COMPLIANCE TO PRENATAL SUPPLEMENT USE IN RELATION TO LOW
BIRTH WEIGHT IN MALAWI
By
Aaron Thokozani Chikakuda

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Human Nutrition – Master of Science

2017

ABSTRACT
COMPLIANCE TO PRENATAL SUPPLEMENT USE IN RELATION TO LOW
BIRTH WEIGHT IN MALAWI
By
Aaron Thokozani Chikakuda
Background: Prenatal iron and folic acid (IFA) supplements are offered free to pregnant
women in Malawi to reduce maternal anemia and improve birth outcomes. We
investigated the association between self-reported compliance to IFA intake and risk of
low birth weight (LBW).
Methods: Pregnant women who attended Bwaila Maternity Wing of Lilongwe District
Hospital for delivery were recruited (n=220). We used questionnaire to collect selfreported information on IFA use and maternal sociodemographic data. Before delivery
blood samples for maternal hemoglobin (Hb) and folate status, and upon delivery, birth
weight, and other newborn anthropometrics were measured. We used multivariate logistic
regression to determine risk of LBW by prenatal IFA intake.
Results: The self-reported number of IFA pills taken during pregnancy was positively
associated with Hb, but not serum and RBC folate concentration: <45, 45-89 and > 90
pills taken corresponded with mean (SD) Hb 10.7 (1.6), 11.3 (1.8), and 11.7 (1.6) g/dl
respectively (P= 0.006). The prevalence of LBW was 20.1%, 13.5% and 5.6% for those
who reported taken IFA pills < 45 , 45 – 89, and ≥ 90 pills, respectively (P = 0.027).
Taking > 60 IFA pills reduced risk of LBW delivery (OR (95% CI)= 0.11 (0.02-0.056),
P = 0.008) than taking ≤ 30 pills.
Conclusion: Self-reported compliance to IFA is valid for assessing prenatal supplement
program in Malawi, especially Hb status, can improve adherence and reduce LBW.

ACKNOWLEDGEMENTS

Achieving anything in life would not mean much if I did not acknowledge the
Lord God almighty, due to whose grace this project was successfully completed.
My heartfelt gratitude goes to my major advisor Dr. Won Song for her unfailing
support, guidance and enthusiasm throughout this program. I thank her for her selfless
help and for inspiring me to persevere in the face of all odds.
Many thanks are due to my guidance committee members Dr. S. Comstock and
Dr. J.B. Kaneene who provided expert technical advice, support and encouragement
during my studies and research.
I offer my special thanks to Dr. S. J. Song for her invaluable technical guidance
on data handling and processing. I am also thankful to Nicole Jess for her input on basic
statistics. I am grateful to Hannah Koch for assisting me with data entry.
I am very grateful to the MasterCard Foundation Scholars Program at Michigan
State University (MSU), and the Department of Food Science and Human Nutrition for
supporting not only my studies, also for supporting this research financially.
Many thanks to the four research midwives who administered questionnaires,
collected blood samples from pregnant women and took anthropometric measurements of
women and newborns during this research, namely; Phaggies Kakowa, Davie Phiri,
Grace Chirombo and Muderanji Kambudzuma. They did this selflessly both at night and
during the day in the hot humid summer in Malawi. I am grateful to the Management of
Lilongwe District Hospital and staff of the maternity wing for allowing us to use their
facility and services as well as supporting the research activities.

iii

To all members of Dr. Song’s lab – The Food and Nutrition Database Research
Centre, FNDRC, Dr. Ki Won Lee, Dr. Dayeon Shin, Elizabeth Ndaba, Amanda Knox,
Beatrice George, Clement Kubuga, Mei Lim, Sarah E. Pawloski, Kaitlyn Moorhead-Hill
and the community nutrition lab for their amazing technical and moral support, genuine
friendship and inspiration.
This acknowledgement would not be complete without mentioning the 220
pregnant women of Bwaila Maternity Wing, Lilongwe District Hospital in Malawi, who
were the study subjects and voluntarily allowed us to collect their blood samples and take
measurements on their newborns for this research to happen. I feel greatly indebted to
them.

iv

TABLE OF CONTENTS

LIST OF TABLES .......................................................................................................... vii
LIST OF FIGURES ....................................................................................................... viii
CHAPTER ONE: INTRODUCTION ............................................................................. 1
Scope of the problem .................................................................................................... 4
Significance of the study ............................................................................................... 8
Research gap.................................................................................................................. 9
Research objectives and hypotheses .......................................................................... 11
Objectives ................................................................................................................. 11
Hypotheses ................................................................................................................ 11
CHAPTER TWO: LITERATURE REVIEW .............................................................. 12
Geography, economy and education in Malawi ....................................................... 12
Nutrition and food security in Malawi and other countries ................................... 13
Nutrition and health status in Malawi and developing countries .......................... 15
Maternal and child health in Malawi ........................................................................ 17
Prevalence of LBW and consequences in later life .................................................. 20
Micronutrient deficiency of iron and iodine in Malawi .......................................... 21
Iron ............................................................................................................................ 21
Iodine ........................................................................................................................ 23
Policies and programs addressing nutrition problems in Malawi ......................... 25
Programs and policies targeting women and children in Malawi .......................... 25
Compliance to prenatal supplements ........................................................................ 30
Role of placenta ........................................................................................................... 32
Nutrient transport and kinetics in the placenta ....................................................... 33
Placental iron transport ............................................................................................. 34
Placental iodide transport .......................................................................................... 37
CHAPTER THREE: METHODS ................................................................................. 38
Research site and design............................................................................................. 38
Ethical clearance / IRB approval............................................................................... 40
Training of research team .......................................................................................... 41
Study subjects .............................................................................................................. 43
Data collection ............................................................................................................. 44
Demographics, antenatal care, and maternal anthropometrics ................................. 44
Blood specimen collection ........................................................................................ 46
Hemoglobin and folate analyses ............................................................................... 47
Neonatal anthropometry, APGAR scores, and placenta weight ............................... 49
v

Placenta weight ......................................................................................................... 51
Statistical analyses ...................................................................................................... 52
CHAPTER FOUR: RESULTS ...................................................................................... 53
Sociodemographics ..................................................................................................... 53
Prenatal care, iron and folic acid (IFA) supplement use and anemia status ......... 55
Compliance to IFA supplements and timing of prenatal care ............................... 58
Newborn characteristics ............................................................................................. 61
Hemoglobin, serum and RBC folate status by IFA taken ....................................... 63
Hemoglobin, folate status and newborn anthropometry by IFA pills taken ......... 70
Risk of LBW by IFA pills taken during pregnancy ................................................. 78
CHAPTER FIVE: DISCUSSION.................................................................................. 84
Biomarker status by self-reported intake of IFA supplement ................................ 88
Maternal hemoglobin and folate status and low birth weight ................................ 90
Prenatal IFA supplements are associated with low risk of low birth weight ........ 91
Summary and Conclusion .......................................................................................... 95
Recommendations and future studies ....................................................................... 98
APPENDICES ................................................................................................................. 99
Appendix A: Literature Review Articles ................................................................ 100
Appendix B: Architect i System for Folate Analysis ............................................. 106
Appendix C: Descriptive Statistics .......................................................................... 109
Appendix D: Consent Form (English) .................................................................... 111
Appendix E: Consent Form (Chichewa Version) .................................................. 115
Appendix F. Survey Instrument .............................................................................. 118
Appendix G: Survey Tool (Chichewa Version) ...................................................... 121
REFERENCES.............................................................................................................. 125

vi

LIST OF TABLES

Table 1. Maternal and child health indicators in selected developing countries.............. 18
Table 2. Sociodemographic information of pregnant women who participated in the
study. ......................................................................................................................... 54
Table 3. Maternal characteristics related to prenatal care, iron and folic acid supplement
use, anemia status and medical history. .................................................................... 56
Table 4. Timing and reasons of the first prenatal care visits............................................ 59
Table 5. Reasons for taking certain number of IFA supplement pills during pregnancy. 60
Table 6. Newborn anthropometry and health characteristics at birth. ............................. 62
Table 7. Spearman’s correlation matrix of maternal and newborn characteristics and
biomarkers................................................................................................................. 68
Table 8. Sociodemographic and prenatal care characteristics by number of IFA
supplements taken during pregnancy. ....................................................................... 72
Table 9. Mother’s and newborn’s variables by number of IFA supplements taken during
pregnancy. ................................................................................................................. 74
Table 10. Differences in characteristics between mothers of normal weight and LBW
newborns. .................................................................................................................. 75
Table 11. Differences in characteristics of mothers who delivered normal vs. LBW
babies. ....................................................................................................................... 77
Table 12. Multivariate odds ratios and 95% confidence intervals of LBW by its risk
factors ........................................................................................................................ 79
Table 13. Associations of mother’s IFA pills taken and biomarkers with newborn
anthropometry ........................................................................................................... 83
Table 14. Summarized literature review of selected articles. ........................................ 100
Table 15. Summary descriptive statistics. ...................................................................... 109

vii

LIST OF FIGURES
Figure 1. Diagram depicting research hypotheses ........................................................... 10
Figure 2. Prevalence of malaria parasitaemia by age/sex groups (Source: Malawi
micronutrient report 2009). ....................................................................................... 17
Figure 3. Prevalence of malnutrition in under-five children in Malawi (MDHS: 1992,
2000, 2004 and 2010). .............................................................................................. 20
Figure 4. Prevalence of anemia in Malawi (Malawi government micronutrient survey
2009) ......................................................................................................................... 22
Figure 5. Mean maternal hemoglobin levels by number of IFA pills taken during
pregnancy. ................................................................................................................. 64
Figure 6. Mean maternal serum folate levels by number of IFA supplement pills taken
during pregnancy. ..................................................................................................... 65
Figure 7. Mean maternal RBC folate levels by number of IFA supplement pills taken
during pregnancy. ..................................................................................................... 66
Figure 8. Scatter plots of hemoglobin, serum folate and RBC folate levels by IFA pills
taken. ......................................................................................................................... 67
Figure 9. Mean birth weight by IFA pills taken during pregnancy.................................. 81

viii

CHAPTER ONE: INTRODUCTION
Low birth weight (LBW) is a birth outcome of importance to public health that is
associated with increased morbidity and mortality in neonates and infants and
cardiovascular disease risks later in life (Arnold et al., 2015; Smith et al., 2016). LBW is
internationally recognized as a birth weight below 2500 g (5.5 pounds). This practical
cutoff for international comparison is based on epidemiological observations that LBW
babies are 20 times more likely to die than heavier infants (Wardlaw, 2004).
Over 20 million infants worldwide are born with LBW. More than half of LBW
babies are born in developing countries, particularly South-Central Asia, where more
than quarter (27%) of babies born weigh less than 2500 g. LBW prevalence in SubSaharan Africa (15%), is one of the highest burden regions similar to the level in
Caribbean region (14%). The Central America and Oceania region has a LBW rate of
10% (Wardlaw, 2004). LBW is still a leading cause of neonatal and infant mortality in
the U.S. and other industrialized countries, although this prevalence is still much lower
than in developing countries (Lau et al., 2013).
More than half of LBW babies are born in the developing countries and Malawi is
as affected as other developing countries, with a LBW prevalence of above the world
average. The national prevalence of LBW in Malawi is 12%, with the highest prevalence
seen among mothers younger than 20 y of age (16%) and those older than 35 y of age.
The Central region has a higher prevalence of LBW than Northern and Southern regions
within Malawi (NSO-ICF, 2017).
Micronutrient deficiencies during pregnancy, particularly iron and folate,
contribute significantly to the prevalence of LBW (Abubaker, 2016). In a recently
1

reported study, correction of micronutrient deficiency in pregnancy with prenatal
supplementation improved birth outcomes (Wang et al., 2016).
Deficiencies of micronutrients are a major global health problem. More than 2
billion people in the world today are estimated to be deficient in key vitamins and
minerals, particularly vitamin A, iodine, iron and zinc. Pregnant and lactating women are
particularly prone to micronutrient deficiencies as their requirements for the nutrients are
higher than those of non-pregnant women. Multiple micronutrient supplementation
(vitamin A, iron and folic acid) and food fortification are some of the recommended
approaches to fighting micronutrient deficiencies (WHO, 2016).
Many programs have been in place to fight LBW and other nutrition related
problems in Malawi and other parts of the world. The World Health Organization
(WHO) has put a world target of a 30% reduction in LBW by 2025. This means a 3%
reduction every year from 2012 and 14 million LBW infants, down from 20 million
(WHO, 2016). Malawi joined the global movement to reduce maternal and child
malnutrition (major contributor of LBW) and embarked on the Scaling Up Nutrition
(SUN) 1000 special days program. This new intervention called the “SUN 1000 special
days” targets the first 1000 days of a child’s life from conception to 24 months of age
(i.e, 270 days of conception and 730 days after birth). SUN is a global programmatic
approach in the fight against maternal and child undernutrition. This movement was
started when the Lancet published an article that showed major economic returns when
countries invest in nutrition (Black et al., 2008a; Black et al., 2008b; Bryce et al., 2008;
Morris et al., 2008; Victora et al., 2008). Malawi was among the first countries to adopt
and launch its SUN 1000 special days program in 2011. The program includes prenatal

2

micronutrient supplementation, good complementary feeding practices of children and
food security initiatives targeting mainly the early days of a child’s life.
There has been a micronutrient supplementation program in Malawi since the
early 1990s. However, in 2011 the program was subsumed under the SUN-1000 special
days program because SUN encompasses all interventions fighting maternal and child
malnutrition. The SUN aims at improving birth outcomes by improving maternal
nutritional status and health, especially in early pregnancy. The activities range from
direct interventions that promote maternal nutrition, to much broader interventions such
as production to achieve food security, infection prevention to maintain general health of
the pregnant and reproductive age woman. The four major areas of focus of SUN-1000
are increasing the intake of vitamins and minerals (i.e. vitamin A, zinc, iron, folic acid
and iodine oil capsules), promoting good nutrition practices (e.g., hygiene during food
preparation, breast feeding and proper complementary feeding after six months),
provision of micronutrients through food fortification (e.g., iron fortification of staples,
vitamin A supplementation in sugar and cooking oil and the iodization of salt) and
therapeutic feeding of malnourished children with special food.
The Malawian government uses prenatal supplements as a short-term solution in
fighting micronutrient malnutrition (particularly iron deficiency anemia) in women of
reproductive age and pregnant women to improve health status of mothers and newborns.
All pregnant women, regardless of hematological status or the trimester of pregnancy
receive prenatal supplements of pills of combined iron and folic acid daily from the first
day of antenatal care clinic visit, throughout pregnancy to delivery. The tablet has 60 mg
iron (ferrous) and 0.25 mg folic acid and taken once a day. Every month the woman gets

3

a new supply without checking whether she actually took the prescription given the
previous month. The program is run on the assumption that women understand the need
to take the supplements despite the documented evidence of poor compliance due to
forgetting to take the pills and side effects (Kalimbira et al., 2009; Young et al., 2000).
Monitoring prenatal supplementation intake has been continued because it is the most
feasible way to fight micronutrient malnutrition and improve health outcomes at least in
the short term, compared to diet, considering the social economic status of Malawians
currently.
Scope of the problem
LBW increases the child mortality rate for children under the age of five, stunting
levels, and chance of non-communicable disease (coronary heart disease) later in life
(Smith et al., 2016). LBW contributes significantly to neonatal and infant morbidity and
mortality in Malawi. Despite the Malawian government’s efforts to improve birth
outcomes and health status for Malawians, the prevalence of most health risk indicators
remains high. Anemia prevalence has gone up in the past 6 y in reproductive age and
pregnant women from 28% to 33% and 38% to 45%, from 2010 to 2016 respectively.
Prevalence of LBW remains high at 12% in Malawi, with a higher than the national
prevalence rate in mothers <20 y of age and >35 y and in the central part of the country.
The infant mortality rate is at 42/1000 births, down from 135 per 1000 live births in 1992,
neonatal mortality has dropped to 27/1000 births, down from 41 per 1000 live births in
1992 and maternal mortality ratio has improved to 439/1000 births, down from 1,123 per
100,000 live births in 2000 (NSO-ICF, 2017). The current maternal mortality rate of
439/100,000 live births indicates the need to improve maternal and child health. Maternal

