Guidelines on Maternal Nutrition in Uganda - MINISTRY OF HEALTH - 1st EDITION DECEMBER 2010
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MINISTRY OF HEALTH
Guidelines on Maternal
Nutrition in Uganda
1st EDITION DECEMBER 2010
1
ACKNOWLEDGEMENTS
The Ministry of Health would like to acknowledge the valuable contribution of partners, groups,
and individuals at various stages of the development of these guidelines.
Ministry of Health is indebted to A2Z: The USAID Micronutrient and Child Blindness
Project/AED and UNICEF for technical and financial support that made the development and
finalization process of the guidelines possible.
Ministry of Health is grateful to the technical working group: Dr. Alfred Boyo (A2Z/AED),
Annet Kyarimpa Mugabe (A2Z/AED), Dr. E. Madraa (MOH), Tim Mateeba (MOH), Rebecca
Mirembe (MOH), Dr. Jacinta Sabiiti (MOH), Sheila Katurebe (MOH), Dr. G. Bisomborwa
(WHO), Dr. Miriam Mutabazi (MSH-Strides).
Special thanks and appreciation is extended to Dr. Alfred Boyo, Annet Kyarimpa Mugabe and
Tim Mateeba for coordinating the entire process.
Dr. Anthony. K. Mbonye
Commissioner Community Health
Ministry of Health
2TABLE OF CONTENTS
ACRONYMS .............................................................................................................................................. 5
FOREWARD............................................................................................... Error! Bookmark not defined.
1. INTRODUCTION................................................................................................................................ 9
1.1. Overview............................................................................................................................................ 9
1.2. Situation analysis .............................................................................................................................. 11
1.3. Justification ....................................................................................................................................... 11
1.4. Purpose of the guidelines................................................................................................................. 12
1.5. Goal and objectives of the guidelines .............................................................................................. 12
1.6. Target audience................................................................................................................................ 12
2. MATERNAL NUTRITION INTERVENTIONS........................................................................... 13
2.1. Maternal nutrition interventions during preconception.................................................................. 13
2.1.1. Nutritional assessment during preconception.......................................................................... 13
2.1.2. Micronutrient deficiencies prevention and control through diet and supplementation........... 14
2.1.3 Nutrition education/counseling during preconception.............................................................. 16
2.2. Maternal nutrition interventions during antenatal care ................................................................... 17
2.2.1. Nutritional assessment .............................................................................................................. 17
2.2.2. Nutritional requirements of pregnant women.......................................................................... 22
2.2.3. Nutrition education/counseling during antenatal care .............................................................. 23
2.2.4. Common physiological disturbances during pregnancy............................................................ 23
2.3. Maternal nutrition interventions during postnatal care................................................................... 24
2.3.1. Nutritional assessment of lactating women .............................................................................. 24
2.3.3. Nutritional requirements during lactation ................................................................................ 25
3. MATERNAL NUTRITION UNDER SPECIAL CIRCUMSTANCES ...................................... 26
3.1 Diseases ............................................................................................................................................ 26
33.2. Social factors, local practices, and environmental issues affecting maternal nutrition .................... 27
3.2.1. Child spacing.............................................................................................................................. 27
3.2.2. Myths, local practices, and gender issues that affect maternal nutrition ................................. 28
3.2.3. Substance abuse........................................................................................................................ 28
3.2.4. Maternal nutrition in emergencies ............................................................................................ 29
3.2.5. Nutritional care for adolescent pregnancy ............................................................................... 29
3.2.6. Community support for maternal nutrition.............................................................................. 29
3.2.7. Water, sanitation, and hygiene.................................................................................................. 30
4. IMPLEMENTATION ........................................................................................................................ 31
5. MONITORING AND EVALUATION......................................................................................... 34
ANNEX I: Counseling Job aid for Health Workers on Prevention and Control of Anemia .................. 35
ANNEX 2: Protocols for Interventions to Prevent and/or Treat Maternal Anemia............................... 36
4ACRONYMS
AED Academy for Education Development
ANC Antenatal Care
BFHI Baby-friendly hospital initiative
BMI Body Mass Index
DHT District Health Team
DOT Direct observed Therapy
FP Family planning
HIMS Health Information Management Service
IDD Iodine deficiency disorders
IEC Information Education and Communication
IFA Iron and Folic Acid
IPT Intermittent Presumptive treatment
ITNs Insecticide Treated Nets
LBW Low birth weight baby
MDG Millennium Development Goals
MOH Ministry of Health
MUAC Mid-Upper Arm Circumference
NDP National Development Plan
NGO Non-Governmental Organization
NTD Neglected Tropical Diseases
PEM Protein energy malnutrition
PMTCT Prevention of mother-to-child transmission
PNC Prenatal care
RCT Routine Counseling and Testing
TB Tuberculosis
UDHS Uganda Demographic Health Survey
VAD Vitamin A deficiency
VHT Village health teams
WHO World Health Organization
YCC Young Child Clinic
5FOREWARD
Maternal nutrition plays a critical role in the reduction of maternal morbidity and mortality.
This document provides guidance on nutrition for women of reproductive age. During periods
of pregnancy and lactation, women’s nutrition becomes particularly vulnerable. Maternal
malnutrition in Uganda is cyclical: mothers give birth to low birth-weight babies who were
undernourished in utero, and these children are then stunted during childhood, pregnant during
adolescence, underfed and overworked during pregnancy and lactation, and ultimately give birth
to low birth weight babies of their own. This report provides guidance on how to break this
intergeneration cycle of maternal malnutrition by outlining special nutritional interventions at
preconception, pregnancy, and lactation that enable safer and more optimal birth outcomes.
These guidelines should be implemented in conjunction with the existing Infant and Young Child
Feeding policy guidelines to improve the health of babies, which will ultimately result in
healthier adolescents and adults.
It is important that all maternal health stakeholders in Uganda utilize these guidelines by
integrating the recommendations for implementation into their programs and supporting and/or
funding the interventions, thus contributing to a reduction of maternal malnutrition as well as
the associated morbidity and mortality.
