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Effect of Multiple Micronutrient Supplementation during Pregnancy on Maternal and Birth Outcomes

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Haider BA, Yakoob MY, Bhutta ZA.  Effect of multiple micronutrient supplementation during pregnancy on maternal and birth outcomes.  BMC Public Health. 2011;  11 (Suppl 3): S19.


  • The incidence of low birth weight in developing countries varies from 6-30%, and at least one-third of these are small for gestational age (SGA), especially in settings with high rates of maternal undernutrition.  SGA babies are those whose birth weight lies below the 10th percentile for a particular gestational age (1), and the vast majority of these are due to fetal growth problems that occur during pregnancy, including intrauterine growth restriction (IUGR). (2)
  • Pregnant women in developing countries are at risk of multiple micronutrient (MMN) deficiencies (i.e. iron, folic acid, iodine, zinc, vitamins A and D, riboflavin, B6 and B12), with the likelihood of adverse effects on the mother and pregnancy outcomes. (3, 4)
  • Iron deficiency contributes to one of the largest prevalence of micronutrient deficiencies among pregnant women – anemia affects approximately 41.8% of all pregnancies globally (5) with iron deficiency accounting for half of the cases (6).
  • A 2006 Cochrane review (7) indicated that compared to iron-folate, MMN supplementation did not have any significant benefits on maternal anemia and prevalence of SGA births.   Additionally, there are concerns regarding increased risk of perinatal and neonatal mortality with MMN supplementation. (6)

Intervention Effects

Multiple Micronutrient (MMN) Supplementation on Maternal Anemia

  • No significant benefit (as compared to iron folate) on maternal anemia in third trimester (RR: 1.03; 95% CI 0.87-1.22; random model)
  • 4 RCTs – high outcome-specific quality

Multiple Micronutrient (MMN) Supplementation on Small for Gestational Age (SGA) Births

  • 9% reduction in SGA (RR: 0.91; 95% CI 0.86-0.96; fixed model)
  • 12% reduction in SGA (RR: 0.88; 95% CI 0.81-0.95; random model)
  • 14 RCTs – high outcome-specific quality

Multiple Micronutrient (MMN) Supplementation on Neonatal Mortality

  • 9 cRCT/RCT - high outcome-specific quality
  • Overall, there was no increase in risk of neonatal mortality (RR: 1.05; 95% CI 0.92-1.19) 
  • Increased risk of neonatal mortality where majority of births were at home (RR: 1.47; 95% CI 1.13-1.92)
  • No increased risk where > 60% of births occurred in facility settings (RR: 0.94; 95% CI 0.81-1.09)

Intervention Recommendation

  • There is a significant benefit of MMN supplementation during pregnancy on reducing SGA births as compared to iron-folate, with no significant increase in the risk of neonatal mortality in populations where skilled birth care is available and majority of births take place in facilities.  Given comparability of impacts on maternal anemia, the decision to replace iron-folate with MMN during pregnancy may be taken in the context of available services in health systems and birth outcomes monitored.
  • A 9% point estimate of reduction in SGA is recommended for situations where countries may decide to replace routinely used iron-folate supplements during pregnancy with MMN.

References from Haider Paper Cited Here

  1. Bakketeig LS. Current growth standards, definitions, diagnosis and classification of fetal growth retardation. Eur J Clin Nutr. 1998;52(Suppl 1):S1–4.
  2. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera J. Maternal and child undernutrition: global & regional exposures & health consequences. Lancet. 2008;371(9608):243–260.
  3. Steer P. Small for Gestational Age: Causes and Consequences. J Anat. 2009. 
  4. Black RE. Micronutrients in pregnancy. Br J Nutr. 2001;85(Suppl 2):S193–197. 
  5. de Benoist B et al, editor. Geneva World Health Organization. 2008. Worldwide prevalence of anaemia 1993-2005. WHO Global Database on Anaemia. (, accessed 3 February 2009)
  6. Christian P, Osrin D, Manandhar DS, Khatry SK, de LC AM, West KP Jr.  Antenatal micronutrient supplements in Nepal. Lancet. 2005;366(9487):711–712. 
  7. Haider BA, Bhutta ZA. Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Rev. 2006. p. CD004905.

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