Addressing barriers to maternal nutrition in low‐ and middle‐income countries: A review of the evidence and programme implications

Adequate maternal nutrition during the “first 1,000 days” window is critical from conception through the first 6 months of life to improve nutritional status and reduce the risk of poor birth outcomes, such as low birthweight and preterm birth. Unfortunately, many programmes have targeted implementation and monitoring of nutrition interventions to infants and young children, rather than to women during pregnancy or post‐partum. A literature review was conducted to identify barriers to food choice and consumption during pregnancy and lactation and to examine how low‐ and middle‐income countries have addressed maternal nutrition in programmes. A literature review of peer‐reviewed and grey literature was conducted, and titles and abstracts reviewed by authors. Twenty‐three studies were included in this review. Barriers to adequate nutrition during pregnancy included cultural beliefs related to knowledge of quantity of food to eat during pregnancy, amount of weight to gain during pregnancy, and “eating down” during pregnancy for fear of delivering a large baby. Foods considered inappropriate for consumption during pregnancy or lactation contributed to food restriction. Drivers of food choice were influenced by food aversions, economic constraints, and household food availability. Counselling on maternal diet and weight gain during pregnancy was seldom carried out. Programming to support healthy maternal diet and gestational weight gain during pregnancy is scant. Tailored, culturally resonant nutrition education and counselling on diet during pregnancy and lactation and weight gain during pregnancy, as well as monitoring of progress in maternal nutrition, are areas of needed attention.     

Dietary behaviours and weight management: A thematic analysis of pregnant women's perceptions

Maternal obesity is associated with increased risk of gestational diabetes and other complications. Although antenatal interventions to help prevent these complications are ongoing, an understanding of overweight and obese pregnant women's opinions and attitudes is lacking. Therefore, this study aims to explore these women's experiences and perceptions of dietary behaviours and weight management during pregnancy. Secondary analysis of qualitative data originally collected to examine lifestyle behaviours in pregnant women was conducted. The data were from a purposive sample of overweight and obese pregnant women attending a public antenatal clinic in Cork, Ireland. The data were explored using thematic analysis. Interviews with 30 overweight and obese pregnant women were analysed. Three themes were developed relating to overweight and obese women's dietary behaviours and weight management perceptions including ‘pregnancy's influence on dietary behaviours’, ‘external influences on dietary behaviours’ and ‘perception of and preferences for weight related advice and resources’. Together these themes reveal women's experiences of diet and how pregnancy factors (physiological changes) and external factors (family and friends) can influence dietary behaviours. Furthermore, perceptions of weight management advice and lack thereof were highlighted with women drawing attention to potential resources for future use during pregnancy. This study provides important insights into overweight and obese pregnant women's dietary behaviours and perceptions of weight management. According to these findings, there is a need for clear and unambiguous information about weight management, acceptable weight gain, food safety and how to achieve a balanced diet.     

Development and validation of a health and nutrition module for the project-level Women's Empowerment in Agriculture Index (pro-WEAI+HN)

Agricultural development projects increasingly aim to improve health and nutrition outcomes, often by engaging women. Although evidence shows such projects can improve women's and children's health and nutrition and empower women, little is known about their impacts on women's health- and nutrition-related agency and the extent to which impacts emerge through women's empowerment, largely due to a lack of instruments that measure the dimensions of women's agency that are directly relevant to health and nutrition outcomes. We developed an optional, complementary module for the project-level women's empowerment in agriculture index (pro-WEAI) to measure health- and nutrition-related agency (pro-WEAI + HN). Our method for developing related indicators used data collected from six agricultural development programmes implemented across Bangladesh, Burkina Faso and Mali (pooled sample = 12,114) and applied psychometric analysis (exploratory and confirmatory factor analysis) and the Alkire−Foster methodology. Results revealed seven indicators covering women's agency in the areas of her own health and diet; her health and diet during pregnancy; her child's diet; breastfeeding and weaning; purchasing food and health products; and acquiring food and health products. Multigroup confirmatory factor analysis revealed measurement invariance across contexts and samples. Tests of association (Cramer's V) and redundancy suggest that the pro-WEAI + HN indicators measured aspects of agency that are distinct from the core pro-WEAI. The uptake of these indicators in studies of nutrition-sensitive agricultural development projects may strengthen the evidence on how such programming can enhance women's empowerment to improve health and nutrition outcomes for themselves and their children.     