4

and infant mortality indicates the level of quality of health care available to citizens in a
country (Bhutta et al., 2008). For example a high maternal mortality rate might be from
high anemia that negatively affects birth outcomes and health of newborns (Haider et al.,
2013; Steer, 2000). This might indicate that there are inadequate screening and treatment
services available for pregnant women. Anemia is still prevalent in reproductive age
women and pregnant women in Malawi at the rate of 28% and 38%, respectively.
Nutrition status of children is poor as indicated by 37% of children under the age of five
being stunted (NSO-ICF, 2017).
Maternal nutrition status is a major determinant of LBW, but social and
demographic factors have also been reported as major factors (Muula et al., 2011; Ngwira
and Stanley, 2015). Muula et al (2008) in their study found that maternal education was
associated with birth weight. Those with low attainment of education are likely to have a
LBW children than those with higher education (Muula et al., 2011). It was also found
that parity was a factor of low birth weight, i.e., the first delivery was likely to be LBW
with later born children being heavier. The Malawi Demographic and Health Survey
demonstrates that the birth orders, as well as the maternal age are factors in low birth
weight. The first born child is likely to have low weight than the second, and younger
mothers and those giving birth after 35 y are more likely to deliver a LBW child (NSOICF, 2017). In another study, it was found that the mother’s height was associated with
size of child at birth. The wealth index of the family had a positive association with birth
weight, as well as attainment of secondary education and location of residence, for
example cities vs rural areas (Ngwira and Stanley, 2015). Micronutrient supplements
improve maternal nutrition status and birth outcomes (Makrides et al., 2003; Owens et

5

al., 2015; Preziosi et al., 1997; Rwebembera et al., 2006). The Generation R study in
Rotterdam, the Netherlands, found that folic acid supplements increased weight at birth
by 68g and placental weight by 13g in the supplemented group higher than those not
supplemented (Timmermans et al., 2009). In another study in northern China, multiple
micronutrient (MMN) supplements which included IFA increased birth weight, especially
in those who had a low hemoglobin status at baseline (Wang et al., 2016). Anemia is one
of the biggest contributors of low birth. In a case control study in Sudan (a developing
country in Africa), hemoglobin status during antenatal was found to have modulating
effects on birth outcomes, particularly LBW (Abubaker, 2016). If a woman had low
hemoglobin status at baseline during pregnancy, she was likely to have a LBW child. If
the low hemoglobin detected at baseline was corrected, the outcome was also positively
affected).
According to the World Health Organization (WHO), iron deficiency contributes
to 50% of the anemia prevalence in the world. This can be easily reversed if prenatal
supplements are taken consistently, hence the recommendation by WHO that all pregnant
women and women of reproductive age in some countries, take IFA supplements to
reduce anemia and improve birth outcomes. Therefore compliance to prenatal
micronutrient supplements is critical to achieve the desired maternal and child health
outcomes. Studies conducted in Malawi using self-reports from reproductive age women
have shown poor compliance to Ministry of Health universal prenatal supplement
recommendations due to lack of monitoring programs (Kalimbira et al., 2009; Young et
al., 2000). Compliance is as poor as less than 40% of women taking supplements for 2
months only instead on 6 months minimum, and only 2% taking the minimum

6

recommended amount of 180 tablets (6 months intake). Most pregnant women have
complained about side effects such as nausea and vomiting, forgetfulness and the in
availability of iron and folic acid tablets at the antenatal clinic as some of reasons for
their non-compliance in taking supplements for the required amount and period.
The efficacy of the SUN-1000 special days program on maternal micronutrients
status (IFA) and immediate birth outcomes, particularly the prevalence of LBW has not
yet been documented. The prenatal supplements program progress is measured by selfreported compliance of intake of pills using questions that are not validated by
biomarkers (hemoglobin and folate). Poor compliance (less than 10%) of iron
supplementation prescribed during prenatal and postnatal periods has been documented in
Ethiopia, Malaysia (Gebremedhin et al., 2014; Thirukkanesh and Zahara, 2010), and in a
small clinical study in northern Malawi. Poor compliance was explained mainly as due to
the frequent side effects and forgetting to take the pills (Young et al., 2000).
From the studies conducted in China, Zaire (DRC, central Africa), Papua New
Guinea and other developing countries, Zimmermann (2011) summarized that iodine had
an effect not only on cognitive development, but also on somatic growth. Maternal iodine
supplementation and status were associated with children’s weight, length and head
circumference apart from IQ levels (Zimmermann, 2011). These studies and many others
show that newborn health depends on good supply of micronutrients through the
placenta. A good supply of micronutrients depends on placenta functionality, which itself
depends on normal fetus development (angiogenesis and biogenesis). Efficiency of the
placenta is modified by presence or absence of micronutrients during fetal development
from the beginning of pregnancy (Owens et al., 2015). Therefore, placental weight and

7

newborn health may be used to determine maternal exposure to micronutrients early in
pregnancy and to predict birth outcomes.
In Malawi, assessment of nutritional status of pregnant women has not been
possible due to the lack of food composition comprehensive food intake data with
corresponding biomarkers. Compliance to national nutrition supplements programs
targeting pregnant women has only been documented from self-reported interviews and a
small study which combined pill counting (Kalimbira et al., 2009; Young et al., 2000) but
not which did not use appropriate biomarkers. The placenta is a mediator for maternal
nutrition and health status and the fetal growth environment and can provide the evidence
of linking maternal nutritional status and newborn health. Biomarkers can also be used to
validate the self-reported intake of prenatal supplements. To our knowledge, no study in
has been conducted in Malawi validating the effect of self-reported intake of IFA, using
biomarkers and placental weight, on immediate birth outcomes to establish the efficacy
of prenatal supplementation program in Malawi. The main aim of this study is to
investigate whether compliance to prenatal supplements can be used as a determinant of
LBW in Malawi.
Significance of the study
Importantly, micronutrient deficiencies in childhood have been associated with a
country’s low GDP (gross domestic product) thereby affecting the economic
development of a nation in Myanmar (Win, 2016). The significance of this study is that
validation of self-reported intake of IFA with biomarkers (Hb and serum and red blood
cell folate) evaluated the effectiveness of the program in general in improving the health
of women and birth outcomes, and monitoring approaches used by Malawi government

8

for the biggest anemia program in the country. This research provides feedback to
government programs and non-profit organizations working in nutrition area in Malawi
on the efficacy of prenatal supplements to reduce LBW in Malawi. Overall, the research
results provide evidence that self-reported intake of IFA by pregnant women can be used
as a monitoring tool for compliance to prenatal supplements. The study also introduces
the innovation of using the placenta, which is normally discarded in Malawi, to determine
compliance to and efficacy of prenatal supplements taken during pregnancy and impact
on newborn health.
Research gap
The research gap is illustrated in the Figure 1 below. There have been some
clinical studies showing the efficacy of supplements in increasing biomarker status.
However these were conducted in controlled environments, while in real life people take
medications freely at home. There have been no studies in Malawi showing how selfreported use of prenatal supplements (while the pregnant woman is free at home)
increases hemoglobin and folate status as well as birth outcomes. This in turn will
validate self-reported intake of prenatal supplements as a reliable compliance monitoring
method, which can be used to predict birth outcomes.

9

Iron & folic acid
Self-reported
Use/intake

?
1

Compliance to
IFA use biomarkers

?
2

?
3
Figure 1. Diagram depicting research hypotheses.

10

Birth Outcomes
BIRTH WEIGHT
Birth length
Head circumference
APGAR scores

Research objectives and hypotheses
Objectives
1. To validate self-reported compliance to prenatal supplement use by maternal
biomarkers (Hb and serum and RBC folate )
2. To determine the association between maternal hemoglobin and folic acid status
with the risk of LBW in Malawi
3. To determine if birth outcome (low birth weight) is predicted by self reported
prenatal supplement use (IFA).
Hypotheses
1. Self-reported number of IFA intake is positively associated with biomarkers: Hb,
serum and RBC folate status.
2. Hb status is inversely associated with the risk of giving LBW birth.
3. Self-reported number of IFA intake during pregnancy is inversely associated with
LBW risks.

11

CHAPTER TWO: LITERATURE REVIEW
Geography, economy and education in Malawi
Malawi is in Southeast Africa, bordered by Tanzania to the north and northeast,
Zambia to the west and Mozambique to the southwest, south and southeast. Malawi has
a total size of 125 km2; of which 90 km2 is land and water bodies occupy the rest. The
Lake Malawi spans the entire length of the country from north to south covering three
quarters of the country with fertile arable land. The population grew to almost 16 million
in 2016 from 4 million in 1966, as one of the fastest growing and population-dense
countries in Southeast Africa. Over 85% of the population lives in the rural areas where
access to clean water, electricity, hospitals, and good road network remains a challenge
(NSO-ICF, 2017).
The economy of Malawi is agro-based with tobacco being the major cash crop for
foreign exchange. The agriculture is rain fed and production varies every year depending
on amount of rain received. Due to climate change now crop production has not been able
to support the growth of the economy, rendering it unstable in the poor harvest y . Fifty
three percent of the population lives below the poverty line with less than a dollar a day.
According to the Malawi Demographic and Health Survey 2010, 15% of the
population received no formal education. Only 9% had finished primary school, 13% had
secondary school education, and the rest of the population dropped out. Compared to
boys, higher number of girls enrolls at the primary school but drop out at a higher rate.
The situation leads to poor retention of nutrition education and opportunities for

12

knowledge of women on feeding practices of children, nutritional security for women,
children and families, and malnutrition (NSO-ICF, 2017).
Nutrition and food security in Malawi and other countries
In Malawi, achievement of food and nutrition security with diversification of diets
is an uphill task. Maize (corn), the staple grain comprises 50% or more of most
Malawians diet and most households taking it more than once per day (Broadley et al.,
2012). Consequently the major source of calories (70%) for Malawians comes from
maize. It also makes a large portion of the planted and cultivated crops almost 60%. Most
people in Malawi survive on their own production, they are subsistence farmers and only
buy when they don’t have enough food from own produce (Chirwa and Dorward, 2013).
For the past 30 y Malawi experienced food insecurity with about one third of the
general population being severely affected. The country has been intermittently food
insecure partly due to over reliance on the staple food (persistent use one food type) and
failure to diversify the diets. In the 2000s alone Malawi experienced 3 episodes of severe
food insecurity and spikes in the prices of staple food, 2001–02, 2004–05, and 2007–09
by 354%, 218%, and 395%, respectively (Ellis and Manda, 2012). Agricultural
diversification problems have been partly fueled by the government’s Farm Input
Subsidy Program (FISP). Although aimed at achieving food security, this program ended
up focusing on the staple crops and thus the communities had a single food commodity
(mainly maize) with limited diversified diets that lack micronutrients. Food supply is
unstable, because when maize fails due to poor rain and climate change, there is no
alternative means of food production, which results in hunger throughout the country.
This is because Malawi’s agriculture is rain fed, and Malawi only has one rain season,
13

failure of one season equals hunger for the whole year. Currently one in four people are
food insecure in developing countries including Malawi.
From above it can be seen that in Malawi and most developing countries
availability and access to food are the major challenges. This is different with what is
seen in developed countries like the U.S. where food is available throughout the year
round but distribution and political will are the challenges. Unlike developing countries
like Malawi where one third of the population are food insecure, only 14.3% were food
insecure in 2012 in the U.S. with 85.7% having enough to eat (Coleman-Jensen et al.,
2014). This is according to a U.S. food security scale, which is administered every year.
The scale measures if at any time a member of a household had their food reduced or
disrupted because there was not enough money for food in the household. Just like in the
developing countries more vulnerable people are children or households with children. In
U.S. the prevalence of severe food insecurity has been reducing but statistically
insignificant over the y , and those affected only comprise 5.6% (Coleman-Jensen et al.,
2014). There are two main types of access to food namely; physical and economic access
to food. In the U.S., most people have physical access to food except a few, the majority
of those that are food insecure it is due to lack of economic access to food.
In developing countries, both physical and economic access is a challenge. The
distribution systems are poor between where food is produced in abundance and where
food might be greatly needed. For example, roads to transport food might be impassable
and/or difficult physical access due to armed conflict in a region that limits movement
severely. Even when people have access to a place where food is available, they may not
have the economic power to legitimately acquire it. Historically developing countries are

14

at risk of food insecurity because of mono-cropping systems of agriculture left by
colonialism where countries were forced to grow one crop for export. For example
tobacco in Malawi cocoa in Ghana, and tea, coffee, peanuts, cane in others countries
(Nagothu, 2014).
Nutrition and health status in Malawi and developing countries
Health in Malawi is greatly affected by nutrition status of individuals. The
differences with developed countries have been the types of diseases suffered by people
in these countries because of the type of diet available and environment they live in.
While developed countries are fighting non-communicable diseases, which mainly result
from excessive intake of nutrients, the developing countries are still fighting
undernutrition. Under nutrition is major cause of health burden in South Asia and SubSaharan Africa (Müller and Krawinkel, 2005). Undernutrition leads to a cycle of health
challenges, which later lead to poor intake of nutrients and results in malnutrition again.
Apart from undernutrition, developing countries are also facing increasing levels of
obesity, non-communicable diseases like cancer, hypertension and diabetes which is
being referred to as the double burden of malnutrition (Boutayeb, 2006). The rise in noncommunicable diseases is mainly in cities due to increase in population, where demand
for fast foods is also high (Dalal et al., 2011).
Obesity and overweight prevalence in Malawi has risen from 9% in 1992 to 21%
in 2016 while the prevalence of thinness has remained relatively the same with just
decrease from 10% to 7% in 2016, confirming the double burden of malnutrition (NSOICF, 2017). Overweight/obesity is higher among women in urban areas (36%) than rural
areas (17%) where as thinness (BMI < 18.5) is higher among teenagers (15-19 y ).
15

Overweight/obesity increases with increasing education and wealth, 12% in women in
lowest wealth quintile and 36% in women in the highest wealth quintile. Women’s
nutrition status is a major concern for every country because they are major contributors
to the next generation health as they do not only conceive but also nourish the fetus
during the critical stages of life (Victora et al., 2008). The thin women (BMI<18) are
likely to have low education, less wealth and young (15-20 y )(Victora et al., 2008; West
and Christian, 2008). This partly explains the prevalence of chronic malnutrition among
children born from these women which is very high (NSO-ICF, 2017)
Infections (viral, bacterial and parasites) complicate health and nutrition status of
individuals in developing countries. Human immune deficiency virus (HIV) worsens
nutrition status of children and women because HIV increases energy and nutrient
demand which is not easy to meet in people who are food insecure. It severely reduces
immunity rendering individuals prone to other infections like gastroenteritis that
predispose them to malnutrition (Bradley and Mishra, 2008). In 2016, the prevalence of
HIV in Malawi was 8.8%, with higher rates in those who are working, have higher
education (at least secondary), higher income and in women who had an education of
secondary or higher (10.8%) levels (NSO-ICF, 2017). Malaria is also the leading cause of
morbidity and mortality in under-five children and pregnant women. It affects nutritional
status of children and especially in pregnant women thereby affecting the outcome of
pregnancy as well. Pregnant women and children suffering from malaria will be anemic
since malaria parasites feed on iron in human red blood cells. Although there has been a
decrease in prevalence of malaria parasitaemia in different age groups as shown in
Figure1below pregnant women are still at higher risk. Malaria prevalence is supposed to

16

be much lower in pregnant women because they are specifically targeted with malaria
control programs (Malawi Government, 2009). Pregnant women in prenatal clinics
receive antimalarial prophylaxis and insecticide treated mosquito nets to sleep under with
their under-five children if they have any, however, adoption has been slow (NSO-ICF,
2017). Previous studies have shown association between placental malaria and LBW
hence the need to continue promotion malaria control programs (Rogerson et al., 2003;
Steketee et al., 1996).

