Modifying effect of maternal nutritional status on the impact of maternal multiple micronutrient supplementation on birthweight in Indonesia.

BACKGROUND/OBJECTIVE: Low birthweight (LBW) and intrauterine growth restriction are linked with maternal nutritional status during pregnancy, and maternal supplementation with multiple micronutrients (MMNs) is reported to increase birthweight. Responses to MMN, however, might be modified by maternal nutrition. SUBJECTS/METHODS: To examine the differential effects of maternal nutritional status on birthweight responses to prenatal MMN supplementation, data from the Supplementation with Multiple Micronutrient Intervention Trial, a cluster-randomized trial in Indonesia was analyzed. Birthweight outcomes of 7001 infants whose mothers received iron/folic acid were compared with 7292 infants whose mothers received MMN. The modifying effects of maternal short-term nutritional status (mid-upper arm circumference (MUAC) and long-term nutritional status (height) on the birthweight response to MMN supplementation were assessed. RESULTS: For women with higher MUAC (≥23.5 cm), MMN increased mean birthweight by 33 g (95% confidence interval (CI): -1 to 66, P=0.06) and significantly reduced LBW by 21% (relative risk: 0.79, 95% CI: 0.64-0.99, P=0.04). The modifying effect of MUAC on mean birthweight, LBW and small for gestational age was significant. There was no evidence of a modifying effect of maternal height on the response to MMN. CONCLUSIONS: Supplementation with MMN in pregnancy increased birthweight, but maternal nutritional status modified this response, with infants born to women with better short-term nutrition having greater birthweight response.

Effect of maternal multiple micronutrient supplementation on fetal loss and infant death in Indonesia: a double-blind cluster-randomised trial.

BACKGROUND: Maternal nutrient supplementation in developing countries is generally restricted to provision of iron and folic acid (IFA). Change in practice toward supplementation with multiple micronutrients (MMN) has been hindered by little evidence of the effects of MMN on fetal loss and infant death. We assessed the effect of maternal supplementation with MMN, compared with IFA, on fetal loss and infant death in the setting of routine prenatal care services. METHODS: In a double-blind cluster-randomised trial in Lombok, Indonesia, we randomly assigned 262 midwives to distribute IFA (n=15 ,86) or MMN (n=15,804) supplements to 31 290 pregnant women through government prenatal care services that were strengthened by training and community-based advocacy. Women obtained supplements, to be taken daily, every month from enrolment to 90 days post partum. The primary outcome was early infant mortality (deaths until 90 days post partum). Secondary outcomes were neonatal mortality, fetal loss (abortions and stillbirths), and low birthweight. Analysis was by intention to treat. The study is registered as an International Standard Randomised Controlled Trial, number ISRCTN34151616. FINDINGS: Infants of women consuming MMN supplements had an 18% reduction in early infant mortality compared with those of women given IFA (35.5 deaths per 1000 livebirths vs 43 per 1000; relative risk [RR] 0.82, 95% CI 0.70-0.95, p=0.010). Infants whose mothers were undernourished (mid upper arm circumference <23.5 cm) or anaemic (haemoglobin <110 g/L) at enrolment had a reduction in early infant mortality of 25% (RR 0.75, 0.62-0.90, p=0.0021) and 38% (RR 0.62, 0.49-0.78, p<0.0001), respectively. Combined fetal loss and neonatal deaths were reduced by 11% (RR 0.89, 0.81-1.00, p=0.045), with significant effects in undernourished (RR 0.85, 0.73-0.98, p=0.022) or anaemic (RR 0.71, 0.58-0.87, p=0.0010) women. A cohort of 11 101 infants weighed within 1 h of birth showed a 14% (RR 0.86, 0.73-1.01, p=0.060) decreased risk of low birthweight for those in the MMN group, with a 33% (RR 0.67, 0.51-0.89, p=0.0062) decrease for infants of women anaemic at enrolment. INTERPRETATION: Maternal MMN supplementation, as compared with IFA, can reduce early infant mortality, especially in undernourished and anaemic women. Maternal MMN supplementation might therefore be an important part of overall strengthening of prenatal-care programmes.

Feasibility of voluntary counselling and testing services for HIV among pregnant women presenting in labour in Pune, India.