Program considerations for integration of nutrition and family planning: Beliefs around maternal diet and breastfeeding within the context of the nutrition transition in Egypt

In Egypt, rising maternal overweight and obesity is consistent with the transition to westernized diets and a growing reliance on energy‐dense, low nutrient foods. Although the first 1,000 days of life are the focus of many programmes designed to prevent many forms of malnutrition, little attention has been paid to maternal dietary practices and weight gain during pregnancy. This study used in‐depth interviews with pregnant women (N = 40), lactating women (N = 40), and nonlactating women (N = 40) to gain an understanding of behaviours, perceptions, and cultural beliefs in relation to maternal dietary intake during pregnancy, lactation, and nonlactation; weight gain during pregnancy; birth spacing; and family planning. Study findings reveal that food choice was driven by affordability, favoured foods, or foods considered appropriate for a specific life stage (pregnant, lactating, and nonlactating). Knowledge of weight gain during pregnancy is limited, especially with regards to excessive weight gain during pregnancy. Diet is often modified during lactation to support breast milk production, and a normal diet resumed when breastfeeding ceases. Within the context of breastfeeding, the lactational amenorrhea method provides an opportunity to improve exclusive breastfeeding practices, maternal diet during lactation, and the transition to other family planning methods by 6 months postpartum. Health care providers should discuss limiting maternal consumption of low nutrient foods such as junk foods, soda, and teas during pregnancy and postpartum. Dietary counselling should accompany information on appropriate weight gain during pregnancy and exercise to prevent excessive weight gain, in the context of the nutrition transition.     

Knowledge about the Developmental Origins of Health and Disease is independently associated with variation in diet quality during pregnancy

Environmental factors affecting development through embryogenesis, pregnancy, and infancy impact health through all subsequent stages of life. Known as the Developmental Origins of Health and Disease (DOHaD) hypothesis, this concept is widely accepted among health and social scientists. However, it is unclear whether DOHaD‐based ideas are reaching the general public and/or influencing behaviour. This study thus investigated whether and under what circumstances pregnant people in Canada are familiar with DOHaD, and if DOHaD familiarity relates to eating behaviour. Survey responses from pregnant people from Hamilton, Canada, were used to assess respondents' knowledge of DOHaD (hereafter, DOHaD_KNOWLEDGE) compared with their knowledge of more general pregnancy health recommendations (Pregnancy Guideline_KNOWLEDGE). The survey also characterized respondents' pregnancy diet quality and sociodemographic profiles. We fit two multiple, linear, mixed regression models to the data, one with DOHaD_KNOWLEDGE score as the dependent variable and the other with diet quality score as the dependent. In both models, responses were clustered by respondents' neighbourhoods. Complete, internally consistent responses were available for 330 study‐eligible respondents. Relative to Pregnancy Guideline_KNOWLEDGE, respondents had lower, more variable DOHaD_KNOWLEDGE scores. Additionally, higher DOHaD_KNOWLEDGE was associated with higher socio‐economic position, older age, and lower parity, independent of Pregnancy Guideline_KNOWLEDGE. Diet quality during pregnancy was positively associated with DOHaD_KNOWLEDGE, adjusting for sociodemographic factors. A subset of relatively high socio‐economic position respondents was familiar with DOHaD. Greater familiarity with DOHaD was associated with better pregnancy diet quality, hinting that translating DOHaD knowledge to pregnant people may motivate improved pregnancy nutrition and thus later‐life health for developing babies.     

Changes in women's dietary diversity before and during pregnancy in Southern Benin

Dietary diversity before and during pregnancy is crucial to ensure optimal foetal health and development. We carried out a cohort study of women of reproductive age living in the Sô‐Ava and Abomey‐Calavi districts (Southern Benin) to investigate women's changes in dietary diversity and identify their determinants both before and during pregnancy. Nonpregnant women were enrolled (n = 1214) and followed up monthly until they became pregnant (n = 316), then every 3 months during pregnancy. One 24‐hr dietary recall was administered before conception and during each trimester of pregnancy. Women's dietary diversity scores (WDDS) were computed, defined as the number of food groups out of a list of 10 consumed by the women during the past 24 hr. The analysis included 234 women who had complete data. Mixed‐effects linear regression models were used to examine changes in the WDDS over the entire follow‐up, while controlling for the season, subdistrict, socio‐demographic, and economic factors. At preconception, the mean WDDS was low (4.3 ± 1.1 food groups), and the diet was mainly composed of cereals, oils, vegetables, and fish. The mean WDDS did not change during pregnancy and was equally low at all trimesters. Parity and household wealth index were positively associated with the WDDS before and during pregnancy in the multivariate analysis. Additional research is needed to better understand perceptions of food consumption among populations, and more importantly, efforts must be made to encourage women and communities in Benin to improve the diversity of their diets before and during pregnancy.     

