Many women in low- and middle-income countries enter pregnancy with low nutritional reserves with increased risk of fetal growth restriction and poor birth outcomes, including small-for-gestational-age (SGA) and preterm birth. Balanced energy-protein (BEP) supplements have shown reductions in risk of stillbirth and SGA, yet variations in intervention format and composition and limited evidence on the impact of BEP during lactation on growth outcomes warrant further study.  This paper describes the protocol of the Maternal Infant Nutrition Trial (MINT) Study, which aims to evaluate the impact of a fortified BEP supplement during pregnancy and lactation on birth outcomes and infant growth in rural Nepal. MINT is a 2×2 factorial, household randomised, unblinded, efficacy trial conducted in a subarea of Sarlahi District, Nepal. The study area covers six rural municipalities with about 27,000 households and a population of approximately 100,000. Married women (15-30 years) who become pregnant are eligible for participation in the trial and are randomly assigned at enrolment to supplementation with fortified BEP or not and at birth to fortified BEP supplementation or not until 6 months post-partum. The primary pregnancy outcome is incidence of SGA, using the INTERGROWTH 21st standard, among live born infants with birth weight measured within 72 hours of delivery. The primary infant growth outcome is mean length-for-age z-score at 6 months using the WHO international growth reference.

Maternal undernutrition is critical in the etiology of poor perinatal outcomes and accounts for 20% of small-for-gestational-age (SGA) births. High levels of food insecurity, antenatal undernourishment, and childhood undernutrition necessitate the supplementation of fortified balanced energy protein (BEP) during pregnancy in low-income settings especially with scarce literature available in the subject. Hence, this paper extensively covers the protocol of such a trial conducted in an urban slum of Karachi, Pakistan. The trial is community-based, open-labelled, four-arm, and randomized controlled that will include parallel group assignments with a 1:1:1:1 allocation ratio in low-income squatter settlements in urban Karachi, Pakistan. All pregnant women if identified between >8 and <19 weeks of gestation based on ultrasound, will be offered routine antenatal care (ANC) counseling and randomly allocated to one of the four arms receiving: (1) ANC counseling only (control group), (2) ANC counseling plus BEP supplement (intervention arm 1), (3) ANC counseling plus BEP supplement plus 2 doses azithromycin (intervention arm 2), or (4) ANC counseling plus BEP supplement plus daily dose of nicotinamide and choline (intervention arm 3).

The Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study will test the impact of packages of pregnancy interventions to enhance maternal nutrition and infection management on birth outcomes in rural Ethiopia. ENAT is a pragmatic, open label, 2×2 factorial, randomised clinical effectiveness study implemented in 12 rural health centres in Amhara, Ethiopia. Eligible pregnant women presenting at antenatal care (ANC) visits at <24 weeks gestation are enrolled. ANC quality is strengthened across all centres. Health centres are renadomised to receive an enhanced nutrition package (ENP) or standard nutrition care, and within each health centre, individual women are randomised to receive an enhanced infection management package (EIMP) or standard infection care. At ENP centres, women receive a regular supply of adequately iodised salt and iron-folate (IFA), enhanced nutrition counseling and those with mid-upper arm circumference of <23cm receive a micronutrient fortified balanced energy protein supplement (corn soya blend) until delivery. This study hopes to increase the evidence-base on the role of antenatal infection management on maternal and birth outcomes, and increase the evidence-base on the role of targeted fortified balanced energy protein supplementation on maternal and birth outcomes in a low resource rural setting in sub-Saharan Africa.

Almost two billion people are deficient in key vitamins and minerals, mostly women and children in low- and middle-income countries (LMICs). Deficiencies worsen during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child, but could be mitigated by interventions like micronutrient supplementation. This systematic review aimed to compile evidence from both efficacy and effectiveness trials, evaluating different supplementation interventions on maternal, birth, child health, and developmental outcomes. This review assessed randomized controlled trials and quasi-experimental studies published since 1995 in peer-reviewed and grey literature that assessed the effects of calcium, vitamin A, iron, vitamin D, and zinc supplementation compared to placebo/no treatment; iron-folic (IFA) supplementation compared to folic acid only; multiple micronutrient (MMN) supplementation compared to IFA; and lipid-based nutrient supplementation (LNS) compared to MMN supplementation. Seventy-two studies, which collectively involved 314 papers (451,723 women), were included. Meta-analyses showed improvement in several key birth outcomes, such as preterm birth, small-for-gestational age (SGA) and low birthweight with MMN supplementation, compared to IFA. MMN also improved child outcomes, including diarrhea incidence and retinol concentration, which are findings not previously reported.

