Date: Mon, 26 Oct 1998 09:34:27 +0000

From: "Pushpa Acharya"<acharyapatun.org>

Subject: Ngonut: anthro assessement in pregnamcy

Can anybody provide me information on indicators for assessing PEM on pregnant and lactating women? Appreciate any suggestion.

Pushpa Acharya, World Food Programme, Iraq

Acharyapatun.org

Date: Mon, 26 Oct 1998 16:15:54 +0000

From: Andy Seal <A.Sealatich.ucl.ac.uk>

Subject: Re: Ngonut: anthro assessement in pregnamcy

Hello

You could try this publication. Hope its useful.

Maternal anthropometry and pregnancy outcomes. A WHO Collaborative Study.

Bull-World-Health-Organ. 1995; 73 Suppl: 1-98

Andrew Seal PhD, Researcher in Public Health Nutrition

Centre for International Child Health Institute of Child Health

30 Guilford Street, London, WC1N 1EH

tel. +44 (0)171 242 9789 ext. 2468, fax +44 (0)171 404 2062

e.mail a.sealatich.ucl.ac.uk

Subject: Re2: anthro assessement in pregnancy

Author: Saskia VD KAM at MSF-Amsterdam

Date: 13-11-98 15:16

Dear Pushpa,

Checking my E-mail after a few weeks of absence I found your inquiry and,

surprisingly, there was hardly any reaction on this.

This reflects the feeling of several staff members of Médecins Sans

Frontières on the subject of nutritional supplementation of pregnant and

lactating women.

Often we include pregnant and lactating women in our supplementation

programmes because they belong to the classic vulnerable groups. However,

we did not see much impact of these supplementations in the projects. This

has several reasons: lack of proper admission criteria, lack of monitoring

of the admitted individuals, and lack of criteria to assess the impact of

the supplementation programme. Additionally the objectives of the

supplementation programmes are not clear.

Last year a student of the LSHTM choose this as the subject for her thesis:

Md. Mija Ververs: Nutrition intervention for pregnant and lactating women

in relief situations: the assessment of need and impact. November 1997.

In this document the author gives an excellent overview about the different

indicators which could be used in supplementation programmes for pregnant

and lactating women.

She concludes that Mid Upper Arm Circumference (MUAC) can identify

pregnant women at risk of Low Birth Weight, Intra Uterine Growth

Retardation and foetal or infant mortality. MUAC is simple to use and is

fairly stable over the pregnancy period so it can be used throughout the

entire pregnancy period as a tool for screening and identification of

beneficiaries. However, because of the small or late change in MUAC after

an intervention, the MUAC is not suitable for evaluation of the impact of

the supplementation programme. Weight gain during pregnancy is a good

indicator for measuring impact of the supplementation programme.

Cut-off points for screening are between 21 and 23 cm. A MUAC of 23 cm is

associated with a weight below 45kg, a cut of for risk on IUGR.

Also suggestions are given for cut-off points for screening; unfortunately

Iraq had not been mentioned:

21 cm: India,Nepal, Guatemala

22 cm: China,Indonesia, Myanmar,Sri Lanka

22,5 cm: Bangladesh, Guatemala

23 cm: The Gambia, Thailand, Vietnam, Malawi

23,5 cm: Brazil

24: Chile

Other indicators like Weight-for-gestational age, weight gain and BMI are

valid to identify people at risk, but they don't have particular

advantages above MUAC, more over several variables are not easily

identified in emergencies: pre-pregnancy weight, subsequent weighings, age

of the women. teenage pregnant girls deserve a different approach: the are

besides being prganant still growing themselves. As groth of tissues

related to preganancy has preference above the normal growth of a teenager,

these teanger are at risk for their own develpemnt and later preganancies.

Therefore height which could be used for selection and monitoring and

impact for teenage pregnant girls.

The author also examined the impact of a nutrition interventions.

Various researchers suggest that there is a direct relationship between

maternal dietary intake and birthweight only when maternal stores are low

or depleted. (low pre-pregnancy weight or gestational undernutrition)

The relationships between supplementation and birth weight are twofold: 1.

supplementation shows a significant increase in maternal weight;

additionally maternal weight has a significant relation with birthweight.

2. supplementation shows significant increase in birthweight

In non-famine situations there is no significant direct relationship

between supplementation and birthweight;

Aditinoally in non-famine situations the impact of a supplementation

programme is modest. Threshold values are mentioned of an foodavailability

of 6.3 - 7.3 MJ/d (1500 - 1740 kcal/d). These thresholds are a result of

epidemiological studies; the individual variation is great.

