Maternal nutrition intervention and maternal complications in 4 districts of Bangladesh: A nested cross-sectional study

Autoři: Catherine S. Todd aff001;  Zakaria Chowdhury aff002;  Zeba Mahmud aff002;  Nazia Islam aff003;  Sadia Shabnam aff003;  Musarrat Parvin aff002;  Alissa Bernholc aff001;  Andres Martinez aff001;  Bachera Aktar aff004;  Kaosar Afsana aff004;  Tina Sanghvi aff005
Působiště autorů: Global Health, Population, and Nutrition, FHI 360, Durham, North Carolina, United States of America aff001;  Alive & Thrive Program Office, Dhaka, Bangladesh aff002;  BRAC, Dhaka, Bangladesh aff003;  BRAC James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh aff004;  Alive & Thrive Headquarters Office, Washington, District of Columbia, United States of America aff005
Vyšlo v časopise: Maternal nutrition intervention and maternal complications in 4 districts of Bangladesh: A nested cross-sectional study. PLoS Med 16(10): e32767. doi:10.1371/journal.pmed.1002927
Kategorie: Research Article



Maternal morbidity is common in Bangladesh, where the maternal mortality rate has plateaued over the last 6 years. Maternal undernutrition and micronutrient deficiencies contribute to morbidity, but few interventions have measured maternal outcomes. We compared reported prevalence of antepartum, intrapartum, and postpartum complications among recently delivered women between maternal nutrition intervention and control areas in Bangladesh.

Methods and findings

We conducted a cross-sectional assessment nested within a population-based cluster-randomized trial comparing a nutrition counseling and micronutrient supplement intervention integrated within a structured home-based maternal, newborn, and child health (MNCH) program to the MNCH program alone in 10 sub-districts each across 4 Bangladesh districts. Eligible consenting women, delivering within 42–60 days of enrollment and identified by community-level health workers, completed an interviewer-administered questionnaire detailing the index pregnancy and delivery and allowed review of their home-based care register. We compared pooled and specific reported antepartum, intrapartum, and postpartum complications between study groups using hierarchical logistic regression. There were 594 women in the intervention group and 506 in the control group; overall, mean age was 24 years, 31% were primiparas, and 39% reported facility-based delivery, with no significant difference by study group. There were no significant differences between the intervention and control groups in household-level characteristics, including reported mean monthly income (intervention, 6,552 taka, versus control, 6,017 taka; p = 0.48), having electricity (69.6% versus 71.4%, p = 0.84), and television ownership (41.1% versus 38.7%, p = 0.81). Women in the intervention group had higher recorded iron and folic acid and calcium supplement consumption and mean dietary diversity scores, but reported anemia rates were similar between the 2 groups (5.7%, intervention; 6.5%, control; p = 0.83). Reported antepartum (69.4%, intervention; 79.2%, control; p = 0.12) and intrapartum (41.4%, intervention; 48.5%, control; p = 0.18) complication rates were high and not significantly different between groups. Reported postpartum complications were significantly lower among women in the intervention group than the control group (33.5% versus 48.2%, p = 0.02), and this difference persisted in adjusted analysis (adjusted odds ratio [AOR] = 0.51, 95% CI 0.32–0.82; p < 0.001). For specific conditions, odds of retained placenta (AOR = 0.35, 95% CI 0.19–0.67; p = 0.001), postpartum bleeding (AOR = 0.37, 95% CI 0.15–0.92; p = 0.033), and postpartum fever/infection (AOR = 0.27, 95% CI 0.11–0.65; p = 0.001) were significantly lower in the intervention group in adjusted analysis. There were no significant differences in reported hospitalization for antepartum (49.8% versus 45.1%, p = 0.37), intrapartum (69.9% versus 59.8%, p = 0.18), or postpartum (36.1% versus 29.9%, p = 0.49) complications between the intervention and control groups. The main limitations of this study are outcome measures based on participant report, non-probabilistic selection of community-level workers’ catchment areas for sampling, some missing data for variables derived from secondary sources (e.g., dietary diversity score), and possible recall bias for reported dietary intake and supplement use.


