EVIDENCE BASED NUTRITION

INTERVENTIONS FOR PREGNANT WOMEN

Ir. Doddy Izwardy, B.Sc, MA, PhD

Director of PPKMI

INTERNATIONAL SEMINAR:
BECOMING THE BEST HUMANE HELATH WORKER IN THE MODERN ERA
At the 22nd anniversary of the Medistra Indonesia of Health College
Saturday 22 June 2024
 FACTS FOR ALL COUNTRIES TO ACHIEVE IT
• The World Health Assembly (WHA) has set program achievement targets
improving nutrition by 2025 which has been accepted as a reference in
various countries.
• The targets for achieving the nutrition improvement program include
reducing stunting cases in toddlers by 40%, the reduction in the rate of
low birth weight (LBW) babies was 40%, 30%, reduction in anemia in
women of childbearing age by 50% (WHA, 2013).
• For to achieve this target, nutritional interventions should be carried out
early, namely from the beginning of life to the first 1000 days of life
(1000 HPK).
 FACTS FOR ALL COUNTRIES TO ACHIEVE IT
• The concept of 1000 HPK is calculated from the moment of conception,
throughout the period pregnancy, until the child is 2 years old. This period is a
golden age the child's life cycle, the critical period that will determine the
quality of the child's life in future which will come. However, the beginning of
life starts at conception up to 8 weeks the first part of pregnancy
(periconceptional period) is difficult to reach by programs intended for
pregnant women. Therefore, in order to save 1000 HPK (Sumarmi et al.,
2017).
• Investing in nutrition in the first 1,000 days from conception not only supports
individual lifetime health, education, and productivity, but is also key to
breaking the intergenerational cycle of malnutrition and enhance equitable
development pathways for low- and middle-income countries.
 FACTS FOR ALL COUNTRIES TO ACHIEVE IT
Peer-reviewed manuscript as of February 11, 2023 for the Copenhagen Consensus Center
project Halftime for the Sustainable Development Goals states that a decade ago, Bhutta et
al (2013) presented a comprehensive update of a package of evidence-based interventions to
address undernutrition and micronutrient deficiencies in women and children. The package
consisted of ten interventions. Four are for pregnant women: periconceptional folic acid
supplementation or fortification, maternal balanced energy protein supplementation,
maternal calcium (Ca) supplementation, multiple micronutrient (MMN) supplementation in
pregnancy.