These maternal nutrition guidelines have been developed to improve the knowledge and skills
necessary for service providers at all levels to adequately respond to maternal and child
nutritional needs; improve provision of quality maternal and child nutritional services at the
community and health facility level; to provide a basis for advocacy efforts that garner support
for maternal nutrition interventions at all levels, to facilitate workshops for health care
providers and other stakeholders on interpersonal nutrition education and counseling,
community dialogue, development of IEC materials, and health education for improved maternal
nutrition; and to strengthen integration of nutrition interventions for adolescent, pregnant, and
lactating women within existing health services.
These recommendations set forth by the Ministry of Health aim to ensure the provision of
optimal maternal nutrition services. MOH will continue to coordinate and monitor the
implementation of the guidelines.
The following recommendations can be followed to improve the provision of maternal health
and nutrition services in Uganda:
Recommendation 1: Folic acid at preconception
Folic acid should be provided as a supplement, in addition to adequate intake of foods rich in
folic acid, to women prior to conception to prevent neural tube defects in newborns.
Recommendation 2: Proper weight gain during pregnancy
i. Based on BMI results, women who are underweight, overweight, or obese should
receive counseling regarding appropriate diet for adequate weight gain during pregnancy.
ii. A woman at preconception is considered to be underweight when her MUAC reading is
less than 21.0cm.
6iii. A pregnant or lactating woman is considered to be underweight when her MUAC
reading is less than 23.5cm.
Recommendation 3: Antenatal care and iron and folic acid supplementation
i. All pregnant women should be screened for anemia and corrective action taken.
ii. All pregnant women should be encouraged to attend at least four ANC sessions at
health facilities during which they receive iron and folic acid supplementation according
to nationally accepted protocols to prevent anemia.
iii. Pregnant women should be counseled to ensure compliance with the recommended
iron and folic acid supplementation intake of at least 90+ tablets.
Recommendation 4: Malaria and worm control to prevent anemia
i. All expectant mothers should be given preventive doses of fansidar and dewormers
during the second and third trimesters.
ii. Women should be advised to sleep under ITNs and practice adequate personal and
environmental hygiene.
Recommendation 5: Diet during pregnancy and lactation
In addition to the regular three meals, women should be counseled to eat at least one extra
meal (snack) per day while pregnant and two extra meals per day while lactating, to meet the
daily energy requirements of pregnancy and lactation respectively.
Recommendation 6: Vitamin A supplementation
i. Women should be counseled and given a one-time dose of 200,000IU of vitamin A
within eight weeks of giving birth.
ii. For mothers who have opted NOT to breast feed their infants, a one-time, low dose of
50,000IU should be given to the infant to help boost immunity.
Recommendation 7: Postnatal care and iron and folic acid supplementation
All postnatal women should be given routine iron and folic acid supplementation within six
weeks of delivery and be counseled to ensure compliance with the recommended dosage of
one tablet per day for three months.
Recommendation 8: Iodine supplementation
All women of reproductive age should be counseled on the daily intake of iodine by using
iodized salt.
Recommendation 9: Nutrition counseling and education
All women of reproductive age should be given sufficient nutritional counseling and education
to promote improved nutritional status on the following topics:
i. Intake of foods rich in iron, folate, vitamin A, and iodine.
ii. Intake of variety of foods that includes protein, energy, vitamin and mineral rich foods.
i. Clean and safe drinking water and personal and environmental hygiene.
7Recommendation 10: Breastfeeding and family planning
Women should be counseled on the role of, and conditions for, exclusive breastfeeding as a
method of family planning in addition to other family planning methods.
Recommendation 11: Education regarding local practices that negatively affect
maternal nutrition
Health care providers should educate and counsel mothers and family members regarding all
forms of myths, taboos, or local practices that affect the nutritional status of women before,
during, and after pregnancy.
Recommendation 12: Nutrition during emergencies
During emergency situations, humanitarian aid programs should prioritize vulnerable groups
that include children, pregnant women, and lactating mothers in their nutrition outreach to
meet their energy and other nutrient needs.
Dr. Nathan Kenya-Mugisha
For Director General of Health Services
81. INTRODUCTION
1.1. Overview
The term maternal nutrition refers to nutrition of a woman during any stage of her reproductive
age, which eventually affects the health of the fetus and/or infant, as well as herself.
There are heightened nutrient needs during pregnancy and lactation. Without an increase in
energy and other nutrient intake to meet the increased needs during this time, the woman’s
body uses its own reserves, leaving her weakened and vulnerable to pregnancy-related
complications.
Many women are undernourished at birth, stunted during childhood, become pregnant during
adolescence, are underfed as well as overworked during pregnancy and lactation, and,
consequently, give birth to low birth weight babies. It is these children who eventually become
stunted women, perpetuating the intergeneration cycle of malnutrition among women.
Undernutrition weakens a woman’s ability to survive childbirth and give birth to a healthy baby,
translating into increased morbidity and mortality of mothers and their infants.
The impact of poor maternal nutrition begins before a woman conceives, and continues
through pregnancy, delivery, and finally, lactation, where the cycle may resume.
In Uganda, as in many developing countries, most pregnancies are not planned. In such
circumstances, health service providers should emphasize the importance of good nutrition for
women during contact with communities, adolescents, when pregnancy is confirmed, and during
Young Child Clinic visits.
The main forms of maternal malnutrition include:
� Macronutrient deficiencies (Protein Energy Malnutrition - PEM):
o PEM is managed by ensuring: (a) adequate frequency of food intake (b) adequate
amounts of food (c) adequate variety of foods to include the 3 major groups, and
(d) proper personal and environmental hygiene.
� Micronutrient deficiencies, such as iron deficiency anemia, vitamin A deficiency (VAD),
and iodine deficiency disorders (IDD): These conditions result in increased risk of
maternal mortality, low birth weight, and neonatal and infant mortality. Anemia is
observed to contribute to about 20% of maternal deaths. It increases the risk of
hemorrhage and prolonged labor, which can lead to sepsis.
� Micronutrient deficiencies can be managed by (a) adequate intake of foods rich in
micronutrients such as fruits and dark-green and brightly colored vegetables, (b)
supplementation with fortified foods and mineral/vitamin formulations.
