Nutrition in Pregnancy and Women's Health

Preconception Care Definition

• Preconception care is a set of interventions to identify and modify risks affecting a woman's health or pregnancy outcomes.
• It aims to improve pregnancy outcomes by addressing biomedical, behavioral, and social risks.
• This includes risk assessment, health education, and management.
• Preconception care is provided during the preconception and inter-pregnancy periods.
• It's now integrated into maternal care protocols.

Preconception Care Components

• Assessment
  • Identifying risk factors related to poor pregnancy outcomes.
  • Screening all couples of reproductive age, and specifically those planning a pregnancy within the next three months, for preconception care.
• Intervention
  • Treating identified risk factors and complications.
  • This includes counseling, treatment, and linkage/referral services.

Core Components of Preconception Care (PCC)

• Family planning
• Nutrition
• Folic acid supplementation
• Sexual health and violence
• Environmental exposure/occupational hazards
• Medications with adverse effects on pregnancy
• Mental health
• Oral health
• Infectious diseases
• Vaccine-preventable diseases
• Genetic risks
• Chronic medical conditions
• Substance use
• Reproductive organ anomalies
• Cervical cancer

1. Family Planning and Contraception

• Family planning (FP) is an action by individuals or couples to decide the number and timing of children.
• Modern FP includes pills, injectables, IUCDs, while traditional methods include abstinence, withdrawal, and calendar methods.
• Emergency contraception includes IUCDs and COCs (combined oral contraceptives) and POPs (progesterone-only pills).
• FP is a key component of preconception care, reducing adolescent pregnancy rates and promoting spacing between pregnancies.
• FP can reduce unwanted pregnancies by 71%, eliminating 22 million unplanned births, 25 million induced abortions, and seven million miscarriages globally.
• FP also reduces the risk of HIV transmission through consistent condom use.

Why Preconception Care is Needed

• The embryonic period is crucial for pregnancy outcomes.
• Preconception risks include underweight, overweight, unintended pregnancy, anemia, alcohol intake, smoking, chronic medical conditions, STIs, and malaria.
• Preconception care helps prevent adverse outcomes like miscarriage, preterm birth, low birth weight, birth defects, and antepartum hemorrhage.
• Addressing preconception risks reduces maternal and child mortality (by 57%) and morbidity (by 73%).

Why ANC is Not Adequate

• Most antenatal care (ANC) visits occur later in pregnancy
• The median antenatal attendance for Ethiopian women is around 16 weeks of gestation.
• Implementing solely antenatal care is not adequate for improving pregnancy and birth outcomes.

What Do We Assess?

• Reproductive life plan (Are you planning to be pregnant within three months' time?)
• History of unintended pregnancies and abortions.
• Medications, health conditions, and activities affecting fertility.

Intervention

• Counsel and inform individuals desiring or needing delayed pregnancy for medical reasons for family planning.
• Couples should be informed about return to fertility following cessation of contraception to delay conception.
• Information for women and girls to delay teenage pregnancies and inform on birth spacing.
• Counsel and refer clients to family planning units for services.

2. Nutrition

• Underweight or overweight women, those with short stature, or women with micronutrient deficiencies during pregnancy increase complications for both the mother and the fetus.

• In Ethiopia, 22% of women of reproductive age are underweight, 8% are overweight/obese, and 24% are anemic.

• Additionally, 29% of pregnant and lactating women in Ethiopia are also anemic.

• Maternal undernutrition and iron-deficiency anemia account for at least 20% of maternal mortality.

• Women of reproductive age have increased nutrient needs for adequate folic acid, iron, iodine, calcium and zinc, through varied and fortified foods or supplementation.

Nutritional Assessment

• Anthropometric factors (e.g., BMI – 18.5-24.9).
• Biochemical factors (e.g., anemia).
• Clinical assessment (e.g., conjunctiva pallor – iron deficiency).
• Dietary assessment (e.g., dietary practice, diversity).

