NUTRITIONAL COUNSELING FOR PREGNANT WOMEN IN TANZANIA

1. NUTRITIONAL COUNSELING FOR PREGNANT WOMEN IN TANZANIA Dr. Eleonore Fosso Seumo ACCESS Program Dr. Fatma Abdallah TFNC Tanzania

2. 1.1 Objectives of the Training • To raise awareness among ANC providers on the importance of enhancing the nutritional status of pregnant women in Tanzania. • To enhance ANC providers’ knowledge and strengthen their skills in nutritional counseling for both HIV-positive and HIV-negative pregnant women. • To strengthen ANC providers’ counseling skills to contribute towards improved adherence to iron and folic acid supplements by pregnant women.

3. 1.2 Sessions Part 1 • Session 1: Introduction and pretest • Session 2: Why nutrition matters during pregnancy

4. Sessions (cont’d) Part 2 • Session 3: Nutritional counseling for HIV-negative pregnant women • Session 4: Nutritional counseling for HIV-positive pregnant women • Session 5: Counseling pregnant women to improve adherence to iron and folic acid supplements

5. Sessions (cont’d) Part 3: • Session 6: Evaluation

6. Session 1: Introduction • Become acquainted with each other. • Shared their expectations. • Discussed the training objectives and time-table. • Established roles and rules. Objectives of the Session At the end of the session, participants will have:

7. Objectives • Describe the types and the magnitude of malnutrition during pregnancy in Tanzania. • Discuss causes of malnutrition during pregnancy. At the end of this session, participants will be able to:

8. Objectives (cont’d) • Describe the consequences of malnutrition during pregnancy for the woman, the child, the community, and the nation. • List the indicators of maternal nutrition during pregnancy.

9. 2.1 Nutritional Deficiencies in Women in Tanzania • 19% of women of the age group 15–19. suffer from acute malnutrition (BMI < 18.5). • 18% of women are overweight or obese with 4% being obese. • 58% of pregnant women are anemic.

10. 2.1 Nutritional Deficiencies in Women in Tanzania (cont’d) • Vitamin A deficiency in pregnant women: 65% of pregnant women have plasma retinol below 1.05 µmol/L. • Iodine deficiency: 43% of households use salt that is adequately iodized.

11. 2.2 Causes of Malnutrition During Pregnancy

12. Immediate Causes of Malnutrition During Pregnancy Food Intake • Low, highly variable over seasons, and often of low nutrient density. • In some areas, pregnant women are advised to eat less than before pregnancy. • Food taboos. • Intra-household food distribution does not favor women.

13. Immediate Causes of Malnutrition During Pregnancy (cont’d) Women’s Poor Health • Compromised by poor hygiene, heavy workloads, frequent births and high levels of poverty. • Infections and other diseases increase nutritional needs and at the same time hinder nutrient absorption. • Poor access to basic health services and inadequate knowledge worsen the nutrition-infection cycle.

14. The Underlying Causes of Malnutrition in Women • Food insecurity: 15% of the rural households are food insecure, 15% are vulnerable to becoming food insecure. • Poor/limited care given to pregnant women: The good habits about care of a pregnant woman and the extended family support to reduce her workload are now non-existent. • Poor hygiene and sanitation: Frequent parasites and infections.

15. Root Causes of Malnutrition in Pregnant Women • Political • Ideological • Ecological

16. 2.3 Consequences of Malnutrition During Pregnancy • Are at increased risk of maternal complications and death. • Have a higher prevalence of infections because of reduced immuno-competence. • Are at increased risk of obstructed labor because of the disproportion between the size of the baby’s head and the maternal pelvis. Maternal Malnutrition Increases Morbidity and Mortality in Women Women who suffer from chronic energy deficiency:

17. Maternal Malnutrition Increases Morbidity and Mortality in Women Iron Deficiency Anemia • Anemic women are more likely to die from blood loss during delivery. • Obstetric hemorrhage is the leading cause of maternal death in developing countries, accounting for approximately 25% of all maternal deaths. • Severe anemia can lead to heart failure or circulatory shock at the time of labor and delivery. • Anemic women are more susceptible to puerperal infection.

18. Maternal Malnutrition Increases Morbidity and Mortality in Women (cont’d) Vitamin A Deficiency • Is associated with an increased risk of night blindness. Night blindness is associated with low levels of serum retinol. • Increases vulnerability to infections. • Is associated with an increased risk of maternal mortality and miscarriage.

