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Prenatal Nutritional Care Improved Perinatal Outcome of Pregnant Women in the Context of Primary Health Care

Beatriz Della Líbera, Mirian Ribeiro Baião, Denise Cavalcante de Barros, Marta Maria Antonieta de Souza Santos, Roberta Gabriela Araújo, Cláudia Saunders

Abstract: The aim of the study was to assess the impact of a prenatal nutritional care programme on perinatal outcome in the context of primary health care. That’s a non-randomised controlled clinical trial developed in a care unit in Rio de Janeiro, Brazil. 284 pregnant women were allocated into one of two groups: an intervention group (IG; n = 122), comprising pregnant women who received the intervention of nutritional care through collective consultations with a nutritionist, and a control group (CG, n = 162) consisting of pregnant women who did not receive the intervention. There was a higher proportion of pregnancy complications (p=0.000) and abnormal total gestational weight gain (p=0.031) in the CG. In the final model, it was found that belonging to the CG (adjusted OR=4.721; CI 95%=1.009-22.090) and living with four or more people in the household (adjusted OR=2.692; CI 95%=1.021-7.101) were predictors of pregnancy complications, while belonging to the CG (adjusted OR=2.354; CI 95%=1.063-5.213) and starting prenatal care after 16 weeks (adjusted OR =8.509; CI 95%=1.023-70.784) were determinants of abnormal pregnancy weight gain. The findings reinforce that the prenatal nutritional care programme contributed to improving the health of pregnant women.

Keywords: pregnancy, nutrition programmes, prenatal nutrition, primary health care, intervention studies, food and nutrition education

Citation: Beatriz Della Líbera, Mirian Ribeiro Baião, Denise Cavalcante de Barros, Marta Maria Antonieta de Souza Santos, Roberta Gabriela Araújo, Cláudia Saunders, Prenatal Nutritional Care Improved Perinatal Outcome of Pregnant Women in the Context of Primary Health Care. Journal of Food and Nutrition Research, 5 (9). 689-696. January 2017. doi:10.12691/jfnr-5-9-9

1. Introduction

Maternal morbidity is strongly associated with neonatal mortality. Adequate prenatal care, with early detection and intervention during risk situations, as well as good quality care during labour, are key health indicators related to mother and child. These indicators have potential to further reduce the effects of risk factors related to maternal and neonatal mortality [1,2,3].

Scientific evidence also suggests the importance of prenatal nutritional care for the woman and her newborn [4,5,6,7,8,9]. The World Health Organization [10] highlights nutritional care as a pre- and post-natal strategy to improve maternal, newborn and child health. The Brazilian Ministry of Health provides for the organisation of nutritional care in the health services, especially in the context of primary health care (PHC), in order to meet the demands related to nutrition generated by the most vulnerable people, such as maternal and child groups [11,12].

Considering the growing number of studies that confirm the benefits of proper nutrition on pregnancy outcomes and the need to plan and organise nutritional care during the different phases of the life course, including pregnant women, mothers, and children under two years of age, this study aimed to assess the impact of a prenatal nutritional care model, focused on PHC, on perinatal outcomes in a Family Clinic (FC) in the region of Manguinhos, Rio de Janeiro, Brazil.

2. Materials and Methods

This non-randomised controlled trial is part of the project entitled "Nutritional Prenatal Care in Primary Health Care in the area of Manguinhos, Rio de Janeiro, Brazil". The project studied 284 pregnant and postpartum women in this region between 2012-2015. The study was published in the Brazilian Platform of Clinical Trials Records under the RBR-2x4gm7 registration number.

The inclusion criteria for the pregnant women were: maternal age not more than 45 years old; singleton pregnancy; gestational age up to 24 weeks; no history of chronic diseases; and attending for prenatal care at the clinic where the study was conducted. Pregnant women who were homeless or had a miscarriage or stillbirth during the pregnancy were excluded. Women who moved to a region that was not covered by the FC, and women without postpartum data, were considered as sample losses.

2.1. Study Groups

In specific days of the week, all pregnant women attending the FC between 2012-2105 who met the pre-established inclusion criteria were invited to participate in collective appointments in which they would receive structured nutritional care. From this recruitment, two groups were defined: the intervention group (IG) and the control group (CG). IG was comprised by pregnant women attending prenatal care at the FC on the days of the recruitment, who met the pre-established inclusion criteria, agreed to participate in the collective appointments and received the intervention of structured nutritional care. IG members were invited in waiting rooms, in dental consultations or by health team referrals. A team of trained researchers interviewed IG participants, and collected data during the first and in subsequent (including postpartum) appointments. CG women were identified using the electronic medical record system and retrospective data from CG participants were collected using their medical records. It was comprised by pregnant women who met the pre-established inclusion criteria but, as they were not attending prenatal care at the FC on the days of the recruitment, they couldn’t be invited to participate in collective appointments.

