Maternal nutrition and newborn health outcome

Abstract

Early life nutrition is one of the most substantial environmental factors that shapes future health. This extends from the women’s nutritional status prior to conception and during pregnancy to the offspring’s nutritional conditions during infancy and early childhood. During this critical period, various body organs are undergone growth and development at incredible rates and programming of body systems take place. This thesis basically provides evidence on the associations between nutritional circumstances early in life, particularly during preconception and gestation period, with newborn health outcomes. We outlined this thesis into three parts. The first part (chapters 2, 3, 4, and 5) mainly focuses on in utero Ramadan exposure as nutritional determinants that may influence newborn health outcome. The second part (chapters 6 and 7) provides evidence about the effect of maternal nutrition status early in pregnancy on the development of pregnancy complications and newborn outcome. In the third part of this thesis (chapter 8), we described a protocol of a randomized trial on breastfeeding which is aimed to investigate the effect of breastfeeding on health outcomes during the first years of life. Part 1 begins with a description of various factors that predict women’s adherence to Ramadan fasting during pregnancy (Chapter 2). Although the health effects of Ramadan fasting during pregnancy are still unclear, it is important to identify various factors behind women’s adherence to Ramadan fasting. The results of our cross sectional study among Indonesian women showed that demographic factors such as age, income, education, or employment do not influence fasting adherence, but higher pre-pregnancy body mass index (BMI), earlier gestational age, opposition from husband and fear of adverse fasting effects on their own or the baby’s health do. These factors need to be addressed properly during counseling. In Chapter 3, we present the association between Ramadan exposure and fasting during pregnancy with newborn’s birth weight and the risk of gestational hypertension. In our Indonesian cohort of pregnant women, we found that birth weight was generally higher with Ramadan exposure as compared to without exposure. Analyses among women with Ramadan exposure revealed that although women who fasted had significantly lower nutrient intake in Ramadan, no different in the newborn’s birth weight nor in the risk of gestational hypertension was found. These findings suggest that a transient life style modification that occurs with Ramadan does not seem to affect pregnancy outcomes investigated. In Chapter 4, we show that among women of Moroccan and Turkish background living in The Netherlands, Ramadan fasting during the first trimester of pregnancy was associated with lower birth weight. No difference of birth weight was found if the fasting took place later in pregnancy. This suggests that the effect of Ramadan fasting on newborn’s birth weight may depend on the timing exposure. Furthermore, differences in finding as compared to the study in Indonesian women indicate that the effects may (partially) be influenced by culture or dietary habits as well as the length of fasting duration. Chapter 5 addresses the association between in-utero Ramadan exposure with various birth outcomes. We analyzed 1,987,124 newborns from 11 birth cohorts of the Perinatal Registry of the Netherlands (Perined), 139,322 of these were classified as Muslims. No clinically relevant effect of Ramadan exposure was found, including on birth weight, Apgar score, congenital anomalies, sex ratio, gestational duration and perinatal mortality. In Part 2, we focus on the effects of maternal nutrition status early in pregnancy on pregnancy outcomes. We present the associations between hyperemesis gravidarum, as a model of nutritional disturbance, on the development of placental dysfunction disorders in Chapter 6. Using the data from our prospective cohort study in Jakarta, Indonesia, we found that women who experienced severe hyperemesis had significantly lower birth weight newborns. Hyperemesis did not affect the development of placental dysfunction disorders (gestational hypertension, preeclampsia, stillbirth, and miscarriage), other newborn health measures (SGA, low birth weight, Apgar score, and gestation length), nor the placental dimension (placental weight and placental-weight-to-birth-weight ratio). In Chapter 7, we elaborate the effect of women’s prepregnancy body mass index (BMI) on their blood pressure during pregnancy. Using the data from our prospective cohort study in Jakarta, Indonesia, we showed that pre-pregnancy BMI determined women’s systolic and diastolic blood pressure level during pregnancy. Higher prepregnancy BMI was also associated with higher risk of gestational hypertension and preeclampsia. These associations imply that pre-pregnancy (cardiovascular) risk factors strongly influence women’s blood pressure. This finding also suggests the importance of prevention of pregnancy complications which should be done prior to pregnancy. Part 3 (Chapter 8), we described a study protocol of a randomized trial on breastfeeding optimization (BRAVO) that is on going in Jakarta, Indonesia. This study is aimed to provide evidence about the short and long term health effects of breastfeeding, mainly on the children’s cardiovascular and metabolic risks. Pregnant women with low intention to breastfeed are randomly allocated into either usual care or receiving an add-on breastfeeding optimization program which includes antenatal, perinatal, postnatal intervention, and special support for working mothers. Primary outcomes include breastfeeding rate, lung function, and blood pressure during the first year of life and vascular/cardiac characteristics which will be measured when the children are between 4 to 5 years old. So far, BRAVO has been successfully conducted with satisfactory completeness of follow up. Finally in Chapter 9 (general discussion), we discuss our findings in light of implementable intervention measures, both in the context of maternal and child health and in the prevention of later health consequences. Findings from the etiologic studies described in this thesis about maternal nutrition, including Ramadan (fasting) exposure in pregnancy, hyperemesis gravidarum, pre-pregnancy BMI, and breastfeeding, although may not directly translatable to practice, could provide indications for prevention and directions future research in this area.