MMN supplementation for pregnant women replacing IFA, as well as MMN and Ca combined,
have the highest benefit-cost ratios (BCRs)
BACKGROUND: CHALLENGES THAT MUST BE FACED
BY INDONESIA, AS A MIDDLE INCOME COUNTRY
 MOTHER'S NUTRITIONAL INTERVENTION GUIDE
• The World Health Organization has provided comprehensive, evidence-based
guidance on the practice, organization and delivery of ANC to facilitate a
positive pregnancy experience, with 14 of the 49 recommendations in the
WHO ANC guidelines relating to nutrition. This guide was updated in 2020
regarding MMS and Vitamin D supplementation, and in 2021 regarding zinc
supplementation.
• UNICEF also published guidance to support UNICEF's vision for maternal
nutrition programs outlined in the UNICEF Nutrition Strategy 2020–2030.
This guide is accompanied by a program summary that describes a range of
approaches to strengthen maternal nutritional counseling
 THESE GUIDELINES… 1)
The WHO's comprehensive antenatal care (ANC) guidelines WHO recommended antenatal
services for a positive pregnancy experience were first published in 2016 with the aim of
improving the quality of routine health services that all women and adolescent girls receive
during pregnancy.
Recognizing that ANC provides a strategic platform for important health care functions,
including health promotion and disease prevention, 14 of the 49 recommendations in the 2016
WHO ANC guidelines relate to nutritional interventions in pregnancy. In April 2019, the
Executive Guideline Steering Group (GSG) prioritized these two antenatal nutrition
recommendations for updating in response to new evidence regarding these interventions,
namely: Vitamin D supplements during pregnancy, and Various micronutrient supplements
during pregnancy.
Oral vitamin D supplementation is not recommended for all pregnant women to improve
maternal and perinatal outcomes. (Not recommended)
These recommendations update and do not change WHO recommendations regarding vitamin D
supplementation during pregnancy is found in the WHO ANC guidelines. Pregnant women should be
© World Health Organization 2016 encouraged to receive adequate nutrition – which is best achieved through consuming a healthy,
balanced diet – and refer to healthy eating guidelines
Source: https://iris.who.int/bitstream/handle/10665/344010/9789240030466-
eng.pdf?sequence=1 accesed 19 June 2024
 THESE GUIDELINES… 2)
These recommendations update and replace the WHO recommendations contained in the
WHO ANC guidelines issued in 2016.
Evidence was obtained from trials using MMS containing 13 to 15 micronutrients (including
iron and folic acid) and the widely available United Nations International Multiple
Micronutrient Antenatal Preparation (UNIMMAP), which contains 15 micronutrients, including
30 mg of iron and 0.4 mg folic acid.
Because the evidence mostly comes from low and middle income countries
Research in this context includes:
• controlled clinical trials in which early pregnancy ultrasound is used to determine
gestational age with certainty, with assessment of important maternal and perinatal
outcomes, and follow-up of infants who survive into childhood;
• where an MMS program is being considered, implementation research to determine the
impact of switching from MMS iron and folic acid supplements to MMS, including
© World Health Organization 2020 evaluation of acceptability, feasibility, sustainability, equity and cost effectiveness.

Source: https://iris.who.int/bitstream/handle/10665/344010/9789240030466-
eng.pdf?sequence=1 accesed 19 June 2024
 THESE GUIDELINES… 3)
• Many MMS contain 30 mg or less of elemental iron and WHO
recommends antenatal iron and folic acid supplements containing 60 mg
of elemental iron in populations where anemia is a serious public health
problem (prevalence of 40% or higher). Therefore, countries should
consider the population size and distribution of nutritional determinants
of anemia (i.e. iron deficiency), as well as the magnitude and distribution
of complex low birth weight and its component parts (i.e. prematurity,
small for gestational age [SGA] or a combination of these), when
conducting any research in the context of these recommendations.
• Pregnant women should be supported and encouraged to receive
adequate nutrition, which is best achieved through consuming a healthy
and balanced diet in accordance with healthy eating guidelines.
© World Health Organization 2020

Source: https://iris.who.int/bitstream/handle/10665/344010/9789240030466-
eng.pdf?sequence=1 accesed 19 June 2024
 SCOPE OF THE RECOMMENDATIONS
• These updated recommendations are relevant for all pregnant women and
adolescent girls receiving ANC in health facilities or community-based
settings, and for their fetuses and unborn babies To prepare the mother
for childbirth.
• In 2019, this was prioritized for updating in the WHO context commitment
to living guidelines.
• The authors of the Cochrane review on which the 2016 ANC guideline
panel was based recommendations were based on updating their review
to include new studies. Therefore, the results are interesting the same as
ANC guideline priorities relevant to nutritional interventions.
 ANC NUTRITIONAL INTERVENTIONS OUTCOMES OF INTEREST
Maternal outcomes
Infections
Anaemia
Pre-eclampsia/eclampsia
Gestational diabetes mellitus
Mode of delivery
Excessive weight gain
Side effects
Maternal mortality
Maternal satisfaction
Fetal/neonatal outcomes
Neonatal infections
Small for gestational age
Low birthweight
Preterm birth
Congenital anomalies
Macrosomia/large for gestational age
Fetal/neonatal mortality
Rwanda Study: The Gikuriro program, an integrated nutrition-specific and nutrition-
sensitive intervention, was implemented in 5 districts of Rwanda.