9Causes and consequences of maternal malnutrition in Uganda
There are many factors contributing to maternal malnutrition as summarized in Table I below:
Figure I: Summary Causes of Maternal Malnutrtion
Underlying Causes Immediate Causes Consequences
� Inadequate maternal Women’s Poor Health Maternal Health
care. • Infections and diseases � Increased risk of maternal
• Poor access to basic health death.
� Household food services (e.g. inadequate iron � Increased infections.
insecurity. � Anemia
and folic acid
� Compromised immune
supplementation).
� Unhealthy functions.
• Frequent parasites and � Lethargy and weakness.
environment,
infections. � Lower productivity.
insufficient health
services, and poor
Inadequate Food Intake Infant/Child Health
hygiene and
� Due to diet characterized by � Increased risk of fetal and
sanitation. neonatal death.
Low, highly variable over
� Intrauterine growth
seasons, and often of low
retardation, low birth
nutrient density. weight, preterm birth.
� Compromised immune
functions.
Basic Causes � Birth defects.
� Cretinism and reduced IQ.
� Political structure
� Resources and their control
� Heavy workloads
� Frequent births
� Harmful local practices and food taboos.
� Intrahousehold food distribution does not favor women.
101.2. Situation analysis
The current maternal mortality ratio in Uganda is estimated at 435/100,000 live births, 1
translating to 6,000 women dying annually. Twenty percent of these deaths (1,200 women) are
attributable to maternal malnutrition (Lancet Series, 2008)2
Demographic and Health Surveys data from 2006 indicate that maternal malnutrition is highly
prevalent in Uganda as shown below:
� 12% of women (neither pregnant nor lactating) between the ages of 15–49 years are
undernourished or “thin” (BMI less than 18.5).
� Anemia prevalence: 49% of women in reproductive age, 64% of pregnant women, and
53% of lactating women.
� VAD prevalence: 18.6% of pregnant women and 17.3% of lactating mothers.
Although known interventions that address maternal malnutrition exist, the majority of
mothers in Uganda do not have access to this information or services.
For example:
� 1 in 3 mothers receive postpartum vitamin A supplementation.
� 47% of mothers attend four or more ANC visits.
� Less than 1% of mothers followed the recommended dose of 90+ IFA supplementation.
� 60% of pregnant women took iron supplements for 60 days or less.
� 16% of pregnant women received IPT2.
� 24% of women reported sleeping under mosquito nets.
� 26.8% deworming coverage of pregnant women.3
1.3. Justification
In Uganda, one of the obstacles to the provision of improved maternal nutrition health services
is lack of comprehensive reference nutrition recommendations for health service providers to
use in providing nutrition counseling to women on how to meet their nutritional requirements
through dietary and behavioral changes.
This document aims to:
� Highlight the plight of maternal malnutrition and the attention it deserves in the
minimum health care package and nutrition programs.
� Provide information to, and increase knowledge amongst, health service providers on
how to counsel women to meet their increased nutritional requirements through
dietary and behavioral changes and health care-based services.
� Provide a comprehensive reference material for maternal nutrition.
1
Uganda Demographic and Health Survey (UDHS), 2006.
2
Lancet Series, 2008.
3
UDHS, 2006.
11The adequate implementation of the recommendations outlined in this document will
contribute significantly to provision of improved and adequate maternal nutrition services in
Uganda. It will contribute information that will, together with other maternal health
improvement programs, support the reduction of maternal morbidity and mortality, and help
Uganda move towards attainment of Millennium Development Goal (MDG) 5 of reducing the
maternal mortality ratio by 3/4.
1.4. Purpose of the guidelines
The main purpose of these guidelines is to support health care providers in the provision of
maternal nutrition care and support services. The guidelines can also be used by health training
institutions, schools, and other organizations, as well as other line ministries implementing
maternal nutrition interventions.
1.5. Goal and objectives of the guidelines
To contribute to the reduction of maternal and child morbidity and mortality through improved
maternal nutrition in Uganda and with specific focus:
� To improve the knowledge and skills of service providers at all levels to respond to
maternal and child nutritional needs.
� To improve provision of quality maternal and child nutritional services at community
and health facility level.
� To advocate for support of appropriate interventions that address maternal nutrition at
all levels.
� To facilitate health care providers and other stakeholders in interpersonal nutrition
education and counseling, community dialogue, development of IEC materials and health
education for improved maternal nutrition.
� To strengthen integration of nutrition interventions for adolescent, pregnant, and
lactating women within existing health services.
1.6. Target audience
Primary target: This includes health care providers such as midwives, nurses, clinical officers,
doctors, nutritionists, dieticians, counselors, health promoters and educators, nutrition
teachers, and institutions and organizations implementing maternal nutrition interventions.
Secondary target: This includes, health training institutions, schools, non-governmental
organizations (NGOs) and community-based organizations implementing maternal nutrition
interventions.
Additional target: Other line ministries - such as education, agriculture, animal industry and
fisheries, gender, labor and community development, local government, and water and
sanitation can use these guidelines.
122. MATERNAL NUTRITION INTERVENTIONS
2.1. Maternal nutrition interventions during preconception
The nutritional status of a woman before conception is a key determinant of the pregnancy
outcome and the health of the newborn. Adolescent girls and women need to attain
appropriate nutritional status in order to prepare them to meet the future needs of pregnancy -
for both the mother and unborn child.
The objectives of nutritional care in the pre-conception period are to encourage women to
achieve appropriate weight for height and healthful dietary habits.
The interventions during preconception are:
� Macro-nutrient assessment
� Micro –nutrient deficiency prevention and control through supplementation
� Nutrition education/counseling
2.1.1. Nutritional assessment during preconception
To offer proper nutrition services for macro-nutrients, health workers need to establish the
nutritional status of women 15-49 years using BMI and MUAC. Suggested contact points for
this activity include family planning visits, community outreaches for maternal health care,
immunization/young child clinic visits.
Body mass index (BMI)
BMI is one of the measures used to determine a woman’s nutritional status., It is a measure of
thinness or obesity. Measuring BMI prior to pregnancy is important because it allows a health
worker to determine the weight that should be gained during pregnancy.