Reported overall postpartum and specific intrapartum and postpartum complications were significantly lower for women in intervention areas than control areas, despite similar rates of facility-based delivery and hospitalization for reported complications, in this exploratory analysis. Maternal nutrition interventions providing intensive counseling and micronutrient supplements may reduce some pregnancy complications or impact women’s ability to accurately recognize complications, but more rigorous evaluation is needed for these outcomes.

Klíčová slova:

anémia – Antenatal care – Labor and delivery – Malnutrition – Pregnancy – Pregnancy complications


1. Alliance for Maternal and Newborn Health Improvement (AMANHI) mortality study group. Population-based rates, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa: a multi-country prospective cohort study. Lancet Glob Health. 2018;6(12):e1297–308. doi: 10.1016/S2214-109X(18)30385-1 30361107

2. Geller SE, Koch AR, Garland CE, MacDonald EJ, Storey F, Lawton B. A global view of severe maternal morbidity: moving beyond maternal mortality. Reprod Health. 2018;15(Suppl 1):98. doi: 10.1186/s12978-018-0527-22 29945657

3. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2:e323–33. doi: 10.1016/S2214-109X(14)70227-X 25103301

4. Christian P, Mullany LC, Hurley KM, Katz J, Black RE. Nutrition and maternal, neonatal, and child health. Semin Perinatol. 2015;39(5):361–72. doi: 10.1053/j.semperi.2015.06.009 26166560

5. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427–51. doi: 10.1016/S0140-6736(13)60937-X 23746772

6. Rush D. Maternal nutrition and perinatal survival. J Health Popul Nutr. 2001;19(3):S217–64. 11761778

7. Christian P, Katz J, Wu L, Kimbrough-Pradhan E, Khatry SK, LeClerq SC, et al. Risk factors for pregnancy-related mortality: a prospective study in rural Nepal. Public Health. 2008;122(2):161–72. doi: 10.1016/j.puhe.2007.06.003 17826810

8. Sikder SS, Labrique AB, Shamim AA, Ali H, Mehra S, Wu L, et al. Risk factors for reported obstetric complications and near misses in rural northwest Bangladesh: analysis from a prospective cohort study. BMC Pregnancy Childbirth. 2014;14:347. doi: 10.1186/1471-2393-14-347 25282340

9. Scalone F. Effects of nutritional stress and socio-economic status on maternal mortality in six German villages, 1766–1863. Popul Stud (Camb). 2014;68(2):217–36. doi: 10.1080/00324728.2013.821153 24134511

10. Christian P, West KP Jr, Khatry SK, Kimbrough-Pradhan E, LeClerq SC, Katz J, et al. Night blindness during pregnancy and subsequent mortality among women in Nepal: effects of vitamin A and beta-carotene supplementation. Am J Epidemiol. 2000;152(6):542–7. doi: 10.1093/aje/152.6.542 10997544

11. Hofmeyr GJ, Lawrie TA, Atallah ÁN, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2018;10:CD001059. doi: 10.1002/14651858.CD001059.pub5 30277579

12. Peña-Rosas JP, De-Regil LM, Garcia-Casal MN, Dowswell T. Daily oral iron supplementation during pregnancy. Cochrane Database Syst Rev. 2015;(7):CD004736. doi: 10.1002/14651858.CD004736.pub5 26198451

13. Kavle JA, Stoltzfus RJ, Witter F, Tielsch JM, Khalfan SS, Caulfield LE. Association between anaemia during pregnancy and blood loss at and after delivery among women with vaginal births in Pemba Island, Zanzibar, Tanzania. J Health Popul Nutr. 2008;26(2):232–40. 18686556

14. Christian P, Khatry SK, LeClerq SC, Dali SM. Effects of prenatal micronutrient supplementation on complications of labor and delivery and puerperal morbidity in rural Nepal. Int J Gynaecol Obstet. 2009;106:3–7. doi: 10.1016/j.ijgo.2009.03.040 19368922

15. McCauley ME, van den Broek N, Dou L, Othman M. Vitamin A supplementation during pregnancy for maternal and newborn outcomes. Cochrane Database Syst Rev. 2015;(10):CD008666. doi: 10.1002/14651858.CD008666.pub3 26503498