Effect and Challenges of an Integrated Nutrition-Intervention Package Utilization among

Pregnant Women and Lactating Mothers in Rwanda: An Exploratory Qualitative Study
Michael Habtu, et all, Current of Developments of Nutrition, 2023

The study has demonstrated several positive effects of an integrated nutrition-specific and nutrition-
sensitive intervention package, such as promoting women empowerment, perceived improved nutritional
status and enhanced knowledge/skills on cooking a balanced diet, kitchen garden, hygiene practices, and
savings. Despite these benefits, there were some challenges identified that hindered pregnant
women and lactating mothers from using the integrated nutrition intervention, including
poverty/economic restrictions, lack of husband support and time, and lack of awareness and
negative beliefs about the nutrition intervention.
Awareness campaigns on the misconceptions about nutrition interventions, involving
husbands/ men in the interventions, support for pregnant women and lactating mothers, and
their economic development/empowerment should be enhanced.
 Vitamins and minerals, education, and selfcare need during preconception to 1000days of
life in Southeast Asia: An expert panel opinion…1)
Unnop Jaisamrarn. et.al, 2023
SAGE Open Medicine Volume 11: 1–17

Addressing maternal malnutrition and its drivers is paramount in Southeast Asia. This article summarizes the key clinical
learnings and evidence-based opinions from the experts to understand the need for vitamins and minerals
supplementation, education, and self-care from preconception to the first 1000days of life, which warranted further
attention since COVID-19 pandemic. Evidence describing the importance of vitamins and minerals during preconception,
pregnancy, and lactation stages was identified using literature databases.

Nine experts from Southeast Asia provided evidence-based opinion on the vitamins and minerals
supplementation, education, and self-care need during preconception, pregnancy, and lactation stages. The
expert opinions underpin maternal malnutrition as a prevalent issue and discuss appropriate interventions and
prevention strategies for women in Southeast Asia
 Vitamins and minerals, education, and selfcare need during preconception to 1000days of
life in Southeast Asia: An expert panel opinion…2)
Unnop Jaisamrarn. et.al, 2023
SAGE Open Medicine Volume 11: 1–17

The expert panel emphasized a need to improve existing inadequacies in education, self-
care, and social support, and discussed the role of policymakers in addressing the barriers
to dietary changes
As inadequacies in regular vitamins and minerals supplementation, education, and self-care
for women of reproductive age implicate maternal and child health outcomes, there is an
urgent need for addressing malnutrition concerns in this population. Thus, a strong
partnership between policymakers, healthcare professionals, and other relevant sectors is
required
 Vitamins and minerals, education, and selfcare need during preconception to 1000days of
life in Southeast Asia: An expert panel opinion…3)
Unnop Jaisamrarn. et.al, 2023
SAGE Open Medicine Volume 11: 1–17

For interesting to study in more depth in this journal is Appropriate interventions promoting adherence to a
healthy diet and supplementation should start as early as preconception and continue through
the “first 1000 days” of life

According to Blondin JH and LoGiudice JA (2018): Adequate knowledge of dietary

recommendations can help pregnant women achieve healthy weight gain. Results of
research conducted by Thandar MM, Kiriya J, Shibanuma A, et al (2019): in Myanmar, 86% of
pregnant women have a low to moderate level of knowledge about nutritional needs during
pregnancy.
 Vitamins and minerals, education, and selfcare need during preconception to 1000days of
life in Southeast Asia: An expert panel opinion…4)
Unnop Jaisamrarn. et.al, 2023
SAGE Open Medicine Volume 11: 1–17