Assessment using BMI:
� Below 18.5 – Underweight (chronic energy deficiency)
� 19 – 24.9 - Normal
� 25 – 30 - Overweight
� More than 30 - Severe overweight (obese)
How to calculate BMI:
BMI = Weight in kilograms / [(Height in meters) x (height in meters)]
There is a strong relationship/association between low pre-pregnant weight and height, and
intra uterine growth retardation of the fetus.
Mid upper arm circumference (MUAC)
MUAC directly assesses the amount of soft tissue in the arm and is a measure of thinness or
fatness. It is the easiest index to use in the community for screening and identifying women in
need of further nutrition assessment and/or treatment
13Assessment using MUAC:
� A woman at pre-conception is considered underweight when the MUAC reading is
less than 21cm.
� A pregnant or lactating woman whose MUAC is less than 23.5cm is considered to
be underweight.
How to measure MUAC:
1. Locate tip of shoulder bone with your fingertips.
2. Bend the woman’s elbow to make a right angle and find the tip of the elbow.
3. Place the beginning of the measuring tape at the tip of the shoulder and pull the
tape straight down past the tip of the elbow.
4. Read the number at the tip of the elbow to the nearest centimeter.
5. Divide the reading in step number four to get the midpoint of the upper arm. Mark
midpoint (or as an alternative, bend the tape in two from the elbow to the
shoulder to estimate the mid-point and mark it).
6. Straighten the arm and let it hang loose. Measure around the upper arm at the
midpoint, making sure that the tape is flat around the skin and the numbers are
right side up.
7. Make sure the tape has the proper tension i.e. it should not be too tight or too
loose around the mid-upper arm.
8. Once the tape is in the correct position, with the correct tension, read the
measurement in centimeters (cm) to the nearest 0.1cm.
9. Record the reading accurately.
2.1.2. Micronutrient deficiencies prevention and control through diet and
supplementation
The relevant micronutrients at preconception include:
� Folic acid
� Iron
� Iodine
� Calcium
Folic acid
The role of folic acid at preconception is to reduce the risk of birth defects of the brain and
spine, called neural tube defect (NTD) in the newborn.
The neural tube closes during the 4th week of pregnancy - a time when most women may not
even know they are pregnant. Because most pregnancies in Uganda are unplanned, it is
especially crucial for all women of childbearing age (15 – 49 years) to have an adequate intake
of folic acid through food diets and/or supplementation.
Those women at high risk of neural tube defect outcomes include:
- Those previously affected by folic acid deficiency
- Those with a family history of NTD or diabetes, who have sickle cell anemia, or who
are on anti-epileptic medication.
14Recommended actions
� Folic acid should be taken in through appropriate diets and supplementation by women
prior to conception to prevent NTD in the newborn. Counsel women on the
consumption of foods rich in folic acid such as dark green leafy vegetables (i.e. spinach),
citrus fruits, nuts, legumes, whole grains, and fortified breads and cereals.
Supplement dosage
� 400 micrograms a day for one month for pre-pregnancy care.
Iron
The intake of iron before conception helps to provide adequate reserves that help to prevent
anemia later during pregnancy.
Recommended actions
� Women should be counseled on intake of iron rich foods such as liver, red meat,
kidney, fish, chicken, millet, ground nuts, and green leafy vegetables.
� Women should be counseled to avoid foods containing iron absorption inhibitors (tea/
coffee) just before, during and shortly after meals, and to consume foods containing
caffeine two or more hours before or after iron containing foods or iron supplements.
� Women should be counseled on intake of foods containing iron absorption enhancers
just before, during and after meals (e.g. foods rich in vitamin C like oranges, tangerines,
mangoes, meat and fish products, tomatoes, green peppers etc.).
� Weekly iron supplementation of 60mg (200mg of iron sulphate) as is recommended for
women for three months prior to conception, per the WHO guidelines, 2009.
Iodine
Role of iodine in maternal nutrition:
� Iodine helps to prevent IDD
Symptoms of iodine deficiency
� Enlargement of thyroid gland (goiter) is the first sign of iodine deficiency, and presents
as a swelling on the forward lower part of the neck.
Recommended actions
All women should be counseled on intake of iodine through use of iodized salt.
Calcium
Calcium is needed for building bones and teeth, for blood clotting, for regulating nerve and
muscle activity and for absorption of iron. Women’s bone density diminishes in the first three
months of pregnancy as a result of increased calcium uptake by the developing fetus.
It is advisable to ensure sufficient calcium intake during preconception to build up calcium
reserves in preparation for pregnancy.
15Recommended action
Women should be counseled to consume foods rich in calcium such as dairy products (yoghurt,
milk, and cheese), eggs, fish, beans, soybeans, beef and cereals like whole millet and rice.
2.1.3 Nutrition education/counseling during preconception
Health workers should provide nutrition education and counseling prior to pregnancy in order
to promote maternal health and good pregnancy outcomes. Nutrition education should be
conducted for individuals, communities, schools, in outreaches and at health facilities. The
counseling should include:
� Variety of foods
� Frequency of foods
� Hygiene
� Focus on locally available foods
� Importance of the adequate nutrition before pregnancy.
� Folic acid supplementation
� Prevention of anemia
Advise on nutritional requirements during preconception
No single food contains all the nutrients the body needs. A variety of foods should be
consumed at every meal. These include:
� Energy giving foods, such as cereals like maize meals, rice, millet, sorghum, roots and
tubers e.g. potatoes, cassava, and plantains like bananas etc
� Protein giving foods include animal products such as meat, milk, eggs, and fish, and plant
products such as legumes like beans, peas, soya, and groundnuts.
� Minerals and vitamin rich foods such as fruits and vegetables
Key nutrition messages during preconception
� Prevention of worm infestations through regular de-worming at least twice a year and
wearing of footwear.
� Regular exercise.
� Adequate consumption of water (at least 2 liters per day).
� Regular consumption of fiber rich foods which are essential for movements of the
gastrointestinal tract (whole grains, fruits, vegetables).
� Encourage consumption of a variety of locally available foods.
� Provide guidance on appropriate food preparation methods to preserve the nutritional
value and safety.
