Effects of prenatal micronutrient and early food supplementation on maternal hemoglobin, birth weight, and infant mortality among children in Bangladesh: the MINIMat randomized trial.
BACKGROUND
Nutritional insult in fetal life and small size at birth are common in low-income countries and are associated with serious health consequences.


OBJECTIVE
To test the hypothesis that prenatal multiple micronutrient supplementation (MMS) and an early invitation to food supplementation would increase maternal hemoglobin level and birth weight and decrease infant mortality, and to assess whether a combination of these interventions would further enhance these outcomes.


METHODS
A randomized trial with a factorial design in Matlab, Bangladesh, of 4436 pregnant women, recruited between November 11, 2001, and October 30, 2003, with follow-up until June 23, 2009.


METHODS
Participants were randomized into 6 groups; a double-masked supplementation with capsules of 30 mg of iron and 400 μg of folic acid, 60 mg of iron and 400 μg of folic acid, or MMS containing a daily allowance of 15 micronutrients, including 30 mg of iron and 400 μg of folic acid, was combined with food supplementation (608 kcal 6 days per week) randomized to either early invitation (9 weeks' gestation) or usual invitation (20 weeks' gestation).


METHODS
Maternal hemoglobin level at 30 weeks' gestation, birth weight, and infant mortality. Under 5-year mortality was also assessed.


RESULTS
Adjusted maternal hemoglobin level at 30 weeks' gestation was 115.0 g/L (95% CI, 114.4-115.5 g/L), with no significant differences among micronutrient groups. Mean maternal hemoglobin level was lower in the early vs usual invitation groups (114.5 vs 115.4 g/L; difference, -0.9 g/L; 95% CI, -1.7 to -0.1; P = .04). There were 3625 live births out of 4436 pregnancies. Mean birth weight among 3267 singletons was 2694 g (95% CI, 2680-2708 g), with no significant differences among groups. The early invitation with MMS group had an infant mortality rate of 16.8 per 1000 live births vs 44.1 per 1000 live births for usual invitation with 60 mg of iron and 400 μg of folic acid (hazard ratio [HR], 0.38; 95% CI, 0.18-0.78). Early invitation with MMS group had an under 5-year mortality rate of 18 per 1000 live births (54 per 1000 live births for usual invitation with 60 mg of iron and 400 μg of folic acid; HR, 0.34; 95% CI, 0.18-0.65). Usual invitation with MMS group had the highest incidence of spontaneous abortions and the highest infant mortality rate.


CONCLUSIONS
Among pregnant women in poor communities in Bangladesh, treatment with multiple micronutrients, including iron and folic acid combined with early food supplementation, vs a standard program that included treatment with iron and folic acid and usual food supplementation, resulted in decreased childhood mortality.


BACKGROUND
isrctn.org Identifier: ISRCTN16581394.
Department of Women’s and Children’s Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden. lars-ake.persson@kbh.uu.se
Lars Åke
LÅ
Persson
Shams
S
Arifeen
Eva-Charlotte
EC
Ekström
Kathleen M
KM
Rasmussen
Edward A
EA
Frongillo
Md
M
Yunus
D000328:Adult; D001459:Bangladesh / Q000453:epidemiology; D001724:Birth Weight; D019587:Dietary Supplements; D005260:Female; D005492:Folic Acid / Q000008:administration & dosage; D005502:Food; D006454:Hemoglobins / Q000032:analysis*; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D007501:Iron / Q000008:administration & dosage; D044342:Malnutrition / Q000188:drug therapy*; D039382:Maternal Nutritional Physiological Phenomena; D018977:Micronutrients / Q000008:administration & dosage*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000178:diet therapy*; D011256:Pregnancy Outcome; D011295:Prenatal Care; D055815:Young Adult
D006454:Hemoglobins; D018977:Micronutrients; D005492:Folic Acid; D007501:Iron