Both study groups received traditional prenatal care offered by the clinic during individual attendances, based on diagnostic evaluations, requests for additional tests, prescriptions, counselling and referrals. Nutritional guidelines were offered verbally and informally by doctors and nurses, according to the demands of the pregnant women.

2.2. Intervention

Women in the IG, in addition to the traditional prenatal care, received nutritional care offered in three collective appointments during the prenatal period, characterised as "conversation circles" (CCs) and structured as follows: evaluation of medical records, nutritional assessment, development of educational activities related to health and nutrition, and delivery of educational material. All the three nutrition sessions had an approximate duration of one and a half hours.

Nutritional assessment and medical records provided the basis for the delivery of nutritional care developed during the CC, in which we applied nutritional and dietary counselling techniques [13], taking into account each individual woman’s opinions, her life style, her attitude to pregnancy, and her eating habits.

The intervention was delivered by trained nutritionists with the aim of standardising the procedures of the nutritional care protocol. During the CC, pregnant women were informed about their nutritional diagnosis and weight gain, with explanations of what they represented in order to provide appropriate guidance for each individual.

The patient was counselled about healthy eating, based on the Food Guide for the Brazilian Population [14] and according to the nutritional recommendations. The intervention content included written guidance on the groups of foods that should be eaten at each meal, nutrition in pregnancy, weight gain, and emphasis on dietary sources of iron, calcium, and vitamins C and A. Guidance was also provided about the prevention and treatment of digestive disorders, pregnancy complications, pica, anaemia, and gestational night blindness. Diets with calorie restriction were not recommended during pregnancy even for pregnant women with excessive weight gain. Furthermore, adherence to the use of supplements was also evaluated. In all CCs, educational material related to the health of women and children was distributed, a child's health booklet and pregnancy cards.

In addition to the issues related to the nutrition of pregnant women, other topics were covered in the CC such as body and psychosocial changes and fetal development, physical activity, oral health, postpartum and baby care, as well as specific issues raised by the participants, such as family and marital insecurity and violence in the community, among others. The CCs were multidisciplinary; other clinical professionals (doctor, nurse, social worker, dentist, psychologist) were invited to join the groups. The materials delivered to pregnant women were the cards ‘Following the development of pregnancy’ and ‘Mother Bag Book’ [15,16].

2.3. Variables Studied

The dependent variables or outcomes studied were pregnancy complications and inadequacy of total gestational weight gain.

Gestational complications considered were hypertensive disorders of pregnancy, gestational diabetes, gestational anaemia, urinary tract infection, oligohydramnios and polyhydramnios, identified from the medical records [3]. A haemoglobin level of <11g/dL was adopted for the diagnosis of anaemia [3]. The variable of gestational complications was analysed in a dichotomous way, forming two categories: with complications (when pregnant women had one or more complications) and without complications.

Anthropometric and total gestational weight gain evaluations were made, based on the following measures: pre-pregnancy weight as informed or measured before the 14th week of gestation, and height and weight before birth measured at the last prenatal appointment before delivery. The pre-gestational body mass index (BMI) was calculated and evaluated [17] using the formula: BMI = pre-gestational weight (kg)/height (m²). The total gestational weight gain was estimated by subtracting the pre-pregnancy weight or the antepartum weight from the weight recorded in the last prenatal visit occurring no later than seven days before delivery. This variable was analysed in a dichotomous way, forming the two categories: adequate weight gain (total gestational weight gain within the recommended range), and abnormal weight gain (total gestational weight gain below or above the recommended range) [17].

The independent variables analysed incuded socio-economic and environmental factors, data from prenatal care and obstetric data. The socio-economic and environmental characteristics analysed were: level of education (less than elementary school degree; elementary school degree or more), skin colour (white or black and brown), marital status (married / living with partner), smoking during pregnancy (yes or no); number of household members (<4 or >4) and housing sanitation conditions (appropriate - when the mother reported access to treated water, the sewage system and garbage collection, and inappropriate when at least one parameter was not met ).