Figure 2. Prevalence of malaria parasitaemia by age/sex groups (Source: Malawi
micronutrient report 2009).

Maternal and child health in Malawi
The United Nations Millennium Development Goals (MDGs) that would impact
on prevalence of LBW are 4 and 5 (MDG 4 and 5) in 2015 focused on children and
women respectively. MDG 4 was aimed at reducing child mortality while MDG 5 aimed
at improving maternal health by the year 2015. The suggested indicators for MDG 4
were; reducing under-five mortality and infant mortality per 1,000 live births as well as
improving the proportion of children under one year who are vaccinated. The indicators
17

for MDG 5 were increasing access to family planning and skilled health care, antenatal
and perinatal care and reduced maternal mortality ratios. In MDHS 2017 the maternal
mortality ratio was 439/100,000 live births compared to 984/100,000 live births in 2004,
which is still a very high number of women dying in this age. In 2010, about one out of
seven (14%) of babies are delivered in the villages attended by unskilled traditional birth
attendants, 9% assisted by a relative, and 3% delivered with no assistance (NSO-ICF,
2017).
Table 1. Maternal and child health indicators in selected developing countries.
Country
MMR
IMR
Stunting (%)
Underweight
Wasting (%)
(%)
Malawi
439
42
37.1
11.4
2.7
Tanzania
530
43
34
13.5
4.4
Rwanda
253
32
37.9
9.3
2.2
Mali
368
56
38
25.5
12.7
Nepal
281
46
40.5
28.8
10.9
Afghanista
1,291
45
n
Indonesia
313
32
Cambodia
170
28
32.4
23.9
9.6
Infant mortality (IMR): the probability of dying before the first birthday (rate per 1,000
live births). MMR= maternal mortality ratio per 100,000 live births.

Malawi faces many other public health concerns that lead to poor health
indicators such as high neonatal, infant, under-five, and maternal mortality. According to
MDHS 2016, the prevalence of LBW (LBW < 2.5 kg) was 12% with the highest rates
(16%) in central region and among newborns born to young mothers (<20 y) and older
mothers (ages 35- 49 y). Infant and child mortality rates, basic indictors of a country’s
socioeconomic status and quality of life (UNDP 2007) are high. In 2017, the mortality
rates (per 1,000 live births) of neonates, infants and children under-five were 27, 42, and

18

63 from 41, 135, and 234 in 1992 respectively. Although there has been a decrease in
child mortality, the numbers has have not met the international policies like MDGs. The
Millennium Development Goal number 4 was to reduce child mortality by two thirds by
the year 2015, however, from Table 1 above it can be seen that Malawi did not meet the
goal (NSO-ICF, 2017).
In Malawi antenatal care is given to all women and is free in all public health care
institutions. Prenatal care is an important opportunity for women to learn about hygiene,
child feeding and nutrition for pregnant women. Antenatal care visit occur monthly in
first and second trimester and every two weeks in the final trimester or as determined by
health care professional. All pregnant women receive iron and folate supplements (60 mg
and 0.25 mg), anti-helminthes, vaccines for tetanus, and screening for HIV, syphilis, and
urinary tract infections. In 2010, 50% of pregnant women had antenatal visit once or
twice only while 2% did not have prenatal care at all. The reduced number of antenatal
care visits was mostly due to long distance to the health facility. Hence majority of
pregnant women did not receive iron and folate supplements, nutrition education and
screening for disease, which are some of the services given at the antenatal care clinic.
Nutrition status of children reflects socio-economic of a population and can
predict the economy of a country in the future. This is so because the stunted children
will make a large proportion of the work force in the next 2 decades and if not well
developed they will not be productive. High proportion of stunted children indicates that
the population is likely going to underperform in future in terms of productive capacity
for economic development (Bryce et al., 2008; Morris et al., 2008; Win, 2016). In 2016 a
large percentage of children under-five were undernourished as indicated by stunting

19

(37%), underweight (11.4%) and wasting (2.7%). Figure 3 shows that prevalence of
underweight and wasting in under-five children has been decreasing. On the other hand
stunting remained stagnant for 2 decades before making a significant drop in the last five
y , indicating the existence of challenges in reducing malnutrition in Malawi (NSO-ICF,
2017).

Figure 3. Prevalence of malnutrition in under-five children in Malawi (MDHS: 1992,
2000, 2004 and 2010).

Prevalence of LBW and consequences in later life
The national prevalence of LBW is 12% with the central region having the
highest (16%) than the other parts of the country. Birth weight is an important indicator
for assessing child health in terms of early exposure to childhood morbidity and
mortality. Children whose birth weight is less than 2500 g, or children reported to be
‘very small’ or ‘smaller than average’ are considered to have a higher-than-average risk
of early childhood death , (Arnold et al., 2015). The national prevalence of LBW directly
contributes to the 37% prevalence of stunting levels in Malawi. Young mothers aged 20
or less are more likely to give birth to a LBW baby followed by older mothers aged 35 y
and above. The least number of LBW babies is observed in mothers aged at least 20 y to
20

34 y old (NSO-ICF, 2017).
Children born to mothers below the age of 20 y will not have the necessary
support in their upbringing because most teen mothers are financially unstable. These
children will be underdeveloped, when they grow up, they may end up in early marriages,
which increase the risk of giving birth to LBW babies as well, continuing the vicious
cycle. Probably this occurs because teen pregnancies are associated with complications in
the family structure and support for the children is low as teenagers are not economically
stable to provide for their children (Victora et al., 2008).
The central region has high prevalence of LBW compared to the south or the
northern regions (NSO-ICF, 2017). For this reason, Lilongwe district in central Malawi
was chosen as a research site.
Micronutrient deficiency of iron and iodine in Malawi
Along with the general health and nutrition problems, Malawi faces nutrition
problems associated with micronutrient deficiencies. Most prevalent ones with great
concerns at the global level are iodine (2 billion at risk) iron (2 billion) zinc (estimated to
be very high in developing countries) and vitamin A (254 million preschool children).
According to the WHO World Health Report, almost one third of the world’s population
is affected by them, the majority living in developing countries (Ahmed et al., 2013).
Iron
Iron is the micronutrient that is of great concern almost worldwide, although
the severity differs from region to region and country to country. However, the
developing world is disproportionately affected. Malawi is not spared and the pregnant
21

mothers are affected by anemia. WHO reports that half of the anemia cases worldwide
are caused by iron deficiency anemia, and occur in resource-poor areas. Malaria,
HIV/AIDS, hookworm infestation, schistosomiasis, and other infections such as
tuberculosis are particularly important factors contributing to the high prevalence of
anemia in some areas (WHO, 2016). In Malawi the national prevalence of anemia is
13.6%. This anemia prevalence reported in the Malawi government National
Micronutrient survey report 2009, could have been reduced by half if iron deficiency had
been eradicated and improve birth outcomes (Allen, 2000; Malawi Government, 2009).
However,

Figure 4. Prevalence of anemia in Malawi (Malawi government micronutrient survey
2009)

According to the National Micronutrient Survey report 2009 the prevalence of
iron deficiency anemia in Malawian women of the reproductive age group was 26.1%
from 32.4% in 2001, and in under-five children it was 49.1% from 61.5% in 2001 (Figure
4). Although anemia is decreasing there is still a significant number of school aged
children, men, reproductive age, and pregnant women affected by iron deficiency anemia

22

(using transferrin as a biomarker). Iron is important for normal development of children
not only when they are young after birth but beginning right in utero.
Therefore it is important to note that the micronutrient survey report 2009 shows
iron deficiency in Malawi is common in women of reproductive age group (Figure 4)
even before they conceive babies (Malawi Government, 2009). This is a cause of worry
in that Malawian women go into pregnancy with reduced iron stores yet it is well known
that pregnancy increases the nutritional demands of micronutrients (Berti et al., 2011;
Black, 2001; Cao and O'Brien, 2013; Cetin et al., 2010; Pasricha et al., 2013).
Perhaps it is not surprising that anemia is common in pregnancy as well (see
Figure 4) because these women cannot make up for the increased demand of nutrients in
pregnancy when they could not meet their own need before pregnancy. Hence chances
are high that they may transfer the iron deficiency to the unborn child risking poor
physical and cognitive development of baby right from the uterus unless the placenta
saves them by pooling nutrients towards the fetus at the expense of the malnourished
mother (Black, 2001; Lager and Powell, 2012). This could also partly explain the
occurrence chronic malnutrition in children (stunting).
Iodine
The recommendation of WHO is that only 50% of the population of school-agedchildren and non-pregnant women should have urinary iodine levels of less than 50 ug/L
in a country. According to Malawi government micronutrient survey report 2009, only
12.6% of school-aged children and 12% of non-pregnant women had urinary iodine
status below 50 ug/L. Of the households surveyed over 90% had iodized salt in the house

23

and over 80% of salt samples from these households had the recommended iodine of 15
ppm (NSO-ICF, 2017).
However, half (50%) the population store their iodized salt in an open container
and 45% of the at risk group, women of reproductive age, did not know that iodine
deficiency results in goiter. Knowledge deficit on importance of iodine and its proper
storage has implications on iodine intake the population in the long term (Glinoer et al.,
1995). This is evidenced by the fact that only 17% of school-aged children had heard
about iodized salt (NSO-ICF, 2017). This is critical in that the school-aged population,
which is good at retaining information and passing it to others, is deficient of knowledge.
Another important issue to note is that some household (17%) had salt with higher
iodine than the recommended levels, indicating problems with quality control in the
industry where the salt is iodized. Salt in Malawi is imported already iodized or is bought
in bulk, repackaged into smaller bags and iodized in the country. Salt is required to be
repackaged in smaller bags so that when traders open it, it should not overstay in the
shops before it reaches the consumer who will likely keep it in an open jar for sometime
(NSO-ICF, 2017).
However, problems with illegal entry of salt have been reported and this is usually
not iodized, because if passes through normal borders the port health officers will test it
and if not iodized the consignment will be sent back or detained for destruction, hence a
lot of it uses the informal routes and find its way to the markets. The it is surprising that
only a small proportion of the population (12.6%) has iodine deficiency since most salt
readily available to rural communities is un-iodized as it is cheap (unpackaged) compared
to the industrially packaged one.

24

Policies and programs addressing nutrition problems in Malawi
Malawi is a member of the United Nations; therefore it subscribes to many
international treaties and agreements on human rights and international development
goals. The best examples are the Millennium Development Goals (MDGs) stated above
and the Scaling Up Nutrition, (SUN) 1000 days. Malawi like any other country in the
world is concerned with the nutrition status of her people and has put mechanisms in
place to combat inadequacies to save the next generation from effects of nutrient
deficiencies. The Malawi government oversees all the nutrition activities in the country
through the ministry of health’s department of nutrition and HIV. The department ensures
that all government departments have nutrition activities; NGOs involved in nutrition are
doing and aligning their programs to the nutrition policy, which will be launched soon in
2016.
Programs and policies targeting women and children in Malawi
The major approach of Malawi government for fighting malnutrition is an
adaptation of the global movement of scaling up nutrition being implemented by many
developing countries. The initiative was started after the Lancet published maternal and
child undernutrition series in 2007 describing the importance of investing in nutrition
(Black et al., 2013). Malawi was among the first countries to launch the initiative in 2011.
The program is called “Scaling Up Nutrition (SUN) 1000 special days.” It uses direct
nutrition and health specific interventions as well as multi-sector approaches to fight
malnutrition with a special focus on the most critical period of development in children
(from 0 to 24 months). Thus SUN aims to increase activities that make women to be

25

nutritionally sufficient during pre-pregnancy period, during pregnancy and up to 2 y after
birth of the child and beyond.
One of the programs that have been implemented in the SUN movement is
supplementation of IFA to pregnant women in antenatal clinics. Knowing that iron
inadequacy is a global problem and that during pregnancy iron is very crucial, it is being
supplemented in all pregnant women universally in Malawi. Since it is recommended
worldwide that supplementation of iron and folate more efficient folic acid is also given
although its effect is much better before and very early in pregnancy. This is according to
WHO which recommends that in countries that have anemia prevalence of 40% or more
universal iron and folic acid supplementation be done with antimalarial prophylaxis in
malaria endemic areas (WHO, 2012). Pregnant women receive the iron and folic acid
supplements regardless of hematologic status from the day of their first antenatal visit
throughout pregnancy. The IFA is given in tablet form, which comprises of 60 mg iron
and 0.25 mg combined. The women are expected to take the tables daily for a period of at
least 91 days as recommended by WHO. Every monthly visit the pregnant woman gets a
supply that lasts approximately just over one month. Therefore the number of antenatal
visits achieved by a pregnant woman may potentially determine how many pills of iron
and folic acid are consumed. However, there is no program in place to check whether or
not the woman actually takes all the iron and folic acid supplements. The program runs
on trust that the women understands the importance of taking the supplements and will
not miss the doses and will finish the whole monthly supply.
During the first visit the pregnant woman gets a diagnostic wake up where
different primary diseases are screened. The woman will give samples of blood, urine and

26

stool for screening HIV, malaria, worms, and for checking hemoglobin levels among
others. After screening the women are given anti-helminthes treatment as well as antimalaria prophylaxis in the first and last trimester of pregnancy. The prophylaxis
treatment of malaria is given as a single dose taken at once in the first trimester, repeated
in the third trimester.
During the same first antenatal period the pregnant women get free mosquito nets
treated with insecticide to protect themselves and under-five children from mosquitoes
that transmit malaria and antimalarial as recommended by WHO (WHO, 2012). Malaria
in pregnancy is a priority area just like other nutrition programs because malaria causes
anemia, morbidity and also mortality. The other important health measure taken in early
pregnancy is the vaccination that pregnant women receive against tetanus. This is to
boost the antibodies, which they will pass to the fetus so that the child will be protected
from tetanus infection.
The other activities in the SUN program include agronomic bio-fortification of
crops for example the bio-fortification of sweet potatoes (orange-fleshed sweet potatoes)
with vitamin A, and promotion of its consumption so that the general population
especially women have sufficient stores of vitamin A. The government distributes the
seed (potato vines) to farmers to plant for their own consumption.
Every six months there is a massive campaign in Malawi to mobilize health
workers in ministry of health and all concerned sectors like ministry of education and
ministry of agriculture to distribute vitamin A supplements and deworming pills as well
as health talks. The officers will go to schools and clinics to give supplements to all

27

children aged 6 months to 12 years. Each child will get one drop of vitamin A in an oil
capsule ranging from 100,000 IU to 200,000 IU every six months.
At the same time school going children (above 6 y old) and infants also receive deworming tablets to clear parasites and reduce the risk of anemia. The Malawi government
through the ministry of education has introduced a school-feeding program which is
rolling out all over country, ensuring school going children are not hungry while at
school.
Once every year the ministry of health with other concerned ministries, conduct
breastfeeding week. This is conducted with massive campaign for breastfeeding and
promoting exclusive breastfeeding for six months as well as proper complementary
feeding after six month. The ministry of health officers go to schools, villages and streets
to spread messages about hygienic feeding practices and the benefits of breastfeeding.
There are also posters and billboards on town streets and jingoes/adverts on radio and
television promoting breastfeeding especially the first six months (exclusive breast
feeding).
When the worst comes to the worst severely malnourished children are treated in
nutrition rehabilitation centers located in hospitals. Malawi is implementing another
program called active community management of acute malnutrition (CMAM) where
children at risk of malnutrition or with mild malnutrition are identified actively by
community workers as early as possible and treated or referred to treatment centers
before they worsen.
Children with diarrhea receive zinc supplements. The children receive 20mg of
zinc supplements as tablets to take for at least 10 days. This is also a program, which has