� Counsel on iron/zinc/calcium absorption inhibitors. Examples of foods containing
inhibitors include tea, coffee, spinach and soya bean. Intake of these foods that contain
the inhibitors should be avoided when consuming other iron-rich foods. It is advisable to
consume foods containing caffeine two or more hours before or after iron-rich foods or
iron supplements have been taken.
� Counsel on nutrient absorption enhancers. Encourage intake of foods rich in absorption
enhancers just before, during, and after meals, such as vitamin C-rich foods like oranges,
tangerines, mangoes, meat and fish products, tomatoes, green peppers etc.
16� Counsel on obtaining the optimal weight for height as indicated by a BMI value that is at
or higher than 18.5, but lower than 25.
2.2. Maternal nutrition interventions during antenatal care
Antenatal care offers an opportunity for assessment of the nutritional status of a pregnant
woman as well as the assessment of essential nutritional actions and continuous monitoring
throughout pregnancy. There are heightened nutrient needs during pregnancy. Without a
corresponding increase in energy and other nutrient intakes, the body’s own reserves are used,
leaving a pregnant woman weakened and vulnerable to maternal and fetal complications, and, at
worst, death.
The interventions during antenatal care are categorised as:
� Nutritional status assessment
� Micronutrient supplementation
� Nutrition education/counseling during antenatal care
� Managing common nutrition related physiological disturbances during pregnancy
2.2.1. Nutritional assessment
The relevance of nutrition assessment during pregnancy is for monitoring progress of
pregnancy and detecting risk factors for the mother, the fetus and/or the infant associated with
nutritional deficiencies. A pregnant woman who is underweight or micronutrient deficient is
more likely to have poor birth outcomes affecting both mother and baby. On the other hand, a
pregnant woman who is overweight has an increased risk of coronary heart disease, high blood
pressure, high blood cholesterol, and diabetes that can complicate a pregnancy.
Comprehensive nutrition assessment
This should commence on the woman’s first contact with the health worker, and should include
aspects shown in Table I on the following page.
17Table I. Nutrition Assessment during Pregnancy
Assessment What to Ask or Measure
Nutrition � Dietary intake (frequency, quantity and diversity)
History � Eating habits (dieting, craving, food myths & taboos)
� Food intolerance and dislikes
� Fatigue and physical activity
� Nausea, vomiting
� Heartburn
� Substance abuse during pregnancy (alcohol, smoking)
� Availability of clean, and safe water
� Sanitation and hygiene practices in food preparation and handling
(personal hygiene, food preparation and handling,
� Daily intake of iron and folic acid supplements
� Use of iodized salt
Physical Anthropometric measurements:
Assessment � Height
� Pre-pregnancy weight
� Weight gain during pregnancy
� MUAC
Other physical features
� Oedema
� Pallor (palm, tongue, conjunctiva)
� Goitre
Medical � History of constipation, diarrhea, previous births with NTD
History � Concurrent medical problems (e.g., diabetes, hypertension,
coronary heart disease, asthma)
� Outcome of previous pregnancy/pregnancies (e.g. LBW, difficult
deliveries, prematurity)
Laboratory � Heamoglobin level
Investigations
Medication � Medications used for concurrent medical problems (e.g., diabetes,
Profile hypertension, ischemic heart disease, malaria, HIV/AIDS, TB)
Psychosocial � Living environment and functional status (income, housing,
Profile amenities for cooking, access to food, attitudes to nutrition and
food preparation)
� Age
� Family or support system
� Educational level
Source: Regional Centre for Quality of Health CARE, FANTA, and LINKAGES. 2003.
18Following the assessments detailed in Table I above, women at risk of malnutrition and its
complications will be identified. At-risk groups may include the following:
� Women who were obese at the time of conception.
� Women who gain too little or too much weight (see 2.2.2.1 below).
� Women whose height is less than 145cm.
� Women with MUAC less than 23.5 cm.
� Pregnant adolescents (younger than 18 years of age).
� Women with short birth intervals (less than 1 year).
� Women with too-early pregnancies below 18 years of age.
� Women with too-late pregnancies above 40 years of age.
� Women with a history of low birth weight infants (less than 2500gm).
� Women who are HIV positive/ have AIDS.
� Women living in poor socio-economic situations.
� Women in emergency situations like famine, wars, civil strife and other hazards –
manmade and natural.
Recommended action
Women identified as at-risk of malnutrition need closer nutritional and medical attention and
should be advised to have more frequent visits to the health service providers in order to
receive appropriate care and support.
Weight gain during pregnancy
It is important to measure the BMI of a woman prior to pregnancy in order to determine the
weight that should be gained during pregnancy. Recommended weight gain under normal BMI
during pregnancy is:
� 0.5kg per month for the first trimester
� A minimum of 1kg to 1.5kg per month in the second and third trimester.
Potential problems with too much or too little weight gain during pregnancy.
� Women who gain too little weight are at increased risk of having anemia, premature
rupture of membranes, and a low birth weight baby.
� Women who gain too much weight are at increased risk of premature labor, larger
babies, gestational diabetes, and high blood pressure.
� It is best to aim for something near the recommended gain shown in the table below.
If the pre-pregnancy weight is known, the ideal increase in weight during pregnancy is as
summarized in Table 2:
19TABLE 2: Recommended Weight Gain for Pregnant Women Based on BMI
(kg/m2)
Pre Pregnancy BMI Recommended Gain during Pregnancy Based on
Pre-Pregnancy BMI (kg)
Normal (BMI > 18.5 -Table 3. Recommended Cut-Offs for Categorizing Anemia in Pregnancy and actions. Category of Heamoglobin Action Anemia Levels Normal >11g/dl Dietary diversification and supplementation Mild 10 - 10.9g/dl Dietary diversification and supplementation Moderate 7 – 9.9g/dl Dietary diversification and supplementation Severe
� Consumption of fortified foods: examples include cooking oil fortified with Vitamin
A; wheat flour fortified with iron, margarine with Vitamin A and D.
2.2.2. Nutritional requirements of pregnant women
Pregnant women should be encouraged to eat a variety of foods, according to local availability
and accessibility, in adequate amounts in order to meet their nutritional requirements. It is
particularly important that underweight women increase their energy intake to gain the
required weight during pregnancy as recommended in 2.2.1.1 above.