Data from prenatal care analysed were: number of prenatal consultations (< 6 or 6 or more, the number of prenatal consultations was analysed as a variable in categorical and discrete forms); number of collective appointments (0 to 1, 2 or 3, the number of collective consultations was analysed in categorical and discrete forms) and study group (IG - when the woman received the nutritional care, and CG when she received no planned nutritional care intervention).

Obstetric data analysed were pre-pregnancy BMI (BMI <18.5 kg/m² - low weight, BMI between 18.5 and 24.9kg/m² - normal BMI between 25 and 29.9kg/m² - overweight and BMI > 30,0Kg/m² – obese; the pre-pregnancy BMI was analysed as a variable in categorical, continuous and stratified forms), gestational age at first prenatal visit (<16 weeks, > 16 weeks) and abortion history (yes or no).

2.4. Sample Size

The sample was selected by convenience and was not defined in advance, and included all pregnant women attending the FC who met the pre-established inclusion criteria, over a period of three years (2012-2015) respecting the ethical aspects.

2.5. Statistical Analysis

Measures of central tendency, means and standard deviations for continuous variables were calculated. Initially, we evaluated the similarity between the study groups at baseline, by comparing the socio-demographic, obstetric and prenatal characteristics, using the chi-square test and 5% significance level. In the data analysis, we tested the association between the possible determinants of pregnancy complications and inadequate weight gain in the pregnant women, through bivariate analysis, estimating raw odds ratio (OR) with confidence intervals (CI) 95%, by simple logistic regression.

For the construction of the final models, variables were included if they indicated p-value <0.25 obtained in the bivariate analysis, and also variables identified as relevant according to other scientific findings.

In the final model, the ORs were estimated adjusted with their respective CIs 95% through logistic regression, where the results were expressed through the crude and adjusted OR. The analyses were performed using the SPSS (Statistical Package for Social Sciences) version 20.

2.6. Data Quality

To analyse the reliability of the information obtained in this study, equivalence was measured between the results obtained by different researchers analysing the same records randomly selected (n = 22). The intraclass correlation coefficient (ICC) and the Kappa (k) were calculated to assess agreement of continuous and categorical variables respectively, with a CI of 95% [18]. In interpreting the concordance rates >0.61 was considered as good agreement [19].

2.7. Ethical Issues

The study was approved by the National School of Ethics and Research Committee of Public Health Sérgio Arouca - CEP / ENSP, constituted in terms of CNS Resolution No. 196/96, under the research protocol No. 238/10 on 16/02/2011.

3. Results

In assessing the quality of data through analysis of interrater agreement levels, it was found that there was good standardisation; the ICC values were >0.839 and k >0.808.

Data were analysed from 284 pregnant women attending a FC, divided into two groups: control group (CGn = 162) and intervention group (IG n = 122). The sample selection process is shown in Figure 1.

Figure 1. Sample selection process (CG and IG)

The women studied had a mean age of 23.8 years (SD = 6.4), the youngest was 13 and the oldest 41 years. Most were married or living with a partner (57.3%), had black or brown skin colour (77.5%), completed primary education (56.8%), and had adequate sanitation at home (88.4%). Regarding perinatal outcomes, 65.9% of women had inadequate total gestational weight gain, 35,9% had excessive total gestational weight gain and 75.3% developed pregnancy complications, in particular, urinary tract infections (41.0%), anaemia (21.4%), hypertensive disorders of pregnancy (10.5%) and gestational diabetes (4.3%).

Table 1 consolidates the socio-demographic, obstetric and prenatal care of the women. The members of the two study groups were similar at baseline with respect to skin colour, occupation, housing sanitation, tobacco use during pregnancy and classification of pre-pregnancy BMI.

Table 1. Distribution of pregnant women according to sociodemographic, obstetric and prenatal care characteristics in the control group (CG) and intervention (IG). Manguinhos, Rio de Janeiro, Brazil. 2012-2015

Regarding perinatal outcomes, there was a higher rate of pregnancy complications (p = 0.000) and inappropriateness of the total gestational weight gain (p = 0.028) in the CG (Table 2) compared to the IG. It was also noted that the gain in average total gestational weight gain in the CG was 10.8kg and 13.0kg IG (p = 0.368).