Micronutrient deficiencies during pregnancy pose significant public health issues, considering the potential for negative consequences not only during pregnancy but also throughout life. Anemia in pregnant women is becoming a significant problem in developing countries, with scientific evidence indicating that 41.8 percent of women worldwide suffer from anemia. As a result, investigating the pooled prevalence and factors associated with micronutrient intake among pregnant women in East Africa is critical to alleviate the burden of micronutrient deficiency among pregnant women. The pooled prevalence of micronutrient intake in East African countries was 36.07% (95% CI: 35.82%, 36.33%). In the multilevel logistic regression model, women from the highest wealth quintile were more likely to take micronutrients compared to their counterparts. The overall prevalence of micronutrient intake in East Africa was low. Only 36% of the study participants had micronutrient intake practice. Socioeconomic factors (education level, and household wealth status) have been shown to influence micronutrient intake. Therefore, this necessitates the continuation of ongoing projects as well as the development of fresh ones that concentrate on these variables and include effective treatments and programs, especially among underprivileged and vulnerable populations.

Micronutrient deficiencies in Latin America are a public health concern, nonetheless, lack of information still exists in many countries, so that the true magnitude of the problem remains unclear. The objective was to summarises experiences that can inform the development of policies and programs to address micronutrient deficiencies through supplementation in pregnant women and children under five years of age in Latin America. A review of the most evidence on the effects of micronutrients supplementation, focusing on pregnant women and children under five years of age was done. Several resources and experiences exist that can help favor the development of programs that can realize this biological and programmatic potential. There is need for continuous efforts to augment coverage and achieve results that can translate into economic benefits for individuals, families, and nations.

This document is a report by an expert group capturing the considerations and consensus of the expert consultation on the framework and specifications for macro- and micronutrient composition, form and type, and use-case for nutritious, ready-to-use food supplements for pregnant and lactating women who are inadequately nourished, and/or at-risk of suboptimal nutrient intake related to food insecurity (e.g. residing in food insecure household) or in an area affected by (seasonal food insecurity) in low and middle income country settings. The consultation was held at the Bill & Melinda Gates Foundation on Sept 19-20, 2016 and the report was finalized in April 2017.

Ready-to-use lipid-based nutrient supplements (LNS) are a highly nutrient-dense supplement, which could be a good source of macro and micronutrients for pregnant women who need to supplement their nutrient intake. The objective was to assess the eCects of LNS for maternal, birth and infant outcomes in pregnant women. Secondary objectives were to explore the most appropriate composition, frequency and duration of LNS administration. Randomized controlled trials (RCTs) and quasi-RCTs that compared LNS given in pregnancy to no intervention, placebo, iron folic acid (IFA), multiple micronutrients (MMN) or nutritional counselling. Standard Cochrane procedures were used, and included four studies in 8018 pregnant women. All four studies took place in stable community settings in low-and middle-income countries: Bangladesh, Burkina Faso, Ghana and Malawi. None were in emergency settings. Findings from this review suggest that LNS supplementation has a slight, positive eCectonweight at birth, length at birth, SGA and newborn stunting compared to IFA. LNS and MMN were comparable for all maternal, birth and infant outcomes. Both IFA and MMN were better at reducing maternal anaemia when compared to LNS. Readers should interpret the beneficial findings of the review with caution since the evidence comes from a small number of trials, with one-large scale study (conducted in community settings in Bangladesh) driving most of the impact.

Gestational weight gain is positively associated with fetal growth, and observational studies of food supplementation in pregnancy have reported increases in gestational weight gain and fetal growth. This study assessed the effects of education during pregnancy to increase energy and protein intake, or of actual energy and protein supplementation, on energy and protein intake, and the effect on maternal and infant health outcomes. 149 reports corresponding to 65 trials were examined. This review provides encouraging evidence that antenatal nutritional education with the aim of increasing energy and protein intake in the generail obstetric population appears to be effective in reducing the risk of preterm birth, low birthweight, increasing head circumference at birth, increasing birthweight among undernourished women, and increasing protein intake. There was no evidence of benefit or adverse effect for any other outcome reported. Balanced energy and protein supplementation seems to improve fetal growth and may reduce the risk of stillbirth and infants born small-for-gestational age. High-protein supplementation does not seem to be beneficial and may be harmful to the fetus. Balanced-protein supplementation alone had no significant effects on perinatal outcomes. The results of this review should be interpreted with caution. The risk of bias was either unclear or high for at least one category examined in several of the included trials, and the quality of evidence was low for several important outcomes. Large, well-designed randomized trials are needed to assess the effects of increasing energy and protein intake during pregnancy in women whose intake is below recommended levels.

Prenatal nutrition interventions can lead to improved birth outcomes, which in turn are associated with better education and human capital outcomes later in life. The objective of the study was to estimate the impact of scaling up iron-folic acid (IFA), calcium, multiple micronutrients (MMS), and balanced energy protein (BEP) supplementation for pregnant women, on human capital outcomes in low- and middle-income countries (LMIC). Mathematical modeling with proportional reductions in adverse birth outcomes to estimate the potential gains in school years and lifetime income due to scaling up each prenatal nutrition intervention. Estimates of intervention effects on birth outcomes were derived from meta-analyses of randomized trials, with estimates of the associations between birth outcomes and schooling and lifetime income derived from de novo meta-analyses of observational studies. It was concluded that increasing coverage of prenatal nutrition interventions in LMIC may lead to substantial gains in schooling and lifetime income. Decision makers should consider the potential long-term human capital returns of investments in maternal nutrition.