Nutrition of Indonesian women during pregnancy and lactation: a focus on vitamin A and iron

Nutrition during pregnancy is important for women's health, outcome of pregnancy and child survival. A community-based study was conducted in a rural area of West Java, Indonesia to investigate 1) the effect of weekly vitamin A and iron supplementation during pregnancy on iron and vitamin A status of women near term and on postpartum and pregnancy outcomes, 2) whether weekly iron supplementation was as effective as the ongoing national iron supplementation program in improving iron status. Women from 5 villages, 16 - 20 weeks pregnant, aged 17 - 35 years, parity <6, and with hemoglobin concentrations 80 - 140 g/L, were randomly allocated on an individual basis to receive a weekly supplement either with 120 mg iron as Fe ₂ SO ₄ and 500μg folic acid (n = 121) or the same amount of iron and folic acid plus 4,800 RE vitamin A (n = 122). A third group participating in the ongoing national iron supplementation program in which women are advised to take iron tablets daily during pregnancy ("daily" group) was recruited at the same time from 4 neighboring villages (n = 123). At near term, the iron status of pregnant women in the group supplemented weekly with iron (n = 66) was not different from the "daily" group (n = 53). However, iron status decreased with daily iron supplementation if <50 iron tablets were ingested. Hemoglobin concentrations in the group supplemented weekly with iron and vitamin A (n = 71) increased but serum ferritin concentrations decreased significantly, suggesting that vitamin A improved utilization of iron for hematopoiesis. Concentrations of serum transferrin receptor increased significantly in all groups. Serum retinol concentrations remained constant in the weekly iron and vitamin A group but decreased significantly in the other two groups. At4 months postpartum, compared with the weekly iron group (n = 88), the weekly iron and vitamin A group (n = 82) had significantly fewer subjects with serum retinol concentrations≤0.70μmol/L. The iron status of women in the weekly iron and vitamin A group did not differ from that of women in the weekly iron group. The concentrations of iron and retinol in transitional milk (4 - 7 days postpartum) was almost double than that in mature milk (3 months postpartum). Compared with the weekly iron group, the weekly iron and vitamin A group had significantly higher concentrations of retinol in transitional milk (asμmol/L) and in mature milk (asμmol/g fat). Neonatal weight (3094 ± 440 g) and length (49.1 ± 2.0 cm) did not differ among the three groups (n = 296). Iron and vitamin A status during pregnancy did not influence neonatal weight and length. Gestational age, maternal weight at the beginning of the second trimester and infant gender were the main predictors of neonatal weight and length. The proportion of women with a body mass index≤21.0 kg/m² was 37% at the beginning of the second trimester of pregnancy and 52% at4 months postpartum. Low nutritional status of the women was associated with household characteristics reflecting a lower socioeconomic status. In conclusion, compared with weekly supplementation with iron alone, supplementation with vitamin A and iron given at the time when women entered their second trimester of pregnancy prevented the deterioration of vitamin A status near term and4 month postpartum, and increased retinol concentration in breast milk. The performance of weekly iron supplementation did not differ from the ongoing daily iron supplementation program in improving the iron status during pregnancy and lactation. Intervention did not influence weight and length of the neonates. It is recommended to include vitamin A in the iron supplementation program.