Table 2. Distribution of pregnant women according to perinatal outcomes in the control group (CG) and intervention (IG). Manguinhos, Rio de Janeiro, Brazil. 2012-2015

The proportion of pregnant women who attended six or more times by prenatal care was also higher in the IG compared to the CG, with an average of 6.1 (SD = 3.3) in the CG and 8.1 (SD = 2, 3) in the IG (p = 0.000). The average number of CCs in the IG was 2.1 (SD = 0.8). No differences were observed between the study groups regarding the number of pregnancies (CG = 1.92; IG = 1.96; p = 0.823), number of deliveries (IG = 0.67; CG = 0.82; p = 0.145), gestational age at first prenatal consultation (CG = 12.1; IG = 11.2; p = 0.422), pre-pregnancy BMI (CG= 24.4; IG = 23.6, p = 0.578) or gestational age at delivery (CG = 39.0; IG= 39.2; p = 0.708).

In this study, pregnancy complications and outcomes, and inadequacy of total gestational weight gain were selected as variables of interest, considering the high prevalence among pregnant women studied (75.3% and 65.9%, respectively) and the significant differences noted between the CG and IG.

Bivariate analysis identified the following socio-economic variables as possible determinants of pregnancy complications: marital status (p = 0.006), educational level (p = 0.232), smoking during pregnancy (p = 0.060) and number of people in the household (p = 0.006). The variables number of prenatal visits (p = 0.207), pre-pregnancy BMI (p = 0.255) and the study group (p = 0.002) were associated to the outcome.

From the bivariate analysis to identify the possible socio-economic determinants of inadequate gestational weight gain, it was found that the variables of skin colour (p = 0.132) and smoking during pregnancy (p = 0.115) were associated with this outcome. Regarding the variables related to prenatal care and maternal characteristics, the number of CCs (p = 0.010) and prenatal care (p = 0.198), gestational age at first visit (p = 0.044) and group study (p = 0.030) also were associated with abnormal gestational weight gain. Although the variables concerning the number of people in the family, level of education and pre-pregnancy BMI were associated with p-values of > 0.25 in the bivariate analysis, they were nevertheless considered in the multivariate analysis in view of the widespread findings that have demonstrated their influence on gestational weight gain.

In the multivariate analysis for the outcome pregnancy complications, it was found that after the model fit, the variables marital status, smoking during pregnancy and number of prenatal consultations lost significance, leaving only the variables education level, number of people at home, study group and classification of pre-pregnancy BMI as determinants of pregnancy complications (Table 3). Belonging to the CG (adjusted OR = 4.721; 95% CI = 1009-22090) and living with four or more people at home (adjusted OR = 2.692; 95% CI = 1021-7101) were the determinants of pregnancy complications.

Table 3. Final model with raw and adjusted odds ratio to estimate the determinants of pregnancy complications and inadequacy of total gestational weight gain outcomes. Manguinhos, Rio de Janeiro - Brazil. 2012-2015

In the multivariate analysis for the outcome of inadequate gestational weight gain, after adjustments, the only variables that remained were educational level, study group, gestational age at first prenatal visit, number of prenatal consultations and BMI classification pre-pregnancy (Table 3). Thus, it was found that belonging to the CG (adjusted OR = 2.354; 95% CI = 1063-5213) or starting prenatal care after 16 weeks of gestation (adjusted OR = 8.509; 95% CI = 1023-70784) were determinants of inadequate gestational weight gain.

4. Discussion

Pregnancy complications and inadequacy of total gestational weight gain were the outcomes with the highest prevalence in the study, being less frequent in the intervention group. This finding may be related to the provision to the IG of nutritional and dietary counselling during CCs. This intervention was a differential offered to pregnant women during the prenatal period, reinforcing the importance of nutritional care given to the mother-child group as a part of PHC. It is possible that other associations were not significant due to the small sample size.

Although some women in the CG had received information about eating habits, this was done in a superficial way, possibly because professionals in the health teams are not adequately prepared to deal with non-specific nutritional issues in their training [20].

In the present study, it was observed that belonging to the CG and living with four or more people at home were the determining factors for pregnancy complications. Also, belonging to the CG and starting prenatal care after 16 weeks gestation were associated with inadequacy of gestational weight gain. We chose not to use the variable per capita income due to the large percentage of data losses found (68%).