How can we best use opportunities provided by routine maternity care to engage women in improving their diets and health?

Pregnancy provides motivation for women to improve their diets and increase their physical activity. Opportunistic brief interventions delivered as part of routine primary care have produced improvements in patients' health behaviour. Consequently, there have been calls for midwives to use contacts during pregnancy in this way. This study explored the experiences of pregnant women and research midwives/nurses of a brief intervention called Healthy Conversation Skills (HCS) being delivered as part of a randomised control trial, assessing the acceptability and feasibility of including this intervention in routine maternity care. Three research questions were addressed using mixed methods to produce four datasets: face‐to‐face interviews with participants, a focus group with the HCS‐trained midwives/nurses, case reports of participants receiving HCS and audio‐recordings of mid‐pregnancy telephone calls to the women which produced midwife/nurse HCS competency scores. Midwives/nurses used their HCS to support women to make plans for change and set goals. Women welcomed the opportunity to address their own health and well‐being as distinct from that of their baby. Midwives/nurses were competent in using the skills and saw healthy conversations as an effective means of raising issues of diet and physical activity. Recent extension of maternity appointment times provides ideal opportunities to incorporate a brief intervention to support behaviour change. Incorporating HCS training into midwifery education and continuing professional development would facilitate this. HCS is a scalable, brief intervention with the potential to improve the diets and physical activity levels of women during pregnancy, and hence the health of themselves and their babies.     

Provision of weight management advice for obese women during pregnancy: a survey of current practice and midwives' views on future approaches

A semi‐structured, web‐based questionnaire was developed to survey midwives (n = 241) employed by NHS Tayside, UK, to identify current practice and views on weight management of obese women during pregnancy and the puerperium. A total of 78 (32%) midwives submitted responses following email invitation. Most respondents (79%) reported always calculating women's body mass index (BMI) at booking, with 73% routinely explaining the BMI category. In terms of future practice for obese women, although few respondents (15%) currently offer personalised advice regarding weight management based on a woman's diet and physical activity levels, 77% of respondents thought such advice would be appropriate and 69% thought it could possibly be feasible to offer such advice. The respondents viewed weight management to be of importance and felt that universal advice is appropriate, but confidence in discussing weight management and knowledge of the subject was low. Strategies to improve midwife confidence and weight management services should include training, ongoing support and definition of the midwife's role within the multidisciplinary team to support practice in the future.     

Diet quality among pregnant women in the Navajo Birth Cohort Study

Proper nutrition during pregnancy is vital to maternal health and fetal development and may be challenging for Navajo Nation residents because access to affordable and healthy foods is limited. It has been several decades since reported diet quality during pregnancy was examined on Navajo Nation. We present the first study to estimate iodine intake and use the Healthy Eating Index (HEI‐2015) to assess maternal diet quality among pregnant women in the Navajo Birth Cohort Study (NBCS). Based on dietary intake data derived from food frequency questionnaires, overall estimated micronutrient intake has remained similar since the last assessment in 1981, with potential improvements evident for folate and niacin. A high proportion of women (>50%) had micronutrient intakes from dietary sources below the Estimated Average Requirements during pregnancy. The median urinary iodine concentration for NBCS women (90.8 μg/L; 95% CI [80, 103.5]) was less than adequate and lower than concentrations reported for pregnant women that participated in the National Health and Nutrition Examination Survey (NHANES) between 2011 and 2014. Overall, average diet quality of NBCS women estimated using the HEI‐2015 (62.4; 95% CI [60.7, 64.0]) was similar to that reported for women of child‐bearing age and pregnant women in NHANES. Although, NBCS women had diets high in added sugar, with sugar‐sweetened beverages as the primary contributors. Our study provides updated insights on maternal diet quality that can inform health and nutrition initiatives in Navajo communities emphasizing nutrition education and access to prenatal vitamins and calcium, iodine, and vitamin E dense foods.     