28

been adopted to reduce the risks of micronutrient deficiencies in children. Another reason
zinc is given to children during diarrhea illness is that zinc supplementation has been
known to reduce both the occurrence and frequency of diarrhea. Zinc boost immunity by
increasing cell growth. It also stabilizes the metabolic rate, balances the blood sugar and
improves sense of smell, which may help control diarrhea and help improve appetite with
appropriate diet. Zinc supplementation is now in the national guidelines in the
management of diarrhea in children in Malawi.
Another strategy being used to increase micronutrients intake in both women and
children and the general population at large is food fortification. Industrial fortification of
vitamins A and B- complex in cooking oil, sugar and maize flour is being implemented
by the manufacturing industry and enforced by Malawi government. Unfortunately the
fortified commodities are consumed by those living in cities and towns where
supermarkets are, which are not accessible by rural people who comprise 85% of the
population. This is the major weakness to the approach as it targets wrong people. Due to
rural and urban disparity people in urban areas have lower risk of micronutrient
malnutrition and are few, majority (85% of Malawians) reside in rural areas with no
access to fortified industrial products and increased risk of deficiencies.
Universal iodization of salt has been adopted by Malawi, although it benefits the
whole population, it targets women and children more. In 1995 salt iodization Act was
established by parliament and salt iodization regulations were formed in 1998. This act
makes mandatory for the industry to iodize salt. This enables agencies to prosecute any
one selling salt without iodine. This is critical because Malawi does not manufacture salt
it is all imported either already iodized or it is iodized within Malawi. Food has very low

29

iodine content in Malawi, therefore iodized salt is the major and reliable source (Watts et
al., 2015). However, some traders are still not adhering to the regulations, this is
evidenced by the presence of salt without iodine in households during the MDHS survey
despite the enforcement of the regulations (NSO-ICF, 2017).
The regulation states that only iodized salt should be imported into the country or
some licensed traders will be allowed to bring salt without iodine in bulk, which will be
iodized in the country. The certified industry is allowed to repackage iodized salt into
smaller bags no more than 40 kg to put on the retail markets for consumers. Two steps
that are prone to violations are firstly some unlicensed traders may import and smuggle
salt without iodine and successfully put it on the market. Secondly, the licensed traders
may decide not to iodize after importing salt and just repackage and sell to consumers.
The government has two mechanisms to combat these malpractices, first it has employed
port health officers who work at ports and ensure that imported salt entering the country
is iodized. The second mechanism the government uses the Malawi Bureau of Standards
officials who go out in retail shops with test kits and sample salt from shelves and discard
salt not meeting the standards. Now with the iodization act, the bureau will be able to
prosecute those selling un-iodized salt.
Compliance to prenatal supplements
According to Young et al. 2000, in Malawi compliance of pregnant mother to iron
and folic acid supplementation is poor in the currently adopted method of daily dose from
first antenatal visit to delivery day. A randomized controlled trial in northern Malawi
recruited 413 pregnant women. Of them, 211 got iron and folic acid (60 mg iron and 0.25
mg folic acid) every day and 202 women got the supplements once a week at increased
30

dose (120 mg iron and 0.50 mg folic acid). The results showed that compliance was poor
in the daily dose group than the weekly supplemented group (Young et al., 2000).
The reasons reported most for non-compliance to iron supplementation were side
effects and forgetting to take the pills, s among others. It appears the daily
supplementation becomes a burden for pregnant women to take constantly and
consistently. In another study, which utilized the national data collected using a pre-tested
questionnaire revealed that a large proportion of women know anemia (96.6%) but
nausea from the metallic taste of iron was a drawback to compliance. Most women tried
to take iron tablets with food until they finally stopped after a month only (Kalimbira et
al., 2009). Non-compliance has been reported in Ghana West Africa as well, compared to
Malawi, however knowledge about supplements was low in Ghana (Hill et al., 2007).
Misconceptions about iron supplements were high as taking medicine while healthy was
a new concept to them. Others had thoughts that supplements were for family planning,
or for the childless. When the purpose of the supplementation was explained, the
participants accepted the intervention of prenatal supplementation (Hill et al., 2007).
It has also been reported that access to iron supplements by pregnant women is
low, although prenatal supplementation is considered universal in most developing
countries. In Ethiopia only 35% of pregnant women were reached and received iron
tablets. Of those who received supplements, only 3.5% complied to taking the iron
supplements and the rest did not (Gebremedhin et al., 2014). This means that only 12% of
the target population receives the benefit of prenatal iron supplementation. These studies
show that although micronutrients supplementation shows the potential increasing serum
levels the targeted population is not being met and those reached are not utilizing the

31

supplements. Therefore it may be necessary to re-focus the intervention and plan on how
best the goal can be achieved, as the program is reaching very small numbers of pregnant
women risking anemia and poor development of children.
Role of placenta
Normal placental development relies on an adequate supply of such
micronutrients as iron, iodine and selenium in placental biogenesis and angiogenesis
(Khera et al., 2015; Meher et al., 2015). Efficient placental vascular function relies on
multiple micronutrients supply too (Owens et al., 2015). Placental size and functions are
important for transferring nutrients for fetal growth and better birth outcomes. Therefore
with the evidence that micronutrient deficiencies exist in Malawi and that compliance to
supplementation programs is poor, the risk of malnutrition increases, there is need for
more evidence on the efficacy of micronutrient supplementation in Malawi in order to
develop working programs.
Secondly, micronutrients are important for placental health, fetal growth and newborn
health. Owens and others (2015) in their study in Gambia, west Africa demonstrated that
multiple micronutrient supplementation have the potential to modify placental vascular
function (Owens et al., 2015). Low selenium concentration in the placenta was associated
with hypertensive diseases in pregnancy (pre-eclampsia) which leads to growth
restriction in the newborn due to poor development and vascularization of placenta
(Mistry et al., 2008). As early as 1930s selenium concentration in placental tissue was
described as a proxy to concentration in cord blood or fetal selenium status. In animal
studies (rats and sheep from 1938, 1965 to 1990s) 14% of selenium in the diet of well

32

nourished dam was found in the off-spring against a concentration gradient (Hadjimarkos
et al., 1959; Westfall et al., 1938).
Nutrient transport and kinetics in the placenta
Fetal development comprises of entire intrauterine process of differentiation,
growth and maturation between conception and birth. The conditions under which the
fetus develops are recognized to have major impacts on the future health of the newborn
child (Holme et al., 2015). The developmental environment of the fetus is dependent on
maternal nutrition and metabolic state, and on the placental function, as most nutrients
have to be transported from the maternal circulation across the placenta to the fetus.
Thus the major function of the placenta is transport, and serves as the only link of
the fetus to the outside world unlike other mammals that give birth to an immature young
and have to continue development independent of the placental connection. The placenta
has another function; it secretes hormones and growth factors that change the maternal
metabolism markedly. Hence the placenta controls to large extent the environment in
which the fetus develops and grows (Holme et al., 2015). The main energy source of the
fetus and the placenta is glucose. Glucose is transported via the facilitated carriermediated diffusion using glucose transporters of the GLUT family (Holme et al., 2015;
Lager and Powell, 2012).
Apart from energy the fetus also needs amino acids, fatty acids and micronutrients
for growth and development, which have to cross through the syncytiotrophoblast.
The syncytiotrophoblast is the primary barrier limiting nutrient transport across the
human placenta. As discussed above syncytiotrophoblast has two polarized plasma
membranes, a maternal facing microvillus plasma membrane (MVM) and a basal plasma
33

membrane oriented towards the fetal circulation. These plasma membranes express
numerous nutrient transporters which may be regulated by fetal, maternal and placental
signals (Lager and Powell, 2012).
Amino acids are transported across cellular membranes through either mediated
active transporter processes, which are accumulative thus only sending nutrients towards
one side against a concentration gradient usually co-transporting with sodium, or the
exchanger system that exchanges amino acids between intracellular and extracellular
compartments. There are over 20 amino acid transporters in the human placenta
responsible for facilitating trans membrane transport (Lager and Powell, 2012).
Fatty acids mainly triglycerides are carried by lipoproteins across the placenta, but
first they are hydrolyzed by placental lipases (Lager and Powell, 2012). Most vitamins
cross the placental membranes by simple diffusion especially the B vitamins.
Placental iron transport
Iron is moved from the placenta to fetal circulation against a concentration
gradient. Here are many disagreements concerning the transport of iron in the placenta
with some proposing that the mechanism is not different as that involved in absorption of
iron from the duodenum. However, the absorption of nonheme iron by enterocytes in the
duodenum is controlled by shading of cells after 3 days when there is excess iron thereby
avoiding toxicity (da Silva et al., 2014). The placenta lacks the capacity of shading cells
storing excess iron and the syncytiotrophoblast has to keep excess iron until its the fetus
to avoid toxicity or it will be discarded during parturition.

34

The process recognized involves reduction of Ferric (Fe3+) to ferrous (Fe2+) which is the
first step in the assimilation of nonheme iron and is mediated by the brush-border ferrireductase activity (Cao and O'Brien, 2013).
An enzyme called Duodenal Cytochrome B (DcytB) has been implicated in the
process. Although it does not appear to be an essential gene, DcytB is highly regulated in
response to iron status in both animals and human populations it modifies ferritin levels
through a promoter (da Silva et al., 2014). After reduction by ferri-reductase or other
enzymes, uptake of the ferrous form of iron is mediated by divalent metal transporter-1
(DMT-1). Another model of iron transport across the placenta and is the one that fits very
well with placenta physiology is the vesicular trafficking pathway. This mechanism uses
iron exporter ferroportin to transfer diferric inorganic iron intracellularly by
compartmentalizing it in a membranous vesicle and surrender this to iron free Apotransferrin(da Silva et al., 2014).
According to Cao et al, the serum diferric-transferrin binds to placental transferrin
which is abundantly expressed on the apical side of the syncytiotrophoblast, leading to
endocytosis of the transferrin-transferrin complexes (Cao and O'Brien, 2013). Iron
dissociation is achieved by acidification of the vesicle and iron is reduced by a new
family of ferri-reductase, Steap 1,2,3, and 4, later transported out into the cytoplasm
through a protein channel DMT-1 or a DMT-1 independent pathway which is said to exit
in the placenta. Once in the cytoplasm iron is incorporated into its storage form ferritin or
is delivered to transferrin in the fetal circulation (Cao and O'Brien, 2013).
Allen et al (2000) Serum transferrin carries iron from the maternal circulation to
transferrin receptors located on the apical surface of the placental syncytiotrophoblast,

35

holotransferrin is endocytozed, iron is released, and Apo-transferrin is returned to the
maternal circulation. The free iron then binds to ferritin in placental cells where it is
transferred to Apo-transferrin, which enters from the fetal side of the placenta and exits
as holotransferrin into the fetal circulation (Allen, 2000).
During deficiency the expression of these transport proteins may be up regulated
thus the placenta is able to adapt to maternal supply. As for heme iron the human
placenta exhibits expression of different proteins involved in uptake and utilization; For
example heme carrier protein [proton-coupled folate transporter (PCFT)], heme carrier
protein-1 (HPC-1) and Feline Leukemia virus C receptor 1 (FLVCR 1). FLVCR is an
iron exporter though (Cao and O'Brien, 2013).Net flux of roughly 270g of iron is
transferred across the placenta to be accumulated by the developing fetus especially
during the last 10 weeks of gestation. During late gestation approximately 5.6mg per day
of iron is trafficked through the placenta to meet fetal demands from diet or endogenous
maternal sources (Cao and O'Brien, 2013).
In summary iron transport involves three mechanisms, first DcytB enzyme
reduces Fe3+ to Fe2+, which is easily transported across the syncytiotrophoblast in a
process mediated by divalent metal transporter-1 (DMT-1). The second mechanism,
which is common to heme iron as well, involves serum transferrin bringing ferrous to
transferrin receptors into the microvillus spaces and ultimately a transferrin-transferrin
complex is made and iron is endocytozed into the syncytiotrophoblast later ferrous s
exocytozed to the fetal circulation. The third mechanism of iron transport uses heme
carrier proteins to export heme, for example proton-coupled folate transporter (PCFT),
heme carrier protein-1 (HPC-1) and Feline Leukemia virus C receptor 1 (FLVCR 1).

36

Placental iodide transport
Sodium iodide symporter (NIS) is central in the transport of iodide in the body. It
is an 85kDa membrane protein that couples the translocations of sodium (Na+) and iodine
(I-) (da Silva et al., 2014). Two Sodium ions are translocated from an area of high
concentration to an area of low concentration, while in the same direction iodide will be
translocated against a concentration gradient, from low to high. The above two sodium
ions will be translocated across the membrane along with one iodide anion into the cell.
NIS is a transmembrane glycoprotein which couples the inward transport of two Na+ ion,
along with the transport of one I- ion against its electrochemical gradient (Andersen,
2015). Apart from placental site NIS is also found in the basolateral, membrane of the
follicular cells of the thyroid, the lactotrophs, the lactating mammary gland, in salivary
glands, sweat glands, in the gut mucosae and choroid plexus of the cerebral lateral
ventricle (da Silva et al., 2014). In the same mechanism (NIS) used by gut cells to absorb
iodine from intestinal lumen is also used by placenta to transport iodine to the fetus.