Factors affecting the eligibility and acceptability of voluntary counselling and rapid HIV testing (VCT) were examined among pregnant women presenting in labour in Pune, India. Of the 6702 total women appearing at the delivery room from April 2001 to March 2002, 4638 (69%) were admitted for normal delivery. The remaining women presented with obstetrical complications, delivered immediately or were detected to be in false labour. Overall, 2818 (61%) of the admitted women had been previously tested for HIV during their pregnancy. If previously seen in the hospital's affiliated antenatal clinic, the likelihood of being previously tested was 89%, in contrast to 27% of women having prenatal care elsewhere. Of the admitted women, 3436 (74.3%) were assessed for their eligibility for rapid HIV VCT in the delivery room. Only 1322 (38%) of these women were found to be in early labour and without severe pain or complications, and therefore eligible for rapid HIV screening in the delivery room (DR). Of those 1322 eligible women, only 582 (44%) consented and were tested for HIV, of whom nine (1.6%) were found to be HIV-infected. Of the 1674 women arriving in the DR with no evidence of previous HIV testing, through this DR screening programme, we identified four women with HIV who could now benefit from treatment with ART. Given the high rates of HIV testing in the antenatal clinic at this site and the challenges inherent to conducting DR screening, alternatives such as post-partum testing should be considered to help reduce maternal to infant transmission in this population.

Optimizing the HIV/AIDS informed consent process in India.

BACKGROUND: While the basic ethical issues regarding consent may be universal to all countries, the consent procedures required by international review boards which include detailed scientific and legal information, may not be optimal when administered within certain populations. The time and the technicalities of the process itself intimidate individuals in societies where literacy and awareness about medical and legal rights is low. METHODS: In this study, we examined pregnant women's understanding of group education and counseling (GEC) about HIV/AIDS provided within an antenatal clinic in Maharashtra, India. We then enhanced the GEC process with the use of culturally appropriate visual aids and assessed the subsequent changes in women's understanding of informed consent issues. RESULTS: We found the use of visual aids during group counseling sessions increased women's overall understanding of key issues regarding informed consent from 38% to 72%. Moreover, if these same visuals were reinforced during individual counseling, improvements in women's overall comprehension rose to 96%. CONCLUSIONS: This study demonstrates that complex constructs such as informed consent can be conveyed in populations with little education and within busy government hospital settings, and that the standard model may not be sufficient to ensure true informed consent.

Awareness of HIV/AIDS and household environment of pregnant women in Pune, India.

Our objective was to determine the level of HIV/AIDS knowledge of pregnant women in India. In a sub-sample of these women, we documented the extent to which they experienced adverse social and physical difficulties within their home. The study was performed at an urban antenatal hospital clinic in Maharastra, India. From April to September 2001, structured interviews were conducted on 707 randomly selected antenatal clinic patients related to HIV/AIDS knowledge. Of these, 283 were further interviewed to document any social or physical difficulties they experienced. Over 75% of women displayed knowledge of primary transmission routes. Nearly 70% of women demonstrated knowledge of maternal to child transmission, however, only 8% knew of any methods of prevention. TV and written material were more strongly related to knowledge than access to radio messages or conversations with individuals. Thirty per cent of the women experienced physical or mental abuse or their spouse's alcohol and/or drug problems. Women reporting such abuse were more than twice as likely to have adequate HIV/AIDS knowledge compared with women reporting no such abuse. We found no relationship between reported household abuse and educational level of woman, husband, occupation of either partner, language or religion. We found no relationship between HIV status and knowledge of HIV and no relationship between HIV status and risk of abuse in the household. However, the total number of HIV patients in our sample was very small.

Women's acceptability and husband's support of rapid HIV testing of pregnant women in India.

This study examined acceptability among pregnant women and their husbands for HIV testing within the antenatal clinic (ANC) and delivery room (DR) of a government hospital in Pune, India from September 2000 to November 2001. Acceptance of HIV counselling and testing was high with 83% of eligible women in the antenatal clinic (851 of 1025) and 68% of eligible women in the delivery room (417 of 613) getting tested on the same day. Structured interviews were conducted on 94 pregnant women in the ANC 50 women in the DR, and 100 husbands who accompanied their wives in the ANC. These data indicated that the majority of women agreed to be tested independently without the need for further consultation with family members, a view that was strongly supported in this sub-sample of accompanying husbands. For delivering women who were not progressing in their labour, counselling in the DR allowed for individual attention to questions and concerns thereby making counselling in the DR feasible.

