Associations between food insecurity in high-income countries and pregnancy outcomes: A systematic review and meta-analysis.

BACKGROUND: Maternal nutrition is crucial for health in pregnancy and across the generations. Experiencing food insecurity during pregnancy is a driver of inequalities in maternal diet with potential maternal and infant health consequences. This systematic review explored associations between food insecurity in pregnancy and maternal and infant health outcomes. METHODS AND FINDINGS: Searches included 8 databases (MEDLINE, Embase, Scopus, Web of Science, PsychInfo, ASSIA, SSPC in ProQuest, and CINAHL), grey literature, forwards and backwards citation chaining, and contacting authors. Studies in high-income countries (HICs) reporting data on food insecurity in pregnancy and maternal or infant health, from January 1, 2008 to November 21, 2023 were included. Screening, data extraction, and quality assessment were carried out independently in duplicate. Random effects meta-analysis was performed when data were suitable for pooling, otherwise narrative synthesis was conducted. The protocol was registered on PROSPERO (CRD42022311669), reported with PRISMA checklist (S1 File). Searches identified 24,223 results and 25 studies (n = 93,871 women) were included: 23 from North America and 2 from Europe. Meta-analysis showed that food insecurity was associated with high stress level (OR 4.07, 95% CI [1.22, 13.55], I2 96.40%), mood disorder (OR 2.53, 95% CI [1.46, 4.39], I2 55.62%), gestational diabetes (OR 1.64, 95% CI [1.37, 1.95], I2 0.00%), but not cesarean delivery (OR 1.42, 95% CI [0.78, 2.60], I2 56.35%), birth weight (MD -58.26 g, 95% CI [-128.02, 11.50], I2 38.41%), small-for-gestational-age (OR 1.20, 95%, CI [0.88, 1.63], I2 44.66%), large-for-gestational-age (OR 0.88, 95% CI [0.70, 1.12] I2 11.93%), preterm delivery (OR 1.18, 95% CI [0.98, 1.42], I2 0.00%), or neonatal intensive care (OR 2.01, 95% CI [0.85, 4.78], I2 70.48%). Narrative synthesis showed food insecurity was significantly associated with dental problems, depression, anxiety, and maternal serum concentration of perfluoro-octane sulfonate. There were no significant associations with other organohalogen chemicals, assisted delivery, postpartum haemorrhage, hospital admissions, length of stay, congenital anomalies, or neonatal morbidity. Mixed associations were reported for preeclampsia, hypertension, and community/resilience measures. CONCLUSIONS: Maternal food insecurity is associated with some adverse pregnancy outcomes, particularly mental health and gestational diabetes. Most included studies were conducted in North America, primarily the United States of America, highlighting a research gap across other contexts. Further research in other HICs is needed to understand these associations within varied contexts, such as those without embedded interventions in place, to help inform policy and care requirements.

Food insecurity among pregnant women living in high-income countries: a systematic review.

BACKGROUND: Food insecurity is an increasingly important public health concern in high-income countries following the 2008 global financial crash, and recently with the COVID-19 pandemic. Food insecurity has been understood as a highly gendered issue, affecting more women than men. As women have more complex nutritional needs because of their menstrual cycle, pregnancy, and breastfeeding, the nutritional impact of food insecurity is also greater for women than for men. This systematic review aims to explore pregnant women's experiences of food insecurity in high-income countries and to understand how food insecurity affects their health, wellbeing, diet, and nutrition. METHODS: We did a systematic review following PRISMA reporting guidelines. A comprehensive search strategy was developed using search terms such as "food insecurity" and "pregnancy outcomes". We searched seven databases (MEDLINE, Embase, Scopus, Web of Science, PsychInfo, ASSIA, and CINAHL), grey literature, reference lists, and citations, as well as contacted authors. No language restrictions were used, and only studies primarily containing data collected from Jan 1, 2008, onwards were included. Database searches were completed in April 2022; supplementary searches are ongoing. Inclusion criteria is based on PECOS. Screening, data extraction, and quality assessment were done by two authors independently. This systematic review is registered on PROSPERO, number CRD42022311669. FINDINGS: 27 studies met the inclusion criteria, with all studies published between 2015 and 2022. 24 (89%) of 27 studies were done in the USA, two (7%) in Canada, and one (4%) in the UK. Outcomes reported include dietary intake or dietary quality during pregnancy (seven [26%] of 27), gestational weight gain (seven [26%]), mental health (five [19%]), pregnancy outcomes including pregnancy complications, preterm birth, or birthweight (five [19%]), and other health outcomes or combination of nutrition, health, and wellbeing (three [11%]). Evidence synthesis is ongoing and will be complete by August, 2022. INTERPRETATION: This systematic review suggests that food insecurity experienced during pregnancy was associated with negative health and nutrition outcomes. The rigorous searches are strengths of this study. A limitation is the restricted focus on studies done from 2008 onward. More research to guide efficient interventions that address food insecurity among pregnant women is needed. FUNDING: None.

