Global Maternal and Infant Health Flashcards
pregnancy in developing countries
The risk of mortality (maternal, neonatal and under-five) are much greater than for developed countries
* often give birth successfully at home without skilled care
* majority have babies that survive beyond five years of life
Mortality of live births
- Developed countries: 14 per 100,000 live births
- developing countries: 290 per 100,000 live births; 580 in least developed up to 1,400 in some
Maternal mortality
~350,000 women each year from complications related to pregnancy or childbirth
* Infants of mothers who died giving birth are much more likely to die
* true number may be higher
Causes of maternal mortality
- complications during delivery a direct cause
- Anemia a major indirect cause
- malaria and HIV
What are some complications during delivery that can result in maternal death
- hemorrhage
- infections
- prolonged/obstructed labor
Prevalance of anemia leading to maternal mortality
50-60% of women enter pregnancy with iron deficient anemia
* increases risk of mortality from blood loss
What is considered neonatal mortality?
mortality in the first 28 days of life
prevalance of neonatal mortality
- Developed Countries: 3 per 1,000 live births
- Developing Countries: 25 per 1,000 live births; 34 in least developed countries
What is neonatal mortality linked to?
maternal health
direct causes of neonatal mortality
- infections (pneumonia, tetanus, diarrhea)
- asphyxia
- pre-maturity
indirect causes of neonatal mortality
low birth weight due to prematurity or decreased intra-uterine growth
* maternal undernutrition primary reason for low birthweight
Under 5 mortality
8.7.6M children under 5 years of age died in 2010 (98.7% in developing countries)
* 35-50% under-five deaths accounted for by nutrition related factors
* includes neonatal mortality (~40%)
What are nutrition related factors leading to mortality (under 5?)
- Reduction in intrauterine growth
- Wasting and stunting
- Vitamin A, zinc, iron, iodine deficiencies
- Suboptimal breastfeeding
What causes reduction in intrauterine growth?
Maternal undernutrition
* before and/or during pregnancy
* reduced nutrient stores and availability
* results in low birthweight and inadequate infant nutrient stores
What is wasting?
Acute undernutrition
Assessment of wasting on growth chart
- Weight for length using WHO Growth Standards
- Mid-upper arm circumference below 115mm
- Bilateral edema: venous return insufficiency
Values for wasting with the weight for length using WHO growth standards
Based on z score, a standard deviation score: how different from average
* moderate if z score less than -2
* severe if z score less than -3
What does the WHO growth standards evaluate?
Charts birth to 5 years of age using percentiles and z scores
* Weight for age
* length/height for age
* weight for length (birth-2yrs)
* body mass index for age
* Head and arm circumference for age
* subscapular and tricep skinfolds for age
Severe acute undernutrition disseases
- Marasmus
- Kwashiorkor
Marasmus
- “skin and bones”
- inadequate energy and protein intake
- low weight for age and weight for length (height)
kwashiorkor
- edema - interpretation of weight
- inadequate protein
- “first second” - early weaning from breastmilk to poor protein quality foods
Chronic undernutrition disease
Stunting
* Length (height) and weight for age: moderate if z score less than -2; severe if z score less than -3
* Although less mortality than with wasting, can irreversibly impair early childhood growth and development
What is the vicious cycle of undernutrition?
Importance of exclusive breasfeeding for first 6 months
- protection from respiratory and gastrointestinal infections
- a very important preventive intervention against early childhood mortality
under-5 mortality without exclusive breasfeeding
accounts for ~15% of under-five mortality
What is sub-optimal breastfeeding
Not exclusively breastfeeding for first six months
* predominant breastfeeding - water and teas consumed by infant
* partial breastfeeding – other liquids and solids consumed by infant
* no breastfeeding
common breastfeeding practices in developing countries
- early mixed feeding (predominant or partial breastfeeding)
- some breastfeeding usually to 2 years of age or older
- no breastfeeding at all (less common)
- use of formula (less common)
sub-optimal breastfeeding compared to exclusive breast feeding
- increases the incidence and death from diarrhea
- increases all-cause mortality
What nutrition interventions have the potential to reduce deaths of children <5?