16. Ota E, Mori R, Middleton P, Tobe-Gai R, Mahomed K, Miyazaki C, et al. Zinc supplementation for improving pregnancy and infant outcome. Cochrane Database Syst Rev. 2015;(2):CD000230. doi: 10.1002/14651858.CD000230.pub5 25927101

17. Harding KB, Peña-Rosas JP, Webster AC, Yap CMY, Payne BA, Ota E, et al. Iodine supplementation for women during the preconception, pregnancy and postpartum period. Cochrane Database Syst Rev. 2017;3:CD011761. doi: 10.1002/14651858.CD011761.pub2 28260263

18. Lassi ZS, Salam RA, Haider BA, Bhutta ZA. Folic acid supplementation during pregnancy for maternal health and pregnancy outcomes. Cochrane Database Syst Rev. 2013;(3):CD006896. doi: 10.1002/14651858.CD006896.pub2 23543547

19. National Institute of Population Research and Training, Mitra and Associates, ICF International. Bangladesh Demographic and Health Survey 2014. Rockville (MD): ICF International; 2016.

20. Ahmed SM, Rawal LB, Chowdhury SA, Murray J, Arscott-Mills S, Jack S, et al. Cross-country analysis of strategies for achieving progress towards global goals for women’s and children’s health. Bull World Health Organ. 2016;94(5):351–61. doi: 10.2471/BLT.15.168450 27147765

21. Rahman M, Yunus FM, Shah R, Jhohura FT, Mistry SK, Quayyum T, et al. A controlled before-and-after perspective on the improving maternal, neonatal, and child survival program in rural Bangladesh: an impact analysis. PLoS ONE. 2016;11(9):e0161647. doi: 10.1371/journal.pone.0161647 27583478

22. Khan AI, Kabir I, Eneroth H, El Arifeen S, Ekström EC, Frongillo EA, et al. Effect of a randomised exclusive breastfeeding counselling intervention nested into the MINIMat prenatal nutrition trial in Bangladesh. Acta Paediatr. 2017;106:49–54. doi: 10.1111/apa.13601 27659772

23. Christian P, Shaikh S, Shamim AA, Mehra S, Wu L, Mitra M, et al. Effect of fortified complementary food supplementation on child growth in rural Bangladesh: a cluster-randomized trial. Int J Epidemiol. 2015;44(6):1862–76. doi: 10.1093/ije/dyv155 26275453

24. Sanghvi T, Haque R, Roy S, Afsana K, Seidel R, Islam S, et al. Achieving behaviour change at scale: Alive & Thrive’s infant and young child feeding programme in Bangladesh. Matern Child Nutr. 2016;12(Suppl 1):141–54. doi: 10.1111/mcn.12277 27187912

25. Menon P, Nguyen PH, Saha KK, Khaled A, Sanghvi T, Baker J, et al. Combining intensive counseling by frontline workers with a nationwide mass media campaign has large differential impacts on complementary feeding practices but not on child growth: results of a cluster-randomized program evaluation in Bangladesh. J Nutr. 2016;146(10):2075–84. doi: 10.3945/jn.116.232314 27581575

26. Ali H, Hamadani J, Mehra S, Tofail F, Hasan MI, Shaikh S, et al. Effect of maternal antenatal and newborn supplementation with vitamin A on cognitive development of school-aged children in rural Bangladesh: a follow-up of a placebo-controlled, randomized trial. Am J Clin Nutr. 2017;106(1):77–87. doi: 10.3945/ajcn.116.134478 28490513

27. National Institute of Population Research and Training, International Centre for Diarrhoeal Disease Research, Bangladesh, MEASURE Evaluation. Bangladesh maternal mortality and health care survey 2016: preliminary report. Chapel Hill (NC): MEASURE Evaluation; 2017.