Food insecurity during pregnancy in high-income countries, and maternal weight and diet: A systematic review and meta-analysis.

Food insecurity is a well-established obesity driver. Less is known about food insecurity during pregnancy. This review (PROSPERO:CRD42022311669) aimed to explore associations between food insecurity, maternal obesity, gestational weight gain (GWG), and nutrition. Searches included seven databases, gray literature, references, citations, and contacting authors. Observational studies reporting data from January 1st, 2008 to 21 November 2023 in high-income countries were included. Duplicate screening, data extraction, and quality assessments were performed. Random effects meta-analysis estimated odds ratios (OR), mean difference (MD), and 95% confidence intervals (CI). Narrative synthesis was conducted when data could not be pooled. Database searches identified 22,272 results; 20 studies were included (n = 19 North America, n = 1 Europe; n = 32,803 women). Food insecurity significantly increased obesity (OR 1.53 95%CI 1.39, 1.66), but not underweight (OR 1.12 95%CI 0.89, 1.34) or overweight (OR 1.18 95%CI 0.90, 1.46). Food insecurity significantly reduced GWG (MD -0.42 kg 95%CI -0.62, -0.22) and increased inadequate GWG (OR 1.16 95%CI 1.05, 1.28), but not excessive GWG (OR 1.04 95%CI 0.96, 1.13). Diet outcomes were inconsistent, with some evidence of reduced vitamin E and diet quality and increased red/processed meat consumption. Further studies outside of North America are needed to inform practice and policy to support maternal health.

Effectiveness and implementation of lower-intensity weight management interventions delivered by the non-specialist workforce in postnatal women: a mixed-methods systematic review.

Lower-intensity interventions delivered in primary and community care contacts could provide more equitable and scalable weight management support for postnatal women. This mixed-methods systematic review aimed to explore the effectiveness, implementation, and experiences of lower-intensity weight management support delivered by the non-specialist workforce. We included quantitative and qualitative studies of any design that evaluated a lower-intensity weight management intervention delivered by non-specialist workforce in women up to 5 years post-natal, and where intervention effectiveness (weight-related and/or behavioural outcomes), implementation and/or acceptability were reported. PRISMA guidelines were followed, and the review was prospectively registered on PROSPERO (CRD42022371828). Nine electronic databases were searched to identify literature published between database inception to January 2023. This was supplemented with grey literature searches and citation chaining for all included studies and related reviews (completed June 2023). Screening, data extraction and risk of bias assessments were performed in duplicate. Risk of bias was assessed using the Joanna Briggs Institute appraisal tools. Narrative methods were used to synthesise outcomes. Seven unique studies described in 11 reports were included from the Netherlands (n = 2), and the United Kingdom, Germany, Taiwan, Finland, and the United States (n = 1 each). All studies reported weight-related outcomes; four reported diet; four reported physical activity; four reported intervention implementation and process outcomes; and two reported intervention acceptability and experiences. The longest follow-up was 13-months postnatal. Interventions had mixed effects on weight-related outcomes: three studies reported greater weight reduction and/or lower postnatal weight retention in the intervention group, whereas four found no difference or mixed effects. Most studies reporting physical activity or diet outcomes showed no intervention effect, or mixed effects. Interventions were generally perceived as acceptable by women and care providers, although providers had concerns about translation into routine practice. The main limitations of the review were the limited volume of evidence available, and significant heterogeneity in interventions and outcome reporting which limited meaningful comparisons across studies. There is a need for more intervention studies, including process evaluations, with longer follow-up in the postnatal period to understand the role of primary and community care in supporting women's weight management. Public Health Wales was the primary funder of this review.