Energy and protein requirements
To meet the extra demands needed for growth of the fetus, placenta, and other maternal
tissues, extra energy and protein intake during pregnancy is required - especially in the second
and third trimesters. In addition to the regular three meals, women should be counseled to eat at least
one extra meal (snack) per day to meet the daily energy requirements of pregnancy.
Micronutrient requirements during pregnancy
There is increased demand for micronutrients during pregnancy. Their deficiencies increase the
risk of maternal morbidity and mortality during the pregnancy, delivery, and postpartum
periods. For example, anemia increases the risk of death from postpartum hemorrhage,
prolonged labor and sepsis (infections). Addressing maternal micronutrient malnutrition is
therefore an important intervention for reducing maternal mortality. Micronutrient status of
pregnant women can be improved through diet diversification, micronutrient supplementation,
and food fortification.
Table 4. Micronutrient Requirement during Pregnancy and Postpartum Period
DAILY REQUIREMENTS
NUTRIENT FOR PREGNANCY/POST CONSEQUENCES OF DEFICIENCY
NATAL CARE
Iron 60mg of elemental iron (200mg of � Increased peri-natal and maternal
ferrous sulphate) for pregnant mortality
women. � Increased risk of pre-term birth and/or
low birth weight
(12mg for non-Pregnant � Impaired cognitive development
� Reduced work productivity
19mg for lactating women)
Folic Acid 400ųg for pregnant women � Risk of infants having neural tube defect.
(180 for non-pregnant and 280 for � Higher risk of abnormal pregnancy
lactating women) outcome, including eclampsia, and
premature delivery, and birth defects
such as Clubfoot and cleft palate.
Iodine 175ųg � Goiter
22(150 for non pregnant � Cretinism (mental deficiency, deafness,
and 200 for lactating dwarfism.)
women)
Calcium 1200 mg � risks of pre-eclampsia
� Depletes bone stores, rendering the bones
weak and prone to fracture.
2.2.3. Nutrition education/counseling during antenatal care
Pregnant women should be educated to achieve optimal nutritional status during pregnancy.
Key nutrition information should be provided on the following issues:
� Importance of adequate nutrition during pregnancy.
� Relevancy of appropriate weight gain during pregnancy.
� Increased nutrient requirements.
� Nutrient rich dietary sources.
� Importance of micronutrient supplementation during pregnancy.
� Guidelines for healthy eating habits.
� Appropriate food preparation methods.
� Food safety and hygiene.
� Avoidance of substance abuse (e.g. alcohol, drugs, smoking).
� Nutrition precautions in special circumstances such as chronic diseases, medications,
etc.
2.2.4. Common physiological disturbances during pregnancy
Table 5. Common Physical Symptoms during Pregnancy
Physiological
Description Essential Actions
disturbance
1. Nausea and Associated with hormonal Advise on the following:
Vomiting changes o Counsel mother that nausea will wear
Usually occurs during first off as pregnancy progresses
Trimester, but could continue o Do not take medication unless
into second trimester or prescribed by health worker
throughout the pregnancy. o Avoid foods that trigger nausea, such as
Usually more severe in the fried and heavily-spiced foods
morning. o Eat small frequent meals
o Chew food adequately and eat slowly
NB: Encourage women not to avoid eating
because adequate nutrition during this
period is important for her own health and
that of the development of the fetus.
2. Heart-burn This is a burning feeling, which Assess the diet of the pregnant women so
rises from the upper abdomen as to exclude the foods that may be causing
or lower chest up towards the the heartburn and advise on the following:
throat region. o Avoiding, for a while, foods and drinks
Common in the later stages of that are known to cause heartburn, so
23pregnancy, due to pressure of as to see if symptoms improve. These
the enlarged uterus on the include spiced foods, fried foods,
stomach in combination with alcohol, etc.
the relaxed oesophageal o Eating small frequent meals instead of
sphincter, resulting in occasional three large meals per day.
regurgitation of o Attention should be given to adequate
stomach contents into the chewing and eating slowly.
Oesophagus. o Eating at least three hours before going
to bed to allow for digestion
3. Constipation o Advise pregnant women to take a diet
containing plenty of fluid, fruit juice and
fiber
o Encourage regular exercises as this can
be helpful
o Discourage the use of laxatives
o Advise pregnant women on
constipation resulting from use of iron
supplementation.
4. Oedema Oedema is the retention of o Advise pregnant women to rest with
body fluids and usually manifests legs elevated
as swelling of lower limbs. o Encourage them to lie on their side
while sleeping so that blood flows from
the legs back to the heart
o Discourage the use of diuretics in
pregnancy
o Advice pregnant women not to reduce
salt intake, unless medically
recommended.
o Consult with the health worker to rule
out other causes of oedema
NB. The body needs enough salt to
maintain the balance of fluid.
2.3. Maternal nutrition interventions during postnatal care
Nutritional requirements during postnatal period are greater than during pregnancy due to:
� The need to produce breast milk
� The need to promote recovery and sustain the mother’s health
� Increased physical activity compared to pregnancy
2.3.1. Nutritional assessment of lactating women
The six-week Postnatal Care visit presents an opportunity for assessing nutritional status of
these women.
� Macro nutrient assessment
24� MUAC (Refer to assessment during pregnancy)
Assessment and control of micronutrient deficiencies
Vitamin A
Vitamin A supplementation is given to mothers postnatally to increase Vitamin A in breast milk
to a level adequate to meet the infant’s requirements, as well as to improve the mother’s
immunity.
Night blindness is the first symptom of vitamin A deficiency. Individuals should be asked
whether they have difficulty seeing in dim light. Look out for signs of severe vitamin A
deficiency like corneal opacity, clouding, Bitot’s spots, and xeropthalmia.
