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      Feasibility and effect of life skills building education and multiple micronutrient supplements versus the standard of care on anemia among non-pregnant adolescent and young Pakistani women (15–24 years): a prospective, population-based cluster-randomized trial

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          Abstract

          Background

          Adolescence is a critical period for physical and psychological growth and development, and vitamin and mineral requirements are correspondingly increased. Health and health behaviours correspond strongly from adolescence to adulthood. Developing a preconception care package for adolescent and young women in resource-limited settings could serve to empower them to make informed decisions about their nutrition, health, and well-being, as well as function as a platform for the delivery of basic nutrition-related interventions to address undernutrition.

          Methods

          In this population-based two-arm, cluster-randomized, controlled trial of life skills building education (provided bi-monthly) and multiple micronutrient supplementation (provided twice-weekly; UNIMMAP composition), we aim to evaluate the effectiveness of the intervention on the prevention of anemia (hemoglobin concentration < 12 g/dL) among adolescent and young women (15–24 years) in Matiari district, Pakistan compared to the standard of care. Several secondary objectives related to nutrition (anthropometry [height, weight, middle upper arm circumference (MUAC)], nutritional status [iron, vitamin A, vitamin D]); general health (morbidity, mortality); and empowerment (age at marriage, completion of the 10th grade, use of personal hygienic materials during menstruation) will also be assessed. Participants will be enrolled in the study for a maximum of 2 years.

          Discussion

          Empowering adolescent and young women with the appropriate knowledge to make informed and healthy decisions will be key to sustained behavioural change throughout the life-course. Although multiple micronutrient deficiencies are known to exist among adolescent and young women in low-resource settings, recommendations on preconception multiple micronutrient supplementation do not exist at this time. This study is expected to offer insight into providing an intervention that includes both education and supplements to non-pregnant adolescent and young women for a prolonged duration of time within the existing public health programmatic context.

          Trial registration

          This study is part of the Matiari emPowerment and Preconception Supplementation (MaPPS) Trial. The MaPPS Trial was registered retrospectively on clinicaltrials.gov (Identifier: NCT03287882) on September 19, 2017.

          Electronic supplementary material

          The online version of this article (10.1186/s12978-018-0547-y) contains supplementary material, which is available to authorized users.

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          Most cited references11

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          Maternal and child undernutrition and overweight in low-income and middle-income countries

          The Lancet, 382(9890), 427-451
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            Lady health workers programme in Pakistan: challenges, achievements and the way forward.

            To review the Lady Health Workers programme and critically explore various aspects of the process to extract tangible implications for other similar situations. A descriptive study was carried out over a period of one year (2007-08). A detailed desk review of project documents, interaction with relevant stakeholders, performance validation and extensive feedback from the community were collected. The data so obtained was analyzed and evaluated against predetermined benchmarks. Each LHW serves a population of 1,000 people in the community and extends her services in the catchment population through monthly home visits. The scope of work includes over 20 tasks covering all aspects of maternal, newborn and child care. Total cost incurred on each worker is averaged at PKR 44,000 (US $ 570) per anum.Almost 60% of the total population of Pakistan, mostly rural, is covered by the programme with more than 90,000 LHWs allover the country. The health indicators are significantly better than the national average, in the areas served by the LHWs. The LHW programme has led to a development of a very well placed cader that links first level care facilities to the community thus improving the delivery of primary health care services. However, despite its success and the trust it has earned from the community, there are certain areas which need special attention which include poor support from sub-optimal functional health facilities, financial constraints and political interference leading to management issues. The future carries a number of challenges for management of the programme which have been highlighted.
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              Preconception care: nutritional risks and interventions

              Introduction There is increasingly a double burden of under-nutrition and obesity in women of reproductive age. Preconception underweight or overweight, short stature and micronutrient deficiencies all contribute to excess maternal and fetal complications during pregnancy. Methods A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on maternal, newborn and child health (MNCH) outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture. Results Maternal pre-pregnancy weight is a significant factor in the preconception period with underweight contributing to a 32% higher risk of preterm birth, and obesity more than doubling the risk for preeclampsia, gestational diabetes. Overweight women are more likely to undergo a Cesarean delivery, and their newborns have higher chances of being born with a neural tube or congenital heart defect. Among nutrition-specific interventions, preconception folic acid supplementation has the strongest evidence of effect, preventing 69% of recurrent neural tube defects. Multiple micronutrient supplementation shows promise to reduce the rates of congenital anomalies and risk of preeclampsia. Although over 40% of women worldwide are anemic in the preconception period, only one study has shown a risk for low birth weight. Conclusion All women, but especially those who become pregnant in adolescence or have closely-spaced pregnancies (inter-pregnancy interval less than six months), require nutritional assessment and appropriate intervention in the preconception period with an emphasis on optimizing maternal body mass index and micronutrient reserves. Increasing coverage of nutrition-specific and nutrition-sensitive strategies (such as food fortification; integration of nutrition initiatives with other maternal and child health interventions; and community based platforms) is necessary among adolescent girls and women of reproductive age. The effectiveness of interventions will need to be simultaneously monitored, and form the basis for the development of improved delivery strategies and new nutritional interventions.
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                Author and article information

                Contributors
                zulfiqar.bhutta@aku.edu
                Journal
                Reprod Health
                Reprod Health
                Reproductive Health
                BioMed Central (London )
                1742-4755
                30 May 2018
                30 May 2018
                2018
                : 15
                : 103
                Affiliations
                [1 ]ISNI 0000 0004 0473 9646, GRID grid.42327.30, Centre for Global Child Health, , The Hospital for Sick Children, ; Toronto, ON M6S 1S6 Canada
                [2 ]ISNI 0000 0001 2157 2938, GRID grid.17063.33, Department of Nutritional Sciences, , University of Toronto, ; Toronto, ON Canada
                [3 ]ISNI 0000 0001 0633 6224, GRID grid.7147.5, Centre of Excellence in Women and Child Health, , Aga Khan University, ; Stadium Road, Karachi, 74800 Pakistan
                Article
                547
                10.1186/s12978-018-0547-y
                5977744
                29848335
                a89e2aec-7709-4f66-8cb4-4bb101693c02
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 14 May 2018
                : 24 May 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;
                Funded by: World Food Programme
                Categories
                Study Protocol
                Custom metadata
                © The Author(s) 2018

                Obstetrics & Gynecology
                adolescence,young adult,nutrition,micronutrients,education,preconception,anemia,empowerment

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