37

CHAPTER THREE: METHODS
Research site and design
Data for this research was collected from a cross sectional study carried out from
December 2016 to January 2017. This is a lean period in terms of the availability of food
in Malawi. It is also a festive season when Christians celebrate Christmas and everyone
else celebrates the New Year. Despite having insufficient food during this season
Malawians will try to save a little money to buy some special food for December 25th and
1st January of each year. The study site is the Lilongwe District Hospital Maternity Wing
(locally known as Bwaila Maternity Wing), located in the capital city and central region
of Malawi. The Bwaila Maternity Wing is strategically positioned inside the city, and
provides services to pregnant women from different ethnic groups, educational
backgrounds and socio-economic levels. The Lilongwe District Hospital serves as a
referral hospital for smaller rural hospitals in the district. Thus, it serves rural, peri-urban
and urban populations. Furthermore, the hospital is located in central Malawi, a region
that has a higher prevalence of LBW births than the national level. All these reasons
combine to making this an appropriate research site.
The health system structure in Malawi is organized into five major levels. The
lowest level is a health post (Health Surveillance Assistance, HSA). This is an individual
with one year medical training who stays in the village. The major role of a HSA is to
identify sick children and pregnant women, give them first aid treatment and advise them
to go to the hospital. They have basic medications, such as painkillers, chlorine for the
treatment of water, anthelminthic agents, antimalarial drugs and vaccines. The HSA also

38

runs growth-monitoring clinics for children under five, once or twice a month. The
second level is a health center, which is a small simple rural building manned by a
medical assistant (2 y medical training) and one or two midwives. They conduct normal
pregnancy deliveries, treat simple illnesses like diarrhea and malaria and make referrals
of complicated pregnancies and diseases. The third level is the community hospital,
which has an operating theatre and can conduct minor surgeries especially caesarian
sections of non-complicated cases. There are more medical personnel and midwives, the
hospital is manned by an experienced physician assistant (a clinical officer, with 3 y of
medical training and one year of residency), or one general practitioner. These
individuals perform minor surgeries and prescribe for other diseases. They make referrals
of all complicated cases to the next level.
The fourth level is a district hospital, which provides the highest level of care.
There are 28 districts in Malawi and each has its own district hospital except one, which
is an island. Here more services are available, including major surgeries and consultations
for complicated diseases. The services provided however depend on the type and level of
experience of the staff. Several physician assistants, general practitioners, nurses and
midwives and one or two specialists provide services at the district level. The highest
level of care is provided by central hospitals, of which there only four institutions in the
whole country. At central hospitals, specialists such as Oncologists, Ophthalmologists,
Nephrologists, Surgeons, Internal Medicine Specialists, Pediatricians and Obstetricians
and Gynecologists who provide surgical and advanced obstetric care (e.g.,
hysterectomies, fistula and ruptured uterus repairs) are available. Subjects with diseases
requiring a specialty not available in the country are treated outside of Malawi and the

39

Malawian government pays all the medical bills. Health care is paid for by taxes in
Malawi and the Malawian government uses the tax money to provide citizens with
hospitals, pays for training medical personnel and buys all necessary equipment and
medical drugs. There are private hospitals (expensive and owned by individuals) and
mission hospitals (run by missionaries and subsidized by donors). According to this
health system structure, most district hospitals are located in townships and smaller
hospitals treat the rural people in villages. Catchment areas determine how many patients
seen at each hospital. Rural hospitals see tens of thousands of patients while district
hospitals treat hundreds of thousands of patients. However depending on where they live,
pregnant women may find it easier to go to the district hospital than the community
hospital, hence, making a district hospitals into locations that provide care to both rural
and urban populations. This is the situation for Lilongwe district hospital, although it is
located in the city, it is close to some peri-urban and rural populations who seek obstetric
and medical care here.
Ethical clearance / IRB approval
Ethical clearance or IRB approval was obtained from Michigan State University
and the National Health Sciences Research Committee (NHSRC) in Malawi. At the
hospital level, the Lilongwe District Health Officer (DHO), the overseer of all health
services in the district, was contacted for approval to use the facility and their patients
and a letter of support for this research was issued. The nurse/midwife in-charge of the
maternity unit was contacted to provide her support. She communicated information to
the members of staff in the unit about the study and urged them to give support every day
of the data collection. We obtained consent (Appendix D) from the pregnant woman or
40

the mother/husband of the pregnant woman. If she could not write, we obtained a
fingerprint of the thumb of her non-dominant hand was as proof of her consent to
voluntarily participate in the research. Data and blood sample collection from human
subjects only commenced after the pregnant woman gave voluntary consent to participate
in the study.
Training of research team
The study team was comprised of the following individuals: the Principle
Investigator (PI) and a Study Coordinator from Michigan State University. There were 4
midwives from the Lilongwe District Hospital’s Bwaila Maternity Wing and a laboratory
technologist from the Central Medical Diagnostics (CMED) Laboratory, the main branch
of Lancet laboratories in Malawi. Lancet laboratories have other branches in Ghana,
Tanzania and South Africa. Our samples for folate analysis were sent to the Lancet lab in
South Africa.
The PI and study coordinator were in charge of and responsible for all research
activities both at the hospital and in the laboratory, making sure all supplies and materials
were available and correct procedures were followed. The research midwives were
responsible for administering the questionnaires to the pregnant women, abstracting data
from medical records, collection of blood specimens from pregnant women before
delivery, and measuring newborn anthropometrics after birth and giving incentives ($5
worth of baby wrapping cloth) to women after all data and blood samples were collected.
The midwives worked in teams of 2 per shift (two for the day shift and two for the night
shift) to maximize research participant recruitment. The Laboratory Technologist was
responsible for providing specimen bottles and guidance for proper collection of
41

specimens and handling of samples before analysis. He was also responsible for
preparation and shipping of folate blood samples for analysis at Lancet laboratories in
South Africa.
The research team received a one-day long training on study protocol in general
and sample collection procedures specific for folate. Although the midwives collect blood
samples daily in their work, the handling procedure is slightly different for folate
samples.
The training emphasized respect and safety of human subjects as required by MSU IRB
and the National Health Sciences Research Committee (NHSRC) in Malawi. Midwives
were taught how to appropriately obtain consent respectfully during recruitment of
human subjects into the study. The study coordinator went through the consent forms
approved by the MSU IRB and the survey instrument covering each item on the
questionnaire (Appendix F). This was to make sure that the midwives understood the
meaning of each question as well as the purpose for asking the question. The training also
covered demonstrations of how to take anthropometric measurements of pregnant women
and newborns. The midwives were trained to do neonatal anthropometry in pairs;
emphasis was on birth length and head circumference because these are not routinely
done in the clinic. Weight is the routine measurement for neonates born in Malawi.
The Laboratory Technologist trained midwives on the use of proper specimen
bottles for serum and RBC folate. He also demonstrated on how to draw venous blood
and put specimens into containers from the syringe without excessive pressure to avoid
breaking red blood cells. The Laboratory Technologist trained midwives on how to
measure hemoglobin using a Hemocue Hb 201+ (this was a refresher, as midwives

42

already knew how to do this). Emphasis was made on safety of the midwives during the
handling blood and bodily fluids as well as safety of the human subjects. The training
session ended with hands on practice of the following experimental procedures: how to
measure hemoglobin using Hemocue Hb 201+, how to administer the questionnaire to
patients in the hospital and how to take anthropometric measurements on pregnant
women and newborn babies.
Study subjects
All pregnant women coming for delivery of their babies at the Bwaila Maternity
Wing of Lilongwe District Hospital were asked to participate in the study. Recruitment of
subjects followed convenience sampling and included women of all age groups with
viable singleton pregnancy or twin gestation delivering at 28 weeks or more. The women
were residing in Lilongwe district whether rural peri-urban or urban, which is the
catchment area for this hospital. We recruited women with pregnancies of various
gestation ages (28 weeks and upwards).
The study excluded dyads where the mother had severe anemia (requiring a blood
transfusion), the presence of placenta previa (or history of bleeding during pregnancy due
to early partial separation of placenta), delivery involved instrumentation, and those
where an infant had brain trauma. The study also excluded mothers of babies whose
delivery involved instrumentation, and had brain trauma, mothers with severe anemia
(receiving a blood transfusion) and placenta praevia (or history of bleeding during
pregnancy due to early partial separation of placenta). Additionally participants must not
have had a severe medical condition known to severely affect maternal nutrition status,
placenta health or newborn health. In summary, we excluded all obstetrical and medical
43

emergencies. Babies and mothers that were in intensive care unit (ICU), high dependence
unit (HDU) or required constant medical support and monitoring were excluded, so that
their medical care was not interrupted.
Data collection
Demographics, antenatal care, and maternal anthropometrics
Using a short questionnaire (Appendix F) basic characteristics of the pregnant
woman were collected: age of the mother, gestation age of the pregnancy, gravidity
(number of pregnancies), parity (number of deliveries), gestation age, mother’s weight,
education level of the mother, socio-economic status (occupation of the mother, annual
household income, and area of residence. Two types of maternal weight were recorded.
The first maternal weight taken on her first prenatal visit (at 3 months gestation for most
women, earlier for a few women). The maternal weight at the first prenatal clinic visit
was abstracted from the health passport book (taken as proxy to pre-pregnancy weight,
since most women don’t know their pre-pregnancy weight). The second maternal weight
was taken on the day of the survey just before delivery of the baby using Seca weighing
scale (Seca, Chino, CA). Most of the maternal characteristics are routinely documented
on the labor-monitoring chart, therefore only the parameters that are not available from
the chart were asked from each the pregnant woman to avoid duplication.
The questionnaire also contained questions on antenatal care that the pregnant
woman was able to get during pregnancy. This included information on iron and folic
acid supplement use, which was obtained from self-reports and confirmed by checking
medical records (health passport book, a little hand book that contains all medical
information and previous treatments of the woman, she carries it everywhere with her).
44

We used the same questions as are used in the Malawi demographic and health survey.
The questions ask if the participant received or bought iron and folic acid supplements in
pregnancy; if she took any of the iron and folic acid pills; how many pills was she able to
take during pregnancy. Our questionnaire also included questions on the number of
antenatal visits the woman attained, at what gestation of the pregnancy (trimester) she
started prenatal care, and reasons for starting prenatal care early or late (Kalimbira et al.,
2009). Information about vaccinations, malaria prophylaxis and anti-helminthes use
during pregnancy was abstracted from the medical record (health passport book). We also
obtained medical history about sickness during the current, pregnancy, such anemia
(blood transfusions) and if the pregnant woman was on any long-term treatment or
chronic diseases such as diabetes, hypertension and asthma/allergies. History of
contraceptive use prior to the current pregnancy was obtained. (Abioye et al., 2016;
Ahmed et al., 2015)
The midwives performed the anthropometric measurements on pregnant women
who participated in the study. Immediately after administering the questionnaire, the
subject was asked to step on weighing scale while the midwife recorded her weight. We
used a Seca weighing scale validated by UNICEF. This make and model scale is used
during the Malawi demographic and health survey data collection. The weight was
recorded to the nearest 0.1 g Then the woman’s height was measured using a stadiometer.
The woman stood on the foot board with her back straight as possible against the
measuring surface of stadiometer, making sure the heels, buttocks and shoulders touched
the measuring surface. When the midwife was convinced that the woman was in an
appropriate position (according to the training provided), s/he would lower down the

45

headboard to touch the pregnant woman’s head. The woman had to remove anything that
she was wearing on her head and make braided hair as flat as possible by loosening her
hair and pressing the headboard. The pregnant woman had to remove shoes and heavy
clothes (subjects were dressed in light clothes) during the anthropometric measurement
process. Height was recorded to the nearest 0.1 cm.
Blood specimen collection
We collected blood samples from women before they gave birth to their newborn.
Upon obtaining consent and explaining the procedure the pregnant woman was made
comfortable in a sitting position or lying on the bed, whichever was preferred by the
subject. A tourniquet was applied around the upper left arm and a 70% alcohol swab was
used to clean skin the on the site (cubital). After cleaning, a 10 ml syringe with 21 gauge
needle was used to withdraw a venous whole blood sample from the cubital region.
Each blood specimen was put in two different sample tubes 5 mls each, one for
serum and the other for red blood cell (RBC) folate analysis. The third specimen type was
taken using a Microcuvette from the same 10 mls to measure iron status (hemoglobin)
right away on the bedside using a Hemocue Hb 201+ (described in detail below). The
blood sample for folate was allowed to flow freely into the specimen bottle by vacuum
pressure, after piercing the rubber cover with the needle of the syringe.
Sample for RBC folate analysis was put in a 5 ml tube containing anticoagulant
(ethylenediaminetetraacetic acid, EDTA). The EDTA kept sample fluid and not clotted so
that there was adequate plasma for analysis of hematocrit (needed for calculation of RBC
folate later). After putting blood inside the tube it was gently shaken to mix the blood
with anticoagulant. The serum folate sample was put in the tube without anticoagulant to
46

allow cells to separate from serum after clotting. This tube had a gel to separate the red
cells and from serum after clotting cells. Samples were kept at room temperature for 2 – 6
hours until they were transferred to laboratory outside the Bwaila maternity wing
(research site hospital) at the African Bible College Clinic – Center for Medical
diagnostics (CMED). At CMED the RBC folate blood sample were centrifuged and
frozen, kept at – 80℃. All samples for folate were further transferred to Lancet
laboratories in South Africa (Lancet Johannesburg RSA) for analysis.
Hemoglobin and folate analyses
Hemoglobin measurements were done on the bedside using a Hemocue Hb 201+
(HemoCue America, Brea, CA). For women who gave a whole blood sample for folic
acid, the same sample was used to prepare a specimen for hemoglobin measurement.
After blood sample collection, as described above, we used a microcuvette (HemoCue
America, Brea, CA) to get a drop (5 microliters) of whole blood. The microcuvette takes
up blood by capillary pressure when it is put close to a drop of blood. To ensure no air
bubbles went into the microcuvette, there must be sufficient blood, and when
microcuvette touched the drop of blood, we ensured there was no break in the flow of
blood going into microcuvette until it was adequately filled. If an obvious bubble was
present in the microcuvette or not enough blood got into it, the specimen was discarded
and the sample recollected to ensure credible hemoglobin measurements. A properly
prepared microcuvette specimen was loaded into the Hemocue Hb 201+. After a minute
the reading was noted and recorded to the nearest 0.1 g/dl. After the reading was
recorded, the loader was opened and the used Microcuvette removed and disposed of
accordingly.
47

Folic acid analysis was done in South Africa by Lancet laboratories (Lancet,
Johannesburg, South Africa) using ARCHITECT assay kits on the ARCHITECT i
system. The ARCHITECT Folate assay is a two-step assay for the quantitative
determination of folate in human serum, plasma, and red blood cells (RBC) using
Chemiluminescent Microparticle Immunoassay (CMIA) technology with flexible assay
protocols, referred to as Chemiflex. Two pre-treatment steps mediate the release of folate
from the endogenous folate binding protein. In pre-treatment step 1, sample and pretreatment reagent 2 (Dithiothreitol or DTT) are aspirated and dispensed into a reaction
vessel (RV). In pre-treatment step 2, an aliquot of sample/pre-treatment reagent 2 mixture
is aspirated and dispensed into a second RV. Pre-treatment reagent 1 (potassium
hydroxide or KOH) is then added. An aliquot of the pre-treated sample is transferred into
a third RV, followed by the addition of folate binding protein (FBP) coated paramagnetic
microparticles and assay specific diluent. Folate present in the sample binds to the FBP
coated microparticles. After washing, a pteroic acid-acridinium labeled conjugate is
added which binds to unoccupied sites on the FBP-coated microparticles. Pre-Trigger and
Trigger Solutions are then added to the reaction mixture; the resulting Chemiluminescent
reaction is measured as relative light units (RLUs). An inverse relationship exists
between the amount of folate in the sample and the RLUs detected by the ARCHITECT i
optical system. In the Folate RBC assay, an initial manual pre-treatment step converts
RBC-bound folate to measurable folate, after which these samples are processed as
described above. The results are reported in Nano moles per liter and categorized
according to the World Health Organization’s protocol and cutoffs. See results section
below.

48

Neonatal anthropometry, APGAR scores, and placenta weight
Any obstetrician or midwife on duty delivered the newborn of each research
participant. The study midwives were only collecting data and would assist whenever
there was an emergency that needed their service urgently. Delivery of the baby
happened a few minutes after completing the questionnaire for most mothers, some even
before completing the questionnaire but after giving a blood sample, yet others it took
several hours after questionnaire administration to 2 days in extreme cases. The delayed
delivery cases were mainly due to false labor. After delivery of the baby the midwife or
obstetrician weighs and records the weight and APGAR scores of the neonate. The
research midwife abstracted the weight and APGAR scores from the labor chart.
(Haeussner et al., 2013). Using a Seca weighing scale the baby was weighed naked and
weight was recorded to the nearest 0.1 g immediately after birth. APGAR scores and
weight were taken from the labor charts because they are routine measurements done on
every newborn in the hospital, unlike birth length and head circumference, which are not
routinely done. We ensured minimal interruptions in the care and bonding of the newborn
and mother. This was due to Malawi ministry of health guidelines and international
standards, which require that babies be given to their moms within 30 minutes after birth.
APGAR is an acronym named after Dr. Virginia Apgar who started assessing
neonatal prognosis at birth. Within the first 1 minute of life of the newborn at birth
APGAR scores are taken and repeated after 5 minutes (Bondevik et al., 2001; Zhou et al.,
1998). The baby is scored out of 10 with an aggregate score below 7 as worrisome and
above 7 considered to be better score, as it is associated with greater survival. Newborns
rarely score 10 out of 10 in the first minute because newborns almost always appear a

49

little blue at birth because circulation and respiration is not fully established or may not
cry although they might be breathing normally. APGAR stands for the following:
A= Appearance (0-2); whether the baby was pink, pale, or blue at birth.
P=Pulse (0-2); the peripheral pulses whether regular and of good volume,
however, in the first minute central pulses including the heart beat are assessed. A
pulse between 100 and 180 was considered normal and tachycardia or bradycardia
would be indicated by derangements.
G=Grimace (0-2); the muscular response on the face and other parts of the body
are assessed as well as reflexes.
A= Activity (0-2); whether newborn is active, moving limbs spontaneously at
birth or floppy and flabby.
R=Respirations (0-2); was there a spontaneous cry or not, even if there is no cry,
effort is made to observe if newborn is breathing without difficulties, not grunting
or showing labored respiration and the lower part of the chest is not severely
sunken in.
Each parameter’s score ranges from 0 to 2. However the research midwives made sure
that all necessary steps were undertaken to score the newborn and that the scores were a
true reflection of the overall health of the newborn at birth.
The length of the newborn at birth was measured using an infantometer (Seca,
Chino, CA) by two midwives. The newborn was laid on their back against the measuring
surface of infantometer. One midwife restrained and positioned the head against the
headboard while the other straightened the limbs and took the reading. The birth length
was recorded to the nearest 0.1 cm.

