Predictors for achieving adequate antenatal care visits during pregnancy: a cross-sectional study in rural Northwest Rwanda.

BACKGROUND: Inadequate antenatal care (ANC) in low-income countries has been identified as a risk factor for poor pregnancy outcome. While many countries, including Rwanda, have near universal ANC coverage, a significant proportion of pregnant women do not achieve the recommended regimen of four ANC visits. The present study aimed to explore the factors associated with achieving the recommendation, with an emphasis on the distance from household to health facilities. METHODS: A geo-referenced cross-sectional study was conducted in Rutsiro district, Western province of Rwanda with 360 randomly selected women. Multiple logistic regression analysis including adjusted odd ratio (aOR) were performed to identify factors associated with achieving the recommended four ANC visits. RESULTS: The majority (65.3%) of women had less than four ANC visits during pregnancy. We found a significant and negative association between distance from household to health facility and achieving the recommended four ANC visits. As the distance increased by 1 km, the odds of achieving the four ANC visits decreased by 19% (aOR = 0.81, P = 0.024). The odds of achieving the recommended four ANC visits were nearly two times higher among mothers with secondary education compared with mothers with primary education or less (aOR = 1.90, P = 0.038). In addition, mothers who responded that their household members always seek health care when necessary had 1.7 times higher odds of achieving four ANC visits compared with those who responded as unable to seek health care (aOR = 1.7, P = 0.041). Furthermore, mothers from poor households had 2.1 times lower odds of achieving four ANC visits than mothers from slightly better-off households (aOR = 2.1, P = 0.028). CONCLUSIONS: Findings from the present study suggest that, in Rutsiro district, travel distance to health facility, coupled with socio-economic constraints, including low education and poverty can make it difficult for pregnant women to achieve the recommended ANC regimen. Innovative strategies are needed to decrease distance by bringing ANC services closer to pregnant women and to enhance ANC seeking behaviour. Interventions should also focus on supporting women to attain at least secondary education level as well as to improve the household socioeconomic status of pregnant women, with a particular focus on women from poor households.

Iodine status of postpartum women and their infants aged 3, 6 and 12 months: Mother and Infant Nutrition Investigation (MINI).

To alleviate the re-emergence of iodine deficiency in New Zealand, two strategies, the mandatory fortification of bread with iodised salt (2009) and a government-subsidised iodine supplement for breast-feeding women (2010), were introduced. Few studies have investigated mother and infant iodine status during the first postpartum year; this study aimed to describe iodine status of mothers and infants at 3, 6 and 12 months postpartum (3MPP, 6MPP and 12MPP, respectively). Partitioning of iodine excretion between urine and breast milk of exclusive breast-feeding (EBF) women at 3MPP was determined. In total, eighty-seven mother-infant pairs participated in the study. Maternal and infant spot urinary iodine concentration (UIC) and breast milk iodine concentration (BMIC) were determined. The percentage of women who took iodine-containing supplements decreased from 46 % at 3MPP to 6 % at 12MPP. Maternal median UIC (MUIC) at 3MPP (82 (46, 157) µg/l), 6MPP (85 (43, 134) µg/l) and 12MPP (95 (51, 169) µg/l) were <100 µg/l. The use of iodine-containing supplements increased MUIC and BMIC only at 3MPP. Median BMIC at all time points were below 75 µg/l. Infant MUIC at 3MPP (115 (69, 182) µg/l) and 6MPP (120 (60, 196) µg/l) were below 125 µg/l. Among EBF women at 3MPP, an increased partitioning of iodine into breast milk (highest proportion 60 %) was shown at lower iodine intakes, along with a reduced fractional iodine excretion in urine (lowest proportion 40 %), indicating a protective mechanism for breastfed infants' iodine status. In conclusion, this cohort of postpartum women was iodine-deficient. Iodine status of their breastfed infants was suboptimal. Lactating women who do not consume iodine-rich foods and those who become pregnant again should take iodine-containing supplements.

Prevalence of thyroid dysfunction in postpartum women with suboptimal iodine and selenium and adequate iron status.