The greater the number of people, the more inadequate was the attendance for prenatal care [21] and, consequently, the higher was the risk of adverse obstetric outcomes. In an evaluation of nutrition care processes in prenatal care in family health units, Niquini et al. [20] noted there was less conformity in pre-pregnancy weight and height (p = 0.023) registration procedures on the cooperation card in pregnant women living with three or more people. In the same study, it was noted that pregnant women living with less than three people reported receiving more guidance on food consumption. It is possible that a greater number of people in the family is associated with socio-economic insecurity, less access to health services and to information and, consequently, with greater difficulty in following the guidelines received.

The main pregnancy complications identified in the present study were urinary tract infections, anaemia, hypertensive disorders of pregnancy and diabetes. The literature suggests that prenatal nutritional intervention is associated with a lower prevalence of hypertension and gestational diabetes, as well as anaemia [22,23,24], prematurity and low birth weight. This finding becomes relevant in view of the consequences of pregnancy complications on maternal and child health. Hypertension is considered to be the leading cause of maternal and perinatal morbidity and mortality [25], and it may be associated with prematurity, a small for gestational age (SGA) baby, respiratory distress syndrome and low Apgar scores at 1 and 5 minutes [26]. Gestational diabetes is associated with maternal complications, such as preeclampsia, and predisposes women to the development of type 2 diabetes after delivery. Furthermore, maternal fetal hyperglycaemia may result in hyperinsulinemia leading to macrosomia, and insulin resistance and obesity in childhood [27].

The negative impact of abnormal gestational weight gain on the health of women and children has also been widely discussed in the scientific literature; excessive weight gain is associated with increased risk of gestational hypertension, and macrosomia [28,29]; and insufficient weight gain with the birth of small-to-age babies [30].

We noted in this study that, regarding the women who attended two or three CCs, 92.3% attended for six or more prenatal care appointments, whereas of those who did not participate in the CCs or attended only one, only 58.3% attended six or more prenatal care appointments (p = 0.000; data not shown). Based on these findings, it is suggested that attending for prenatal and nutritional care are associated.

Corroborating these findings, Vitolo et al. [23] found that the prevalence of overweight pregnant women who gained more than 10 kg in the interval between the first and third appointments was higher in the CG (29.1%) when compared to the IG (12.5% ; RR = 0.4; 95%CI 0.19-0.96). A meta-analysis conducted by Thangaratinam et al. [31] pointed out that dietary intervention resulted in a significant reduction of gestational weight gain that was associated with an improvement in perinatal outcomes, compared to other types of interventions.

The limitations of the study include the probable underreporting of information, especially of the CG members, due to the absence of data in their records; however, there was good reliability levels of the collected data, indicated by the CCIC and Kappa values. In addition, the development of research in just one FC in the city of Rio de Janeiro does not allow the findings of this study to be generalized to the population of the city as a whole. Nevertheless, it is important to note that the health unit in question consists of six family health teams, three oral health teams and a street office, serving more than 6,000 users. Also, the fact that women in the CG refused to participate in the CC implies that they may have been less motivated to take care of themselves. Similarly, the profiles of women in the CG were different from those in the IG: they were less educated, had fewer people living with them and attended for fewer prenatal appointments.

Considering the need to plan and organize food and nutrition actions in the health care network, and the lack of national studies that propose a validated nutritional care protocol that can be implemented in the scope of the PHC, the present work aimed to present a proposal to build a nutritional care protocol to be implemented in health facilities. Although the intervention has been coordinated by a nutritionist, it is expected that CCs may also be developed by other health professionals. The nutritionist can contribute with specialised technical support to the interdisciplinary health team.

It is worth noting that the proposed nutritional care was guided by the need for organisation of prenatal nutritional care in PHC, in order to contribute to the structuring of maternal and child health care. Furthermore, we advocate nutritional assessment routines with low technological density and methodological facilities, in order to provide a basis for the structuring of dietary and nutritional care which, it is hoped, will improve the health and nutrition of women and their children.

5. Conclusion

The results of this study reinforce the observation that prenatal nutritional care at PHC level contributes to the health of pregnant women. It is expected that the proposed multidisciplinary nutritional care protocol can be reproduced in other health units as a strategy to promote normal gestational weight gain and to reduce pregnancy complications.

Acknowledgments

Financial support: Projeto de Pesquisa TEIAS parceria Fiocruz/Secretaria Municipal de Saúde do Rio de Janeiro and Programa Institucional de Bolsas de Iniciação Científica – Universidade Federal do Rio de Janeiro - Conselho Nacional de Desenvolvimento Científico e Tecnológico / PIBIC/UFRJ/CNPq.

Statement of Competing Interests

The authors have no competing interests.

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