Nutritional Counseling Interventions

• Nutritional counseling
• Iron-folic acid supplementation
• Micronutrient supplementation (iodine-fortified salt)
• Deworming
• Anemia prevention
• Healthy weight promotion

Nutritional Counseling

• Counsel women on adequate, diversified food consumption during preconception.
• Encourage daily intake of 100-200g of various fruits and vegetables (e.g., tomatoes, carrots, papayas).
• Promote daily inclusion of animal-source foods (60g of meat, 300-400g of dairy)

Additional Nutrition Counseling

• Promote 8-10 glasses of clean water daily and reduce sugar, sweets, and soft drink consumption to below 30g per day.
• Encourage at least 30 minutes of daily exercise.
• Promote calcium-rich foods (dairy, eggs, fish, beef, rice).
• Encourage intake of zinc-rich foods (meat, fish, eggs, whole grains).

Additional Nutritional Counseling Interventions

• Counsel on iodine intake through using iodized salt.
• Educate on avoiding caffeine consumption (within one hour before or after a meal).
• Promote higher intake of vitamin C-rich foods (oranges, etc)
• Encourage decreased consumption of processed foods, junks foods and sugared drinks to prevent overweight and chronic diseases.

Iodine Supplementation

• Iodine deficiency disorders (IDD) can result in adverse maternal and fetal outcomes.
• Neurodevelopmental deficits in the fetal brain are the most significant and irreversible effect of IDD during early pregnancy.
• 80% of pregnant women in Ethiopia have an insufficient iodine intake.
• Counsel women to use iodized salt and take a 150 microgram daily iodine supplement.

Deworming

• Annually or bi-annually deworming with albendazole (400mg) or mebendazole (500mg) controls and/or prevents anemia in women of reproductive age.
• Emphasize hygiene and sanitation practices

Prevention of Anemia

• Anemia during pregnancy increases maternal and perinatal mortality, low birth weight (LBW), and preterm birth.
• Screen all women of reproductive age for anemia via hemoglobin levels.
• Counsel women with diagnosed anemia to take 120mg of elemental iron daily until hemoglobin levels return to normal (Hb12g/L or higher).
• Promote iron-rich foods in meals (meat, fish, and poultry).
• Refer women with non-manageable anemia.

Promoting Healthy Weight During Preconception

• Classify non-pregnant women's nutritional status based on BMI.
• Underweight (<18.5 kg/m2), Normal (18.5-24.9 kg/m2), Overweight (25-29.9 kg/m2), Obese (≥30 kg/m2).
• Women with a low pre-pregnancy BMI (<18.5 kg/m2) are associated with LBW, preterm births, and small for gestational age infants.
• Counsel women with BMI ≥ 25 kg/m2 to improve diet balance, increase physical activity, and understand related health risks, such as hypertension, diabetes, and infertility.

3. Iron-Folic Acid Supplementation

• Provide folic acid as supplementation in addition to foods rich in folic acid (dark green vegetables, fresh fruits, liver).
• Supplementation is 0.4 - 0.5mg daily.
• Folic acid supplementation prevents neural tube defects in newborns.
• Iron supplementation prevents anemia.

Neural Tube Defects.

• Neural tube defects (NTDs) are common CNS congenital anomalies.
• Types include:
  • Spinal bifida occulta
  • Meningocele
  • Myelomeningocele
  • Encephalocele
  • Anencephaly

Daily Oral Iron-Folic Acid Supplementation

• Provide 30-60mg elemental iron and 400µg/0.4mg folic acid daily.
• Counsel women with NTD history to take 5mg of folic acid daily for three months before conception.
• Counsel on the benefits of folic acid supplementation.

4. Sexual Health and Violence

• Violence against women and girls during and before pregnancy negatively affects pregnancy outcomes.
• Female Genital Mutilation (FGM) leads to obstetric complications, psychological trauma, infertility, sexual disharmony, and divorce.
• Gender-based violence encompasses physical, emotional, sexual, and psychological abuse.
• Intimate Partner Violence (IPV) is associated with physical, sexual, and psychological harm.
• 2016 EDHS report shows 23% of women experienced physical violence, 10% experienced sexual violence, and 34% of ever-married women experienced IPV.

