Abstract
BackgroundEvidence is often missing on social differentials in effects of nutrition interventions. We evaluated the adherence to and effect of prenatal food and micronutrient supplementations on mortality before the age of five years in different social groups as defined by maternal schooling.MethodsData came from the MINIMat study (Maternal and Infant Nutrition Interventions, Matlab), a randomized trial of prenatal food supplementation (invitation early, about 9 weeks [E], or at usual time, about 20 weeks [U] of pregnancy) and 30 mg or 60 mg iron with 400 μgm folic acid, or multiple micronutrients (Fe30F, Fe60F, MMS) resulting in six randomization groups, EFe30F, UFe30F, EFe60F, UFe60F, EMMS, and UMMS (n = 4436). Included in analysis after omissions (fetal loss and out-migration) were 3625 women and 3659 live births of which 3591 had information on maternal schooling. The study site was rural Matlab, Bangladesh. The main stratifying variable was maternal schooling dichotomized as <6 years and ≥6 years. We used Cox proportional hazard model for survival analyses.ResultsOverall, women having <6 years of schooling adhered more to food (81 vs. 69 packets, P=0.0001) but a little less to micronutrient (104 vs. 120 capsules, P = 0.0001) supplementation compared to women having more schooling, adjusted for maternal age (years), parity and body mass index (BMI, kg/m2) at week 8 pregnancy. Children of mothers with ≥6 years of schooling had lower under-five mortality, but the EMMS supplementation reduced the social difference in mortality risk (using standard program and schooling <6 years as reference; standard program and schooling ≥6 years HR 0.54, 95% CI 0.27-1.11; EMMS and schooling ≥6 years HR 0.28, 95% CI 0.12-0.70; EMMS and schooling <6 years HR 0.26, 95% CI 0.11-0.63), adjusted for maternal age (years), parity and body mass index (kg/m2) at week 8 pregnancy.ConclusionsThe combination of an early invitation to prenatal food supplementation and multiple micronutrient supplementation lowered mortality in children before the age of five years and reduced the gap in child survival chances between social groups. The pattern of adherence to the supplementations was complex; women with less education adhered more to food supplementation while those with more education had higher adherence to micronutrients.Trial registrationISRCTN16581394.
Highlights
Evidence is often missing on social differentials in effects of nutrition interventions
The Commission for Social determinants of Health quests for solutions that reduce the gap in health induced by social inequity [3]
Design Data came from the MINIMat study (Maternal and Infant Nutrition Interventions, Matlab), a trial where pregnant women were randomized to either an invitation to food supplementation early during pregnancy (E, at around 9 weeks), or at usual time during pregnancy (U, at around 20 weeks) and to one out of three types of micronutrient capsules, 30 mg iron and 400 μgm folic acid (Fe30F), or 60 mg iron and 400 μmg folic acid (Fe60F), or multiple micronutrients (MMS)
Summary
Evidence is often missing on social differentials in effects of nutrition interventions. Interventions delivered by the health system are often more utilized by the well-off section of the population perpetuating injustice and social stratification in health [1] This phenomenon reportedly occurs at least during the first few years after the start of an intervention, and remains true even for a relatively homogenously poor population [2]. It is often assumed that the existing health system and its personnel will ensure that both poor and relatively rich will use interventions and will benefit from the interventions but in reality there can be variations This is because the design of the intervention and the history of development of the health system in that particular country and the way the political trajectory has evolved may not allow equal distribution of intervention let alone equal effect. Social determinants of health may need special attention for improving early life nutrition using a pro-poor equity perspective [7]. It is crucial to know whether such interventions improve equity in health
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