19. Maternal Malnutrition Increases Morbidity and Mortality in Women (cont’d) Folic Acid Deficiency • Is associated with an increased risk of neural tube birth defects. The body needs folic acid for the production, repair, and functioning of DNA, our genetic map and a basic building block of cells, so getting enough is particularly important for the rapid cell growth that occurs during pregnancy.

20. Malnutrition in Pregnant Women Affects Birth Outcomes • Maternal malnutrition may lead to: • Increased risk of fetal, neonatal, and infant death, • Intra-uterine growth restriction, low birth weight and prematurity, • Birth defects, • Cretinism, • Brain damage and • Increased risk of infection.

21. Malnutrition in Pregnant Women Affects Birth Outcomes (cont’d) • In Tanzania, 19% of women in the age group 15–19 suffer from acute malnutrition. • Adolescent mothers are more likely to have low birth weight babies. • Concurrent pregnancy and growth in low-income adolescent girls also has a significant negative effect on the micronutrient status of these mothers.

22. Malnutrition in Pregnant Women Affects Birth Outcomes (cont’d) • Poor nutritional status before and during pregnancy has been associated with intrauterine growth restriction (IUGR), low birth weight (LBW) and premature delivery conditions. • Anemic women are more likely to deliver low birth weight infants. • Low folic acid levels are associated with an increased risk of low birth weight. • Vitamin A deficiency in pregnant women has been associated with an increased risk of stillbirth and low birth weight.

23. Malnutrition in Pregnant Women Affects Birth Outcomes (cont’d) Iodine deficiency in pregnant women increases: • The risk of miscarriage, • Pre-eclampsia, anemia, • Fetal growth restriction, • Early rupture of the membranes, • Perinatal morbidity and • Neonatal death.

24. Special Considerations for HIV-positive Women • Effects of HIV infection on body weight and composition during pregnancy. • HIV-positive women tend to gain less weight than the HIV-negative women during pregnancy. • Wasting during pregnancy is more common in HIV-infected women than in the general population. • Anemia is often more severe in HIV-infected women than in other women. Anemia in HIV-infected women is an independent predictor of more rapid HIV progression and mortality.

25. Nutrition and Prevention of Mother to Child Transmission (MTCT) of HIV • Resulting in low fetal stores of some nutrients. This impairs immune function and fetal growth and may increase the vulnerability of infants to HIV. Malnutrition during pregnancy may increase the risk of MTCT by:

26. Nutrition and Prevention of Mother to Child Transmission (MTCT) of HIV (cont’d) • Impairing the integrity of the placenta, genital mucosal barrier and gastrointestinal tract. Transmission of HIV from mother to infant may be facilitated, although data confirming such relationships independently of maternal HIV disease progression are limited. • Causing low serum retinol levels, associated with an increased risk of MTCT. • Anemia in pregnant women increases the risk of MTCT.

27. Malnutrition in Pregnant Women Affects the Productivity and the Economy of the Nation • 20% of maternal deaths in Tanzania are associated with anemia during pregnancy  According to the 2007 Profile in Tanzania, in the next ten years, losses of female labor force productivity due to iron deficiency anemia are estimated to 295 billion Tanzanian shillings. A 1% drop in iron status leads to a 1% reduction in productivity.

28. 2.4 Indicators of Maternal Nutritional Status During Pregnancy Indicators of good nutritional status during pregnancy include: • Weight gain: within 11.5–16 kg • Hemoglobin level ≥11g/dl • Absence of clinical signs of micronutrient deficiencies

29. Indicators of Good Nutritional Status During Pregnancy Indicators of nutritional status in HIV-infected pregnant women are the same as in non-infected pregnant women. Indicators of good nutritional status during pregnancy include: • Weight gain: within 11.5 –16 kg • Hemoglobin level ≥11g/dl • Absence of clinical signs of micronutrient deficiencies

30. Indicators of Malnutrition in Pregnant Women • Indicators of malnutrition in pregnant women include: • Weight gain ≤ 11.5 kg • Weight gain ≤ 1kg/month in the last trimester of the pregnancy • Mid-upper arm circumference (MUAC) < 23 cm • Hemoglobin level < 11g/dl • Presence of goiter • Presence of clinical signs of micronutrient deficiencies

31. Body Mass Index (BMI) measures weight in relation to height to estimate thinness: (weight/height²) Recommendations for pregnancy: Weight Gain During Pregnancy

32. Session 3: Nutritional Counseling for HIV Infected and Those of Unknown Status Objectives of the Session At the end of this session participants will be able to: • Describe the energy and vitamin and mineral needs/requirements and the key essential nutrition action messages for HIV-negative pregnant women and women of unknown HIV status. • Demonstrate how to carry out nutritional counseling for HIV-negative pregnant women or whose HIV status is unknown.

