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Maternal Supplementation and Birth Outcomes: The Women First Trial

2/11/2020 5:25:35 PM
hands.jpgStunting of fetal growth is a major health challenge in poor communities worldwide. Shorter newborn length and lower birth weight are associated with an increased disease burden throughout childhood and long-term. Although the environmental factors contributing to stunting are complex, maternal undernutrition undoubtedly compromises fetal growth.  
Previous studies have suggested that improved nutrition during pregnancy supports better birth outcomes. Whether beginning nutritional interventions before conception offers any greater advantage than beginning the interventions during pregnancy has not been well studied. To explore this question, researchers at the University of Colorado undertook a trial known as “Women First.”

Study examines diets and growth rates

Women First was a randomized controlled trial conducted at 4 sites in 3 countries around the globe: the Democratic Republic of Congo, Guatemala, and India. All of the sites were resource-poor rural or semirural populations, where there was a high prevalence of stunting. The women’s diets in these locations were primarily based on staples like grains and tubers, with little dietary diversity. Women between the ages of 16 and 35 who expected to conceive within the next 18 months were enrolled in the study—without any screening for undernutrition.

Women were randomized to one of 3 arms. Arm 1 started supplementation at least 3 months before conception and continued until delivery. Arm 2 started supplementation late in the first trimester and continued until delivery. Arm 3 received no supplementation from the study. The supplement was a lipid-based micronutrient supplement (Nutriset), which provided micronutrients, polyunsaturated fatty acids, 2.6 grams of protein, and 118 calories. Women who were underweight received additional supplementation that provided 11 grams of protein and 300 calories.
The primary outcome measure was the newborn length-for-age z score (LAZ), which was the length measurement obtained before 48 hours of age. Secondary outcomes included weight-for-age, weight-to-length ratio-for-age, small-for-gestational-age, and preterm birth.
Delivery outcomes were available for a total of 3188 infants. The mean LAZ was significantly higher for arm 1 than for arm 3 for all sites combined as well as for the Democratic Republic of Congo and Pakistan (p < .01). The effect size was low for all sites combined (effect size: +0.19; 95% CI, 0.08-0.30; p = 0.0008) and moderate for the 2 individual countries (0.20-0.39).

Supplements can benefit low-resource populations

For neither all sites combined, nor any individual site, was the LAZ for arm 1 significantly greater than the LAZ for arm 2. This indicated that supplementation before conception did not provide greater benefit than initiating supplementation towards the end of the first trimester. 
For the secondary outcomes, when arm 1 was compared with arm 3, improvements were seen in the rates of stunting (RR: 0.69; 95% CI, 0.49-0.98, p = .0361) and small-for-gestational-age (RR: 0.78; 95% CI, 0.70-0.88, p < .001). There were no differences in the rates of preterm birth.
This study failed to support the hypothesis that supplementation before conception would offer an advantage over supplementation during pregnancy. However, the study still succeeded in showing that nutritional supplementation initiated either before conception or late in the first trimester resulted in greater birth size and improvements in the rate of stunting in comparison with the control. The improvements were achieved without any nutritional education or attention to other environmental factors. The study supports a beneficial role for nutritional supplementation in women before or during pregnancy in low-resource populations.
Hambidge KM, Westcott JE, Garc├ęs A et al. A multicountry randomized controlled trial of comprehensive maternal nutrition supplementation initiated before conception: the Women First trial. Am J Clin Nutr. 2019; 109: 457-469.