Closing the gender nutrition gap: Addressing micronutrient deficiencies in pregnancy

But safe, cost-effective interventions such as multiple micronutrient supplementation (MMS) can be used to bridge the gender nutrition gap, argued experts at the Women Deliver conference, held in the Rwandan capital, Kigali, last month.

MMS: A safe, cost-efficient, and highly effective intervention

Dr Mairo Mandara is the Africa adviser for the non-profit organisation Sight and Life, which launched a special report on MMS alongside the event.

During a panel discussion exploring how ensuring equity in access to MMS could improve pregnancy outcomes for women in LMICs, she highlighted how seven in 10 women of reproductive age worldwide have at least one micronutrient deficiency. In LMICs, this figure rises to nine in 10.

Diets lacking in key nutrients such as iodine, iron, folate, calcium, and zinc can cause anaemia, pre-eclampsia, haemorrhage, and death in mothers, according to UNICEF, and can lead to stillbirth, low birthweight, wasting, and developmental delays in children.

It is, therefore, imperative that pregnant women are encouraged to attend antenatal care and receive support from well-trained healthcare providers, Mandara said.

MMS – which contain 15 essential vitamins and minerals that a woman needs during pregnancy – have been proven to be “safe, cost-effective, and highly effective in improving nutritional status of the women and improving pregnancy outcomes”, explained Saskia Osendarp, executive director of the Micronutrient Forum.

“We have interventions that can tackle maternal micronutrient deficiencies – we have cost-effective, safe interventions that are able to improve the nutritional status of pregnant women,” she added. “And when combined with interventions that address these inequalities between gender, they have the potential to really close this gender nutrition gap.”

Madnara said ensuring access to MMS was an issue of female empowerment. “Pregnant women should be empowered to be in control of the health of their unborn babies, and above all, determine the future of their unborn babies,” she said.

Building the evidence base for MMS intervention

Emily Mates, maternal and nutritional nutrition specialist at UNICEF, highlighted research schemes that the charity is supporting in countries such as Bangladesh, Burkina Faso, Madagascar, and Tanzania.

“We're looking at how MMS can be used as a lever, as a catalyst, to improve antenatal care services,” she said.

Results from these projects are planned for publication towards the end of this year, with the hope that they will influence changes to MMS recommendations, which are currently restricted in a development context.

“We are working to build the evidence base so that the next time the guideline development group meets we will be able to present … a basket of evidence that really demands a change in the recommendations to ensure that all women across LMICs have a chance to access this excellent product,” Mates said.

She highlighted how widespread access was in some regions compared to others.

“Women in high-income countries have been taking prenatal vitamins for decades – you can go to the pharmacy and buy as many as you like,” she said. “But… sometimes it feels like we require maybe a higher level of evidence for women in LMICs, which isn't right.”

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UNICEF is developing an acceleration plan for improving nutrition during pregnancy, with publication planned for September.

MMS rollout: Spotlight on Ethiopia and Tanzania

Dr Abeba Ayele, manager for child health and development at the Children's Investment Fund Foundation, outlined a pilot programme taking place in Ethiopia, where malnutrition is a significant burden.

One in five women of reproductive age is malnourished, meaning deficiencies in one or more micronutrients and folic acid are “very, very significant” in women of reproductive age, she said.

However, the pilot – which aims to deliver six-month supplies of MMS to 400,000 women in 21 districts – provides an opportunity “to strengthen the whole antenatal care platform”, she added.

Service delivery started in November last year, with 54,000 women reached so far.

“We have a very strong learning agenda,” Ayele explained. “[…B]ecause this is a demonstration project, we want to document the progress the challenges and successes [along the] way.”

Dr Geofrey Mchau, head of nutrition and epidemiology at the Tanzania Food and Nutrition Centre, outlined its work to gather evidence on pregnant women’s preference for MMS over iron-folic acid (IFA) therapy.

In Tanzania, IFA uptake stands at just 29%, while six in ten pregnant women suffer from iron deficiency – a major contributing factor to the country’s high maternal death rate

“Most of the pregnant women are not aware of the benefits behind folic acid, regardless of the defects they still face during their pregnancies,” said Mchau, highlighting the social and cultural drivers that were contributing to low uptake.

“For example, [if] you're living with your grandmother and your aunt, they'll say, ‘Don’t go to the health facilities, it’s OK – you'll be fine,’” he explained. “So [pregnant women] are coming too late, they’re coming in the second trimester – so even if you give them folic acid, it will not work.”

Translating MMS research into policy

With the evidence gathered, what more is needed to translate these findings into practice? Danielle Porfido, associate director of global advocacy at the Eleanor Crook Foundation, said it was necessary to “deliver a clear ask”.

She added: “That could be telling your policymaker to include MMS on your essential medicines list in your country, that could be asking your policymaker to seek out more opportunities to start introducing MMS through some research programmes – I think there's a lot of interested philanthropies that are looking to partner with countries that want to be introducing MMS…

“We need advocates not just working on nutrition, but advocates that care about women's health, that care about maternal health and gender equality, to start to take up this issue.”

Mandara said: “Every pregnant woman has a fundamental right to have a healthy baby, regardless of where you live.”