OBJECTIVE: Postpartum women experience thyroid dysfunction at twice the prevalence of the general population. Adequate biosynthesis of thyroid hormones depends on three trace elements: iodine, selenium and iron. This study aimed to investigate thyroid dysfunction within a cohort of women at six months postpartum in relation to iodine, selenium and iron status. DESIGN: This cross-sectional study was part of an observational longitudinal cohort Mother and Infant Nutrition Investigation; data obtained at six months postpartum are reported. SUBJECTS: Mother-infant pairs (n = 87) were recruited at three months postpartum and followed up at six months postpartum (n = 78). MEASUREMENTS: Thyroid hormones (free triiodothyronine, free thyroxine, thyroid-stimulating hormone) and thyroid peroxidase antibodies were measured. Urinary iodine concentration, breast milk iodine concentration, serum thyroglobulin, plasma selenium, serum ferritin and serum soluble transferrin receptors were determined. Nonparametric data were expressed as median (25th, 75th percentile). RESULTS: Thyroid dysfunction was found in 18% of women, and 4% of women had iron deficiency. Median urinary iodine concentration was 85 (43, 134) µg/L, median breast milk iodine concentration was 59 (39, 109) µg/L, and median serum thyroglobulin at 11.4 (8.6, 18.6) µg/L, indicating iodine deficiency. Median plasma selenium concentration was 105.8 (95.6, 115.3) µg/L. Women with marginally lower plasma selenium concentration were 1.12% times more likely to have abnormal TSH concentrations (p = .001). CONCLUSIONS: There was a high prevalence of thyroid dysfunction. Plasma selenium concentration was the only significant predictor of the likelihood that women had thyroid dysfunction within this cohort, who were iodine deficient and mostly had adequate iron status. Strategies are required to improve both iodine and selenium status to better support maternal thyroid function.

An empirical study of factors associated with height-for-age z-scores of children aged 6-23 months in northwest Rwanda: the role of care practices related to child feeding and health.

We aimed to identify the factors influencing child height-for-age z-scores (HAZ) as a measure of child nutritional status in Rwanda, and to examine the role of child feeding and health practices. We conducted a cross-sectional study involving 379 children (aged 6-23 months) and their mothers in northwest Rwanda. Data were collected using a pre-tested, structured questionnaire. An infant and young child feeding practices index (ICFI) and health practices index (HPI) were developed and categorised into tertiles, and linear regression analyses were performed to assess their association with child HAZ. Overall, mothers of non-stunted children exhibited better feeding and health practices than those of stunted children. ICFI was positively associated with child HAZ. We found an adjusted mean HAZ difference of 0·14 between children whose mothers were in high ICFI tertile compared with those in low tertile. Neither HPI nor any of its components were significantly associated with child HAZ. Other factors that were positively associated with child HAZ were infant birth weight (P < 0·001) and maternal height (P < 0·001). Child age, sex (male) (P < 0·05) and altitude (P < 0·05) were negatively associated with child HAZ. Diarrhoea (P < 0·05) and respiratory infections (P < 0·05) were negatively associated with HAZ in younger children aged 6-11 months. Policies to reduce stunting in this population must focus on both pre- and postnatal factors. Appropriate child feeding practices, particularly breast-feeding promotion and improvement in children's dietary diversity combined with measures to control infections should be given priority.

A qualitative analysis of infant and young child feeding practices in rural Rwanda.

OBJECTIVE: To explore and gain an in-depth understanding of the factors influencing child feeding practices among rural caregivers in Rwanda. DESIGN: In-depth semi-structured qualitative interviews were conducted. Purposive sampling was used to recruit participants. Interviews were audio-recorded, transcribed verbatim and coded. Data were analysed inductively using thematic analysis. SETTING: Rutsiro District, Western Province, Rwanda. PARTICIPANTS: Participants included twenty-four mothers (median age 32 years) with children 6-23 months old. RESULTS: We identified five key themes: (i) breast-feeding practices and role in food supply; (ii) family v. children's food preparations; (iii) food classification systems and their influence on child feeding decisions; (iv) child feeding during diarrhoeal episodes and (v) influence of poverty on child feeding practices and child care. CONCLUSIONS: Mothers' infant and young child feeding decisions are informed by information both from health workers and from traditional/own knowledge. Navigating through this information sometimes creates conflicts which results in less than optimal child feeding. A nutrition educational approach that is cognisant of maternal perceptions should be employed to improve child feeding practices. Efforts to improve child feeding practices must be complemented by programmes that enhance household economic opportunities and access to foods.