Men's nutrition knowledge is important for women's and children's nutrition in Ethiopia

In an effort to address undernutrition among women and children in rural areas of low‐income countries, nutrition‐sensitive agriculture (NSA) and behaviour change communication (BCC) projects heavily focus on women as an entry point to effect nutritional outcomes. There is limited evidence on the role of men's contribution in improving household diets. In this Agriculture to Nutrition trial (Clinicaltrials.gov identifier: NCT03152227), we explored associations between men's and women's nutritional knowledge on households', children's and women's dietary diversity. At the midline evaluation conducted in July 2017, FAO's nutrition knowledge questionnaire was administered to male and female partners in 1396 households. There was a high degree of agreement (88%) on knowledge about exclusive breastfeeding between parents; however, only 56–66% of the households had agreement when comparing knowledge of dietary sources of vitamin A or iron. Factor analysis of knowledge dimensions resulted in identifying two domains, namely, ‘dietary’ and ‘vitamin’ knowledge. Dietary knowledge had a larger effect on women's and children's dietary diversities than vitamin knowledge. Men's dietary knowledge had strong positive associations with households' dietary diversity scores (0.24, P value = 0.001), children's dietary diversity (0.19, P value = 0.008) and women's dietary diversity (0.18, P value < 0.001). Distance to markets and men's education levels modified the effects of nutrition knowledge on dietary diversity. While previous NSA and BCC interventions predominantly focused on uptake among women, there is a large gap and strong potential for men’s engagement in improving household nutrition. Interventions that expand the role of men in NSA may synergistically improve household nutrition outcomes.     

Nutrition in adolescent pregnancy

Prevention of unintended adolescent pregnancy is a primary goal of the American Academy of Pediatrics and of many health providers. Nevertheless, many adolescents become pregnant every year in America. Pediatricians therefore should be aware of nutritional recommendations for pregnant adolescents to provide optimal care. The importance of nutrition during pregnancy is here reviewed from a pediatric perspective. Pregnancy, particularly during adolescence, is a time of extreme nutritional risk. The adolescents most likely to become pregnant are often those with inadequate nutritional status and unfavorable socio-economic background. There is increasing evidence of competition for nutrients between the growing pregnant adolescent and her fetus. Also, the prenatal environment has been implicated in the development of obesity, cardiovascular disease, and diabetes in both the mother and her offspring. Many adolescents have poor diet quality and poor knowledge of appropriate nutrition; these habits may not change during pregnancy. Current knowledge and recommendations regarding the intake of energy, calcium, and folate are discussed in detail.     

Healthier diet associated with reduced risk of excessive gestational weight gain: A Chinese prospective cohort study

Limited studies have examined the associations between diet quality and gestational weight gain (GWG) among Chinese pregnant women, adopting Chinese GWG guidelines. We prospectively investigate the associations of diet quality, using the Chinese Healthy Diet Index for Pregnancy (CHDI-P), which assessed diet quality from ‘Diversity’, ‘Adequacy’ and ‘Limitation’ dimensions with overall 100 points, with GWG among participants enroled in Southwest China. Food consumption was collected by 24 h dietary recalls for three consecutive days and CHDI-P scores were divided into tertiles. GWG was calculated according to the weight measured before delivery and classified into adequate weight gain (AWG), insufficient weight gain (IWG) and excessive weight gain(EWG) following Chinese GWG guidelines. Multinomial regression analyses and stratified analyses by pre-pregnancy body mass index were performed to estimate the association between CHDI-P and GWG. A total of 1416 participants were recruited in early pregnancy, and 971 and 997 participants were respectively followed up in middle and late pregnancy. The mean CHDI-P score was 56.44 ± 6.74, 57.07 ± 7.44 and 57.38 ± 7.94 points in early, middle and late pregnancy, respectively. Women in the lowest CHDI-P scores group had an increased risk of EWG in middle (OR = 1.53, 95% confidence interval [CI] = 1.08–2.17) and late pregnancy (OR = 1.71, 95% CI = 1.21–2.41) than women in the highest group, while overweight/obese women had a greater risk of EWG in late pregnancy (OR = 4.25, 95% CI = 1.30–13.90). No association was found between the CHDI-P scores and IWG. Poor diet quality in middle and late pregnancy was associated with a higher risk of EWG.     

