmermann MB. The effects of iodine deficiency in pregnancy and infancy. Paediatr Perinat Epidemiol. 2012; 26(Suppl 1): 108–17.

 Google Scholar

Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. Cochrane Database Syst Rev. 2009 4 CD008137.

 Google Scholar

Rasella D, Aquino R, Santos CA, Paes-Sousa R, Barreto ML. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities. Lancet. 2013; 382: 57–64.

 Google Scholar

Gibbs CM, Wendt A, Peters S, Hogue CJ. The impact of early age at first childbirth on maternal and infant health. Paediatr Perinat Epidemiol. 2012; 26(Suppl 1): 259–84.

 Google Scholar

Wendt A, Gibbs CM, Peters S, Hogue CJ. Impact of increasing inter-pregnancy interval on maternal and infant health. Paediatr Perinat Epidemiol. 2012; 26(Suppl 1): 239–58.

 Google Scholar