50

The head circumference was taken using a tape (Seca, Chino, CA) measure in
centimeters. One midwife did this measurement with newborn on the mother’s lap or two
midwives when baby was put on examination couch or the neonatal resuscitative table.
The tape was placed around the infant’s head passing through the sinciput just above the
eyebrows (1 cm) and behind the head on the occipital region. When the tape was placed
around the head nicely (not too tight or too loose) the reading was taken to the nearest
0.1cm and verified by the assistant. The newborn head was quickly wrapped, to reduce
heat loss as babies are prone to cold injury and the newborn was given back to the mother
for continued care.
Placenta weight
The placenta was collected at the end of third stage of labor and the cord was cut
at least 10cm, long enough for easy clamping to stop the bleeding which kept the
surroundings clean and maintained fresh weight. The mother was reminded of the request
at the beginning of the study that, apart from measurement of the baby, the placenta
would be weighed as well. Using a digital laboratory weighing scale (Ohaus, NJ, USA),
we took the weight of the placenta. The weighing scale was put on a flat surface and a
kidney dish was put on it first. The weight of the kidney dish weight was tared and the
placenta was put in the dish for reading of its weight. When the digits stopped flashing,
the reading was recorded to the nearest 0.1 g. After taking the weight, the placenta was
discarded according to the routine procedures of the hospital and later incinerated. The
disposing of the placenta was done in the presence of the mother to avoid unnecessary
rumors and beliefs associated with collecting placentas. This arrangement was well
accepted by the participants.
51

Statistical analyses
All the data analyses were conducted using Microsoft Excel (2016) and SPSS
version 24 (SPSS Inc. Armonk, NY). We generated z-scores for weight for height
(WHZ), Height for age z-scores (HAZ), weight for age z-scores (WAZ), body mass index
z-scores (BMIZ) and head circumference z-scores (HCZ) using the WHO anthro (3.2.2.)
software. This software is recommended by the World Health Organization (WHO) for
assessing and monitoring of child anthropometry (WHO anthro 3.2.2 January 2011). The
software is used to calculate and determine anthropometric measurements on the spot and
is also used to individualize data and keep a record for group of children with separate
electronic record for each child.
We calculated summary statistics in SPSS using descriptive and frequencies. We
also determined associations and relationships between maternal health and compliance
to IFA factors, hemoglobin and folate status, placenta weight and birth weight, length,
head circumference and APGAR scores using correlations. Finally, we determined the
degree of influence of iron and folic acid supplements on hemoglobin and folate and birth
outcomes using general linear model (GLM) controlling for covariates. The major
dependent variables were WHZ, HAZ, WAZ, HCZ and placenta weight. Covariates were
education level, maternal age, number of antenatal clinic visits, gravidity (number of
pregnancies), residence, annual household income, and gestation age in weeks.

52

CHAPTER FOUR: RESULTS
Out of 220 pregnant women who gave consent to participate in the study, seven
women delivered twins and were excluded from the final analysis.
Sociodemographics
Sociodemographic and other health information of the pregnant women in the
present study are summarized in Table 2. The majority of the pregnant women were
between 20-35 y of age (70.9%), whereas 18.8% and 10.5% were younger than 20 y of
age and over 35 y of age, respectively. The majority of pregnant women had some
education: 51.6% with primary school education, 40.8% completing secondary school
(high school), and 1.4% had a college education. The participants were from rural
(32.9%), peri-urban (37.6%), and urban (29.6%) areas. The majority (75%) reported
living on less than a dollar a day with the lowest reporting an income of about $250 per
year. Only 11% of the mothers reported that they engaged in skilled labor (teacher,
tailor, mechanic, hotel attendant, etc.) whereas 53.6%, 0.9% and 17.4% were housewives,
students and small-scale business women, respectively. Although 10.8% reported being
subsistence farmers, most of these women were subsistence farmers producing foods
during rainy season, as farming is not considered an occupation for women in Malawi.

53

Table 2. Sociodemographic information of pregnant women who participated in the
study.
Variable

Category

n

Percent

Age (n=213)

< 20y
20y – 34y
≥ 35y

40
151
22

18.8
70.9
10.3

Education Level (n=213)

Never been to school
Junior primary
Senior primary
Secondary
College

12
28
82
87
4

5.6
13.1
38.5
40.8
1.9

Mother's residence (n=213)

Rural
Peri-urban
Urban

70
80
63

32.9
37.6
29.6

Annual HH income quartiles (n=154) USD $249
USD $499
USD $832
USD $13,869
Occupation (n=213)

None
26
12.2
House wife
114
53.5
11
5.2
Skilled labor*
Small scale business
37
17.4
Student
2
0.9
Subsistence farmer
23
10.8
*
Skilled labor = Teachers, tailors, mechanic, hotel attendant, hospital attendant, petrol
pump attendant, and community worker. Housewives are subsistence farmers during the
rainy season.

54

Prenatal care, iron and folic acid (IFA) supplement use and anemia status
Results of prenatal care, IFA use and anemia status are shown in Table 3. The
participants’ average number of pregnancies was three and the maximum was nine
(Appendix C). Primgravida women (first pregnancy) comprised 30% of all pregnancies
and grandmultigravida (more than 4) formed 14%. About 16% had less than 36 weeks of
gestation, indicating premature delivery. The number of prenatal care clinic visits ranged
from 0 to 6 times with an average of 3 visits during the pregnancy. The majority
participants in this study started antenatal care in their second trimester of pregnancy
(74.8%) and another 16.9% in their third trimester, with only 8.6% in their first trimester.
Participants who reported receiving IFA pills comprised 87.7% of the total and 86.9%
reported taking IFA pills during pregnancy. Intake of IFA pills started in the second
trimester as well for most pregnant women (78.7%).
The anemia status of the participants is shown in Table 3. About 40% were
anemic (below 11 g/dl) with 20% moderate anemia (7-9.9 g/dl) and 1% severe anemia
(below 7 g/dl). Recognizing that any degree of anemia in pregnancy increases the risk of
morbidity and mortality for both the pregnant woman and her expected newborn, the high
rate of anemia is clearly a public health issue. The majority of the participants had folate
deficiency with 66.3% having serum folate below 10 nmol/L and 53.5% having red blood
cell folate below 400 nmol/L.
Medical history (Table 3) indicates that 21 of the 213 participants (10%) were on
antiretrovirals (HIV treatment). However less than 5% had other common diseases such
as diabetes, hypertension, asthma and tuberculosis.

55

Table 3. Maternal characteristics related to prenatal care, iron and folic acid supplement
use, anemia status and medical history.

Prenatal
care

Variable

Category

n

Percent

Gestation age at delivery
(n=189)

< 32 wk
33 – 35 wk
≥ 36 wk

9
20
160

4.8
10.6
84.7

Maternal height categories
(n=185)

≤ 150 cm
> 150 cm

48
137

22.5
64.3

Total number of pregnancy
(n=213)

1
2–4
>4

70
113
30

32.9
53.1
14.1

1ST prenatal visit (n=200)

First trimester
Second trimester
Third trimester
0
1–2
3–4
>4

18
157
35
3
39
140
25

8.6
74.8
16.7
1.4
18.8
67.6
12

Yes
No
Yes
No
First Trimester
Second trimester
Third trimester

186
26
179
27
20
144
19

87.7
12.3
86.9
13.1
10.9
78.7
10.4

0 - 30
31 - 60
61 - 120
121 - 180

77
76
42
10

37.6
37.1
20.5
4.9

< 7 g/dl
7 - 9.9 g/dl
10 - 10.9 g/dl

2
44
39

0.9
20.7
18.3

≥11 g/dl

114

53.5

Total prenatal visits # (n=207)

Received IFA supplements
(n=212)
Took IFA supplements
(n=206)
Trimester IFA supplements
started (n=183)

# IFA supplements taken (205)

IFA
intake
and
anemia
status

Maternal Hb* (n=199)

56

Table 3. (cont’d)
IFA and
Serum folate** (n=101)
Anemia
RBC Folate** (n=101)
Medical and
drug history

< 10 nmol/L
≥10 nmol/L
< 400 nmol/L
≥ 400 nmol/L

67
34
54
47

66.3
33.7
53.5
46.5

Tuberculosis drugs (n=213)
Antiretroviral*** (n=212)
Steroids (n=210)
Anti-diabetics (n=213)

Yes
Yes
Yes
Yes

2
21
5
1

0.9
9.9
2.4
0.5

Anti-hypertensive (n=212)

Yes

1

0.5

Other medical drugs (n=212)
Yes
1
0.5
* Maternal hemoglobin was measured prior to delivery; **Folate cutoffs are according to
(WHO, 2015) guidelines for assessing folate status in
Populations; *** Antiretrovirals are given to all HIV positive women throughout
pregnancy.

57

Compliance to IFA supplements and timing of prenatal care
Tables 4 and 5 show reasons for timing of antenatal care clinic visits and reasons
for taking iron and folic acid supplements for a particular duration or amount for those
who received IFA pills. Participants who started prenatal care in the first trimester said it
was because the nurse had advised them (5) or they got sick in the first trimester (8) and
when sought treatment at the hospital they had to start prenatal care immediately. Most
pregnant women started prenatal care in the second and third trimesters and the majority
(55%) declined to give a reason for their delay. Another leading cause for delay was
waiting for pregnancy to grow followed by long distance to the hospital and lack
transport.
Compliance to IFA intake was a challenge (Table 11). In the category of those
who took supplements for only one month (0-30 pills) the leading reason was a shortage
of pills at the hospitals. For pregnant women who took IFA pills for at least 2 months (31
– 60 pills) negligence (65.7%) and nausea (25.4%) were the leading reasons for none
compliance to take of IFA pills. Overall negligence is the leading reason (38.6%)
followed by a shortage of pills at the hospitals (29.9%), nausea (20.7%) and starting late
(7.6%). There was a 1.6% group of participants who reported discarding the pills after
receiving without taking any pills.

58

Table 4. Timing and reasons of the first prenatal care visits.
First trimester
Second trimester
Third trimester
Total
Reasons
n
Percent
n
Percent
n
Percent
n
Percent
Advised by nurse
5
27.8
0
0
0
0
5
2.4
Didn't know when to start ANC
0
0
4
2.5
0
0
4
1.9
Distance, no transport money
1
5.6
11
7
3
8.6
15
7.1
Friends told her to wait
0
0
5
3.2
1
2.9
6
2.9
No doctor at the hospital
0
0
0
0
2
5.7
2
1
Not answered*
2
11.1
96
61.1
17
48.6
115
54.8
She did not know she was pregnant
0
0
7
4.5
2
5.7
9
4.3
Sick
8
44.4
4
2.5
2
5.7
14
6.7
Waited for husband to authorize
0
0
3
1.9
1
2.9
4
1.9
Waited for pregnancy to grow
0
0
24
15.3
7
20
31
14.8
Went to traditional birth attendant first
2
11.1
3
1.9
0
0
5
2.4
18
100
157
100
35
100
210
100
Total
*Not answered = women who opted out to not give a reason, mostly because they started late and did not want to be rebuked by
medical personnel.

59

Table 5. Reasons for taking certain number of IFA supplement pills during pregnancy.
Reasons
IFA pills taken
Bought some
Nausea
Negligence Started late
Stock outs
Discarded IFA
Total
0 -30
n
0
9
8
4
44
3
68
Percent
0
13.2
11.8
5.9
64.7
4.4
100
31 - 60
n
0
17
44
3
3
0
67
Percent
0
25.4
65.7
4.5
4.5
0
100
61 - 120
n
1
9
16
6
7
0
39
Percent
2.6
23.1
41
15.4
17.9
0.0
100
121 - 180
n
2
3
3
1
1
0
10
Percent
20
30
30
10
10
0
100
Total
n
3
38
71
14
55
3
184
Percent
1.6
20.7
38.6
7.60
29.9
1.6
100
Note: IFA is taken one pill daily hence one pill is equivalent to one day of intake or 180 pills is equal to 6 months intake. (WHO
recommends a minimum of 180 pills during pregnancy).

60

Newborn characteristics
Neonatal characteristics (Table 6) show that boy/girl newborn ratio was 1.09 or
52.1% and 47.9%, respectively. LBW newborns comprised 16% of the total deliveries in
this study. The mean, median and range of birth length were 47.8 cm, 48.4 cm, and 32.5
-57.0 cm, respectively. The mean, median and range of head circumference at birth were
34 cm, 35 cm, and 25 - 40 cm, respectively. Over 50% of newborns had low APGAR
scores (below 6) in the first minute of life but improved significantly after 5 minutes.
After 5 minutes 90% had good APGAR scores (above 9). However, 10% had poor scores
even after 5 minutes, which usually predicts a poor quality of life of newborns as they
may have neurological complications.
Z-scores for newborn anthropometry (Table 6) indicate that 20.0% of neonates had height
for age z-scores (HAZ) below -2, 14.55% had weight for age z-scores (WAZ) below -2,
and 28.71% had a weight for height z-scores (WHZ) lower than -2. This shows that a
significant number of newborns are stunted and underweight (low birth weight) at birth,
indicating poor health during pregnancy.

61

Table 6. Newborn anthropometry and health characteristics at birth.
Variable
Sex (n=213)
Birth weight (n=213)

APGAR scores at 1 min
(n=209)

APGAR scores at 5 min
(n=209)

Z-scores
Child’s HAZ (n=213)
Child’s WAZ (n=213)
Child’s WHZ (n=213)
Child’s HCZ (n=213)

Category
Male
Female
<1500 g
1500 g – 2499 g
2500 g – 3499 g
>3500 g

n
112
101
2
32
144
35

Percentage
52.1
47.9
0.9
15
67.6
16.4

<6
6–8
9 – 10

9
98
102

4.4
46.9
48.8

<7
7–9
10

7
14
188

3.4
6.6
90

<-2
>-2
<-2
>-2
<-2
>-2
<-2
>-2

46
163
31
182
60
149
16
197

22.0
78.0
14.6
85.5
28.7
71.3
8.1
91.9

34

16

Prevalence of LBW
(n=213)

Male
15
16.1
Female
19
15.8
APGAR score is out of 10. HAZ=height-for-age z-scores, WAZ=weight-for-age z-scores,
WHZ=weight-for-height z-scores and HCZ =head circumference-for-age z-scores. LBW
= Low birth weight < 2500g.

