Introduction
The World Health Organization’s comprehensive antenatal care (ANC) guideline WHO recommendations on antenatal care for a positive pregnancy experience was published in 2016 with the objective of improving the quality of routine health care that all women and adolescent girls receive during pregnancy. The overarching principle – to provide pregnant service users with a positive pregnancy experience – aims to encourage countries to expand their health-care agendas beyond survival, with a view to maximizing health, human rights and the potential of their populations.
Recognizing that ANC provides a strategic platform for important health-care functions, including health promotion and disease prevention, 14 out of the 49 recommendations in the WHO 2016 ANC guideline relate to nutrition in pregnancy. In April 2019, the Executive Guideline Steering Group (GSG) prioritized two of these antenatal nutrition recommendations for updating in response to new evidence on these interventions, namely:
Multiple micronutrient supplements during pregnancy
Vitamin D supplements during pregnancy.
Evidence on these interventions was evaluated by a Guideline Development Group (GDG) composed of an international group of experts convened during an online GDG meeting held on 4–5 December 2019. The respective recommendations were updated in accordance with WHO’s living guidelines approach. For consistency and continuity, the GDG, including the chair, comprised the same members as the ANC guideline GDG.
This guideline presents that evidence and updated recommendation on antenatal multiple micronutrient supplements (MMS), which supersedes the corresponding recommendation issued in the WHO 2016 ANC guideline.
Target audience
The target audience of this updated recommendation includes national and local public health policy-makers, implementers and managers of national and local maternal and child health programmes, concerned nongovernmental and other organizations, professional societies involved in the planning and management of maternal and child health services, health professionals (including obstetricians, midwives, nurses and general medical practitioners) and academic staff involved in training health professionals.
Guideline development methods
The updating of this recommendation was guided by the standardized operating procedures described in the WHO handbook for guideline development. This involves: (i) identification of priority questions and outcomes (done as part of the ANC guideline development process); (ii) evidence retrieval and synthesis; (iii) assessment of the evidence; (iv) formulation of the recommendations; and (v) planning for the dissemination, implementation, impact evaluation and updating of the recommendations. The scientific evidence supporting the recommendations was synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for the recommendation prioritized for updating. The DECIDE (Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence) framework – an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria – was used to guide the formulation and approval of the recommendation by the GDG.
Recommendation
The WHO technical consultation led to the formulation of one recommendation related to the use of antenatal MMS. The GDG had the option to recommend the intervention, not to recommend the intervention, or to recommend the intervention under certain conditions (in specific contexts, targeted monitoring and evaluation, in the context of rigorous research). The GDG experts also provided additional remarks where they considered them necessary. Users of the guideline should refer to these remarks, as well as to the evidence summary, for further information about the basis of this WHO recommendation.
The updated WHO recommendation on antenatal MMS for a positive pregnancy experience
This recommendation applies to pregnant women and adolescent girls within the context of routine ANC
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| WHO recommendation on antenatal multiple micronutrient supplements (MMS) |
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| Antenatal multiple micronutrient supplements that include iron and folic acid are recommended in the context of rigorous research1. (Context-specific recommendation – research) |
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| Remarks |
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This recommendation updates and supersedes the WHO recommendation found in the WHO ANC guideline issued in 2016 (1). - ▪
The evidence is derived 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 of folic acid (see Box 2). - ▪
As the evidence was mainly derived from low- and middle-income countries, its applicability to high-income countries or to populations not at risk of micronutrient deficiencies – for example, due to an adequate diet and food fortification programmes – is unclear. - ▪
Research in this context therefore includes:
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controlled clinical trials in which early pregnancy ultrasound is used to establish gestational age with certainty,2 with assessment of critical maternal and perinatal outcomes, and follow-up of infants sustained into childhood; and - –
where programmes of MMS are being considered, implementation research to establish the impact of switching from iron and folic acid supplements to MMS, including evaluation of acceptability, feasibility, sustainability, equity and cost-effectiveness.
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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 anaemia is a severe public health problem (a prevalence of 40% or higher) (2). Therefore, countries should consider their population magnitude and distribution of anaemia, its nutritional determinants (i.e. iron deficiency), as well as the magnitude and distribution of the complex low birthweight and its component parts (i.e. preterm, small for gestational age [SGA] or a combination of these) (3), when undertaking any research in the context of this recommendation. - ▪
Pregnant women should be supported and encouraged to receive adequate nutrition, which is best achieved through consumption of a healthy, balanced diet consistent with guidelines on healthy eating (4).
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This recommendation on multiple micronutrients in pregnancy has changed from “not recommended” to “recommended in the context of rigorous research”. The reason for the change in the nature of the recommendation is because, whilst the evidence suggests that there may be a limited benefit and little harm in replacing iron and folic acid supplements with MMS, the evidence on low birthweight and its component parts (preterm birth and SGA) is difficult to interpret. Gestational age accurately assessed by ultrasound emerged as an important feature of future trials. In addition, the sustainability of switching to the higher-cost MMS is not known and more evidence is needed on the effects of switching to a 30 mg dose of iron from a higher dose of iron (e.g. 60 mg), particularly in settings where higher doses of iron are routinely used due to a high anaemia prevalence or other reasons.
- 1
The GDG clarified that rigorous research includes implementation research using high-quality methods appropriate to the specific research questions.
- 2
Gestational age accurately assessed by ultrasound emerged as an important feature of future trials because of the conflicting and confusing differences in intervention effects found on low birthweight and its component parts (preterm birth, and SGA).