- Folic acid
- Iron
- Maternal multiple micronutrient
- Calcium
- Iodine
folic acid supplementation prior to conception
Prior to conception may decrease the risk of development of neural tube defects by 72%
* Linked to improved mean birthweight and reduction in the incidence of megaloblastic aneamia (infant)
What is a better way to meet folic acid supplementation in developing countries?
Fortification of foods, such as grains and cereals, is suggested as a more feasible way to reach women on a population level
result of materal iron deficiency
- decreased tolerance to blood loss
- decreased work productivity
- low infant birthweight, low infant iron stores
result of infant iron deficiency?
- delayed physical and cognitive development
- increased morbidity
prevalance of iron deficiency
Most prevalent nutrient deficiency worldwide (~30% of total population) but more prevalent in developing countries.
why is iron deficiency more prevalent in developing countries?
- low availability of dietary sources of iron
- increased iron losses
- less time between pregnancies
potential benefit of iron supplementation for women
Intermittent iron supplementation among women of reproductive age may reduce anemia
potential benefit of iron supplementation during pregnancy
Daily supplementation linked to reduction in:
* Anemia at term
* Iron Deficiency
* Iron Deficiency Anemia (IDA)
* Low birthweight
result of iron deficiency and cognitive development
Lower scores on physical and mental score and evaluations in infants with iron deficiency at birth even with correction of iron deficiency in infancy
* long term consequences
What is MMN supplementation?
Maternal Multiple Micronutrient Supplementation which have been reported to reduce low birthweight and Small for Gestational Age (SGA) births
* More than one micronutrient deficiency often coexists among women in low- and middle- income countries
Benefit of calcium supplementation
Supplementation during pregnancy, and among women at-risk of low calcium intake, has been shown to reduce hypertensive disorders (e.g., gestation hypertension and pre-eclampsia) and preterm birth
* 52% reduction in incidence of pre-eclampsia with calcium supplementation in populations at risk of low calcium intake
Importance of iodine during pregnancy
- Essential component of hormones produced by the thyroid gland essential for proper development of the CNS, normal metabolism and fetal neurodevelopment
Why do requirements of iodine increase during pregnancy?
↑ Iodine requirements in pregnancy due to
* ↑ Thyroxine (T4) production and transfer in the first trimester
* ↑ transfer to the fetus in later gestation
Result of iodine deficiency during pregnancy
- neorological cretinism
- myxoedemtous
Benefit of iodine supplementation
- Iodine supplementation (oil) reduced the prevalence of cretinism in areas of severe iodine deficiency
- Iodine supplementation during pregnancy has been linked to increased IQ and psychomotor scores in children at 4 and 10 years of age
Effective way to get iodine
Universal salt iodization is an effective way to improve iodine status for women of reproductive age but governmental policies are needed to enforce adequate salt iodization and education on the importance iodized salt
* Cost of salt iodization is $0.02 - $0.05 per child yearly
Importance of vitamin A and zinc?
Both required for immune function
* maintain integrity of mucosal lining and function of immune cells
Why might deficiency in vitamin A and zinc be common?
- rich sources are animal products which not everyone has access too
- fruits and vegetables high in vitamin A usually require more water which may not have access to adequate water supply
Severe zinc deficiency
nutritional dwarfism
* growth retardation
* delayed sexual development
* increased rate of infections & anemia (hemolytic)
marginal zinc deficiency
- ↓ taste & appetite, acne-like rash, hair loss, reduced ability to digest and absorb food, diarrhea, poor wound healing
- ↓ learning ability
WHO guidelines for breastfeeding with maternal HIV
Exclusive breastfeeding for first 6 months with mother receiving antiretroviral treatment
* Formula only recommended if acceptable, feasible, affordable, sustainable and safe
What increases risk of HIV transmission through breastmilk?
- lower maternal CD4 counts
- poor maternal nutritional status
- breast conditions
- oral thrush in infants
- mixed feeding as opposed to exclusive breastfeeding in first six months
Why would exclusive breastfeeding lower HIV transmission compared to mixed feeding?
Antigens in non-breast milk are thought to cause inflammation in the infant gut, making it more vulnerable to HIV infection
Provision of nutrients to restore deficits improve outcomes for
- mothers
- infants
- children