28. Nguyen PH, Kim SS, Sanghvi T, Mahmud Z, Tran LM, Shabnam S, et al. Integrating nutrition interventions into an existing maternal, neonatal, and child health program increased maternal dietary diversity, micronutrient intake, and exclusive breastfeeding practices in Bangladesh: results of a cluster-randomized program evaluation. J Nutr. 2017;147(12):2326–37. doi: 10.3945/jn.117.257303 29021370

29. Nguyen PH, Frongillo EA, Sanghvi T, Wable G, Mahmud Z, Tran LM, et al. Engagement of husbands in a maternal nutrition program substantially contributed to greater intake of micronutrient supplements and dietary diversity during pregnancy: results of a cluster-randomized program evaluation in Bangladesh. J Nutr. 2018;148(8):1352–63. doi: 10.1093/jn/nxy090 29931108

30. Frongillo EA, Nguyen PH, Sanghvi T, Mahmud Z, Aktar B, Alayon S, et al. Nutrition interventions integrated into an existing maternal, neonatal, and child health program reduce food insecurity among recently delivered and pregnant women in Bangladesh. J Nutr. 2019;149(1):159–66. doi: 10.1093/jn/nxy249 30649523

31. Nguyen PH, Huybregts L, Sanghvi TG, Tran LM, Frongillo EA, Menon P, et al. Dietary diversity predicts the adequacy of micronutrient intake in pregnant adolescent girls and women in Bangladesh, but use of the 5-group cutoff poorly identifies individuals with inadequate intake. J Nutr. 2018;148(5):790–7. doi: 10.1093/jn/nxy045 30053285

32. Nguyen PH, Frongillo EA, Sanghvi T, Kim SS, Alayon S, Tran LM, et al. Importance of coverage and quality for impact of nutrition interventions delivered through an existing health programme in Bangladesh. Matern Child Nutr. 2018;14(4):e12613. doi: 10.1111/mcn.12613 29656488

33. Wagner CL, Taylor SN, Dawodu A, Johnson DD, Hollis BW. Vitamin D and its role during pregnancy in attaining optimal health of mother and fetus. Nutrients. 2012;4(3):208–30. doi: 10.3390/nu4030208 22666547

34. Baker BC, Hayes DJ, Jones RL. Effects of micronutrients on placental function: evidence from clinical studies to animal models. Reproduction. 2018;156(3):R69–82. doi: 10.1530/REP-18-0130 29844225

35. Ganguly A, Tamblyn JA, Finn-Sell S, Chan SY, Westwood M, Gupta J, et al. Vitamin D, the placenta and early pregnancy: effects on trophoblast function. J Endocrinol. 2018;236(2):R93–103. doi: 10.1530/JOE-17-0491 29109081

36. Vaivada T, Gaffey MF, Das JK, Bhutta ZA. Evidence-based interventions for improvement of maternal and child nutrition in low-income settings: what’s new? Curr Opin Clin Nutr Metab Care. 2017;20(3):204–10. doi: 10.1097/MCO.0000000000000365 28207425

37. Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA. 2015;314(21):2263–70. doi: 10.1001/jama.2015.15553 26624825

38. Lin PD, Bromage S, Mostofa MG, Allen J, Oken E, Kile ML, et al. Validation of a dish-based semiquantitative food questionnaire in rural Bangladesh. Nutrients. 2017;9(1):E49. doi: 10.3390/nu9010049 28075369

Interní lékařství

Článek vyšel v časopise

PLOS Medicine

2019 Číslo 10
Nejčtenější tento týden
Nejčtenější v tomto čísle

Zvyšte si kvalifikaci online z pohodlí domova

Důležitost adherence při depresivním onemocnění
nový kurz
Autoři: MUDr. Eliška Bartečková, Ph.D.

Koncepce osteologické péče pro gynekology a praktické lékaře
Autoři: MUDr. František Šenk

Sekvenční léčba schizofrenie
Autoři: MUDr. Jana Hořínková, Ph.D.

Hypertenze a hypercholesterolémie – synergický efekt léčby
Autoři: prof. MUDr. Hana Rosolová, DrSc.

Multidisciplinární zkušenosti u pacientů s diabetem
Autoři: Prof. MUDr. Martin Haluzík, DrSc., prof. MUDr. Vojtěch Melenovský, CSc., prof. MUDr. Vladimír Tesař, DrSc.

Všechny kurzy
Zapomenuté heslo

Zadejte e-mailovou adresu, se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.


Nemáte účet?  Registrujte se