Barriers to weight‐related health behaviours: a qualitative comparison of the socioecological conditions between pregnant and post‐partum low‐income women

The association between socioecological factors and poor health outcomes for low‐income women and their children has been the focus of disparities research for several decades. This research compares the socioecological conditions among low‐income women from pregnancy to post‐partum and highlights the factors that make weight management increasingly difficult after delivery. As part of the formative research for an online health intervention, group and individual interviews were conducted with low‐income pregnant and post‐partum women. Five pregnancy group interviews (n = 15 women), five post‐partum group interviews (n = 23 women) and seven individual interviews with a total of 45 participants were conducted in Rochester, New York. All interviews were audio‐recorded. The constant comparative method was used to code interview notes and identify emergent themes. Subjects faced many challenges that affected their attitudes, beliefs and their ability to maintain or improve healthy weight behaviours. These included unemployment, relationship issues, minimal social support, lack of education, limited health care access, pre‐existing medical conditions and neighbourhood disadvantage. Compared with pregnant women, post‐partum women faced additional difficulties, such as child illnesses and custody issues. The most striking differences between pregnancy and post‐partum related to the family's medical problems and greater environmental constraints. Many factors detracted from women's capacity to engage in healthy weight behaviours post‐partum, including challenges present prior to delivery, challenges present prior to delivery that worsen after delivery, and new challenges that begin after delivery. These additional post‐partum challenges need to be considered in designing programmes, policies and interventions that promote healthy weight.     

Evaluation of a smartphone nutrition and physical activity application to provide lifestyle advice to pregnant women: The SNAPP randomised trial

Our objective was to evaluate the impact of a smartphone application as an adjunct to face‐to‐face consultations in facilitating dietary and physical activity change among pregnant women. This multicentre, nested randomised trial involved pregnant women with a body mass index ≥18.5 kg/m², with a singleton pregnancy between 10 and 20 weeks' gestation, and participating in 2 pregnancy nutrition‐based randomised trials across metropolitan Adelaide, South Australia. All women participating in the SNAPP trial received a comprehensive dietary, physical activity, and behavioural intervention, as part of the GRoW or OPTIMISE randomised trials. Women were subsequently randomised to either the “Lifestyle Advice Only Group,” where women received the above intervention, or the “Lifestyle Advice plus Smartphone Application Group,” where women were additionally provided access to the smartphone application. The primary outcome was healthy eating index (HEI) assessed by maternal food frequency questionnaire completed at trial entry, and 28 and 36 weeks' gestation. Analyses were performed using intention‐to‐treat principles, with statistical significance at p = .05. One hundred sixty‐two women participated: 77 allocated to the Lifestyle Advice plus Smartphone Application Group and 85 to the Lifestyle Advice Only Group. Mean difference in HEI score at 28 weeks of pregnancy was 0.01 (CI [?2.29, 2.62]) and at 36 weeks of pregnancy ?1.16 (CI [?4.60, 2.28]). There was no significant additional benefit from the provision of the smartphone application in improving HEI score (p = .452). Although all women improved dietary quality across pregnancy, use of the smartphone application was poor. Our findings do not support addition of the smartphone application.     

Nutrition‐sensitive agriculture programme impacts on time use and associations with nutrition outcomes

Success of nutrition‐sensitive agriculture programmes targeted to women may be influenced by increased demands on women''s and other household members'' time and by time‐related trade‐offs to accommodate programme participation. However, evidence of how such programmes impact time use and whether changes in time‐related demands negatively influence maternal or child health and nutrition outcomes is limited. This paper examines the impact of Helen Keller International''s Enhanced Homestead Food Production programme in Burkina Faso (2010–2012) on women''s and men''s time use and associations between changes in women''s time use and maternal and child health and nutrition outcomes. We used quantitative data from a cluster‐randomized controlled trial (baseline 2010, endline 2012) and qualitative data from two rounds of process evaluation (2011, 2012). Two‐stage analyses were used to first assess programme impacts on women''s and men''s time use using difference‐in‐difference impact estimates and second to evaluate whether programme impacts on women''s time use were associated with changes in women''s and children''s health and nutrition outcomes. Programme impacts were considered significant if corrected P < 0.01, and associations were considered significant if p < 0.05 and p < 0.01. Qualitative data were analysed through manual coding and by calculating the means and standard deviations for the time spent by women and men on activities in intervention and control groups. Findings show that the programme significantly increased the amount of time women spent on agriculture in the intervention compared to the control group, but this was not associated with changes in maternal or child health or nutrition outcomes. Process evaluation data supported these findings.