Development of a nutrition screening tool for the prediction of birth outcomes of women attending the antenatal clinic at Pelonomi hospital
Jordaan, Elizabeth Margaretha
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In countries with limited resources, poor birth outcomes significantly contribute to morbidity and mortality and hold short- and long-term consequences for both the mother and her offspring. Optimal nutrition during pregnancy may lead to improved birth outcomes. Nutrition screening during pregnancy may identify women who are at risk of poor birth outcomes, including premature birth and growth retardation (stunting or wasting). This quantitative, cohort analytical study aimed to develop a nutrition screening tool to identify women at risk of poor birth outcomes among pregnant women attending the high-risk antenatal clinic at Pelonomi Hospital, Bloemfontein. During the first phase, questionnaires were completed for 682 pregnant women in their second or third trimester using structured interviews after which each participant was weighed and measured according to standard techniques. During the interview, information related to socio-demographic and household information, reported health and lifestyle, pregnancy history, household food security (using the Household Food Insecurity Access Scale) and individual dietary intake (using a quantitative food frequency questionnaire and a 24-hour recall) was obtained. Participants were asked to return to Pelonomi Hospital after the delivery to provide the information recorded in the Road to Health Booklet at their babies' birth. A total of 331 mothers returned and, together with their 347 babies, were included in the second phase of the study. Associations between socio-demographic, reported health and lifestyle, and nutrition information and the following individual birth outcomes were investigated, namely method of delivery, gestational age at delivery, birth length-for-age and birth weight-forlength, as well as overall poor birth outcome (defined as prematurity, or birth length-for-age below the -2 SD, or birth weight-for-length below the -2 SD). Separate theme-specific (sociodemographic, reported health and lifestyle and nutrition) logistic regressions with backward selection (p<0.05) were used to select significant independent factors associated with overall birth outcome. Variables with a p-value of < 0.15 on univariate analysis were considered for inclusion in the model. Variables found to be significant in the theme-specific logistic regressions were considered for inclusion in the final logistic regression, which identified variables to be included in the screening tool. The median age of participants was 31.9 years (interquartile range 26.8–36.5 years). Most women had access to basic amenities such as a flush toilet and/or their own tap, inside or outside the house. A concerning percentage of women continued to smoke (30.0%), use snuff or chew tobacco (40.3%), or use alcohol (12.1%) during pregnancy. A large percentage of participants were exposed to various forms of stress during their pregnancy, including not being able to find a job for more than six months (themselves or a close family member) (70.9%) and having so much debt that they did not know how they were going to repay it (36.0%). A high prevalence of overweight and obesity as well as food insecurity was observed. About half of participants returned for phase two of the study. Significant differences were observed in terms of socio-demographic indicators and nutrient intake between women who provided their babies' birth information (responders) compared to those who did not (non responders). Generally, responders were better off, indicating that responders may not have been representative of the population and may be indicative of non-response bias. Most babies were born full-term and by means of caesarean section, with almost one in ten being part of a twin pregnancy. Low birth weight (<2.5 kg) was evident in 14.4%. According to the World Health Organization’s (WHO) Z-scores, 12.6% of neonates were underweight, 18.9% were stunted and 14.5% were wasted at birth. Just over a third of neonates were exposed to Human Immunodeficiency Virus (HIV). Overall, 37.1% of neonates experienced overall poor birth outcome. Several social determinants of health were significantly associated with at least one of the defined birth outcomes. Significant associations between various reported health and lifestyle factors and the individual birth outcomes were also observed, most notably, premature delivery. Significant associations between individual poor birth outcomes and nutrient intakes seem to indicate that improved birth outcomes are associated with improved nutrient intake. The proposed tool included all variables identified in the final logistic regression model of predictors of overall birth outcome namely ownership of a stove, participant’s highest level of education, participant’s employment status, being in real danger of being killed by criminals in the past six months (themselves or a close family member), being diagnosed with or treated for high blood pressure during the current pregnancy, number of babies expected and gestational body mass index (replaced by current body mass index for ease of application in the screening tool). Experiencing weight loss of more than 3 kg during the current pregnancy was added to the tool. A score of two or more was considered as indicative of an overall poor birth outcome since this cut-off gave the best combination of sensitivity and specificity namely. 68.8% and 70.5% respectively, while the positive predictive value was 58.1%, and the negative predictive value was 79.1%. Pregnant women should be educated on the importance of regularly attending antenatal follow-up visits, focusing on the risks associated with poor lifestyle choices during pregnancy and the benefits of following a healthy diet and lifestyle. Pregnant women who regularly attend antenatal visits may be more likely to be screened and referred for specialised nutrition care at an early stage when such interventions can still make a difference to birth outcomes.