BY: JENNAH YOO
Figure 1: A set of typical iron tablets (Source Credit: healthline)
According to the World Health Organization, it is recommended that all pregnant women take iron and folic supplementation daily throughout their period of childbearing (“Antenatal iron supplementation”). Per a large study in Botswana on the micronutrient supplement during pregnancy––this typical notion is about to change.
Figure 2: Ellen C. Caniglia ScD, Assistant Professor of Epidemiology in Biostatistics and Epidemiology in the Department: Biostatistics and Epidemiology (Source Credit: Perelman School of Medicine University of Pennsylvania)
A study in Botswana led by assistant professor of Epidemiology Ellen Caniglia ScD and her cohort of investigators at the Botswana-Harvard AIDS Institute Partnership and Harvard T.H. Chan School of Public Health revealed that nearly 100,000 women who took a relatively inexpensive daily diet supplement of iron, folic acid, and vitamin supplementation in pregnancy reduced complications at birth (Caniglia). According to this large-scale research, scientists found that iron and folic acid supplementation, or IFAS, consumed with other essential vitamins and trace minerals, are correlated with a statistically significant lower rate of underweight newborns and other complications at birth (“Large Study in Botswana”).
In contrast to IFAS, which refers to the sole consumption of iron and folic acid, multiple micronutrient supplementation, or MMS, which refers to the method of incorporating a mixed supplement, has shown more success in decreasing difficulties at birth, compared to the preconceived treatment of intaking iron or folic acid alone. As a part of their corroboration, the team provided statistical evidence on how the rate of low-birthweight babies were under 10.5% for women on an MMS diet––noticeably the lowest out of all comparison groups (“Large Study in Botswana”).
Globally, about 15 to 20 percent of children born annually have a low birthweight of less than 2.5kg at the time of birth. Normally, due to premature birth, low birthweight often leads to increased risks of childhood illnesses—or even death—and heightens vulnerability to diseases later in life, such as diabetes and cardiovascular disease. Hence, as recommended by the World Health Organization (WHO), it has been the common notion that women consume IFAS daily throughout pregnancy. Building from the given information, Professor Caniglia’s research reveals evidence that the method of daily prenatal MMS, more specifically, consuming iron and folic acid along with vitamins (A,C,D,E, B1, B2, B3, B6, B12), minerals, and metals (iodine, selenium, zinc, copper) has shown better results to IFAS alone (“Large Study in Botswana”).
Figure 3: A Handful of Vitamins (Source Credit: Times)
Professor Caniglia and her colleagues examined supplement use and birth outcomes among 96,341 women who were seen between 2014 and 2020 in a group of government hospitals in Botswana (“Large Study in Botswana”). By tracking the supplement initiation in samples prescribed by participating hospitals, researchers analyzed how the rates of birth complications (preterm delivery, stillbirth, neonatal death, underweight) varied according to the supplements each woman took during her time of pregnancy (Caniglia).
The analysis showed that women who initiated IFAS had significantly lower rates of adverse birth outcomes compared to women who only took iron or folic acid. For example, the rate of low-birthweight infants was 16.92% in the folic acid group and 12.7% in the iron-only group, while the IFAS group recorded a comparatively low result of 11.46%. However the most shocking of the comparison groups was the MMS-treatment, with a significantly low rate running at 10.48% (Caniglia).
The results present a broad, real-world confirmation of previous clinical findings.
With HIV infection’s prevalence in Botswana, a quarter of the pregnant women involved in the study were living with the virus. Typically, the risk of adverse birth outcomes is especially high in sub-Saharan Africa, particularly in women with HIV (Caniglia). Analysis on found data revealed that the difference in rates of adverse outcomes between MMS and IFAS, and between IFAS and folic acid or iron alone, were generally larger in HIV-diagnosed women than HIV-negatives (Junior).
Professor Caniglia is unsure of the reason behind this outcome, especially due to women with HIV known to be more micronutrient deficient than the HIV-negative group (Junior). She and her colleagues plan to conduct further studies in Botswana, aimed at understanding barriers to the incorporation of prenatal supplements and demonstrating the value of these supplements in improving birth outcomes (“Large Study in Botswana”).
In a general scope, supplementing IFAS with an additive of vitamins and mineral essentials (i.e. MMS) appear to have a heightened benefit to all pregnant women, but the method is especially beneficial for the women who are HIV-positive.
Q&A:
Anna: Besides the research conducted by Professor Caniglia and her colleagues, what other research has been done to reduce birth complications in Botswana or in other countries?
