How much Antenatal Supplemental Iron is Required to Preserve Maternal Iron Status? The MINIMat Intervention trial in Bangladesh.

Objectives: To prevent iron deficiency in pregnancy universal iron folic acid supplementation is recommended by WHO. We aimed to compare the effect of multiple micronutrients supplements with two different dosages of iron/folic acid supplements on maternal iron status. Methods: In the MINIMat intervention trial in Bangladesh, pregnant women were randomized into three micronutrient supplementation groups: 30 mg iron/400 ugfolic acid (Fe30 F), 60 mg iron/400 ugfolic acid (Fe 60 F) and multiple micronutrients +30 mg iron/400 ugfolic acid (MM). Adherence was electronically monitored by use of eDEM-pillbottles. Plasma-ferritin (p-Ft) was assessed at start of supplementation (week 14) and at week 30 at gestation in random subset. Intent to treat and multivariate regression analyses were performed (n=561). Results: Iron deficiency (ID) was 7% at start of supplementation. At wk 30 ID was 29% and mean p-Ft 20.0 ug/L with no differences according to supplementation type. Within each type there was a significant dose-effect per capsule on p-Ft that did not differ between types when amount of iron in the supplements was taken into consideration. There was no further dose-effect on p-Ft of iron intake exceeding 4 g. Using lowest tertile of iron intake as reference, middle and highest intake tertile increased p-Ft and showed a protective effect on ID at wk30 but did not differ between each other. Conclusions: Despite no further effect on p-Ft of higher iron intake than 4 g, ID developed to become prevalent at wk 30 suggesting that iron intake exceeding 4 g contributes to limited extent to reduce ID in pregnancy. Supplement with multiple micronutrients did not provide any additional effect.

Coverage of Vitamin A Supplementation and Role of Community Health Days as Delivery Mechanism: A Community-based Survey in Southern Ethiopia.

Objectives: To evaluate coverage of Vitamin A Supplementation (VAS) and the contribution of Community Health Days (CHD) in its distribution. Methods: A population based survey was conducted in August to December 2011. All children 6 to 59 months old (n=4258) in randomly selected households were included in this study. Caregivers were shown vitamin A capsules and asked for each child whether they had received a supplement and whether if they had participated in CHD that took place in June 2011. Results: The overall VAS coverage was 43.8%, where 88% of all VAS delivered was through CHD. Half (51%) of the eligible children did not participated in CHD hence did not received VAS. Association between VAS reception and child sex, age and nutritional status was analysed. Children who were acutely malnourished (52.3% wasted versus 43.3% normal P<0.01 and 50.0% underweight versus 41.6% normal P<0.000) were more likely to receive VAS. Conclusions: VAS coverage was low. Most of the distributed VASs were delivered at CHDs but attendance at CHD was poor. Improving coverage of CHD appears as a valuable way to improve coverage of VAS.

Anemia Varies with Season and is not Related to Iron Deficiency in Pre-school Children in Rural Bangladesh.

Objectives: To examine the prevalence of anemia, iron deficiency and iron deficiency anemia in pre-school children and potential seasonal variations. Methods: As part of a community-based trial in rural Bangladesh (the MINIMat-trial) children were assessed for hemoglobin and ferritin concentrations at 4.5 years. Season of blood collection were divided into 2 months categories starting with cool-and-dry season (15 Dec-14 Feb), followed by mild-temperature, hot-and-dry, monsoon-rains, hot-and-humid, and main-harvest season. We used logistic regression for associations between anemia and iron deficiency and chi-square test for seasonal differences. Results: Anemia was found in 7% of the children. Iron deficiency was low, only 3%, and consequently iron deficiency anemia was found in less than 1%. Iron deficiency was not associated with anemia, either in crude or adjusted analyses (SES, maternal education, height). Anemia varied significantly with season (p < 0.001) with the lowest prevalence found in the hot-and-humid season (4%) while anemia prevalence was about threefold in the hot-and-dry season (13%). Iron deficiency did not vary with season. Conclusions: In pre-school children in rural Bangladesh, anemia was relatively uncommon found in less than 10% of the children. A potential reason may be a relatively high iron content of drinking groundwater. The observed anemia was not associated with iron deficiency indicating the importance of other determinants. We found seasonal variations in anemia prevalence suggesting seasonal differences in diet, infections etc. as potential mechanisms in developing anemia. This also illustrates the risk of over- or under-estimating anemia if data are collected in a limited time period.

Arsenic exposure in pregnancy: a population-based study in Matlab, Bangladesh.

This study assessed the exposure of pregnant women to arsenic in Matlab, Bangladesh, an area with highly-elevated concentrations of arsenic in tubewells, by measuring concentrations of arsenic in urine. In a defined administrative area, all new pregnancies were identified by urine test in gestational week 6-8, and women were asked to participate in the assessment of arsenic exposure. Urine for analysis of arsenic was collected immediately and in gestational week 30. In total, 3,426 pregnant women provided urine samples during January 2002-March 2003. There was a considerable variation in urinary concentrations of arsenic (total range 1-1,470 microg/L, adjusted to specific gravity 1.012 g/mL), with an overall median concentration of 80 microg/L (25th and 75th percentiles were 37 and 208 microg/L respectively). Similar concentrations were found in gestational week 30, indicating no trend of decreasing exposure, despite the initiation of mitigation activities in the area. Arsenic exposure was negatively associated with socioeconomic classes and achieved educational level. There were marked geographical variations in exposure. The results emphasize the urgent need for efficient mitigation activities and investigations of arsenic-related reproductive effects.

Do side-effects reduce compliance to iron supplementation? A study of daily- and weekly-dose regimens in pregnancy.

Side-effects of iron supplementation lead to poor compliance. A weekly-dose schedule of iron supplementation rather than a daily-dose regimen has been suggested to produce fewer side-effects, thereby achieving a higher compliance. This study compared side-effects of iron supplementation and their impact on compliance among pregnant women in Bangladesh. These women were assigned to receive either weekly doses of 2 x 60 mg iron (one tablet each Friday morning and evening) or a daily dose of 1 x 60 mg iron. Fifty antenatal care centres were randomly assigned to prescribe either a weekly- or a daily-supplementation regimen (86 women in each group). Side-effects were assessed by recall after one month of supplementation and used for predicting compliance in the second and third months of supplementation. Compliance was monitored using a pill bottle equipped with an electronic counting device that recorded date and time whenever the pill bottle was opened. Of five gastrointestinal side-effects (heartburn, nausea, vomiting, diarrhoea, or constipation) assessed, vomiting occurred more frequently in the weekly group (21%) than in the daily group (11%, p<0.05). Compliance (ratio between observed and recommended tablet intake) was significantly higher in the weekly-supplementation regimen (93%) than in the daily-supplementation regimen (61%, p<0.05). Overall, gastrointestinal side-effects were not significantly associated with compliance. However, the presence of nausea and/or vomiting reduced compliance in both the regimens-but only among women from the lower socioeconomic group. In conclusion, weekly supplementation of iron in pregnancy had a higher compliance compared to daily supplementation of iron despite a higher frequency of side-effects. The findings support the view that gastrointestinal side-effects generally have a limited influence on compliance, at least in the dose ranges studied. Efforts to further reduce side-effects of iron supplementation may not be a successful strategy for improving compliance and effectiveness of antenatal iron supplementation.