Integrating nutrition and mental health screening, risk identification and management in prenatal health programs in India.

Pregnancy is a period of major physiologic, hormonal, and psychological change, increasing the risk of nutritional deficiencies and mental disorders. Mental disorders and malnutrition are associated with adverse pregnancy and child outcomes, with potential long-standing impact. Common mental disorders during pregnancy are more prevalent in low- and middle-income countries (LMICs). In India, studies suggest the prevalence of depression is 9.8%-36.7% and of anxiety is 55.7%. India has seen some promising developments in recent years such as increased coverage of the District Mental Health Program; integration of maternal mental health into the Reproductive and Child Health Program in Kerala; and the Mental Health Care Act 2017. However, mental health screening and management protocols have not yet been established and integrated into routine prenatal care in India. A five-action maternal nutrition algorithm was developed and tested for the Ministry of Health and Family Welfare, aiming to strengthen nutrition services for pregnant women in routine prenatal care facilities. In this paper, we present opportunities and challenges for integration of maternal nutrition and mental health screening and a management protocol at routine prenatal care in India, discuss evidence-based interventions in other LMICs including India, and make recommendations for public healthcare providers.

Evaluating implementation of the FIGO Nutrition Checklist for preconception and pregnancy within the Bukhali trial in Soweto, South Africa.

OBJECTIVE: To evaluate implementation of the FIGO Nutrition Checklist in a low/middle-income South African setting. METHODS: This is a mixed-methods study. Following administration of the FIGO Nutrition Checklist by a dietitian between July 2021 and May 2022, quantitative responses from pregnant (n = 96) and nonpregnant (n = 291) participants with overweight or obesity were analyzed, using logistic regression. Qualitative data from in-depth interviews with the dietitian and a subgroup of participants (n = 15) were analyzed using reflexive thematic analysis. RESULTS: Of 387 participants, 97.4% (n = 377) answered 'no' to at least one diet quality question on the FIGO Nutrition Checklist, indicative of an at-risk dietary practice. Food insecurity was positively associated with having more than three at-risk practices (OR 1.87; 95% CI, 1.10-3.18; P = 0.021). Themes from the dietitian interview included ease of use of the checklist; required adaptations to it, including explanation and translation; and benefits of the tool. Despite challenges to healthy nutrition, participant interviews identified that the checklist is acceptable and supported improved awareness of dietary intakes. CONCLUSION: Considering the high incidence of at-risk dietary practices identified by the FIGO Nutrition Checklist in this population, further research into use of the tool across South African healthcare settings is warranted.

Using FIGO Nutrition Checklist counselling in pregnancy: A review to support healthcare professionals.

The period before and during pregnancy is increasingly recognized as an important stage for addressing malnutrition. This can help to reduce the risk of noncommunicable diseases in mothers and passage of risk to their infants. The FIGO Nutrition Checklist is a tool designed to address these issues. The checklist contains questions on specific dietary requirements, body mass index, diet quality, and micronutrients. Through answering these questions, awareness is generated, potential risks are identified, and information is collected that can inform health-promoting conversations between women and their healthcare professionals. The tool can be used across a range of health settings, regions, and life stages. The aim of this review is to summarize nutritional recommendations related to the FIGO Nutrition Checklist to support healthcare providers using it in practice. Included is a selection of global dietary recommendations for each of the components of the checklist and practical insights from countries that have used it. Implementation of the FIGO Nutrition Checklist will help identify potential nutritional deficiencies in women so that they can be addressed by healthcare providers. This has potential longstanding benefits for mothers and their children, across generations.

Addressing reproductive health needs across the life course: an integrated, community-based model combining contraception and preconception care.

