The State of the World's Children 1998: Focus on Nutrition

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Panel 7

High-energy biscuits for mothers boost infant survival by 50 per cent

Photo: A healthy newborn sleeps peacefully in the Gambia.

In the Gambia, well-targeted interventions to improve the nutrition of pregnant women are making a difference in the birthweight of their babies, and at the same time sharply reducing the risk of babies dying during, or shortly after, birth.

A large, controlled study in the country's rural West Kiang region has determined that the number of low-birthweight babies fell by nearly 40 per cent and that stillbirth and perinatal mortality rates in infants were almost 50 per cent lower when pregnant women received a daily ration of locally prepared, energy-rich biscuits. These remarkable results strengthen the argument for providing food supplements to pregnant women to reduce low birthweight.

"The study clearly demonstrates that improved maternal nutrition, deliverable through a primary health care system, can have highly beneficial effects when efficiently targeted at women in genuine need," says one of the study's authors, Dr. Sana Ceesay, of the Dunn Nutrition Centre affiliated with the University of Cam bridge, which has been working in partnership with the Gambian Health Department. The findings were published in the British Medical Journal in September 1997.

UNICEF estimates that each year over 24 million babies are born below the low-birthweight threshold of 2.5 kg, and that 95 per cent of these births occur in the developing world. Low birthweight puts infants at a greatly increased risk of neonatal death and is an important cause of poor growth and development in later childhood. It can be due to a number of factors, including a woman's small size, uterine infections, smoking, low oxygen levels in the blood (due to excessive work or high altitude) and malarial infection. However, when all these factors are equal, the incidence of low birthweight is higher in economically deprived mothers than in affluent ones.

The most likely explanation for the difference is that inadequate maternal nutrition suppresses foetal growth. It has often been difficult, nevertheless, to show real benefits to infants from improvements to a mother's diet during pregnancy. The study in the Gambia provides such evidence.

In this part of West Africa, previous studies had indicated that pregnant women - challenged as many women are by the high energy demands of water and fuel collection, agricultural work and child-care activities but also by the energy and other nutrient needs of pregnancy - did not eat enough or well enough to meet all these needs. The growth of their babies was thus threatened.

The five-year, prenatal supplementation trial covered 28 villages in one region of the Gambia. In the intervention villages, pregnant mothers received daily high-energy groundnut-based biscuits, providing 1,000 kcal/day on average after 20 weeks of pregnancy. The biscuits were made from local ingredients and were baked by two village bakers in traditional clay ovens. Women in control villages received antimalarials, iron/folate supplements and antenatal care as did women in the intervention villages, but they did not receive the biscuits during pregnancy. Field workers weighed all the women in the study at regular intervals, and weighed and measured all infants at delivery.

The biscuit supplement caused a highly significant increase in birthweight, reducing the numbers of infants classified as low birthweight by 39 per cent. Particularly noteworthy was the reduction in low birthweight occurring in births during the annual 'hungry season', when birthweights normally are lower than in the harvest season, as a result of poor maternal nutrition combined with hard seasonal agricultural work. (It is unlikely that food supplements would have the same impact on pregnant women who are not chronically energy-deficient.)

In addition to these remarkable benefits, this study refutes the idea prevailing in some circles that improving the diet of pregnant women will cause them to suffer higher rates of obstetrical complications because of the larger size of their newborns. Birthweight was indeed higher in the children of women who received the biscuits, but head circumference, which is the factor more closely related to pelvic disproportion in birth, was only slightly greater. The rate of obstetric complications of this kind was not higher in the supplemented women.

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