Supplementation with Micronutrients in Addition to Iron and Folic Acid Does Not Further Improve the Hematologic Status of Pregnant Women in Rural Nepal

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Abstract
Iron deficiency is one of the main causes of anemia during pregnancy, although other micronutrient deficiencies may play a role. We examined the effects of daily antenatal and postnatal supplementation with four combinations of micronutrients on maternal hematologic indicators in a double-masked randomized controlled community trial. Communities, called sectors, were randomly assigned to supplementation with folic acid (400 μg), folic acid plus iron (60 mg), folic acid plus iron and zinc (30 mg) and folic acid plus iron, zinc and 11 other micronutrients, each at the approximate recommended daily allowance for pregnancy all given with vitamin A as retinol acetate (1000 μg retinol equivalent), or vitamin A alone as the control group. Hemoglobin (Hb) and indicators of iron status were assessed at baseline and at 32 wk of gestation. At 6-wk postpartum, Hb assessment was repeated using a finger stick. Severely anemic women (Hb < 70 g/L) were treated according to WHO recommendations. Folic acid alone had no effect on maternal anemia or iron status. Hb concentrations were 14 g/L, [95% confidence limits (CL), 8.3–19.2], 10.0 g/L (CL, 5.2–14.8) and 9.4 g/L (CL, 4.7–14.1) higher in the groups receiving folic acid plus iron, folic acid plus iron and zinc and folic acid plus iron, zinc and multiple micronutrients, respectively, relative to the control. Anemia in the third trimester was reduced by 54% with folic acid plus iron, by 48% with folic acid plus iron and zinc and by 36% with folic acid plus iron, zinc and multiple micronutrients supplementation, relative to the control (P < 0.05). Thus, the combinations of folic acid plus iron and zinc and folic acid plus iron, zinc and multiple micronutrients provided no additional benefit in improving maternal hematologic status during pregnancy compared with folic acid plus iron. The level of compliance and baseline Hb concentrations modified the effect of iron.