Sensitivity and specificity of rapid HIV testing of pregnant women in India.

OBJECTIVE: Efforts to prevent HIV transmission from mother to infants in settings like India may benefit from the availability of reliable methods for rapid and simple HIV screening. Data from India on the reliability of rapid HIV test kits are limited and there are no data on the use of rapid HIV tests for screening of pregnant women. METHODS: Pregnant women attending an antenatal clinic and delivery room in Pune agreed to participate in an evaluation of five rapid HIV tests, including (a) a saliva brush test (Oraquick HIV-1/2, Orasure Technologies Inc.), (b) a rapid plasma test (Oraquick HIV-1/2) and (c) three rapid finger prick tests (Oraquick HIV-1/2; HIV-1/2 Determine, Abbott; NEVA HIV-1/2 Cadila). Results of the rapid tests were compared with three commercial plasma enzyme immunoassay (EIA) tests (Innotest HIV AB EIA, Lab systems/ELISCAN HIV AB EIA, UBI HIV Ab EIA). RESULTS: Between September 2000 and October 1, 2001, 1258 pregnant women were screened for HIV using these rapid tests. Forty-four (3.49%) of the specimens were HIV-antibody-positive by at least two plasma EIA tests. All of the rapid HIV tests demonstrated excellent specificity (96-100%). The sensitivity of the rapid tests ranged from 75-94%. The combined sensitivity and specificity of a two-step algorithm for rapid HIV testing was excellent for a number of combinations of the five rapid finger stick tests. CONCLUSION: In this relatively low HIV prevalence population of pregnant women in India, the sensitivity of the rapid HIV tests varied, when compared to a dual EIA algorithm. In general, the specificity of all the rapid tests was excellent, with very few false positive HIV tests. Based upon these data, two different rapid HIV tests for screening pregnant women in India would be highly sensitive, with excellent specificity to reliably prevent inappropriate use of antiretroviral therapy for prevention of vertical HIV transmission.

Comparison of visual estimates of children's portion sizes under both shared-plate and individual-plate conditions.

OBJECTIVE: This paper compares the accuracy of visual estimations of children's food intake in settings where several children eat together off 1 plate vs individual-plate eating scenarios. DESIGN: Eight trained observers were tested in their ability to estimate food portions consumed by children enacting common eating scenarios. Foods were categorized by food group and according to their presentation by individual-plate and shared-plate. Observed food weight estimates were compared to actual weights. SUBJECTS/SETTING: The 8 observers visually estimated 69 food portions of children eating alone and 26 portions where children were eating from a shared plate. This study was carried out in Sarlahi District, a rural, central lowland region of Nepal. STATISTICAL ANALYSES: Pearson's correlation coefficients were calculated to examine associations between estimated and actual weights. A fixed effects model was constructed to compare observers. RESULTS: Analyses revealed that observer estimates of food weights under field conditions were well correlated with actual weights for individual-plate (r = 0.89) and for shared-plate (r = 0.84) scenarios. Observers estimated food weights when children ate together on a shared plate less accurately than they did in settings where children ate alone. With the exception of 1 observer, observers did not differ significantly in their ability to estimate food weights. Accuracy of estimations was influenced by food weight with greater error associated with food quantities of less than 70 g. CONCLUSIONS: Visual estimation is a relatively accurate, valid method of assessing child food intake under rural field conditions, and the only method to obtain accurate information on dietary intake in regions where shared-plate eating is frequent.

Child feeding and care behaviors are associated with xerophthalmia in rural Nepalese households.