Habitual dietary fibre intake influences gut microbiota response to an inulin-type fructan prebiotic: a randomised, double-blind, placebo-controlled, cross-over, human intervention study.

Dysbiotic gut microbiota have been implicated in human disease. Diet-based therapeutic strategies have been used to manipulate the gut microbiota towards a more favourable profile. However, it has been demonstrated that large inter-individual variability exists in gut microbiota response to a dietary intervention. The primary objective of this study was to investigate whether habitually low dietary fibre (LDF) v. high dietary fibre (HDF) intakes influence gut microbiota response to an inulin-type fructan prebiotic. In this randomised, double-blind, placebo-controlled, cross-over study, thirty-four healthy participants were classified as LDF or HDF consumers. Gut microbiota composition (16S rRNA bacterial gene sequencing) and SCFA concentrations were assessed following 3 weeks of daily prebiotic supplementation (Orafti® Synergy 1; 16 g/d) or placebo (Glucidex® 29 Premium; 16 g/d), as well as after 3 weeks of the alternative intervention, following a 3-week washout period. In the LDF group, the prebiotic intervention led to an increase in Bifidobacterium (P=0·001). In the HDF group, the prebiotic intervention led to an increase in Bifidobacterium (P<0·001) and Faecalibacterium (P=0·010) and decreases in Coprococcus (P=0·010), Dorea (P=0·043) and Ruminococcus (Lachnospiraceae family) (P=0·032). This study demonstrates that those with HDF intakes have a greater gut microbiota response and are therefore more likely to benefit from an inulin-type fructan prebiotic than those with LDF intakes. Future studies aiming to modulate the gut microbiota and improve host health, using an inulin-type fructan prebiotic, should take habitual dietary fibre intake into account.

Iodine intake and status during pregnancy and lactation before and after government initiatives to improve iodine status, in Palmerston North, New Zealand: a pilot study.

Iodine deficiency during pregnancy and lactation may adversely affect fetal and infant development. Two initiatives were introduced in New Zealand to prevent deficiency: (1) mandatory fortification of bread with iodised salt; and (2) provision of a subsidised iodine supplement (150 µg) for all pregnant and breastfeeding women. The aim of this study was to assess iodine intake and status among a self-selecting sample of pregnant and lactating women in Palmerston North, both before and after the two initiatives. Pregnant and breastfeeding women were recruited before (n = 25 and 32; 2009) and after (n = 34 and 36; 2011) the initiatives. Iodine concentration was determined in 24-h urine and breast milk samples using inductively-coupled plasma mass spectrometry. Use of supplements and salt, knowledge of iodine deficiency, and awareness of the initiatives were determined by questionnaire. Median urine iodine concentration (UIC) was higher in 2011 compared with 2009 for both pregnant (85 and 47 µg L(-1) ) and breastfeeding (74 and 34 µg L(-1) ) participants; median UIC were below the cut-offs for adequate iodine status. However, in 2011, the estimated daily iodine intake during pregnancy was 217 µg day(-1) ; 74% of women achieved the Estimated Average Requirement. Knowledge of the initiatives was low, only 28-56% were aware of the need for iodine supplements and only 15-22% were aware of the mandatory addition of iodised salt to bread. Despite initiatives, UIC of these women indicates iodine deficiency, however, dietary intakes appear adequate. Ongoing surveillance of supplement use and iodine status among pregnant and lactating women throughout New Zealand is needed to fully assess the efficacy of the initiatives. Alternative strategies may require evaluation to ensure all women have adequate iodine during pregnancy and breastfeeding.

Portable X-ray fluorescence of zinc and selenium with nail clippings-Mother and Infant Nutrition Investigation (MINI).