Prevention of pregnancy (contraception) and preparation for pregnancy (preconception care) are services that most people need during their reproductive life course. Despite increased attention, and growing recognition that health before pregnancy is crucial to addressing disparities in maternity outcomes, service provision is far from routine. We bring together evidence from the literature, new quantitative and qualitative data on women's preferences, and case studies of existing practice, to develop an integrated, community-based model that synthesises reproductive life planning, contraception, and preconception care. Our model provides a holistic, life course approach, encompassing school-based education, social media, and national campaigns, and highlights the need for training and system-level support for the range of health-care professionals who can deliver it. This high-level model can be adapted across settings, leading to a step change in the provision of preconception care in the community with consequent improvements in health and wellbeing, and reductions in inequalities at population level.

Acceptability of the FIGO Nutrition Checklist in Preconception and Early Pregnancy to Assess Nutritional Status and Prevent Excess Gestational Weight Gain: A Study of Women and Healthcare Practitioners in the UK.

Optimum nutrition and weight before and during pregnancy are associated with a lower risk of conditions such as pre-eclampsia and gestational diabetes. There is a lack of user-friendly tools in most clinical settings to support healthcare practitioners (HCPs) in implementing them. This study aimed to evaluate the acceptability of (1) using a nutrition checklist designed by the International Federation of Gynecology and Obstetrics (FIGO) for nutritional screening of women in the preconception and early pregnancy period and (2) routine discussion of nutrition and weight in clinical care. An online cross-sectional survey was conducted with women (aged 18-45) and HCPs (e.g., general practitioners, obstetricians, and midwives). Quantitative statistical analysis and qualitative content analysis were performed. The concept and content of the checklist were acceptable to women (n = 251) and HCPs (n = 47) (over 80% in both groups). Several barriers exist to implementation such as lack of time, training for HCPs, and the need for sensitive and non-stigmatizing communication. Routine discussion of nutrition was considered important by both groups; however, results suggest that nutrition is not regularly discussed in perinatal visits in the UK. The FIGO nutrition checklist presents a valuable resource for use in clinical practice, offering long-term and intergenerational benefits for both mother and baby.

Population estimates and determinants of severe maternal thinness in India.

OBJECTIVE: To examine prevalence, risk factors, and consequences of maternal severe thinness in India. METHODS: This mixed methods study analyzed data from the Indian National Family Health Survey (NFHS)-4 (2015-2016) to estimate the prevalence of and risk factors for severe thinness, followed by a desk review of literature from India. RESULTS: Prevalence of severe thinness (defined by World Health Organization as body mass index [BMI] <16 in adult and BMI for age Z score < -2 SD in adolescents) was higher among pregnant adolescents (4.3%) compared with pregnant adult women (1.9%) and among postpartum adolescent women (6.3%) than postpartum adult women (2.4%) 2-6 months after delivery. Identified research studies showed prevalence of 4%-12% in pregnant women. Only 13/640 districts had at least three cases of severely thin pregnant women; others had lower numbers. Three or more postpartum women aged ≥20 years were severely thin in 32 districts. Among pregnant adolescents, earlier parity increased odds (OR 1.96; 95% CI, 1.18-3.27) of severe thinness. Access to household toilet facility reduced odds (OR 0.72; 95% CI, 0.52-0.99]. Among mothers aged ≥20 years, increasing education level was associated with decreasing odds of severe thinness (secondary: OR 0.74; 95% CI, 0.57-0.96 and Higher: OR 0.54; 95% CI, 0.32-0.91, compared with no education); household wealth and caste were also associated with severe thinness. CONCLUSION: This paper reveals the geographic pockets that need priority focus for managing severe thinness among pregnant women and mothers in India to limit the immediate and intergenerational adverse consequences emanating from these deprivations.

Screening and management options for severe thinness during pregnancy in India.

This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources.

A systematic review and meta-analysis of school-based interventions with health education to reduce body mass index in adolescents aged 10 to 19 years.