62

Hemoglobin, serum and RBC folate status by IFA taken
IFA pills taken by the women during pregnancy and the mean maternal
hemoglobin, serum folate and RBC folate concentration before delivery are shown in
Figures 5, 6, and 7, whereas scatter plots of the same are shown in Figure 8.
Maternal hemoglobin levels are positively correlated with the number of IFA pills
taken. Hemoglobin levels reached from 10.7 g/dl, 11.3 g/dl to 11.7 g/dl in response to
the reported number of IFA pill taken from <45, 45-89, to ≥ 90, respectively. The
correlation between IFA pills taken and maternal hemoglobin was positive with a
Spearman’s correlation coefficient of r=0.1846, P=0.0102 (Table 7).
The maternal serum folate concentrations of pregnant women before delivery
was positively associated with the reported IFA pills taken during the pregnancy (Figure
6). The IFA supplement intake of <45 to ≥90 pills corresponded to a mean serum folate
status of 7.9 nmol/L and 10.2 nmol/L, (P=0.175) respectively. This positive association
between IFA pills taken and mean serum folate status was marginally significant, r =
0.1839, P = 0.0699 (Table 7). The scatter plot in Figure 8 shows that the majority of
pregnant women took about 60 pills and only 4 women took between 121 – 180 pills.
The relationship between IFA pills taken and maternal RBC folate concentration
before delivery are shown in Figure 7. The mean RBC folate status increases steadily
from 463.1 nmol/L and to 498.8 nmol/L for the IFA pills between <45, and ≥90 (P =
0.949) respectively. A spearman’s correlation coefficient is small (r = -0.0329) and was
found statistically insignificant at P= 0.7481 (Table 7). The scatter plot in Figure 8 shows
the same poor association between the IFA pills taken and RBC folate levels, however it
is positive.

63

Mean hemoglobin (g/dl)

12.5

P = 0.006

12.0
11.5
11.0
10.5

11.3

11.7

10.7

10.0
<45

45-89
>90
Number of IFA pills taken in pregnancy

Figure 5. Mean maternal hemoglobin levels by number of IFA pills taken during
pregnancy.

64

Mean serum folate (nmol/L)

12.0

P = 0.175

10.0
8.0
6.0
4.0

8.9

7.9

10.2

2.0
0.0
<45
45-89
>90
Number of IFA pills taken during pregnancy
Figure 6. Mean maternal serum folate levels by number of IFA supplement pills taken
during pregnancy.

65

RBC folate (nmol/L)

1000.0
900.0
800.0
700.0
600.0
500.0
400.0
300.0
200.0
100.0
0.0

P = 0.949

463.1

488.8

498.8

<45
45-89
>90
Number of IFA pills taken during pregnancy
Figure 7. Mean maternal RBC folate levels by number of IFA supplement pills taken
during pregnancy.

66

Figure 8. Scatter plots of hemoglobin, serum folate and RBC folate levels by IFA pills taken.

67

Table 7. Spearman’s correlation matrix of maternal and newborn characteristics and biomarkers.
# of
Mother Mother Mother *HbSerum
IFA
WT - 1 WT - 2 - HT
2
folate
# of IFA tablets Corr coeff 1.0000 0.0599 0.0042 0.1759 0.1846 0.1839
P-value
n
Mother WT – 1 Corr coeff
P-value
n
Mother WT – 2 Corr coeff
P-value
n
Mother height

206

0.4261

0.9610

179

136

0.0189 0.0102
178

193

0.0699

0.7481

0.9118

0.0113

0.7272

0.5308

98

98

165

206

202

203

0.1794 0.1025

0.0697

0.0266

0.3325

0.2758

0.2420

0.2521

<.0001

0.0215 0.1798

0.5261

0.8089

<.0001

0.0001

0.0010

0.0006

85

85

148

185

181

182

0.2121 0.1489

0.0537

-0.0287

0.3550

0.3204

0.2476

0.2194

0.0150 0.0836

0.6542

0.8107

<.0001

0.0001

0.0034

0.0094

72

72

116

141

138

139

129

164

173

131

136

Corr coeff

0.1819 -0.1529 -0.0432

0.3389

0.3975

0.3511

0.2121

P-value

0.0163

0.1413

0.6791

<.0001

<.0001 <.0001

0.0039

174

94

94

150

185

182

183

Corr coeff

0.3905

-0.0167

0.0172

0.2346

0.2002

0.1582

P-value

<.0001

0.8688

0.8258

0.0009

0.0049

0.0268

100

100

166

199

196

196

Corr coeff

0.2502

-0.0467

0.0622

0.051

0.1522

P-value

0.0116

0.6692

0.5366

0.6183

0.1346

101

86

101

98

98

n
Serum folate

Birth
Head
Length Circ
0.0247 0.0442

0.8910

n
Hemoglobin

RBC
Placenta Birth
folate
WT
WT
-0.0329 0.0087 0.1761

n

68

Table 7. (cont’d)
RBC folate
Corr coeff

-0.1493

-0.075

0.0146

-0.0231

0.17

0.456

0.8865

0.8213

86

101

98

98

0.5727

0.4161

0.3709

<.0001

<.0001

<.0001

171

170

171

Corr coeff

0.6428

0.613

P-value

<.0001

<.0001

209

210

P-value
n
Placenta WT Corr coeff
P-value
n
Birth WT

n
Birth Length Corr coeff

0.5457
<.0001

P-value

209

n
Head Circ

1

Corr coeff
P-value

210

n
Circ, circumference; Hb, hemoglobin; HT, height; WT, weight.
*Hb -2 (Hemoglobin), serum and RBC folate were measured prior to delivery.
Mother WT-1 = Mother’s weight at first prenatal visit, which varied among women
Mother WT-2 = Mother’s weight on the day of survey before delivery.

69

Hemoglobin, folate status and newborn anthropometry by IFA pills taken
The number of IFA pills taken during pregnancy and its association with
biomarkers (hemoglobin, serum and RBC folate and newborn anthropometry (birth
weight, birth length, head circumference and z-scores of newborn anthropometric
measurements) are shown in Tables 8-13 and in Figure 9.
Table 8 shows demographic information and prenatal care characteristics of
mothers by number of IFA supplement intake. Supplement intake did not differ according
to demographic and other prenatal care characteristics like age, residence, education
level, number of pregnancies, timing of starting prenatal care of supplements. However,
there were significant differences according to gestation age and total number of prenatal
visits achieved by the pregnant woman.
Hemoglobin status (10.7 ± 1.6 g/dl, 11.3 ± 1.8 g/dl and 11.7 ± 1.6 g/dl, P= 0.006,
Table 9) was positively associated with the number of IFA pills taken, 45, 45-89 and
above 90 pills, respectively . The associations between IFA pills taken during pregnancy
and mean serum folate (7.9 ± 3.6 nmol/L, 8.9 ± 4.9 nmol/L and 10.2 ± 4.1 nmol/L,
respectively, P = 0.175) and RBC folate status immediately before delivery (463.1 ± 270
nmol/L, 488.8 ± 38.5 nmol/L and 488.8 ± 469.5 nmol/L, respectively, P = 0.949) were
not statistically significant.
Table 10 shows demographics that mothers’ age, residence (rural, peri-urban, and
urban), gravidity (number of pregnancies), parity, number of prenatal care clinic visits,
and trimester of starting intake of IFA pills did not differ between mothers who gave
birth to normal weight versus LBW newborns. Factors that differentiated the two groups

70

were education level (P=0.016), trimester of first prenatal clinic visit (P=0.003) and
gestation age (P= <0.001) Table 9.
Table 10 shows the comparison of mothers’ and newborn variables between
normal weight and LBW newborns. Mean hemoglobin status between mothers of
normal and LBW newborns were 11.4 ± 1.6 g/dl and 9.4 ± 1.6 g/dl P = <0.001,
respectively. However, the difference in serum and RBC folate between mothers of
normal and LBW newborns were not significant, 9.1 ± 4.4 nmol/L 7.5 ± 3.6 nmol/L,
respectively (P = 0.230). The same was observed with RBC folate status between normal
and LBW 494.6 ± 413 nmol/L and 489.8 181.1 nmol/L respectively, (P = 0.942).

71

Table 8. Sociodemographic and prenatal care characteristics by number of IFA supplements taken during pregnancy.
# of IFA supplements taken during pregnancy (tablets)
<45 (n=81)
45–89 (n=89)
≥90 (n=36)
n
%
n
%
n
%
P-value
Age
<19y
13
16.1
10
11.2
1
2.8
0.210
19-29y
53
65.4
59
66.3
25
69.4
30-35y
7
8.6
10
11.2
8
22.2
≥36y
8
9.9
10
11.2
2
5.6
Missing
7
Residence
Rural
31
38.3
27
30.3
10
27.8
0.631
Peri-urban
33
40.7
31
34.8
14
38.9
Urban
17
21.0
31
34.8
12
33.3
Missing
7
Total number of pregnancies
1
25
31.3
32
36.0
12
33.3
0.364
2
22
27.5
17
19.1
5
13.9
3
11
13.8
18
20.2
5
13.9
4
13
16.3
11
12.4
6
16.7
≥5
9
11.3
11
12.4
8
22.2
Missing
8
Total number of births
0
26
32.1
31
35.2
12
33.3
0.225
24
29.6
17
19.3
5
13.9
1
2
11
13.6
19
21.6
5
13.9
3
11
13.6
10
11.4
6
16.7
≥4
9
11.1
11
12.5
8
22.2
Missing
8

72

Table 8. (cont’d)
Gestation weeks
<37
≥37
Missing

32
37
30

46.4
53.6

18
64

22.0
78.1

7
25

21.9
78.1

0.003

5.6
11.2
39.3
43.8

0
4
19
13

0.0
11.1
52.8
36.1

0.371

9.0
83.2
7.9

1
29
6

2.8
80.6
16.7

0.472

8.0
40.9
40.9
10.2

6
15
5
9

17.1
42.9
14.3
25.7

0.006

9.1
83.0
8.0

2
33
0

5.7
94.3
0.0

0.350

Education
Never Been to School
7
8.6
5
Junior Primary
13
16.1
10
Secondary Primary
25
30.9
35
Secondary or more
36
44.4
39
Missing
7
First prenatal visit
First trimester
8
10.1
8
Second trimester
51
64.6
74
Third trimester
20
25.3
7
Missing
9
# of prenatal visits
0–2
28
35.4
7
3
23
29.1
36
4
22
27.9
36
5–6
6
7.6
9
Missing
11
IFA supplements started in
First trimester
10
17.0
8
37
62.7
73
Second trimester
Third trimester
12
20.3
7
Missing
31
Total number of births = parity, total number of pregnancies = gravidity

73

Table 9. Mother’s and newborn’s variables by number of IFA supplements taken during pregnancy.

n
Mother's variables
Age (years)
Body weight- 1(kg)*
Body weight- 2(kg)
Hb-1(g/dl)**
Hb-2 (g/dl)
Serum folate (nmol/L)
RBC folate (nmol/L)
Placenta weight (g)
Baby's variables
Birth weight (g)
Birth length (cm, lying down)
Head circumference (cm)
APGAR score of baby at 1 min
APGAR score of baby at 5 min

Number of IFA supplements taken during pregnancy (pills)
<45 (n=81)
45–89 (n=89)
≥90 (n=36)
Mean
SD
n
Mean
SD
n
Mean
SD

P-value

81
70
44
14
72
34
34
63

24.5
58.1
65.3
8.5
10.7
7.9
463.1
560.7

6.5
9.3
9.6
1.5
1.8
3.6
270.0
147.1

89
77
63
11
87
45
45
72

25.6
60.1
65.3
9.6
11.3
8.9
488.8
573.6

6.5
10.6
11.4
1.5
1.6
4.9
438.5
126.5

36
32
29
4
34
19
19
30

25.6
59.1
66.0
10.9
11.7
10.2
488.8
580.8

5.8
8.3
12.3
1.6
1.6
4.1
369.5
147.7

0.512
0.459
0.961
0.029
0.006
0.175
0.949
0.774

81
79
80
81
81
n

2844.2
47.7
34.2
8.1
9.8

524.3
3.4
2.5
1.5
0.9

89
87
87
85
85
n

2903.9
47.9
34.5
8.0
9.7

461.4
3.5
1.8
1.5
1.3

36
36
36
36
36
n

3188.9 452.2
48.1
3.9
34.9
1.8
8.2
1.1
9.6
1.6
%

0.002
0.852
0.294
0.838
0.785

5.6
94.4

0.027

%

%

Prevalence of LBW
LBW
17
20.1
12
13.5
2
Normal weight
64
79.0
77
86.5
34
Missing
7
*Body weight- 1 was measured at first prenatal clinic visit that vary in trimesters among women.
**Hb-1 (hemoglobin) was measured at the first prenatal clinic visit that varies in trimesters among women.
Hb-2 (hemoglobin), serum and RBC folate samples were taken prior to delivery.

74

Table 10. Differences in characteristics between mothers of normal weight and LBW
newborns.
Birth weight of newborn
Normal weight
Low birth weight (n=34)
(n=179)
n
%
n
%
p-value
Age
<19y
18
10.1
7
20.6
0.235
19-29y
120
67.0
20
58.8
30-35y
23
12.9
5
14.7
≥36y
18
10.1
2
5.9
Residence
Rural
58
32.4
12
35.3
0.722
Peri-urban
68
38.0
12
35.3
Urban
53
29.6
10
29.4
Gravidity
1
54
30.3
16
47.1
0.081
2
40
22.5
7
20.6
3
31
17.4
4
11.8
4
27
15.2
4
11.8
≥5
26
14.6
3
8.8
Missing
1
Parity
0
55
30.7
15
45.5
0.146
1
42
23.5
7
21.2
2
32
17.9
4
12.1
3
25
14.0
4
12.1
≥4
25
14.0
3
9.1
Missing
1
Gestation age (weeks)
<37
38
24.1
22
71.0
<0.001
≥37
120
76.0
9
29.0
Missing
24
Education level
Never been to school
8
4.5
4
11.8
0.016
Junior primary
21
11.7
7
20.6
Senior primary
69
38.6
13
38.2
≥ Secondary
81
45.3
10
29.4

75

Table 10. (cont’d)
Trimester of first prenatal visit
7
23
2

21.9
71.9
6.3

0.003

0–2
33
19.0
9
3
64
36.8
12
4
55
31.6
9
5–6
22
12.6
3
Missing
6
Trimester IFA pill intake started
First
13
8.4
7
Second
126
81.3
18
Third
16
10.3
3
Missing
30
Each variable was run after controlling the rest as covariates.

27.3
36.4
27.3
9.1

0.267

25.0
64.3
10.7

0.088

First
Second
Third
Missing

11
134
33
3

6.2
75.3
18.5

# of prenatal clinic visits

76

Table 11. Differences in characteristics of mothers who delivered normal vs. LBW babies.
Birth weight
Normal weight (n=179)
Low birth weight (n=34)
n
Mean
SD
n
Mean
SD
Mother's variables
Age (years)
179
25.6
6.2
34
23.4
# of IFA pills taken during pregnancy
175
56
37
31
40
Body weight-1 (kg)
159
60.1
9.9
26
54.6
Body weight-2 (kg)
125
66.4
11.2
16
59.5
Maternal Height
154
155.5
5.6
31
151.0
Hb-1 (g/dl))
23
9.7
1.4
6
7.6
Hb-2 (g/dl)
172
11.4
1.6
27
9.4
Serum folate (nmol/L)
87
9.1
4.4
14
7.5
RBC folate (nmol/L)
87
494.6
413.0
14
489.8
Placenta weight (g)
145
591.4
129.2
26
455.6
Baby's variables
Birth weight (g)
179
3071.8
388.0
34
2115.6
Birth length (cm, recumbent)
175
48.6
3.1
34
43.6
Head circumference (cm)
176
34.9
1.5
34
31.8
APGAR score 1 min
175
8.1
1.4
34
8.1
APGAR score 5 min
175
9.7
1.3
34
9.8
Body weight-1: First prenatal visit weight, data were extracted from health passport book.
Body weight-2: Measured prior to delivery.
Hb-1: Hemoglobin status at first prenatal clinic visit, data was extracted from health passport book.
Hb-2: Hemoglobin level measured prior to delivery.

