Maternal Anthropometry and Current Nutritional Interventions to Prevent Adverse Birth Outcomes in the Humanitarian Context: A Systematic Review Open Access

Abstract

Background: Maternal undernutrition in the humanitarian setting is a prominent concern that leaves both mothers and newborns at-risk for adverse outcomes. These risks range from maternal mortality, low birth weight, intra-uterine growth restriction, pre-term birth, small-for-gestational-age, and stunting at birth. In 2013, Médecins Sans Frontiéres (MSF) Switzerland analyzed the relationship of maternal anthropometric indicators for acute malnutrition with adverse birth outcomes. Mid-upper-arm-circumference (MUAC) was established as the preferential indicator, with a proposed cut-off value of < 23 cm as the criteria for enrollment of pregnant women in nutritional programs.

Objectives: The primary goals of this systematic review were to provide an update to the MSF review by (1) determining if MUAC remains the preferential indicator to identify LBW and other potential risks in mothers and their children; (2) determining what specific anthropometric cut-offs have been used to identify adverse birth outcomes and enroll pregnant women in nutritional programs; (3) determining whether or not these nutritional programs, contingent upon enrollment based on anthropometry, are successful in preventing adverse birth or maternal outcomes.

Methods: Two literature reviews covering September 2012 to February 2021 were conducted on the topics of maternal anthropometry to identify adverse birth or maternal outcomes and maternal anthropometry and nutritional interventions. Adapted Quality Assessments for individual studies were completed.

Results: MUAC was demonstrated as a proxy for a BMI of < 18.5 kg/m² to detect undernutrition. A maternal MUAC threshold value of < 23 cm was found to be strongly predictive for identification of pregnant women as at-risk for adverse birth outcomes. Nutritional interventions with enrollment based on MUAC values defined as undernourished that demonstrated improvements in nutritional status were limited, but included ready-to-use-supplementary food and food-based balanced energy and protein supplementation.

Conclusion: The research analyzed in this systematic review supports maternal MUAC as an alternative and more feasible measurement to BMI for identifying pregnant women as undernourished and in need of nutritional intervention to prevent adverse birth outcomes in the humanitarian setting. The preferential MUAC indicator in this context is < 23 cm. Research on nutritional interventions with enrollment contingent upon anthropometry must be further studied.

Table of Contents

INTRODUCTION---------------------------------------------------------------------------------------------1

Background--------------------------------------------------------------------------------------------------1

Purpose Statement------------------------------------------------------------------------------------------ 5

Significance Statement-------------------------------------------------------------------------------------- 6

METHODS--------------------------------------------------------------------------------------------------- 7

Search Strategy---------------------------------------------------------------------------------------------- 7

Study Eligibility Criteria: Inclusion Criteria------------------------------------------------------------------7

Study Eligibility Criteria: Exclusion Criteria----------------------------------------------------------------- 8

Study Eligibility Criteria: Outcome Measures---------------------------------------------------------------- 8

Data Synthesis----------------------------------------------------------------------------------------------- 9

Quality Assessment------------------------------------------------------------------------------------------ 9

RESULTS---------------------------------------------------------------------------------------------------- 11

Studies Identified------------------------------------------------------------------------------------------- 11

Maternal BMI and Adverse Outcomes-----------------------------------------------------------------------15

Relationship Between MUAC and BMI---------------------------------------------------------------------- 17

MUAC Cut-off Threshold------------------------------------------------------------------------------------19

Applying Nutritional Interventions Based on Anthropometry-----------------------------------------------22

Additional Potential Nutritional Interventions--------------------------------------------------------------25

DISCUSSION------------------------------------------------------------------------------------------------ 27

Anthropometric Indicators---------------------------------------------------------------------------------- 27

Nutritional Programs---------------------------------------------------------------------------------------- 29

Limitations-------------------------------------------------------------------------------------------------- 30

Recommendations------------------------------------------------------------------------------------------- 30

CONCLUSION------------------------------------------------------------------------------------------------ 31

APPENDICES------------------------------------------------------------------------------------------------- 32

Appendix A. Adapted Newcastle Ottawa Quality Assessment Scale: Cross-Sectional Studies-----------------32

Appendix B. Adapted Newcastle Ottawa Quality Assessment Scale: Cohort Studies-------------------------- 34

Appendix C. Adapted Newcastle Ottawa Quality Assessment Scale: Case-Control Studies--------------------36

Appendix D. Adapted Joanna Briggs Institute Critical Appraisal Checklist: Randomized Controlled Trials----38

Appendix E. Adapted AMSTAR Checklist: Systematic Reviews and Meta-Analyses----------------------------40

REFERENCES--------------------------------------------------------------------------------------------------42

About this Master's Thesis

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School	Rollins School of Public Health
Department	Environmental Health
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Nutrition Environmental Studies Health Sciences, Public Health
Keyword	maternal anthropometry mid-upper-arm-circumference adverse maternal outcomes adverse birth outcomes nutritional interventions pregnancy
Committee Chair / Thesis Advisor	Dr. Jeremy Sarnat, Emory University
Committee Members	Dr. Mija-Tesse Ververs , Centers for Disease Control and Prevention

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