BACKGROUND: Adolescents are increasingly susceptible to obesity, and thus at risk of later non-communicable diseases, due to changes in food choices, physical activity levels and exposure to an obesogenic environment. This review aimed to synthesize the literature investigating the effectiveness of health education interventions delivered in school settings to prevent overweight and obesity and/ or reduce BMI in adolescents, and to explore the key features of effectiveness. METHODS: A systematic search of electronic databases including MEDLINE, CINAHL, PsychINFO and ERIC for papers published from Jan 2006 was carried out in 2020, following PRISMA guidelines. Studies that evaluated health education interventions in 10-19-year-olds delivered in schools in high-income countries, with a control group and reported BMI/BMI z-score were selected. Three researchers screened titles and abstracts, conducted data extraction and assessed quality of the full text publications. A third of the papers from each set were cross-checked by another reviewer. A meta-analysis of a sub-set of studies was conducted for BMI z-score. RESULTS: Thirty-three interventions based on 39 publications were included in the review. Most studies evaluated multi-component interventions using health education to improve behaviours related to diet, physical activity and body composition measures. Fourteen interventions were associated with reduced BMI/BMI z-score. Most interventions (n = 22) were delivered by teachers in classroom settings, 19 of which trained teachers before the intervention. The multi-component interventions (n = 26) included strategies such as environment modifications (n = 10), digital interventions (n = 15) and parent involvement (n = 16). Fourteen studies had a low risk of bias, followed by 10 with medium and nine with a high risk of bias. Fourteen studies were included in a random-effects meta-analysis for BMI z-score. The pooled estimate of this meta-analysis showed a small difference between intervention and control in change in BMI z-score (- 0.06 [95% CI -0.10, - 0.03]). A funnel plot indicated that some degree of publication bias was operating, and hence the effect size might be inflated. CONCLUSIONS: Findings from our review suggest that school-based health education interventions have the public health potential to lower BMI towards a healthier range in adolescents. Multi-component interventions involving key stakeholders such as teachers and parents and digital components are a promising strategy.

Building resilient societies after COVID-19: the case for investing in maternal, neonatal, and child health.

Resilient societies respond rapidly and effectively to health challenges and the associated economic consequences, and adapt to be more responsive to future challenges. Although it is only possible to recognise resilience retrospectively, the COVID-19 pandemic has occurred at a point in human history when, uniquely, sufficient knowledge is available on the early-life determinants of health to indicate clearly that a focus on maternal, neonatal, and child health (MNCH) will promote later resilience. This knowledge offers an unprecedented opportunity to disrupt entrenched strategies and to reinvest in MNCH in the post-COVID-19 so-called new normal. Furthermore, analysis of the short-term, medium-term, and longer-term consequences of previous socioeconomic shocks provides important insights into those domains of MNCH, such as neurocognitive development and nutrition, for which investment will generate the greatest benefit. Such considerations apply to high-income countries (HICs) and low-income and middle-income countries (LMICs). However, implementing appropriate policies in the post-COVID-19 recovery period will be challenging and requires political commitment and public engagement.

Prevention of noncommunicable diseases by interventions in the preconception period: A FIGO position paper for action by healthcare practitioners.

With the increase in obesity prevalence among women of reproductive age globally, the risks of type 2 diabetes, gestational diabetes, pre-eclampsia, and other conditions are rising, with detrimental effects on maternal and newborn health. The period before pregnancy is increasingly recognized as crucial for addressing weight management and reducing malnutrition (both under- and overnutrition) in both parents to reduce the risk of noncommunicable diseases (NCDs) in the mother as well as the passage of risk to her offspring. Healthcare practitioners, including obstetricians, gynecologists, midwives, and general practitioners, have an important role to play in supporting women in planning a pregnancy and achieving healthy nutrition and weight before pregnancy. In this position paper, the FIGO Pregnancy Obesity and Nutrition Initiative provides an overview of the evidence for preconception clinical guidelines to reduce the risk of NCDs in mothers and their offspring. It encourages healthcare practitioners to initiate a dialogue on women's health, nutrition, and weight management before conception. While acknowledging the fundamental importance of the wider social and environmental determinants of health, this paper focuses on a simple set of recommendations for clinical practice that can be used even in short consultations. The recommendations can be contextualized based on local cultural and dietary practices as part of a system-wide public health approach to influence the wider determinants as well as individual factors influencing preconception health.

