Sharada Ram Shrestha

Double blind, cluster randomised trial of low dose supplementation with vitamin A or β carotene on mortality related to pregnancy in Nepal

Abstract Objective: To assess the impact on mortality related to pregnancy of supplementing women of reproductive age each week with a recommended dietary allowance of vitamin A, either preformed or as βcarotene. Design: Double blind, cluster randomised, placebo controlled field trial. Setting: Rural southeast central plains of Nepal (Sarlahi district). Subjects: 44646 married women, of whom 20119 became pregnant 22189 times. Intervention: 270 wards randomised to 3groups of 90each for women to receive weekly a single oral supplement of placebo, vitamin A (7000¼g retinol equivalents) or βcarotene (42mg, or 7000¼g retinol equivalents) for over 31/2 years. Main outcome measures: All cause mortality in women during pregnancy up to 12weekspost partum (pregnancy related mortality) and mortality during pregnancy to 6weeks postpartum, excluding deaths apparently related to injury (maternal mortality). Results: Mortality related to pregnancy in the placebo, vitamin A, and βcarotene groups was 704,426,and 361deaths per 100000 pregnancies, yielding relative risks (95% confidence intervals) of 0.60(0.37to 0.97) and 0.51(0.30to 0.86). This represented reductions of 40% (P<0.04)and 49% (P<0.01) among those who received vitamin A and βcarotene. Combined, vitaminA or βcarotene lowered mortality by 44% (0.56(0.37to 0.84), P<0.005) and reduced the maternal mortality ratio from 645to 385deaths per 100000 live births, or by 40% (P<0.02). Differences in cause of death could not be reliably distinguished between supplemented and placebo groups. Conclusion: Supplementation of women with either vitamin A or βcarotene at recommended dietary amounts during childbearing years can lower mortality related to pregnancy in rural, undernourished populations of south Asia.

Effects of alternative maternal micronutrient supplements on low birth weight in rural Nepal: double blind randomised community trial

Abstract Objective: To assess the impact on birth size and risk of low birth weight of alternative combinations of micronutrients given to pregnant women. Design: Double blind cluster randomised controlled trial. Setting: Rural community in south eastern Nepal. Participants: 4926 pregnant women and 4130 live born infants. Interventions: 426 communities were randomised to five regimens in which pregnant women received daily supplements of folic acid, folic acid-iron, folic acid-iron-zinc, or multiple micronutrients all given with vitamin A, or vitamin A alone (control). Main outcome measures: Birth weight, length, and head and chest circumference assessed within 72 hours of birth. Low birth weight was defined <2500 g. Results: Supplementation with maternal folic acid alone had no effect on birth size. Folic acid-iron increased mean birth weight by 37 g (95% confidence interval −16 g to 90 g) and reduced the percentage of low birthweight babies (<2500 g) from 43% to 34% (16%; relative risk=0.84, 0.72 to 0.99). Folic acid-iron-zinc had no effect on birth size compared with controls. Multiple micronutrient supplementation increased birth weight by 64 g (12 g to 115 g) and reduced the percentage of low birthweight babies by 14% (0.86, 0.74 to 0.99). None of the supplement combinations reduced the incidence of preterm births. Folic acid-iron and multiple micronutrients increased head and chest circumference of babies, but not length. Conclusions: Antenatal folic acid-iron supplements modestly reduce the risk of low birth weight. Multiple micronutrients confer no additional benefit over folic acid-iron in reducing this risk. What is already known on this topic Deficiencies in micronutrients are common in women in developing countries and have been associated with low birth weight and preterm delivery What this study adds In rural Nepal maternal supplementation with folic acid-iron reduced the incidence of low birth weight by 16% A multiple micronutrient supplement of 14 micronutrients, including folic acid, iron, and zinc, reduced low birth weight by 14%, thus conferring no advantage over folic acid-iron

Young maternal age and the risk of neonatal mortality in rural Nepal.

OBJECTIVES To investigate the relationship between adolescent pregnancy and neonatal mortality in a nutritionally deprived population in rural Nepal, and to determine mechanisms through which low maternal age may affect neonatal mortality. DESIGN Nested cohort study using data from a population-based, cluster-randomized, placebo-controlled trial of newborn skin and umbilical cord cleansing with chlorhexidine. SETTING Sarlahi District of Nepal. PARTICIPANTS Live-born singleton infants of mothers younger than 25 years who were either parity 0 or 1 (n = 10,745). MAIN EXPOSURE Maternal age at birth of offspring. OUTCOME MEASURE Crude and adjusted odds ratios of neonatal mortality by maternal age category. RESULTS Infants born to mothers aged 12 to 15 years were at a higher risk of neonatal mortality than those born to women aged 20 to 24 years (odds ratio, 2.24; 95% confidence interval, 1.40-3.59). After adjustment for confounders, there was a 53% excess risk of neonatal mortality among infants born to mothers in the youngest vs oldest age category (1.53; 0.90-2.60). This association was attenuated on further adjustment for low birth weight, preterm birth, or small-for-gestational-age births. CONCLUSIONS The higher risk of neonatal mortality among younger mothers in this setting is partially explained by differences in socioeconomic factors in younger vs older mothers; risk is mediated primarily through preterm delivery, low birth weight, newborns being small for gestational age, and/or some interaction of these variables. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00109616.

Determinants of Maternal Vitamin A or Beta-Carotene Supplementation Coverage: Village-Based Female Distributors in Nepal

Success rates of community-based micronutrient supplementation programs may be enhanced if local residents take primary responsibility for distribution of supplements. Hence this study attempts to identify such characteristics among village-based women hired to deliver nutritional supplements to women of childbearing age in Nepal. Between 1994 and 1997 a community randomized placebo trial was conducted in the Sarlahi district to assess the impact on maternal and infant health and survival of weekly supplementation among 44646 women of childbearing age. Overall results show that successful supplement distribution can depend on factors external to the distributor as well as personal attributes such as age and literacy. Illiterate distributors may have related better to women who were more like themselves leading to increased compliance. Recipient characteristics that predicted higher coverage rates included older age and higher parity previous history of child deaths and lower socioeconomic status. Furthermore it is noted that compliance is higher among distributors who are similar to recipients in terms of education level.

Impact of providing a small income on women's nutritional status and household food expenditures in rural Nepal

This study evaluated the impact of providing a small income on the household food expenditures and nutritional status of women employed part-time in a health project. A prospective, nonrandomized, unmasked, controlled trial was conducted in Sarlahi District in rural southeastern Nepal. The study subjects were 870 women who applied for a job with a project distributing nutritional supplements in their villages. Of these women, 736 (85%) completed the two-year follow-up; 341 were hired for the job and 395 were not hired. The intervention consisted of part-time employment that provided a small income, and the outcome was the two-year change in mid-upper-arm circumference (MUAC) and household food expenditures after adjustment for baseline demographic and socioeconomic differences. The women who were hired were younger and better educated than those who were not hired, but in other respects the two groups of women were similar. After adjustment for these baseline differences, the change in MUAC was not significantly different between the two groups of women. The two groups of women also had similar two-year changes in total household food expenditures and in expenditures on meat, clarified butter, fish, eggs, milk, and vegetables. There was a decline in the proportion of households buying milk and ghee, and the decline was significantly smaller in the households of women who were hired. Although employment by the project did not appear to affect the nutritional status of the women or change their overall expenditure on food, households of women who were hired were more likely to be able to continue to buy certain higher-status foods that could have a nutritional benefit for other household members.