Multiple-micronutrient supplementation for women during pregnancy

Consumption of multiple micronutrient supplements (MMS) during pregnancy offers additional benefits compared with iron‐folic acid (IFA) supplementation, but the tablets are more expensive. We estimated the effects, costs, and cost‐effectiveness of hypothetically replacing IFA supplements with MMS for 1 year in Bangladesh and Burkina Faso. Using baseline demographic characteristics from LiST and effect sizes from a meta‐analysis, we estimated the marginal effects of replacing IFA with MMS on mortality, adverse birth outcomes, and disability‐adjusted life years (DALYs) averted. We calculated the marginal tablet costs of completely replacing MMS with IFA (assuming 180 tablets per covered pregnancy). Replacing IFA with MMS could avert over 15,000 deaths and 30,000 cases of preterm birth annually in Bangladesh and over 5000 deaths and 5000 cases of preterm birth in Burkina Faso, assuming 100% coverage and adherence. We estimated the cost per death averted to be US$175–185 in Bangladesh and $112–125 in Burkina Faso. Cost per DALY averted ranged from $3 to $15, depending on the country and consideration of subgroup effects. Our estimates suggest that this policy change would cost‐effectively save lives and reduce life‐long disabilities. Improvements in program delivery and supplement adherence would be expected to improve the cost‐effectiveness of replacing IFA with MMS.

Section: Methodsmentioning

confidence: 99%

Replacing iron‐folic acid with multiple micronutrient supplements among pregnant women in Bangladesh and Burkina Faso: costs, impacts, and cost‐effectiveness

Engle‐Stone

Kumordzie

Meinzen-Dick

et al. 2019

“…The analyses in the Cochrane Review demonstrated that overall MMS resulted in a 12% reduction in LBW (RR: 0.88; 95% CI: 0.85–0.91) and a 8% reduction in SGA births (RR: 0.92; 95% CI: 0.88–0.97), compared with IFA supplementation, with high and moderate quality evidence (based on GRADE criteria), respectively . There were no significant differences identified for other maternal or pregnancy outcomes assessed, including preterm birth, stillbirth, maternal anemia in the third trimester, miscarriage, maternal mortality, perinatal mortality, neonatal mortality, or risk of delivery by caesarean section when MMS was compared with supplementation with iron or without folic acid.…”

Section: Revisiting the Evidence Base On The Effect Of Multiple‐micromentioning

confidence: 96%

“…There were no significant differences identified for other maternal or pregnancy outcomes assessed, including preterm birth, stillbirth, maternal anemia in the third trimester, miscarriage, maternal mortality, perinatal mortality, neonatal mortality, or risk of delivery by caesarean section when MMS was compared with supplementation with iron or without folic acid. A summary of these analyses is presented in Table , alongside the results from the IPD meta‐analysis for comparison, which is discussed in more detail below . However, it should be noted that the IPD was based on voluntary participation of the trial's investigators and was primarily aimed at conducting subgroup analyses, while the Cochrane Review was focused on the overall effects of all available trials.…”

Section: Revisiting the Evidence Base On The Effect Of Multiple‐micromentioning

confidence: 99%

Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low‐ and middle‐income countries

Bourassa

Osendarp

Adu‐Afarwuah

et al. 2019

Inadequate micronutrient intakes are relatively common in low‐ and middle‐income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost‐effectiveness of MMS compared with IFA. Recent meta‐analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual‐participant data meta‐analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost‐effective method to reduce the risk of adverse birth outcomes.

“…In comparison to current recommendations, there is some variation in the UNIMMAP formulation around 100% of the RDA/AI; however, all values are substantially below ULs. As well, more than 20 randomized controlled trials have been published comparing multiple micronutrient (often, but not always similar to UNIMMAP) to iron and folic acid supplementation in LMIC . Conducting such trials is inherently challenging, and morbidities such as nausea and vomiting were either not collected or have not yet been reported in a way that would allow collective conclusions about the side effects of supplementation …”

Section: Potential For Excess Intake When Taking Daily Unimmapmentioning

confidence: 99%

The upper level: examining the risk of excess micronutrient intake in pregnancy from antenatal supplements

Gernand

2019

Micronutrient deficiencies are prevalent and co‐occurring among pregnant women in low‐ and middle‐income countries (LMIC). To prevent and treat deficiencies, antenatal vitamin and mineral supplements are the most common interventions during gestation. With most micronutrients, there can be health risks when intake regularly exceeds a high amount, and an upper threshold value set by the United States and Canada, the World Health Organization, and other groups is commonly called an upper intake level (UL). This review summarizes what is known about risks in pregnancy when ULs are exceeded and assesses the potential risk of exceeding the UL if a pregnant woman is taking a multiple micronutrient supplement. Overall, there is limited information on pregnancy‐specific risks from excess intake. When assuming high dietary intake plus the amount in a standard multiple micronutrient supplement (with 30 mg of iron), only niacin and iron would be expected to slightly exceed the UL. Known risks for this level intake for each nutrient are transient and mild.