Impact of preconceptional micronutrient supplementation on maternal mental health during pregnancy and postpartum: results from a randomized controlled trial in Vietnam.

BACKGROUND: Micronutrient malnutrition has been associated with maternal depressive symptoms (MDS), but little is known about the effects of preconceptional micronutrient supplementation. This paper examined the effects of preconceptional micronutrient supplementation on MDS during pregnancy and postpartum. METHODS: We used data from a double-blind controlled trial (PRECONCEPT) in which 5011 Vietnamese women were randomized to receive weekly supplements containing either a) multiple micronutrients (MM) b) iron and folic acid (IFA) or c) folic acid (FA) until conception (n = 1813). Maternal mental health was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) at baseline (preconception), and the Edinburgh Postnatal Depression Scale (EPDS) during pregnancy and 3 months postpartum. Elevated MDS was defined as EPDS score ≥ 4. All group comparisons were done using ANOVA or chi-square tests of proportions intention to treat and per protocol analyses (women consumed supplements ≥26 weeks before conception). We also conducted stratified analyses by preconception CES-D scores, underweight, or anemia status using generalized linear models. RESULTS: Baseline CES-D scores were similar across treatment groups. The proportion of women experiencing elevated MDS was 11.3, 8.1 and 4.9% at first, second and third trimesters of pregnancy, respectively, and 3.6% at 3 mo postpartum. Mean EPDS scores at first (1.5 ± 2.7), second (1.1 ± 2.4), and third trimester of pregnancy (0.7 ± 2.0) and early postpartum (0.6 ± 1.8) were low and did not differ by treatment group. However, among women in the highest tertile of CES-D scores at preconception, mean EPDS scores in the first and second trimesters of pregnancy were lower in the MM and IFA groups compared to FA only (P < 0.05). CONCLUSIONS: Weekly preconceptional micronutrient supplements containing iron did not improve depression measures relative to folic acid alone among all women, but may have benefitted women who were at risk for depression. TRIAL REGISTRATION: The trial was registered retrospectively at ClinicalTrials.Gov as NCT01665378 on August 13, 2012.

Predictors of adherence to micronutrient supplementation before and during pregnancy in Vietnam.

BACKGROUND: Poor adherence to micronutrient supplementation often limits the effectiveness of public health programs. While predictors of adherence to micronutrient supplementation during pregnancy are well documented, information on adherence to preconception supplements is scarce. The objective of this study was to describe the predictors of adherence to preconception and prenatal micronutrient supplementation among women participating in a randomized control trial in Vietnam. METHODS: Adherence data were collected prospectively from a double blind randomized controlled trial in rural Vietnam. Five thousand eleven women of reproductive age were randomized to receive preconception supplements for weekly consumption containing either: Folic Acid, Iron and Folic Acid (IFA), or Multiple Micronutrients. Women who became pregnant received prenatal IFA supplements for daily consumption through delivery. Village health workers visited participants' homes every two weeks to deliver supplements and record consumption and side effects. Multivariate logistic regression was used to assess individual, household, and programmatic predictors of supplement adherence. RESULTS: Adherence was high with 78 and 82% of the women consuming more than 80% of the preconception and prenatal supplements, respectively. Women of minority ethnicity (OR = 0.78 95% CI = 0.67, 0.91) and farmers (OR = 0.71 95% CI = 0.58, 0.88) were less likely to consume >80% of the preconception supplements while socioeconomic status (SES) (OR = 2.71 highest vs. lowest quintile; 95% CI = 2.10, 3.52) was positively associated with >80% adherence in the entire preconception sample with available information (n = 4417). Women in their first pregnancy had lower prenatal adherence compared to multiparous women. At the programmatic level, each village health worker visit was associated with higher odds of >80% adherence by 3-5% before pregnancy and 18% during pregnancy. CONCLUSIONS: Key determinants of adherence included SES, ethnicity, occupation (farmer) and parity which may be helpful for targeting women for counseling on supplement adherence. Increased contact with village health workers was positively associated with adherence to micronutrient supplementation both before conception and during pregnancy indicating the need for resources to support community outreach to women of reproductive age. TRIAL REGISTRATION: NCT01665378 . Registered on August 12, 2012.

Impact of Preconception Micronutrient Supplementation on Anemia and Iron Status during Pregnancy and Postpartum: A Randomized Controlled Trial in Rural Vietnam.