33. Recommended Energy Intake and Weight Gain during Pregnancy 3.1 Energy Requirements

34. Frequency of Meals • Pregnant women should increase the frequency of meals to meet their daily energy needs. • It is recommended that pregnant women have a snack every day in addition to the regular 3 meals per day to meet their daily energy requirement.

35. 3.2 List of Available and Affordable Snacks (300kcal) for Pregnant Women

36. List of Available and Affordable Snacks (300kcal) for Pregnant Women (cont’d) • Dried cashew nut 1 package • Roasted groundnut 1 package • Roasted cashew nut 1 package • 2 cups of milk • 2/3 cup of sour milk

37. 3.3 Vitamin and Mineral Requirements

38. Vitamin and Mineral Requirements (cont’d)

39. Vitamin and Mineral Requirements (cont’d) • Iron requirements during pregnancy:Some foods contain substances that can inhibit the absorption of iron. These substances are: • Phytates in whole grains • Polyphenols such as tannins in legumes, coffee, tea, and cocoa • Calcium salts in milk products • Oxalates in green leafy vegetables • Plant protein such as in soybeans and nuts

40. Vitamin and Mineral Requirements (cont’d) • Other foods contain substances that enhance iron absorption.These substances are: • Vitamin C in fruits and raw vegetables • Animal blood, organ, and muscle products • Some fermented and germinated foods such as soy sauce and leavened bread • Citric and other organic acids

41. Counseling Pregnant Women and Mothers About Iron Supplements Counseling Points • When and how to take supplements • How to store supplements • Where to return for tablets • Side effects • Managing side effects • Importance of taking all supplements • No negative effects

42. Nutrition Recommendations for Pregnant Women • Weight gain: 12–16 kg • Daily additional energy intake: 300kcal/day • Diversified diet • Iron and folic acid supplementation: 60mg of iron and 400 µg folic acid every day

43. Nutrition Recommendations for Pregnant Women (cont’d) • Daily consumption of iodized salt • Prevention and treatment of malaria • Provide presumptive hookworm treatment • Adequate rest

44. 3.4 Nutritional Counseling • ANC providers should: • Assess the nutritional status of all pregnant women. • Treat, educate and provide nutrition counseling. • Carry out follow up sessions.

45. 3.4 Nutritional Assessment Physical Assessment • Anthropometric measurements: Weight gain during pregnancy and, if available, BMI and MUAC (Mid-upper-arm circumference). MUAC of less than 23 cm indicates nutrition risk.

46. Nutritional Assessment (cont’d) Dietary Assessment • Eating patterns: foods regularly consumed, frequency of meals • Foods available and affordable • Food intolerance and aversions • Dietary problems

47. Nutritional Assessment (cont’d) Dietary Assessment • Hygiene and food preparation and handling practices. • Psychosocial factors contributing to inadequacy of intake, such as social isolation, depression, stigma. • Fatigue and physical activity. • Use of vitamin and mineral supplements and alternative practices.

48. Nutritional Assessment (cont’d) Medical History • GI problems (e.g., diarrhea, abdominal pain, nausea, vomiting) • Pattern of bowel movements (constipation) • Presence of opportunistic infections • Concurrent medical problems (e.g. diabetes, hypertension, malaria) • Physical condition (examination)

49. Nutritional Assessment (cont’d) • Medication Profile • Medication taken • Side effects of medications: Negative effects of food intake or malabsorption of nutrients • Biochemical profile (where available) • Serum albumin • Evaluation of anemia (iron, B12, and folate status) • Urinalysis ( for the proteinuria) • Psychosocial • Living environment and functional status (income, housing, amenities to cook, access to food, attitude regarding nutrition and food preparation)

50. 3.5 Scenario for Role Play • Scenario A • Scenario B • Scenario C