The study examined caregiver-child interactions, intrahousehold food allocation and general child care behaviors and their effect on children's xerophthalmia status in the rural Terai region of Nepal. Seventy-eight households with a child having a history of xerophthalmia (cases) were matched with 78 households with a child of the same age having no history of xerophthalmia (controls). Seven day-long continuous monitoring observations were performed in each household (over 15 months) by trained Nepali observers, focusing on feeding and care of a focus child and his/her younger sibling. Nineteen different behavioral variables were operationalized, including serving method, second helpings, serving refusals, encouragement to eat, request intensity, meal serving order, food channeling, food sharing, positive social behaviors, negative social behaviors, and positive health behaviors. Automatic serving and request intensity were strongly negatively correlated, especially among younger siblings. Children who serve themselves receive less encouragement to eat. Those children who are refused in their requests for food tend to ask for food more frequently, for a longer time, and be less likely to self-serve. Children who eat from a shared plate are less likely to interact with a food server and more likely to self-serve. Negative social behavior towards children is associated with the child having to request food more frequently and a greater likelihood of being refused food. Children who receive positive health care from their caregivers are also more frequently asked if they would like food by the server and are encouraged to eat. Several caregiver child feeding behaviors were related to a child's risk of having past vitamin A deficiency. Controls were much more likely to be served food automatically. Cases were more likely to serve themselves food and have multiple servings of food. Cases were nearly two times more likely than controls to be treated with neglect or harshly, and much less likely than controls to have their health needs receive attention. Examining intrahousehold behavior is critical for understanding the causes of vitamin A deficiency in rural Nepalese children, and has great potential for identifying and improving interventions to improve children's diets and care.

Eating from a shared plate affects food consumption in vitamin A-deficient Nepali children.

This case-control study evaluates the relationship between shared-plate eating behavior in young Nepali children (aged 1-6 y) and risk of vitamin A deficiency. Day-long observations of dietary practices were conducted on 7 d over a 15-mo period in 162 households: 81 households with a child with a known history of mild xerophthalmia (cases) were matched with 81 having a non-xerophthalmic child of similar age (controls). Shared-plate eating occurred in 25% of all feeding episodes and at least once in 65% of all days observed. Overall, children engaging in shared-plate eating were significantly more likely to consume grains, vegetables, carotenoid-rich vegetables, pulses, fruits, meats and fish, and dairy products and had significantly larger portion sizes for grains, vegetables, fruits, pulses and dairy products, compared with children who ate alone. In general, feeding behaviors between case and control children tended to be similar. However, shared-plate feeding episodes among case children were significantly less likely to include meats or fish [odds ratio (OR) = 0.5, confidence interval (CI) = 0.3-0.8], dairy products (OR = 0.6, CI = 0.4-0.9) or pulses (OR = 0.7, CI = 0.5-1.0). Individual-plate feeding episodes among case children were more likely to include vegetables (OR = 1.3, CI = 1.0-1.6) than those of control children. Case children were more likely to share a plate with a male adult (OR = 1.7, CI = 1.0-2.8), but less likely to eat from a plate shared with females of any age compared with controls (female adult: OR = 0.6, CI = 0.4-0.9; female child: OR = 0.6, CI = 0.4-1.0). Shared-plate eating may benefit a young child's dietary intake, but the identity of the food sharer may modify this influence.

Infant feeding practices reflect antecedent risk of xerophthalmia in Nepali children.

OBJECTIVE: To determine the relationship between infant feeding history and risk of xerophthalmia due to vitamin A deficiency (VAD) in early childhood. DESIGN: A case-control study of previously xerophthalmic and non-xerophthalmic children. SETTING: Rural lowland region of Nepal. SUBJECTS: One hundred and fifty-six children (aged 1-6 y old), half of whom previously had xerophthalmia due to vitamin A-deficiency, the other half matched by locale, age and the presence and age of a younger sibling (n = 102). METHODS: Xerophthalmia was determined by trained ophthalmic assistants on the basic of current Bitot's spots, corneal xerosis or report of night blindness. Infant feeding history was collected through a diet history method obtained from the mother of the focus child. Exploratory factor analysis was conducted to determine the presence of underlying patterns in infant feeding practices. Conditional logistic regression was used to estimate odds ratios. RESULTS: Mothers of control children tended to have a higher level of education (P < 0.10) and to have fewer children who had died (P < 0.10) than mothers of case children. Feeding of meat (OR = 0.09, CI = 0.01-0.70) or fish (OR = 0.41, CI = 0.17-0.99) with liver, eggs (OR = 0.11, CI = 0.01-0.88) and mango (OR = 0.28, CI = 0.13-0.60) were protective in association with xerophthalmia in early childhood. Factor analysis uncovered several distinct patterns in infant feeding, which varied by age of the infant. Only the 'animal flesh' feeding pattern (factor), practiced in the second year of life, proved significantly protective from xerophthalmia (OR = 0.43, CI = 0.20-0.94). Feeding patterns of younger children closely paralleled those of their older siblings with and without VAD. CONCLUSIONS: The study supports the hypothesis that infant dietary practices can influence subsequent risk for VAD. Our findings emphasize the importance of introducing vitamin A-rich foods during weaning to reduce the risk of VAD-associated xerophthalmia in the later preschool years.