OBJECTIVE: Preconception micronutrient interventions may be a promising approach to reduce anemia and iron deficiency during pregnancy, but currently we have limited data to inform policies. We evaluated whether providing additional pre-pregnancy weekly iron-folic acid (IFA) or multiple micronutrient (MM) supplements compared to only folic acid (FA) improves iron status and anemia during pregnancy and early postpartum. METHODS: We conducted a double blind randomized controlled trial in which 5011 Vietnamese women were provided with weekly supplements containing either only 2800 µg FA (control group), IFA (60 mg Fe and 2800 µg FA) or MM (15 micronutrients with similar amounts of IFA). All women who became pregnant (n = 1813) in each of the 3 groups received daily IFA (60 mg Fe and 400 µg FA) through delivery. Hematological indicators were assessed at baseline (pre-pregnancy), during pregnancy, 3 months post-partum, and in cord blood. Adjusted generalized linear models were applied to examine the impact of preconception supplementation on anemia and iron stores, using both intention to treat and per protocol analyses (women consumed supplements ≥ 26 weeks before conception). RESULTS: At baseline, 20% of women were anemic, but only 14% had low iron stores (ferritin <30 µg/L) and 3% had iron deficiency (ferritin <12 µg/L). The groups were balanced for baseline characteristics. Anemia prevalence increased during pregnancy and post-partum but was similar among intervention groups. In intention to treat analyses, prenatal ferritin was significantly higher among women receiving MM (geometric mean (µg/L) [95% CI]: 93.6 [89.3-98.2]) and IFA (91.9 [87.6-96.3]) compared to control (85.3 [81.5-89.2]). In per protocol analyses, women receiving MM or IFA had higher ferritin 3 months postpartum (MM 118.2 [109.3-127.8]), IFA 117.8 [108.7-127.7] vs control 101.5 [94.0-109.7]) and gave birth to infants with greater iron stores (MM 184.3 [176.1-192.9]), IFA 189.9 [181.6-198.3] vs control 175.1 [167.9-182.6]). CONCLUSION: Preconception supplementation with MM or IFA resulted in modest increases in maternal and infant iron stores but did not impact anemia. Further research is needed to characterize the etiology of anemia in this population and identify effective interventions for reducing prenatal anemia. TRIAL REGISTRATION: ClinicalTrials.Gov NCT01665378.

Neither Preconceptional Weekly Multiple Micronutrient nor Iron-Folic Acid Supplements Affect Birth Size and Gestational Age Compared with a Folic Acid Supplement Alone in Rural Vietnamese Women: A Randomized Controlled Trial.

BACKGROUND: Maternal nutritional status before and during early pregnancy plays a critical role in fetal growth and development. The benefits of periconception folic acid (FA) supplementation in the prevention of neural tube defects is well recognized, but the evidence for preconception micronutrient interventions for improving pregnancy outcomes is limited. OBJECTIVE: This study aimed to evaluate whether preconception supplementation with weekly iron and folic acid (IFA) or multiple micronutrients (MMs) improves birth outcomes compared with FA alone. METHODS: We recruited 5011 women of reproductive age in a double-blind, randomized controlled trial in Vietnam and provided weekly supplements containing either 2800 µg FA, 60 mg Fe and 2800 µg FA (IFA), or the same amount of FA and iron plus other MMs until they conceived (n = 1813). All pregnant women received daily IFA through delivery, and were followed up for birth outcomes, including birth weight, gestational age, preterm delivery and small for gestational age (SGA). Group comparisons were done with the use of ANOVA or chi-square tests for both intention-to-treat (n = 1599) and per-protocol analyses (women consumed supplements ≥26 wk before conception; n = 824). Effect modification by baseline underweight or anemia status was tested with the use of generalized linear models. RESULTS: The mean age of the women was 26 y, 30% were underweight, and <10% were nulliparous. The groups were similar for most baseline characteristics. The mean ± SD duration of the preconception intervention was 33 ± 25 wk and compliance was high (>90%). Infants born to the 3 groups of women did not differ (P ≥ 0.05) on mean ± SD birth weight (3076.8 ± 444.5 g) or gestational age (39.2 ± 2.0 wk), or prevalence of SGA (12%), low birth weight (5%) and preterm delivery (10%). There were no significant differences in women who consumed supplements ≥26 wk before conception or by baseline underweight or anemia. CONCLUSION: Weekly supplementation with MMs or IFA before conception did not affect birth outcomes compared with FA in rural Vietnamese women. The trial was registered at clinicaltrials.gov as NCT01665378.

Patterns of Fetal Growth Based on Ultrasound Measurement and its Relationship with Small for Gestational Age at Birth in Rural Vietnam.