Zinc and selenium are essential minerals for human nutrition. Reliable biomarkers of zinc status and selenium status in humans are therefore important. This work investigates a novel portable X-ray fluorescence (XRF) method with the ability to rapidly assess zinc and selenium in nail clippings. This approach used a mono-energetic X-ray beam to excite characteristic X-rays from the clippings. Nail clippings were obtained from the Mother and Infant Nutrition Investigation (MINI), a study designed to assess nutrition in a population of women and their breastfed children in New Zealand. Twenty mother-infant pairings were selected to provide nail clippings at two time points (visit 1 at 3 months postpartum; visit 2 at 6 months postpartum). Nail clippings from each mother-infant pairing were divided into three groupings of clippings prior to analysis: those obtained from a big toe of the mother, those from the other toes of the mother, and those from the toes and fingers of the infant. Clippings were prepared and mounted prior to XRF measurement, providing four distinct fragments from each clipping grouping. These fragments were assessed by XRF using a measurement time of either 300 s (visit 1) or 180 s (visit 2). XRF results were determined through both an automated system output and an analysis of the X-ray energy spectrum. Following this assessment of zinc and selenium with the non-destructive XRF method, clippings were measured for zinc and selenium concentration using a "gold standard" technique of inductively coupled plasma mass spectrometry (ICP-MS). Mean ICP-MS concentrations ranged from 122 µg/g to 127 µg/g for zinc, and from 0.646 µg/g to 0.659 µg/g for selenium. Precision, assessed by a relative standard deviation of measurement, was superior for ICP-MS relative to XRF. For both zinc and selenium, XRF results were compared with ICP-MS concentrations. Linear equations of best fit were determined for each comparison between XRF and ICP-MS results. Coefficients of determination (r2) were stronger for zinc (from 0.74 to 0.95) than selenium (from 0.53 to 0.70). A decrease in XRF measurement time from 300 s to 180 s did not appear to adversely affect the correlation between XRF and ICP-MS results. Using the mono-energetic portable XRF method, the correlation of XRF zinc results with ICP-MS zinc concentrations was improved over previous findings, and selenium measurement was reported for the first time. The method may prove useful for future applications to trace element analysis using nail clippings as a biomarker.

Sweet potato-based complementary food for infants in low-income countries.

BACKGROUND: In low-income countries, most infants are given cereal-based complementary foods prepared at the household level. Such foods are high in phytate, which limits the bioavailability of nutrients, including iron, calcium, zinc, and in some cases proteins, which are crucial to the development of infants. OBJECTIVE: To compare the levels of macronutrients (protein, fat, and carbohydrate), gross energy, and fructose in sweet potato-based (denoted ComFa) formulations and enriched Weanimix (dehulled maize-dehulled soybean-groundnut blend with fish powder and sugar incorporated). The phytate level was also compared. METHODS: A composite flour of sweet potato and soybeans containing fish powder was processed by oven toasting as a home-based complementary food. Another blend containing skim milk powder was processed by extrusion cooking or roller drying as industrial-based prototypes. The macronutrient composition and the levels of fructose and phytate were determined in the ComFa formulations and enriched Weanimix. RESULTS: The ComFa formulations and the enriched Weanimix met the stipulated values in the Codex Alimentarius Commission standard for energy (400 kcal/100 g), protein (15 g/100 g), and fat (10 to 25 g/100 g) for complementary food, with the exception of the industrial-based ComFa formulations, which satisfied 83% of the protein requirement (15 g/100 g). The ComFa formulations had a quarter of the phytate level of enriched Weanimix. The fructose level in the sweet potato-based complementary foods was more than five times that in enriched Weanimix. CONCLUSIONS: The sweet potato-based formulations were superior to enriched Weanimix as complementary foods for infants in low-income countries, based on the fructose (which makes the porridge naturally sweet) and phytate levels.

Sweetpotato-based complementary food would be less inhibitory on mineral absorption than a maize-based infant food assessed by compositional analysis.

The availability of micronutrients from sweetpotato-based complementary foods (CFs): oven-toasted and roller-dried ComFa, and from a maize-based infant food, enriched Weanimix, was compared using phytate/mineral molar ratios, polyphenols and ß-carotene levels. The phytate/calcium, iron and zinc molar ratios of approximately 0.17, 1 and 15 predict better absorption of calcium, iron and zinc respectively. Generally, the sweetpotato-based CFs had at least half the phytate/mineral ratios of enriched Weanimix. The phytate/iron ratio in both the sweetpotato- and the maize-based CFs was greater than 1. Only the ComFa formulations had phytate/zinc ratio lower than 15. The level of polyphenol (iron inhibitor) was similar for the formulations. Only the sweetpotato-based CFs contained measurable levels of ß-carotene, a possible iron enhancer. The lower phytate/mineral ratios and the ß-carotene level of the sweetpotato-based CFs suggest that calcium, iron and zinc absorption could be better from them than from the maize-based infant food.