Examining the use of the FIGO Nutrition Checklist in routine antenatal practice: multistakeholder feedback to implementation.

OBJECTIVE: To gain insights from pregnant women and obstetricians on the utility of the FIGO Nutrition Checklist in antenatal practice. METHODS: Women were recruited from the antenatal department of a large tertiary-level university maternity hospital in Dublin, Ireland, between October and December 2019. Participants completed the FIGO Nutrition Checklist before their routine antenatal appointment. Obstetricians and women were encouraged to discuss the FIGO Nutrition Checklist during the clinical visit. Completed FIGO Nutrition Checklists were collected after appointments. Acceptability was assessed through questionnaires. RESULTS: The majority (80.0%) of women answered "No" to at least one diet quality question, indicating a potential nutritional risk. While none of the participating obstetricians routinely discussed nutrition with women, all agreed that using the Checklist encouraged them to address nutrition with pregnant women. Nearly every woman (99.0%) found the Checklist quick to complete; however, all participating obstetricians felt there was not enough time to discuss it in routine practice. Despite this, most obstetricians and pregnant women recommended the FIGO Nutrition Checklist for use. CONCLUSION: The FIGO Nutrition Checklist is acceptable for use in routine antenatal practice in tertiary care settings. It helped identify potentially at-risk women during early pregnancy and facilitated conversations related to optimum diet.

"It only takes two minutes to ask"-a qualitative study with women on using the FIGO Nutrition Checklist in pregnancy.

OBJECTIVE: To gain an in-depth understanding of how the FIGO Nutrition Checklist could work in clinical practice, from the perspective of pregnant women. METHODS: This qualitative study was part of a pilot study of the FIGO Nutrition Checklist in the antenatal department of a tertiary-level university maternity hospital in Dublin, Ireland. Individual semistructured phone interviews were conducted with pregnant women who had completed the FIGO Nutrition Checklist as part of the pilot. Interviews were transcribed verbatim and analyzed using content analysis after manual coding of transcripts. Themes and subthemes are described. RESULTS: Ten interviews were completed. Subthemes related to the FIGO Nutrition Checklist emerged including ease of use and comprehension. Participants discussed how the tool could add value to their appointment by supporting initiation of nutrition conversations and highlighting nutritional issues. The first trimester was identified as the highest priority for using the FIGO Nutrition Checklist. The convenience of having nutrition addressed as part of standard care, rather than a separate appointment, also emerged. CONCLUSION: Women in this study had a desire for nutrition and weight to be addressed by clinicians during routine antenatal appointments. The findings support using the FIGO Nutrition Checklist to address this.

Do the concepts of "life course approach" and "developmental origins of health and disease" underpin current maternity care? Study protocol.

OBJECTIVE: To explore the knowledge of Developmental Origins of Health and Disease (DOHaD) concepts among midwives and obstetricians and to identify barriers and facilitators for clinicians to engage women and their partners before or early in pregnancy on risk factors associated with DOHaD, and thus to embed the concept of DOHaD in routine clinical practice. METHODS: A qualitative study using semi-structured interviews will be conducted in Ghana, India, Pakistan, Brazil, the UK, and USA in collaboration with the International Confederation of Midwives and the International Federation of Obstetricians and Gynecologists. Participants will be contacted via email and telephone interviews will be conducted until data saturation followed by inductive thematic analysis. RESULTS: Findings from this exploratory study will provide new knowledge about the perspectives of midwives and obstetricians on DOHaD and their role in preventing the intergenerational passage of non-communicable disease (NCD) risk and improving preconception care. CONCLUSION: This study will help us understand the current use of DOHaD principles in international maternity care and how this can be improved. Bringing DOHaD to clinical practice will help healthcare practitioners adopt a long-term approach in the prevention of NCDs and childhood obesity and will help women to enter pregnancy in optimum health.

The FIGO Pregnancy Obesity and Nutrition Initiative (PONI).

The activities of the FIGO Pregnancy Obesity and Nutrition Initiative are aimed at reducing all types of malnutrition in women before, during and after pregnancy.