BACKGROUND: Small for gestational age (SGA) is a global health problem. Identifying the timing of fetal growth faltering is critical for developing preventive interventions. We aim to describe patterns of fetal growth and to predict SGA at birth using fetal ultrasound measurements. METHODS: We studied 1412 pregnant women enrolled in a randomised-controlled trial evaluating maternal micronutrient supplementation in Thai Nguyen province, Vietnam. Ultrasound examinations included biparietal diameter (BPD), head circumference (HC) and abdominal circumference (AC), and femur length (FL). Measures were assessed using the new international fetal growth standards (INTERGROWTH-21st Project). Generalised linear mixed logit regression models were used to examine the association between ultrasound measures and SGA at birth. RESULTS: Overall fetal growth restriction began in early pregnancy and continued through delivery, but the timing of growth faltering varied by measure: it began by 20 weeks for HC, BPD and AC, earlier as compared to FL growth that started >30 weeks. SGA infants had significantly lower mean fetal growth parameters as early as 14 weeks. Ultrasound measures below the 10th percentile were associated with a two to four times higher risk of SGA at birth compared to fetuses greater than the 50th percentile, with the largest odds ratios for AC (OR 3.9, 95% confidence interval (CI) 2.7, 5.7). CONCLUSIONS: Fetal growth faltering by ultrasound begins in early gestation among rural Vietnamese populations; these patterns clearly identified those to be born SGA. Efforts to prevent fetal growth faltering must begin early in pregnancy and perhaps even before pregnancy.

Micronutrient intakes among women of reproductive age in Vietnam.

BACKGROUND: Micronutrient deficiencies are a public health concern worldwide negatively affecting maternal and child health outcomes. The primary underlying causes of micronutrient deficiencies are insufficient intake and poor bioavailability of micronutrients. However, reliable data on micronutrient intakes are sparse. The objectives of this study were to identify the key local food sources providing the majority of micronutrients and assess the adequacy and determinants of micronutrient intakes. METHODS: The study used data from a survey of 4,983 rural women of reproductive age (WRA) participating in a preconception micronutrient supplementation trial in Vietnam. Micronutrient intakes were assessed using a validated 107-item semi-quantitative food-frequency questionnaire. Multivariate linear and logistic regression analyses were used to examine the association between socioeconomic status and micronutrient intakes. RESULTS: Starchy staples were the main source of iron and zinc (37% and 54%, respectively) with only a small proportion from meat (10% and 18%, respectively). The primary source of folate and vitamin A were vegetables; vitamin B12 came from meat and eggs. The proportion of the population with intakes below the estimated average requirement was 25% for iron, 16% for zinc, 54% for folate, 64% for vitamin B12 and 27% for vitamin A. Socioeconomic status was the main determinant of micronutrient intakes. WRA in the highest quintile consumed 26% more iron, 19% more zinc, 36% more folate, 82% more vitamin B12 and 47% more vitamin A compared to those in the lowest quintile. Women in the upper quintiles of SES were more likely to obtain nutrients from more nutritious and higher bioavailable foods than those in the lowest quintile. CONCLUSIONS: Underprivileged women were at increased risk for insufficient micronutrient intakes due to poor diet quality. Targeted efforts to promote the consumption of local nutrient rich foods along with educational programs and social development are needed.

Food consumption patterns and associated factors among Vietnamese women of reproductive age.

BACKGROUND AND OBJECTIVES: Adequate nutrient intakes among women of reproductive age (WRA) are important determinants of maternal, neonatal and child health outcomes. However, data on dietary intake for WRA in Vietnam are lacking. This paper aimed to examine the adequacy and determinants of energy and macronutrient intakes among WRA enrolled in a study of preconceptual micronutrient supplementation (PRECONCEPT) being conducted in 20 rural communes in Thai Nguyen province, Vietnam. METHODS: Dietary intakes were determined for 4983 WRA who participated in the baseline survey using a previously validated 107-item (semi-quantitative) food-frequency questionnaire that was administered by trained field workers. Multivariate linear and logistic regression analyses were used to examine factors associated with energy and macronutrient intakes. RESULTS: A disproportionate number of energy came from starches, primarily rice. Carbohydrate, fat and protein constituted 65.6%, 19.5% and 14.8% of total energy, respectively. Fat intake was below recommended levels in 56.5% of respondents, but carbohydrate intakes were above recommended level in 54.6%. Only 0.1% and 5.2% of WRA achieved adequate intake of n-3 and n-6 long-chain polyunsaturated fatty acids, respectively. Multivariate linear regression revealed that low education, low socioeconomic status, and food insecurity were significant predictors of reduced total energy intake, reduced energy from protein and fat, and greater energy from carbohydrates. Logistic regression confirmed that inadequate macronutrient intake was more common among the poor, food insecure, and less educated. CONCLUSIONS: Imbalanced dietary intakes among underprivileged women reflect lack of dietary diversity. Nutrition programs should be linked with social development, poverty reduction, education programs and behavior change counseling in order to improve the nutritional status of WRA in Vietnam.