For lactating women there is no good anthropometric indicator developed to

identify women at risk of poor lactational performance, or to select women

who might benefit from a supplementation programme.

Again MUAC has the greatest potential to identify women at risk of a poor

milk composition.

Weight losses during lactation is an indicator for prediction of the

benefit from a supplementation programme (not more then 600-7000

grams/month) BMI, which has no particular advantage above MUAC can be used

: 20.3 post partum, reduced by 0,3 monthly resulting in 18.5 after six

months. It is clear that research is needed to come to conclusive answers.

The milk volume is less subject to change due to nutritional changes of the

mother than the composition of the milk, which is, in itself, important

enough. The infant hardly benefit of a energy supplement; but the mother

does, what might be reflected in an reduced weight loss or increased

physical activity (work) of the mother.

Conclusion:

MUAC is the best screening and identification tool for pregnant and

lactating women, weight gain (or loss) is the best indicator to monitor

progress in individuals and the project s a whole.

It seems that supplementation of pregnant women is particularly effective

when given during times of food shortage. (seasonal fluctuations, drought,

war, floods) and when it is timely given, from the first trimester in

order to give time to increae body weight etc as a reaction on the

supplement. Supplementation of the lactating mother benefits the child in

terms of a better composition of hte milk. The supplement benefits the

mother in terms of energy supplement. However, the greatest impact for

lactation performance could be expected from a timely supplement given

during pregnancy: the end of the 1rst trimester and the 2nd trimester are

crucial in terms of growth in the breast and uterus tissue, blood volume

and accumulation of fat.

The author purposes an intervention model:

*If food security is an problem:

Include in an supplementation programme all pregnant and lactating women

regardless anthropometry and stage of pregnancy.

*If food security is not a problem:

Include for pregnancy:

MUAC 21-23 cm and/or weight gain < 1,5 kg/month in 2&3 trimester

Include for lactation:

MUAC 21-23 cm and/or BMI 20.3 at birth with decrease of 0,3/month to 18.5

at six months and mother with malnourished infants who are breastfed.

*If food security is a moderate problem:

Pregnancy: all anthropometric indicators of the non problematic food

security plus all pregnant teenagers

Lactation: all anthropometric indicators of the non problematic food

security plus individual cases like mothers of twins, teenage mothers,

mothers of LBW babies, lactating mothers with malnourished children under

five years,

Saskia van der Kam, Médecins Sans Frontières Holland

(also on behalf of Md Msc Mija Tesse Ververs)

Date: Tue, 05 Jan 1999 18:03:27 +0000

From: Penelope Nestel <pnestelaterols.com>

Subject: Re: Re2: anthro assessement in pregnancy

Dear Pushpa,

To add to Saskia's comments you may find the following refs helpful:

Gueri M, Jutsum P, Sorhaindo B. Anthropometric assessment of nutrition

status in pregnnat women: a reference table of weight-for-height by week

of pregnancy. AJCN. 1982:35;609-11.

Krasovec K, Anderson MA. Metranla nutrition and pregnancy outcomes:

abthropometric assessment. PAHO Scientific Publication No 529. 1991.

I have seen a preprint draft of a WHO monograph called Maternal

anthropometry and pregnancy outcomes: A WHO collaborative project meta

analysis by A. Kelly et al, but do not know if the final has been

published.

Penny

Date: Wed, 6 Jan 1999 14:00:01 +0100

From: David Morley <Davidatmorleydc.demon.co.uk>

Subject: MUAC

Dear Penelope Nestel, In response to your e-mail query over PEM in pregnant

and lactating. TALC has an accurate 'insertion tape' printed on non stretch

plasticised paper. On the back of this we have printed under 24cm

significant and real concern under 20cm. Delighted to send you a sample if

you will let me have an address. DAvid Morley.

David Morley

Davidatmorleydc.demon.co.uk

From: Monika Bloessner bloessnermatwho.ch

Date: Wed, 6 Jan 1999 08:46:05 +0100

Subject: Re[2]: Re2: anthro assessement in pregnancy

The supplement to Volume 71, 1995, of the Bulletin of the World Health Organization Maternal anthropometry and pregnancy outcomes: A WHO collaborative study. is available from the WHO Distribution and Sales office (E-mail address: publicationsatwho.ch).

Furthermore there is a summary paper A WHO Collaborative Study of Maternal Anthropometry and Pregnancy Outcomes. Int J Gynaecol Obstet. 1996 Jun;53(3):219-33.

I hope this information will be useful.

Kind regards,

Monika Bloessner

Nutrition for Health and Development