Iron
This is to prevent anemia in mothers during lactation/breast feeding. Supplementation with 1
tablet/day (60mg) for 3 months after delivery is recommended in addition to the intake of iron rich
foods. (See annex 2)
2.3.3. Nutritional requirements during lactation
Every breastfeeding woman should:
� Eat at least 4 meals a day (approximately 650 additional calories), to meet the energy
needs of lactation ensuring variety of the 3 food groups:
o Body-building foods: beef, fish, eggs, meat, liver, lean beef, pork, fish and legumes
o Energy giving foods: mainly cereal foods, tubers,
o Micronutrient-rich foods: fruits such as passion fruits, paw-paws, pineapples,
guava, avocado, mango, pumpkin and vegetables like spinach, dodo, nakati, buga,
sukuma wiki, tomatoes, etc. Fortified foods to improve micronutrient intake (oil
e.g. fortified with Vitamin A,
� Take a dose of (200,000 IU) of Vitamin A immediately after delivery or within the 1 st
eight weeks after delivery.
� Take iron (60mg) and folic acid 400µg daily for 3months.
� Take iodized salt
� Be counseled on:
o Uptake of family planning services and timing and spacing of pregnancies
o Importance of exclusive breastfeeding
o Appropriate infant and young child feeding, growth monitoring and promotion.
253. MATERNAL NUTRITION UNDER SPECIAL CIRCUMSTANCES
3.1 Diseases
The nutritional status of pregnant women is undermined by the presence of communicable and
non-communicable diseases. The common diseases affecting pregnant women and pregnancy
outcomes are outlined in the table below:
Table 6: Common Diseases Affecting Pregnant Women and Pregnancy Outcomes
Illness Risk Factors Essential Actions
Hypertension � Family history (genetic � Monitor the condition regularly.
factors) � Encourage women to maintain a healthy
� Obesity diet during pregnancy
� Lack of regular physical � Advise on increasing exercise
activity � Advise on reducing intake of table salt
� Poor nutrition especially � Advice on increasing calcium intake.
low calcium intake. � Discourage the use of alcohol
� Stress
Diabetes � Family history � Eating small, regular meals helps control
Mellitus (DM) � Obesity weight and glucose levels.
In some cases, � Sedentary life style � Eating a variety of foods will help maintain
diabetes develops � May be drug induced adequate nutrition.
during pregnancy � Moderate exercise for 30 minutes or
(pregnancy induced more on most days of the week.
diabetes) and is as a � Eat low fat foods.
result of glucose � Encourage consumption of carbohydrate
intolerance. foods that contain dietary fiber (e.g. fruits,
vegetables, whole wheat bread, cereals,
brown rice, legumes).
� Avoid smoking.
� Avoid alcohol intake.
Sickle cell Anemia � Family history of sickle cell � Appropriate care and nutrition education
disease for sickle cell patients should be ensured
i.e. a healthy diet (providing zinc, vitamin
E, vitamin C, vitamin A, vitamin B6, and
vitamin B12, folic acid supplements and
prevention of dehydration.
� All sicklers should receive preventive
doses of anti-malarials.
� More frequent prenatal visits allow for
close monitoring of the mother and of
fetal well-being.
� Counsel on using family planning.
26� Caution should be taken in prescribing
iron, and refer for appropriate
management.
� Give appropriate dose of folic acid.
Malaria � Stagnant polluted water � All pregnant women should be given a
and large mosquito preventive doze of anti-malarials and
population near living when diagnosed with malaria managed
environment according to the current national malaria
� Lack of ITN protocols.
� Sleep under a long-lasting, insecticide
treated nets.
� Increase fluid intake including water.
� Small frequent meals of wide variety in
case of low appetite and vomiting.
� Continued intake of iron and folic acid
supplements.
HIV/AIDS � Unprotected sex with � To preserve their health and nutritional
HIV/AIDS puts extra infected partners/a person status HIV positive pregnant and lactating
demands for energy of unknown sero-status women should eat at least 2 nutritious
and nutrients and � Multiple sexual partners snacks in addition to the regular 3 meals
adds to those already � Transfusion with to meet their energy and nutrient needs.
imposed by unscreened blood � Support pregnant women and lactating
pregnancy and � Use of unsterilized mothers to seek, early treatment of HIV.
lactation equipment � Regularly monitor the nutritional status of
� Sharing of syringes and pregnant and lactating mothers.
needles and razor blades � Prevent and treat all opportunistic
infections/illness that may affect their
nutritional status or their ability to eat.
� Encourage good food safety and hygiene
practices to avoid food and water-borne
diseases.
Source: Guidelines for service providers on Nutritional care and support for People Living with HIV and
AIDS, in Uganda (May, 2006).
3.2. Social factors, local practices, and environmental issues affecting maternal
nutrition
3.2.1. Child spacing
Encourage the use of family planning to ensure healthy timing and spacing of pregnancies.
Recommended actions
� Support mothers to initiate breastfeeding within the first hour after birth and exclusively
breastfeed for six months, as this constitutes a form of natural contraception.
27� Counsel on the need for birth spacing through promotion of other appropriate family
planning methods in order to allow the body to regain nutrient stores 4.
� Promote safe sex practices
� Counsel on inter-pregnancy interval of 3-5 years
3.2.2. Myths, local practices, and gender issues that affect maternal nutrition
Myths and local practices and gender issues influence food habits and may negatively impact on
the nutrition status of women because most of them prohibited foods are usually protein-rich.
Recommended actions
Health care providers should be able to overcome myths by using the following suggested
actions:
� Be conversant about local practices pertaining to nutrition that have a negative impact
on women’s nutrition in the areas where they work.
� Counsel both men and women on how to adapt local practices so that women receive
adequate nutrition
� Raise the awareness of communities on appropriate nutritional interventions for women
during pregnancy and lactation, and as to the influence of local practices on nutrition.
Health care providers should counsel families to involve men, within the cultural
context, to support nutritional interventions.
� Educate communities on the need for reduced workload and enough rest for pregnant
and lactating women
� Health workers should dispel myths about food taboos that affect women from
accessing highly nutritious foods like fish, meat, eggs, etc.
� Educate families and counsel adolescents on the physical and emotional dangers of early
marriages and childbearing.
3.2.3. Substance abuse
� Substance abuse is the excessive use of a potentially addictive substance such as alcohol,
tobacco, and drugs (marijuana, qat, cannabis, cocaine, etc) that may modify body
functions.