Research conducted by Girard AW, Olude O (2015) and Darnton-Hill I, Mkparu UC (2012), states that nutritional
counseling and consultation has increased knowledge and understanding of pregnant women and reduced
maternal risks (reducing premature birth by 54%, risk of maternal anemia by 30%, and increased gestational
weight gain by 0.45 kg) and fetal complications.
However, research in Indonesia conducted by Rahmawati W, Willcox JC, van der Pligt P, et al (2021) and
Rahmawati W, van der Pligt P, Worsley A, et al (2021), only a few women visited community health centers to
receive nutritional counseling . Most pregnant women do not actively search for nutritional information.
These findings suggest improvements in antenatal nutrition education and related services for pregnant
women.
 Vitamins and minerals, education, and selfcare need during preconception to 1000days of
life in Southeast Asia: An expert panel opinion…5)
Unnop Jaisamrarn. et.al, 2023
SAGE Open Medicine Volume 11: 1–17

Research conducted in Malaysia by Daud NAA, et al (2020) reported that the majority of
pregnant women (87.9%) were aware of the role of food supplements during pregnancy, but
only half of them admitted to consuming important supplements during pregnancy (49.1%) .
Consumption of micronutrients such as vitamin B12, either through food or supplements,
was found to be inadequate in seven Asian regions (Hong Kong, Indonesia, Philippines,
Singapore, Taiwan, Thailand and Vietnam). Inadequate concentrations of essential nutrients
during critical periods of fetal development can lead to reprogramming in fetal tissues,
thereby making the baby vulnerable to chronic conditions later in life.
 IMPORTANT POINTS THAT MUST BE UNDERSTOOD BY PREGNANT
WOMEN…1)
The importance of nutrition for
pregnant women:
• To meet the nutritional needs of the mother during pregnancy and the
fetus she is carrying
• To prepare the mother for childbirth
• To prepare mothers to be able to breastfeed their babies perfectly
• To store fat during pregnancy with the aim of providing energy reserves
needed later during breastfeeding activities.
 IMPORTANT POINTS THAT MUST BE UNDERSTOOD BY PREGNANT
WOMEN…2)

Nutritional needs during pregnancy

• To meet the nutritional needs of the mother during pregnancy and the fetus she is
carrying
• The aim of nutritional management in pregnant women is to achieve optimal maternal
nutritional status so that the mother undergoes a safe pregnancy, giving birth to a baby
with good physical and mental potential.
• Increasing the amount of nutrients to meet the needs of the mother's body and fetal
development
• If the mother's diet does not provide enough nutrients, then food for the fetus is taken
from the mother's food stores.
• Nutritional needs must be met, both in terms of quantity and type.
 IMPORTANT POINTS THAT MUST BE UNDERSTOOD BY PREGNANT
WOMEN…3)
First trimester of pregnancy
• Appetite is often reduced due to nausea, sometimes even vomiting,
dizziness or other general symptoms.
• Weight gain is usually not much.
• The menu should be prepared well so that it can increase appetite and
meet nutritional needs.
• Small portions (300 – 400 calories) with frequent frequency (6 – 8
times/day)
• A menu was chosen that did not give off a "nek" feeling, and was
combined with attractive flavors and presentation
 IMPORTANT POINTS THAT MUST BE UNDERSTOOD BY PREGNANT
WOMEN…4)

II & III Trimester of pregnancy

• Appetite begins to improve, fetal growth and development increases
rapidly.
• Therefore, adequate nutrition is needed
• The increase in fetal body length is very rapid in the second trimester
• Significant weight increase occurred in the third trimester
• Therefore, it is necessary to prepare a menu in the form of complete food
& balanced nutritional value from various types of food ingredients, while
still paying attention to quantity & quality
 IMPORTANT POINTS THAT MUST BE UNDERSTOOD BY PREGNANT
WOMEN…5)
Nutritional planning
• Nutrition planning for pregnant women should refer to the RDA (Recommended
Daily Allowances).
• Compared to non-pregnant mothers, pregnant women's need for protein
increases by 68%, folic acid increases by 100-122%, calcium increases by 50%
and iron increases by 200-300%. The recommended food ingredients must
include six groups, namely foods containing protein (animal & vegetable), milk
and its dairy products, bread & whole grains, fruit & vegetables rich in vitamin C,
dark green vegetables, other fruit & vegetables.
 IMPORTANT POINTS THAT MUST BE UNDERSTOOD BY PREGNANT
WOMEN…6)