A household-level sweet potato-based infant food to complement vitamin A supplementation initiatives.

Vitamin A deficiency (VAD) prevalence in Sub-Saharan Africa is high in spite of vitamin A supplementation programmes among children in most countries. Plant-based complementary foods remain the key source of nutrients in addition to breast milk for infants in lower income countries. Cereal-legume blends are superior in protein and energy densities compared with maize, millet or sorghum-only porridge. However, unfortified cereal-legume and cereal-only porridges are low in vitamin A. A household-level sweet potato-based infant food, rich in vitamin A, has been developed to complement vitamin A supplementation initiatives in Sub-Saharan Africa. A composite flour containing sweet potato, soybean, soybean oil and fishmeal was processed as complementary food by oven toasting (denoted oven-toasted ComFa). The oven-toasted ComFa and enriched Weanimix (processed from dehulled maize, dehulled soybean, groundnut and fishmeal) were assessed for suitability as complementary food based on the nutrient composition using specifications in the Codex Standard (CS) as a reference. The sweet potato-based formulation and enriched Weanimix met the energy, protein, fructose and fat specifications but barely met the amino acid score as indicated in the CS. However, only the oven-toasted ComFa met the calcium and almost half the vitamin A levels as specified in the CS. Oven-toasted ComFa was slightly lower in energy, protein and fat by a difference not greater than 4.0% but was higher by more than 100% in fructose and vitamin A levels. Therefore, the sweet potato-based complementary food is likely to support vitamin A supplementation initiatives in low-income countries better than the cereal-based formulation.

Improving Iodine Status in Lactating Women: What Works?

PURPOSE OF REVIEW: Iodine deficiency is a global concern, and in recent years, there has been a significant improvement in the number of countries identified as being iodine-sufficient. This review considers the best strategies to ensure iodine sufficiency among breastfeeding women and their infants. RECENT FINDINGS: Fortification strategies to improve iodine intake have been adequate for school-age children (SAC); however, often, iodine deficiency remains for breastfeeding women and their infants. Daily supplementation with iodine is not an ideal strategy to overcome deficiency. Countries defined as iodine-sufficient, but where pregnant and breastfeeding women have inadequate intake, should consider increasing salt iodine concentration, such that the median urinary iodine concentration of SAC can be up to 299 µg/L. This will ensure adequate intake for mothers and infants, without SAC being at risk thyroid dysfunction. Consensus is required for thresholds for iodine adequacy for breastfeeding women and infants.

Do Micronutrient and Omega-3 Fatty Acid Supplements Affect Human Maternal Immunity during Pregnancy? A Scoping Review.

Maternal dietary micronutrients and omega-3 fatty acids support development of the fetal and neonatal immune system. Whether supplementation is similarly beneficial for the mother during gestation has received limited attention. A scoping review of human trials was conducted looking for evidence of biochemical, genomic, and clinical effects of supplementation on the maternal immune system. The authors explored the literature on PubMed, Cochrane Library, and Web of Science databases from 2010 to the present day using PRISMA-ScR methodology. Full-length human trials in English were searched for using general terms and vitamin A, B12, C, D, and E; choline; iodine; iron; selenium; zinc; and docosahexaenoic/eicosapentaenoic acid. Of 1391 unique articles, 36 were eligible for inclusion. Diverse biochemical and epigenomic effects of supplementation were identified that may influence innate and adaptive immunity. Possible clinical benefits were encountered in malaria, HIV infections, anemia, Type 1 diabetes mellitus, and preventing preterm delivery. Only limited publications were identified that directly explored maternal immunity in pregnancy and the effects of micronutrients. None provided a holistic perspective. It is concluded that supplementation may influence biochemical aspects of the maternal immune response and some clinical outcomes, but the evidence from this review is not sufficient to justify changes to current guidelines.

Iodine-only supplements for breastfeeding women: a call to action in New Zealand.

Nil.

Saccharomyces cerevisiae Yeast-Based Supplementation as a Galactagogue in Breastfeeding Women? A Review of Evidence from Animal and Human Studies.