I believe that a complete answer to this inquiry requires a separate case study in comparing the past/current research records related to identifying the factors of reduction for birth complications. From a considerably light Google search, several researchers does seem to have been focusing on identifying both the external and internal factors, such as general medical facility issues (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728153/), or diversified inner city population (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8562498/). In retrospect, the Botswana study conducted by Professor Caniglia seems to be the most influential and noticeable one so far, especially related to the field of medical science.
David: Are there any tests and experiments done specifically towards women with HIV to test the efficiency of MMS?
As mentioned in the article above, HIV-positive women in Botswana were a specific test group. This experimental group was specifically treated with MMS to find the possible correlation between the treatment and its efficiency in reducing birth defects (which did turn out to be positive).
Hannah: What are the potential harms of IFAS and MMS? Are there specific instances where the doctors would not recommend pregnant women to take these supplements?
Iron folic acid supplementation (IFAS) is a globally acknowledged and recommended method for all pregnant women in general. Although it largely depends on the doctor and their prescriptions, in general, in instances where pregnant women are diagnosed with a rare condition, they may be refrained from taking these supplements, but rather, sticking to natural means. Based on this article, MMS has shown to be effective in both general and rare conditions (represented by the HIV-positive group); however, it is never 100% determinable or conclusive to say that all pregnant women are to commit to these treatments. Again, it depends on the doctor and his/her decisions of what’s best for their patient and their conditions.
Fabian: From your perspective, what are some misconceptions that led WHO to “recommend all pregnant women to take iron and folic [acid] supplementations daily”?
I believe that the statement is not a misconception, but rather a result of limited knowledge in the field. In reality, before the Botswana research was released, the most efficient and recently updated method was iron and folic acid supplementation (IFAS). Rather than calling it a misconception, it would be better to consider it as a great basis for development and opportunity for extended research on the topic of nutrient supplementation and birth defects.
Ian: Does consuming IFAS and MMS directly decrease the chances of premature birth?
As this research is identifying the possibility of a correlation, we cannot state that the two groups are a “cause-and-effect” relationship, or a “directly” related relationship with one another. Based on the article, IFAS and MMS have both been revealed to be effective in reducing the possibility of birth complications, most prevalently premature birth.
John: What are some other supplements that can benefit pregnant women who are HIV-positive, if there are any?
This question yet again requires extensive research on the topic of nutrient supplementation on birth complications, specifically on HIV-positive pregnant women. However, the supplementations mentioned in the article, such as vitamins and natural minerals would likely benefit the targeted group.
Melissa: Are there any side effects of the medications that can affect patients in the long term?
Another question that requires extended research. Based on this research alone, it is difficult to identify the side effects on the patients, especially in the long term, as the study was not conducted for a long period of time. Generally, side effects that are related to taking IFAS are stomach-related symptoms such as the following (but not limited to): constipation, diarrhea, stomach cramping (https://www.webmd.com/drugs/2/drug-2557/iron-folic-acid-oral/details#:~:text=Constipation%2C%20diarrhea%2C%20stomach%20cramps%2C,your%20doctor%20or%20pharmacist%20promptly).
Works Cited
“Antenatal iron supplementation.” WHO | World Health Organization, https://www.who.int/data/nutrition/nlis/info/antenatal-iron-supplementation. Accessed 5 June 2022.
Caniglia, Ellen C., et al. “Iron, folic acid, and multiple micronutrient supplementation strategies during pregnancy and adverse birth outcomes in Botswana.” Articles, vol. 10, no. 6, 2022, pp. 1-12. The Lancet Global Health, https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(22)00126-7/fulltext. Accessed June 13, 2022 June 2022.
Junior, Jason. “Large study in Botswana finds daily micronutrient supplementation during pregnancy reduces complications at birth: Results suggest iron plus folic acid and vitamins is better at reducing adverse birth outcomes compared to iron or folic acid alone.” News Azi, 13 May 2022, https://newsazi.com/large-study-in-botswana-finds-daily-micronutrient-supplementation-during-pregnancy-reduces-complications-at-birth-results-suggest-iron-plus-folic-acid-and-vitamins-is-better-at-reducing-adverse-birth/. Accessed 13 June 2022.
“Large Study in Botswana Finds Daily Micronutrient Supplementation During Pregnancy Reduces Complications at Birth.” Penn Medicine, 11 May 2022, https://www.pennmedicine.org/news/news-releases/2022/may/study-finds-daily-micronutrient-supplementation-during-pregnancy-reduces-complications-at-birth. Accessed 13 June 2022.
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