Multivitamin Supplementation and Maternal-fetal Disproportion among HIV-negative Women in Tanzania.

Objectives: We evaluated the effect of multivitamin supplementation on delivery complications that can arise from maternal-fetal disproportion. Methods: We used data from a double-blind, randomized controlled trial among 8286 HIVnegative pregnant women in Dar es Salaam, Tanzania. From August 2001 to July 2004, eligible women were randomly assigned to receive daily multivitamins or placebo between 12 and 27 gestational weeks. All women received prenatal iron and folic acid supplementation. Results: Women in the multivitamin group experienced a 50% higher risk of prolonged labor requiring cesarean section or forceps delivery compared to the women in the placebo group (relative risk 1.52, 95% CI: 1.12-2.07; p=0.007). There was also a non-significant increase in the incidence of vaginal tear (RR-1.11 95% CI 0.99-1.24, p=0.06 ) in the multivitamin group. We found no difference in the risks of need for newborn resuscitation, low APGAR score and signs of fetal distress among the infants born to women receiving multivitamin and placebo. Increases in birth weight and head circumference of the newborn mediated 63% (95% CI- 33- 85%; P <0.0001) of the effect of the multivitamins on prolonged labor. In addition, maternal short stature (height <150 cm) and obesity (BMI≥30) were independently associated with significantly increased risks of prolonged labor. Conclusions: Multivitamin supplementation increased the risk of prolonged labor among HIVnegative pregnant women in Dar es Salaam. However, this risk did not result in any increased adverse fetal outcome. Routine multivitamin supplementation is best integrated in programs that provide emergency obstetric care for women at high risk for prolonged labor.

Clinic-based Assessment of Folate Levels for Women of Reproductive Age, as an Impact Indicator for a National Food Fortification Program in Tanzania.

Objectives: To determine prevalence of folate deficiency and effectiveness of the National Food Fortification Program on folate levels among women of reproductive age in Tanzania. Methods: A Prospective cohort study comparing participants’ folate levels prior and gradually upon the roll-out and scale-up of the national food fortification program. A total of 636 women of reproductive age (18-49 years) enrolled and undergoing follow-up across 10 primary health facilities in Dar Es Salaam. Blood samples, food frequency, and fortified food consumption data collected at baseline (prior the program roll out), 6, 9 and 12 months. Serum folate assays performed using e411Cobas machine and results merged with food frequency and intake data. Results: We present baseline and follow-up data, estimating pre & fortification era folate levels for women of reproductive age in Tanzania. More than 25% of women have pre-fortification intake <80% their RDA for folate (mean 446, median 416, IQR ranging between 313-551micrograms). Wheat consumption is high with median portion intake of wheat-carbohydrates approximating 1 portion/day. demographics, complementing serum folate assays results will be presented. Conclusions: Low folate intake and high wheat consumption suggest potential for mandatory folate fortification of wheat in Tanzania.

Multivitamin and Iron Supplementation to Prevent Periconceptional Anemia in Rural Tanzanian Women.

Objectives: Women's nutritional status during conception and early pregnancy can influence maternal and infant outcomes. This study examined the efficacy of pre-pregnancy supplementation with iron and multivitamins to reduce anemia prevalence during the periconceptional period among rural Tanzanian women and adolescent girls. Methods: A double-blind, randomized controlled trial was conducted in which non-pregnant women aged 15-29 years (n=802) were randomized to receive daily oral supplements of folic acid alone, folic acid and iron, or folic acid, iron, and vitamins A, B-complex, C, and E at approximately single recommended dietary allowance doses for six months. Results: The study arms were comparable in participant characteristics including compliance (p>0.05). In total, 561 (70%) completed the study and were included in the intention-to-treat analysis. Hemoglobin levels were not different across treatments (median: 11.1 g/dL, Q1-Q3: 10.0-12.4 g/dL, p=0.65). However, compared with the folic acid arm (28%), there was significant reduction in the risk of hypochromic microcytic anemia in the folic acid and iron arm (17%, RR: 0.61, 95% CI: 0.42-0.90, p=0.01) and the folic acid, iron, and multivitamin arm (19%, RR: 0.66, 95% CI: 0.45-0.96, p=0.03). Inverse probability of treatment weighting (IPTW) to adjust for potential selection bias due to loss to follow-up did not materially change results. The regimen effect was not modified by baseline characteristics or compliance (p>0.2). Conclusions: Daily oral supplementation with iron and folic acid among non-pregnant women and adolescents reduces risk of anemia. The potential benefits of supplementation on the risk of periconceptional anemia and adverse pregnancy outcomes warrant investigation in larger studies.

Malarial Morbidity and Postnatal HIV Infection in Breastfeeding HIV-exposed Infants.

Background: For at-risk HIV-negative individuals, whether malarial morbidity increases the likelihood of HIV infection when exposed is unknown. Hence, we investigate the malaria-associated risk of postnatal HIV infection in 1804 breastfeeding infants of HIV-positive women from Dar es Salaam, Tanzania. Methods: Six-week-old HIV-negative infants were followed until breastfeeding cessation or postnatal HIV infection. HIV-1 status was determined by a DNA PCR test. Malarial morbidity was diagnosed by physicians using a combination of clinical symptoms and laboratory tests. For analytic purposes, malaria was distinguished by diagnostic specificity as: (1) clinical; (2) probable, where laboratory testing is requested for parasitemia; and (3) blood smear-confirmed. Hazard ratios (HR) and 95% confidence intervals (CI) for the risk of HIV infection were estimated from multivariate Cox regression models. Results: Mean follow-up duration was 6.2 months (standard deviation=2.4 months), during which 91 new HIV infections developed and clinical malaria was diagnosed in 594(32.3%) children, including 283 (15.5%) probable and 80(4.4%) confirmed malaria episodes. Infants ever diagnosed with clinical and probable malaria were at 73% (95%CI:1.11 - 2.69) and 100% (95%CI:1.17-3.42) higher risk of postnatal HIV infection, respectively. This risk increased by 39% (95%CI: 1.08-1.80) and 59% (95%CI: 1.00-2.32), respectively, per episode increment in clinical and probable malarial; however, confirmed malaria was not significantly associated with HIV incidence (HR=2.09; 95%CI: 0.74 - 5.91). Conclusion: We found positive associations between child malarial infection and postnatal HIV infection among breastfeeding HIV-negative children of HIV-positive women. These findings suggest that malaria prevention in such infants may decrease the risk of HIV mother-to-child-transmission. However, specific future studies using laboratory-confirmed malaria in HIV-negative but HIV at risk populations are needed to substantiate these findings.