Perceived insufficient milk production (PIM) adversely affects breastfeeding duration. Women sometimes use galactagogues with the intent to increase breast milk production and support lactation. Saccharomyces cerevisiae yeast-based supplement (SCYS) is an inactive form of Saccharomyces cerevisiae yeast (SCY) either obtained from the fermentation process or grown on molasses. Anecdotal evidence suggests SCYS is a galactagogue. SCYS is promoted on the internet as a galactagogue in various forms and doses. Dietary supplementation with SCYS during gestation and lactation significantly increases milk yield in ruminants. No human study has evaluated efficacy of SCYS as a galactagogue. SCYS is rich in B vitamins, beta-glucan, mannan oligosaccharides and bioavailable chromium; these may impact breast milk production or composition, thus may alleviate PIM. The safety of taking SCYS during lactation is not well studied. Studies have reported contamination of SCYS with ochratoxin A (OTA) as well as minor side effects from SCYS. Studies are needed to evaluate the efficacy of SCYS on breast milk production and composition and to assess the safety of taking SCYS during lactation in humans.

A Mixed-Methods Study of Factors Influencing Access to and Use of Micronutrient Powders in Rwanda.

The World Health Organization recommends point-of-use fortification with multiple micronutrients powder (MNP) for foods consumed by children aged 6-23 months in populations where anemia prevalence among children under 2 years or under 5 years of age is 20% or higher. In Rwanda, anemia affects 37% of children under 5 years. The MNP program was implemented to address anemia, but research on factors affecting the implementation of the MNP program is limited. We conducted a mixed-methods study to examine the factors influencing access to and use of MNP among mothers (N=379) in Rutsiro district, northwest Rwanda. Inductive content analysis was used for qualitative data. Logistic regression analysis was used to determine factors associated with the use of MNP. Qualitative results indicated that the unavailability of MNP supplies and distribution issues were major barriers to accessing MNP. Factors influencing the use of MNP included mothers' perceptions of side effects and health benefits of MNP, as well as inappropriate complementary feeding practices. Mothers of older children (aged 12-23 months) were more likely to use MNP than those of younger children (aged 6-11 months) (adjusted odds ratio [aOR]=3.63, P<.001). Mothers whose children participated in the supplementary food program were nearly 3 times more likely to use MNP than those whose children had never participated in the program (aOR=2.84, P=.001). Increasing household hunger score was significantly associated with lower odds of using MNP (aOR=0.80, P=.038). Mechanisms to monitor MNP supply and program implementation need to be strengthened to ensure mothers have access to the product. MNP program implementers should address gaps in complementary feeding practices and ensure mothers have access to adequate complementary foods.

Use of Iodine Supplements by Breastfeeding Mothers Is Associated with Better Maternal and Infant Iodine Status.

Adequate iodine status during conception, pregnancy and lactation is essential for supporting infant neurodevelopment. Iodine status in adults and children was improved after two New Zealand government initiatives, but the status of breastfeeding women is unknown. This study aimed to investigate the iodine intake and status of lactating mother-infant pairs at 3 months postpartum and to assess maternal iodine knowledge and practice. Iodine intake was estimated by a weighed 4-day diet diary (4DDD). Maternal urinary iodine concentrations (UIC) in spot urine, breast milk iodine concentrations (BMIC) and infant UIC were measured. Questions about iodine-specific knowledge and practice were asked. In 87 breastfeeding mother-infant pairs, maternal iodine intake was 151 (99, 285) µg/day, and 58% had an intake below the estimated average requirement (EAR) of 190 µg/day. Maternal median UIC (MUIC) was 82 (46, 157) µg/L indicating iodine deficiency (i.e., < 100 µg/L). Women who used iodine-containing supplements had a significantly higher MUIC (111 vs 68 µg/L, P = 0.023) and BMIC (84 vs 62 µg/L, P < 0.001) than non-users. Infants fed by women using iodine-containing supplements had a higher MUIC (150 vs 86 µg/L, P = 0.036) than those of non-users. A total of 66% (57/87) of women had no or low iodine knowledge. The iodine knowledge score was a statistically significant predictor of consuming iodine-containing supplements [(beta = 1.321, P = 0.008)]. Despite a decade of initiatives to increase iodine intakes in New Zealand, iodine knowledge was low; iodine intake and status of these lactating women were suboptimal, but women who used iodine-containing supplement were more likely to achieve adequate status.Study Registration Number (Australia and New Zealand Clinical Trials Registry): ACTRN12615001028594.