PREgnancy Nutrition: A protocol for the development of a Core Outcome Set (PRENCOS).

OBJECTIVE: To develop a Core Outcome Set (COS) for pregnancy nutrition research that is relevant to varied stakeholders and resource settings. METHODS: This study has three distinct phases. The first phase involves generating a list of outcomes for consideration for the COS. This includes a systematic review of studies evaluating nutrition during pregnancy where all outcomes reported in relevant literature will be extracted. Qualitative interviews with currently or previously pregnant women will also be conducted. This step will supplement the findings of the systematic review by identifying additional outcomes of importance to this stakeholder group. In the second phase of the study, healthcare professionals, researchers, and mothers from various international resource settings will be invited to participate in a two-round modified Delphi survey. The aim of the survey is to gain consensus on which outcomes are most important to include in the COS. Finally, a face-face consensus meeting will be held with a select group of participants to finalize the COS. CONCLUSION: This COS will support standardization of outcome reporting in pregnancy nutrition research and ensure that selected outcomes are considered important by a variety of stakeholders. This will enhance the evidence behind nutrition interventions in pregnancy to improve outcomes for pregnant women.

Narrative review of reviews of preconception interventions to prevent an increased risk of obesity and non-communicable diseases in children.

Evidence for the effect of preconception and periconceptional risk factors on childhood outcomes such as obesity and other non-communicable diseases (NCDs) in later life is growing. Issues such as maternal malnutrition need to be addressed before pregnancy, to prevent a transgenerational passage of risk of NCDs. The aim of this review was to evidence for preconception interventions to prevent obesity and other risk factors for NCDs in children. A search for systematic reviews of interventions in the preconception period published between 2006 and 2018 was conducted on academic databases. Fifteen reviews were included, two of the reviews also included pregnant women. None of the reviews directly reported on obesity or NCD outcomes in children. Results suggest that exercise- and diet-based interventions significantly reduced maternal weight postpartum, weight gain during pregnancy, and improved prevention and control of gestational diabetes. Balanced protein energy supplementation during and before pregnancy was associated with an increase in mean birth weight and reduction of low birth weight babies. There is a dearth of evidence for preconception programmes that follow up on childhood outcomes related to a risk of NCDs. Nevertheless, results suggest that women who received preconception interventions were more likely to have improved pregnancy-related and behavioural outcomes.

What quantitative and qualitative methods have been developed to measure the implementation of a life-course approach in public health policies at the national level?

A life-course approach to health and well-being has become a pillar in health policy-making; for example, Member States of the WHO European Region in the 2015 Minsk Declaration resolved to make greater use of a life-course approach in health policies. However, strategies for implementation of a life-course approach, and a plan for monitoring and evaluating this implementation, are lacking. This scoping review identified a lack of literature with a focus on measurement of the implementation of a life-course approach. The report provides suggestions from research on a life-course approach in public health interventions and national-level strategies that could aid policy-makers in developing a measurement framework. For example, Member States using a life-course approach in policy at a population level could report on existing interventions in key stages of the life-course using existing survey platforms and routinely collected quantitative data. Ideally, a monitoring and evaluation framework collecting data longitudinally across different life stages over time should be created for Member States.

What quantitative and qualitative methods have been developed to measure the implementation of a life-course approach in public health policies at the national level?

A life-course approach to health and well-being has become a pillar in health policy-making; for example, Member States of the WHO European Region in the 2015 Minsk Declaration resolved to make greater use of a life-course approach in health policies. However, strategies for implementation of a life-course approach, and a plan for monitoring and evaluating this implementation, are lacking. This scoping review identified a lack of literature with a focus on measurement of the implementation of a life-course approach. The report provides suggestions from research on a life-course approach in public health interventions and national-level strategies that could aid policy-makers in developing a measurement framework. For example, Member States using a life-course approach in policy at a population level could report on existing interventions in key stages of the life-course using existing survey platforms and routinely collected quantitative data. Ideally, a monitoring and evaluation framework collecting data longitudinally across different life stages over time should be created for Member States.