� Substance abuse has the following effects on maternal nutrition:
o Suppressing the woman’s appetite, leading to reduced food intake which is one
of the major immediate causes of malnutrition.
o In the case of lactating mothers, the substances can pass through breast milk and
affect the baby’s health.
o Drugs can have a direct effect on the mother’s health when they cause illnesses
eg lung and liver cancer from tobacco and alcohol respectively. Illnesses
negatively affect maternal nutrition.
4
Consider breastfeeding status when prescribing contraception.
28Recommended actions
� All forms of substance abuse should be avoided and discouraged in pregnancy and
lactation.
3.2.4. Maternal nutrition in emergencies
Hunger and malnutrition are rampant in incidences of emergencies. Women of reproductive
age, and pregnant and lactating mothers in particular, are more vulnerable to malnutrition in
these settings. Besides wasting, deficiencies of iodine, vitamin A and iron are common in
emergency-affected populations. In Uganda humanitarian agencies support government in
general provision of food aid.
Recommended actions
� In cases of emergency, humanitarian aid programs should prioritize vulnerable groups
like pregnant and lactating women and meet their energy and other nutrient needs
through the rations that are usually served.
� Routine iron and folic acid supplementation should still remain priority to pregnant and
lactating mothers despite the emergence situations.
3.2.5. Nutritional care for adolescent pregnancy
The proportion of adolescent pregnancies in Uganda stands at 25% of the age bracket 10 – 19
years. The nutritional needs of pregnant adolescents are similar to those of other mothers.
However, because their bodies are still developing, younger adolescents compete with the fetus
for nourishment, exhausting iron and other nutrient reserves. As a result, nutritional
deficiencies such as iron deficiency anemia are more common in pregnant adolescents.
Recommended actions
Health workers should ensure that they;
� Assess the nutritional status of these adolescents.
� Counsel and provide appropriate advice/information to the supporting families on
adequate nutrition and eating behaviors of the adolescent.
� Counsel on compliance and intake of micronutrient supplements according to national
protocols.
3.2.6. Community support for maternal nutrition
In order to establish a social environment conducive to optimal maternal nutrition, the
following actions are recommended:
� Utilize the referral system using of the Village Health Teams (VHTs) linking to the
established health care system.
� Supportive social networks through the VHTs (e.g. family support groups, women
groups for improved nutrition).
� Effective referrals with other agencies that can help to improve household food security
and uptake of preventive health services (e.g. antenatal care, adolescent-friendly health
services, nutritional information, micronutrient supplementation, etc.).
� Provision of nutrition education and counseling to ensure proper utilization, preparation
and storage of foods.
293.2.7. Water, sanitation, and hygiene
One of the major causes of malnutrition in an individual is the presence of disease. Poor
sanitation and the use or consumption of unsafe or contaminated water is usually the primary
source of diseases related to environmental hygiene. Food and water should be handled in a
hygienic manner in order to avoid food and water-borne illnesses. Pregnant women’s immune
systems are weaker, and thus they are susceptible to infection.
Recommended actions
� Always wash hands with soap before and after touching food.
� Wash fruits and vegetables thoroughly before eating.
� Make sure that food preparation and eating areas are perfectly clean.
� Cover food that is not eaten to avoid contamination.
� Serve cooked foods when hot.
� Serve foods using clean utensils.
� Water meant for drinking should be brought to a rolling (bubbling) boil and boiled for 3
minutes to kill germs.
� Avoid consuming expired processed food products by checking on the “best before”
dates.
304. IMPLEMENTATION
Implementation should be effected at all levels and the strategies should be integrated in the
existing maternal health care services such as Goal-oriented ANC, maternity, postnatal care
(PNC), baby-friendly health facility initiative (BFHI), prevention of maternal to child transmission
(PMTCT) of HIV, FP, YCC, etc.
Table 7: Implementation of the Maternal Nutrition Interventions.
Intervention Activities Level Responsibilit Target
y
Macronutrient Education and counseling on Health facility Health care All women
deficiency diet diversification, amounts and providers at of
control and frequencies of meals community facility and reproductive
community. age.
Micronutrient � Supplementation with Health facility Health care Adolescent
deficiency iron and folic acid and providers. girls
control during pre pregnancy, community, Pregnant and
pregnancy and including lactating
lactation. schools women.
� Vitamin A within 8
weeks after delivery.
� Education and
counseling on diet
diversification
� Deworming. Health facility, Health care Pregnant and
� Malaria control using community providers, lactating
ITN and IPT2. VHTs women.
Promote availability and All levels MOH, DHT, Women of
use of Fortified foods: Community reproductive
leaders age.
Nutritional � Anthropometry Health facility Health care Women of
assessments � Clinical and and providers reproductive
biochemical community. age.
assessments
Nutrition Production and National and MOH, partners Health care
promotion and dissemination of IEC District and DHT providers
education materials, Job Aids and
Protocols.
Nutrition � Health education talks All levels MOH and Women of
counseling DHT reproductive
age.
31Intervention Activities Level Responsibilit Target
y
Community � Home visits Districts and DHT Women of
mobilization and � Community meetings Community VHT reproductive
sensitization � Media programs age.
� Linkages to social
support groups.eg to
health facilities,
income generating
activities and women
support groups.
Partnerships/ � Review and report District and MOH Partner
Inter-sectoral sharing meetings National organizations
collaboration � Joint implementation partners
and Networking of prioritized
activities
Capacity building � Provide adequate National and MOH and Health care
Staffing Orientation District DHT providers
of service providers.
� Introduce Maternal
nutrition as part of
the pre-service
training for teachers
and health workers
Provision of adequate National and MOH and Service
equipment and tools. District DHT delivery
points.
Logistics and � Accurate and reliable National, MOH, DHT Service
supplies Quantification district and and health delivery
management Procurement health facility facility. points.
� Storage and
distribution system
developed.
Policy aspects Maternal nutrition be National, MOH, DHT Service
integrated in RCT, Goal district and and health delivery
oriented ANC, PMTCT, and health facility facility. points.
Family planning services
Monitoring and Review data collection, National MOH Districts and
Evaluation support supervision and health
reporting tools for maternal facilities
nutrition
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