ENERGY
• The amount of energy intake is the most important nutritional factor in pregnant women when
it is associated with low baby weight.
• The amount of energy that must be prepared until the end of pregnancy is 80,000 calories.
(National Academy of Sciences, 1980) or approximately 300 calories per day above the needs
of non-pregnant women. This value is calculated based on the equality of protein and fat
accumulated for fetal growth and maternal needs.
• Energy requirements in the 2nd & 3rd trimester increase until the end of pregnancy.
• Additional energy during the second trimester is needed for the expansion of maternal tissue,
namely increasing blood volume, uterine and breast growth, and fat accumulation.
• Throughout the 3rd trimester, additional energy is used for fetal and placental growth.
 IMPORTANT POINTS THAT MUST BE UNDERSTOOD BY PREGNANT
WOMEN…6)
PROTEINS
• National Widyakarya Food and Nutrition V 2019 recommended adding 12 grams
/ day. Thus, protein intake can reach 75-100 grams or around 1.3 grams/kg body
weight/day.

IRON
• Iron requirements in pregnant women increase by 200-300%, and is used for
the formation of the placenta & fetal red blood cells.
• Increased blood volume, until the end of pregnancy. The blood volume
increases to 4/3 times the normal blood volume, so that blood dilution
appears, so that the levels of hemoglobin (Hb), albumin and other nutrients in
the serum relatively decrease.
 IMPORTANT POINTS THAT MUST BE UNDERSTOOD BY PREGNANT
WOMEN…7)

CALSIUM
• For the growth of fetal bones and teeth, and protects pregnant women from
osteoporosis.
• The calcium needs of pregnant women must be met, because otherwise the
fetus will take it from the calcium reserves in the mother's bones.
• The recommended calcium is 1200 mg/day for pregnant women aged over 25
years.
• Sources: milk and dairy products, egg whites, green vegetables.
 IMPORTANT POINTS THAT MUST BE UNDERSTOOD BY PREGNANT
WOMEN…8)
WEIGHT GAIN BASED ON BMI BEFORE PREGNANCY
BMI VALUE ADDITIONAL BW (Kg)

Low (< 19,8) 12,5 – 18

Normal (19,8 – 26) 11,5 – 16

High (26,1 – 29) 7,0 – 11,5

Obesity (> 29) 6

 Evidence from Indonesia: Effectiveness of MMS on
pregnancy outcomes
MMS reduces IMR by
18%, 25% if the mother
is malnourished and
38% if the mother is
anemic
MMS reduces LBW by
14%
MMS reduces fetal and
neonatal deaths by 11%,
15% if the mother is
malnourished and 29%
if the mother is anemic.
 CLOSING AND RECOMMENDATION
• Pregnant women should be encouraged and supported to receive
adequate nutrition, which is best achieved through consuming a healthy,
balanced diet and adhering to healthy eating guidelines.
• Strategies to improve mothers’ knowledge, attitudes, and practices
regarding nutrition and reproductive health have consistently contributed
to save of the first 1000 days of life.
• Nutrition and reproductive health education delivered by community
health workers as agents of behaviour change was effective in improving
knowledge, attitude, and practices regarding nutrition and reproductive
health in pregnant women.
 CLOSING AND RECOMMENDATION
• A diet-based approach is less suitable for overcoming existing deficiencies
but more suitable for preventing deficiencies. This approach includes
food fortification with micronutrients and dietary interventions to
increase micronutrient intake and bioavailability
• Interventions to control micronutrient deficiencies in women of
reproductive age, including during pregnancy and breastfeeding, can be
broadly divided into healthy eating patterns and supplementation.
THANK YOU