Assessment for Violence

• Screen for past and present physical, sexual, and emotional violence.
• Evaluate for physical signs indicative of prior trauma.
• Inquire about a history of FGM.

Preconception Interventions relating to Violence

• Counsel on STI screening, including HIV/AIDS; and provide post-exposure prophylaxis as needed.
• Provide emergency contraception.
• Identify and counsel survivors and ensure their safety including provision of psychosocial support.
• Create awareness regarding gender-based violence and connect survivors with community support networks.
• Counsel and educate individuals about FGM consequences and encourage early and regular antenatal care and discourage re-infibulation post-delivery.

5. Environmental Exposure/Occupational Hazards

• Exposure to lead, ionized radiation, pesticides, mercury, and pollution related to biomass fuel during preconception can cause adverse pregnancy outcomes.
• Adverse effects such as miscarriage, stillbirth and anemia.

Assessment for Environmental Exposure

• Determine exposure to heating devices such as coal stoves, ventilation during heating or cooking.
• Exposure to X-ray or radiation therapy
• Exposure to heavy metals such as mercury, lead, arsenic, and aluminum.
• Exposure to organic solvents including benzene and methanol.

Interventions - Environmental Exposure

• Advice to reduce environmental and occupational exposures.

6. Medicines with Adverse Effects on Pregnancy

• Exposures to medications during the first trimester can cause miscarriages.
• Emphasize the need for thorough counselling for women on teratogenic medication use to avoid unplanned pregnancies.
• Assess medication history for over-the-counter, herbal, natural, recreational and illicit substances.

Preconception Considerations regarding Medication

• Advise women about the potential effects of teratogenic drugs on the fetus.

7. Substance Use

• Substance use, including smoking (active and passive), alcohol consumption, Chat, and recreational drug use, negatively impacts pregnancy.
• Potential adverse effects for both the woman and the fetus include premature birth, birth defects, and infant death.

Assessment for Substance Use

• Provide assessment for exposure to alcohol, cigarette smoking (including passive smoking), Khat chewing, and other substances and ensure privacy.

Preconception Interventions regarding Substance Use

• Counsel women on avoiding alcohol, cigarette smoking (all forms), inhalants, and chewing substances.
• Provide psychosocial support to stop substance use before, during, and after pregnancy.
• Counsel and educate participants on how to reduce coffee intake to less than or equal to 3 cups daily.
• Facilitate access to appropriate counselling and referral to rehabilitation centers for women experiencing substance abuse.

Cigarette Smoking

• Cigarette smoke contains nicotine, cotinine, cyanide, thiocyanate, carbon monoxide, cadmium, lead, and various hydrocarbons.
• These substances have vasoactive effects, reducing oxygen levels, and are fetotoxic.
• Smoking is linked to various birth defects such as microcephaly, omphalocele, gastroschisis, cleft lip and palate, LBW, and increased risks of hydrocephaly, fetal growth restriction, preterm birth, spontaneous abortion, and placenta abruption.

5 As for Smoking Cessation

• Ask about current smoking habits.
• Advice or counseling related to risks of continued smoking and cessation.
• Assess the patient's willingness to cease smoking.
• Assist the patient with cessation methods including providing materials or support networks.
• Arrange the patient to track smoking abstinence progress.

Fetal Alcohol Syndrome

• Fetal alcohol syndrome (FAS) is characterized by a thin upper lip, a flat midface, and a hypoplastic philtrum (the region of the upper lip).

Recreational Drugs

• Marijuana use during pregnancy only leads to adverse pregnancy outcomes such as preterm birth and low birth weight if combined with tobacco use.
• Chronic heroin use is associated with preterm birth, placental abruption, fetal growth restriction, and fetal death.