PIP: The association between infant feeding patterns and vitamin A deficiency (VAD)-associated xerophthalmia was investigated in a case-control study of 156 children, 1-6 years old, from a rural lowland region of Nepal. The 78 children with previous xerophthalmia determined on the basis of current Bitot's spots, corneal xerosis, or night blindness were matched with 78 controls on the basis of locale, age, and the presence and age of a younger sibling. The diet history method was used to elicit infant feeding practices from mothers. Frequency of consumption of 21 key foods was calculated over the 2-year period of the diet history. The analysis supported the hypothesis that infant dietary practices can influence the subsequent risk for VAD. The feeding of meat (odds ratio (OR), 0.09; 95% confidence interval (CI), 0.01-0.70) or fish (OR, 0.41; 95% CI, 0.17-0.99) with eggs (OR, 0.11; 95% CI, 0.01-0.88) and mango (OR, 0.28; 95% CI, 0.13-0.60) was protective in association with xerophthalmia in early childhood. In factor analysis, only the "animal flesh" feeding pattern, practiced in the second year of life, was significantly protective against xerophthalmia (OR, 0.43; 95% CI, 0.20-0.94). These findings confirm the importance of introducing vitamin A-rich foods during weaning to reduce the risk of VAD-associated xerophthalmia in the later preschool years.

Chronic low intakes of vitamin A-rich foods in households with xerophthalmic children: a case-control study in Nepal.

Dietary patterns in 81 rural Nepali households with a 1-6-y-old child with a history of xerophthalmia were compared with dietary patterns of 81 households with an age-matched nonxerophthalmic control subject. Weekly food-frequency questionnaires were collected from case and control "focus" children, a younger sibling (if present), and the household 1-2 y after recruitment and treatment of cases. Control households and children were more likely than case households and children to consume vitamin A-rich foods during the monsoon (July-September) and major rice harvesting (October-December) seasons. Cases were less likely to consume preformed vitamin A-rich foods throughout the year [odds ratio (OR) = 1.2-4.5] with the strongest differences observed from October to December (OR = 2.0-4.2). Dietary risks were generally shared by younger siblings of cases, suggesting that infrequent intake of beta-carotene and preformed vitamin-A rich foods begins early in life and clusters among siblings within households, a pattern that is consistent with their higher risk of xerophthalmia and mortality. In developing countries where vitamin A deficiency is endemic, dietary counseling for children with xerophthalmia should be extended to their younger siblings. Moreover, dietary intake of preformed vitamin A may be as, or more, important as carotenoid-containing food consumption in protecting children and other members of households from vitamin A deficiency.

Accuracy of estimating food intake by observation.

OBJECTIVE: To determine the accuracy of direct observation in food-weight estimation as measured under controlled field conditions. DESIGN AND SUBJECTS: Ten local Nepalis were trained in observational techniques and tested in food-weight estimation during a 3-month training period and for 4 months after training. SETTING: The study was carried out in the Sarlahi District, a rural, central lowland region of Nepal that borders India. MAIN OUTCOME MEASURES: Thirty testing sessions (a total of 6,902 observations) were completed on more than 150 different foods. Estimates of observed food weight were compared with actual weights and were analyzed. STATISTICAL ANALYSES PERFORMED: Pearson's correlation coefficients were calculated to examine associations between estimated and actual weights. RESULTS: Observer estimates of food weights were highly correlated with actual weights (r = .96) for the entire testing period. The linear regression equation (y = .96x + 1.3) suggests that the relationship between actual and observed food weights (in grams) was also accurate. Most observers showed improvement with training. Substantial reductions in both mean and standard deviation of percentage error were achieved over time. Accuracy of estimates was influenced by characteristics of foods weighted; small quantities (less than 20 g), certain nonstaple foods, and foods of high volume but light weight had less accurate estimates. CONCLUSIONS: Direct observation is an important method for assessing dietary intake that does not rely on a respondents' ability to recall his or her own or another's food consumption. It is feasible to train local observers to make visual estimates of food weight, but the accuracy of their estimates varies by food and portion size.