77

P-value

6.8
28
8.4
8.6
6.4
1.7
1.6
3.6
181.1
153.9

0.064
0.021
0.008
0.019
<0.001
0.005
<0.001
0.230
0.942
<0.001

310.0
3.3
2.7
1.3
0.9

<0.001
<0.001
<0.001
0.887
0.653

Risk of LBW by IFA pills taken during pregnancy
The results of multivariate odds ratio for LBW and IFA pills intake and other
variables are shown in Table 12. The odds ratio was not significant for age categories,
residence (rural, peri-urban, and urban), gravidity, parity, education levels, number of
prenatal clinic visits, and trimester of starting IFA pill intake. IFA supplement intake
during pregnancy reduces the risk of delivering a LBW newborn. As shown in Table 12,
women who took IFA pills greater than 60 lower risk (OR = 0.11, CI: 0.02, 0.056, P =
0.008) compared with the reference group who took ≤ 30 pills (OR = 1.00). The risk of
LBW was also lower for women who took ≥ 90 pills (OR = 0.19, CI: 0.04, 1.01, P =
0.051). Risk of LBW was lower for a gestation age ≥ 37 weeks (OR = 0.15, CI: 0.06,
0.40, P = <0.001) at their first prenatal care visit (OR = 0.06, CI: 0.01, 0.41, P = 0.005).
This might suggest new cutoffs for prenatal IFA supplements in future. As demographic
information seems to contribute very little to factors compelling women to adhere
(compliance) to prenatal supplements intake. Gestation age lowered the risk of LBW,
however, somewhat unusual was the starting of prenatal care, as those who started early
seemed to have higher risk than those who were late.
The relationship of number of IFA pills consumed during pregnancy and mean
birth weight of the newborn is shown in Figure 9. For pregnant women who took no pills
the mean birth weight 2,887 g and dropped to 2,816.3 g for those who took 1–30 pills.
From 1-30 pills of IFA any increase in IFA number results in increased mean birth
weight of the newborn, 31-60, 61-120 and 121-180 pills has corresponding increase in
mean birth weight of 2,909.9 g, 3,061.9, and 3,210 g respectively.

78

Table 12. Multivariate odds ratios and 95% confidence intervals of LBW by its risk
factors
Low birth weight
OR
95% CI
P-value
Age (n=204)
<19y
1.00
19-29y
0.98
0.25
3.92
0.981
30-35y
3.00
0.35
25.68
0.316
≥36y
1.38
0.09
20.27
0.814
Residence (n=204)
Rural
1.00
Peri-urban
1.17
0.43
3.16
0.760
Urban
0.86
0.30
2.49
0.778
Gravidity (n=204)
1
1.00
2
0.58
0.18
1.88
0.360
3
0.30
0.07
1.30
0.108
4
0.34
0.06
2.08
0.244
≥5
0.22
0.03
2.02
0.182
Parity (n=204)
0
1.00
1
0.55
0.17
1.84
0.333
2
0.30
0.07
1.31
0.110
3
0.41
0.07
2.56
0.341
≥4
0.25
0.03
2.18
0.208
Gestation weeks (n=182)
<37
1.00
≥37
0.15
0.06
0.40
<0.001
Education (n=204)
Never Been to School
1.00
Junior Primary
1.04
0.17
6.37
0.965
Secondary Primary
0.42
0.08
2.23
0.306
Secondary or more
0.38
0.07
2.07
0.262
First ANC visit trimester (n=204)
First
1.00
Second
0.20
0.06
0.72
0.013
Third
0.06
0.01
0.41
0.005
# of prenatal clinic visits (n=204)
0–2
1.00
3
0.60
0.19
1.92
0.388
4
0.39
0.11
1.36
0.139
5–6
0.32
0.07
1.53
0.153

79

Table 12. (cont’d)
Trimester IFA supplements started (n=177)
First
1.00
Second
0.29
0.06
1.35
0.115
Third
0.43
0.06
3.05
0.399
# of IFA pills taken in pregnancy (n=199)
≤30
1.00
31–60
0.55
0.22
1.42
0.220
>60
0.11
0.02
0.56
0.008
# of IFA pills taken in pregnancy (n=199)
<45
1.00
45–89
0.48
0.19
1.25
0.132
≥90
0.19
0.04
1.01
0.051
*Adjusted for maternal age, education, total number of pregnancies, first prenatal visit
trimester, and total number of prenatal visits.

80

Birth Weight (g)

4000
3500
3000
2500
2000
1500
1000
500
0

P = 0.002

<45
45-89
>90
Number of IFA pills taken during pregnancy
Figure 9. Mean birth weight by IFA pills taken during pregnancy.

81

Using mother’s Hb, serum folate, and RBC as independent variables and the
newborn anthropometric outcomes as dependent variables, the regression coefficients of
number of IFA pills, mother’s Hb, serum folate, and RBC folate for predicting newborn
anthropometry vs. the number of IFA pills are shown in Table 13. After controlling for
covariates (age, maternal height, gravidity, gestation, ANC visits, education, residence,
and annual household income), mothers’ hemoglobin levels were positively associated
with WHZ and WAZ scores. An increase in mothers’ Hb of 1 g/dl corresponded to an
increase in the WHZ score of (β = 0.232, P = 0.045), when all covariates are constant.
Also an increase in mothers’ Hb of 1 g/dl corresponds to an increase in WAZ score of β =
0.130, P = 0.021. Higher serum folate levels were also significantly related to increased
WAZ and HCZ scores of β = 0.057, P = 0.043 and β = 0.119, P = 0.023 respectively.
However, mothers intake of IFA pills during pregnancy and RBC folate status of
pregnant woman were not significantly associated with newborn anthropometric
outcomes.

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Table 13. Associations of mother’s IFA pills taken and biomarkers with newborn
anthropometry
WHZ - scores
HAZ - scores
WAZ - scores
HCZ - scores
Models
β
P-value
β
P-value
β
P-value
β
P-value
(n=91)
(n=113)
(n=115)
(n=113)
# of IFA pills 0.006
0.255 -0.001 0.889
0.003
0.219
-0.002 0.662
(n=91)
(n=113)
(n=116)
(n=114)
0.007 0.945
Mother’s Hb 0.232
0.129
0.202
0.045
0.130
0.021
(n=43)
(n=59)
(n=61)
(n=59)
Serum folate 0.075
0.174 0.062 0.247
0.043
0.119
0.023
0.057
(n=59)
(n=43)
(n=59)
(n=61)
RBC folate
0.001
0.097 <0.001 0.910 <0.001 0.944 <0.001
0.747
All models were adjusted for maternal age, maternal height, gravidity, # of prenatal visits,
education, residence, and annual household income. Each model also controlled for the
other three variables considered in these four models.

83

CHAPTER FIVE: DISCUSSION
Prenatal supplements containing iron and folic acid are a short-term solution to
the anemia problem in pregnant women in developing countries with high burden of
anemia and food security challenges. The policy in Malawi supports that all pregnant
women receive free prenatal IFA supplements at the prenatal clinics with every visit,
throughout pregnancy. However, there have been challenges with compliance to these
free supplements, risking anemia during pregnancy and poor birth out comes among this
population. This research was conducted to evaluate the effect of non-compliance to
taking prenatal supplements during pregnancy on prevalence of LBW in Malawi.
Compliance to prenatal supplements itself depends on several other factors. Some of the
factors explored in this study are; parity, availability of supplements at the hospital,
timing of the first prenatal care clinic visit, level of education, age of pregnant woman,
economic status, gestation age due to changes in early pregnancy, residence or distance to
the hospital and number of pregnancies (gravidity).
We observed that the pregnant women involved in our study were mainly young
women who were younger than 35 y (89.7%) with almost 20% being teenage mothers
(under 20 y ). This is in agreement with national data that show that Malawi is a young
country compromised of a youthful population making over 50% of the national
population, just like the rest of Sub-Saharan Africa. Another reason is that in Malawi life
expectancy is low (below 60 y ) because of health care and economic challenges (NSOICF, 2017).
Education level of the majority of the pregnant women fairly good, as only 5.6%
had never been to school, with over 40% having attended primary school (middle school)
84

and another 40% attended secondary school (high school). This could be because a good
number of pregnant women’s resided in urban and peri-urban areas (over 60%) with the
remainder coming reporting their residence as rural. Those living in the urban and periurban areas are likely to have access to education. Contrary to our expectation of such a
literate population, we observed that their household income per annum was very low,
with the majority living with less than a dollar a day. Although a good number was
literate, stayed in urban and peri-urban areas they did not do any skilled labor. About
60% were housewives and those that could not mention their occupation, with only 11%
and 17% reporting that they were doing skilled labor and small scale businesses
respectively (Table 2).
Gestation length is highly associated with birth weight, i.e., the longer a woman
gestates the higher the chances of allowing the fetus to grow and reducing the risk of low
birth weight, assuming good nutrition and less infections of the pregnant woman. In our
study we observed that prevalence of premature birth was about 15%, slightly lower than
it was observed by other researchers recently in Malawi (Chagomerana et al., 2017),
however, our findings are in line with national prevalence of premature births of 15%
(NSO-ICF, 2017).
A significant number of women (22.5%) were shorter in height (≤150 cm). Short
maternal height (≤150 cm) is associated with LBW (Raghunath et al., 2016). Average
number of pregnancies (Appendix C) per woman was 3 with a minimum of 0 and
maximum of 9. About 30% of the pregnant women were Primgravidae (first pregnancy),
and 53% multigravidae (2-4 pregnancies) and 14% grandmultigravidae (more than 4
pregnancies). Although the fertility rate has dropped to 4.4 in 2016 from 6.3 the past

85

decade, the pregnant women in this study had more children than the national average
(NSO-ICF, 2017). Most pregnant women started attending prenatal care in the second
trimester of pregnancy (74.8%) and also start to take IFA in the same trimester. Number
of visits ranged from 0 to 6 and the majority attended 3 to 4 visits (67%). Prenatal
attendance is critical to health care of pregnant women in Malawi because on top of the
general medical care, prenatal clinics serve as outlets for prenatal supplements to all
pregnant women. The Malawian government through the Ministry of Health, distributes
prenatal supplements (iron and folic acid) to be given for free to all pregnant women
regardless of hematological status in all prenatal clinics. Therefore a woman can only
have access to IFA supplements if she goes to the prenatal clinics, hence attendance is
very important during pregnancy. The supplements are available in private pharmacies
for those with financial power to access but the majority cannot afford among other
priorities in the households. Besides it has been shown that those pregnant women who
report buying their supplements and not receiving them from prenatal clinics have poor
compliance, perhaps due to lack of counseling on side effects and other medical advice
(Sununtnasuk et al., 2016).
Also to achieve WHO recommendation of taking a minimum of 180 pills of IFA,
6 months intake (WHO, 2012) throughout pregnancy requires starting of prenatal
attendance early. Our research shows that compliance to prenatal supplements is likely to
be a challenge as the majority of pregnant women, 74.5% (Table 3) started prenatal care
in the second trimester of pregnancy and another 17% starting prenatal care in the third
trimester. This renders a lot of pregnant women unable to take the required number of
pills of supplements aside compliance factors.

86

In this study, 88% pregnant women reported receiving IFA pills at some point of
their pregnancy and 87% reported taking at least IFA pill at some point in pregnancy
which is in agreement with other published data. This seems to indicate that access to
IFA pills may be improving but compliance to take them still depends on other factors
(Sununtnasuk et al., 2016). Table 3 shows that although the majority reported receiving
and taking IFA pills during pregnancy, only 4.9% (n=10) took above 121 IFA pills and
none achieved the 180 pills minimum recommendation by WHO. This calls for a deep
examination of the biggest anemia prevention program in the country, the prenatal
supplementation program. In this study we found that 40% of pregnant women had some
anemia (Hb <11g/dl), with 19% having mild anemia, 20% moderately severe anemia, and
1% very severe anemia requiring transfusion according to the guidelines of anemia
treatment not only in Malawi but other countries in the world. Folate status showed that
over 50% had serum folate <10 nmol/L and RBC folate lower than 400 nmol/L. The
prevalence of anemia in this population is of great concern, considering that anemia has
direct consequences on the fetus (Allen, 2000; Black et al., 2008b).
Based on the patients’ medical and drug histories our study shows that the
majority were free from major illnesses except 0.9% (n=2) were on anti-tuberculosis
treatment, 2.4% (n=5) on steroids, on diabetic treatment 0.5% (n=1), on anti-hypertensive
0.5% (n=1), other drugs 0.5% (n=1) and on anti-retroviral (HIV treatment) 9.9% (n=21).
Although HIV positive women comprised about 10% this did not affect the prevalence of
LBW in our study, because Malawi practices “option-B plus” for all pregnant women.
This regimen ensures all pregnant women start treatment as soon as they are diagnosed
positive to reduce viral load regardless of immunological status. Malawi is one of the

87

leading countries in mother-to-child transmission of HIV but of the majority of babies are
born HIV free from these positive mothers. Also Chagomerana and friends in their recent
study found that those on HIV treatment did not significantly differ with their
counterparts without HIV in terms of prevalence premature birth who are likely born
LBW babies (Chagomerana et al., 2017).
Biomarker status by self-reported intake of IFA supplement
One of the major weaknesses of self-reported data is that it is very subjective.
Because of this, the validity of results generated this way has always been questioned. On
the other hand, the advantage of self-reported data is that it is easy to in large
epidemiological studies it would be difficult and expensive for example to send a team to
go door-to-door to collect data. Some studies have found contradicting results when they
tried to validate self-reported data with verified data for compliance, even in clinical trials
(Dieltjens et al., 2013; Kaunitz et al., 2015).
In Malawi compliance to prenatal supplements had been previously reported as poor,
(Kalimbira et al., 2009; Young et al., 2000) but no one had validated self-reports of
prenatal supplement intake nor actually examine the extent of this non-compliance in
terms on biomarker status, let alone birth outcomes.
In our study we found that self-reported IFA pills taken during pregnancy are
positively associated with biomarker status of the pregnant woman before delivery.
Increased intake of IFA pills from 45, 45-89 and above 90 pills significantly increased
mean hemoglobin status from 10.7 ± 1.6 g/dl, 11.3 ± 1.8 g/dl and 11.7 ± 1.6 g/dl (P=
0.006) respectively (Table 9). This is in agreement with what Alwan and friends (2014)
found in their study which found that the intake of prenatal iron supplements was
88

associated with an increase in hemoglobin status of the mother more than dietary intake
of iron (Alwan et al., 2014). In another clinical study it was found that self-reported
intake of supplements was only confirmed in 53% of the women the other half lied about
taking the supplements. They confirmed intake by performing stool analysis looking for
iron, and intake was only confirmed in half the women involved in the study, and
hematological changes were observed in those who actually took the supplements
(Schultink et al., 1993). This shows that self-reporting data has some challenges but at the
same time confirmed intake. In Ethiopia another study showed non-compliance to be
over 90% mainly due to challenges of coverage of distribution of the supplements in the
country and for the few that had access to the supplements, the majority did not comply
due to side effects and forgetting to take the pills (Gebremedhin et al., 2014). However,
in our study we found that IFA pills taken were positively associated with hemoglobin
status in pregnant women, which provides evidence that the Malawi prenatal
supplementation program has a chance to be successful. The major challenge in Malawi
is that none of the subjects met the WHO recommendation of 180 pills during pregnancy
- hence the need for policy changes to address the problem of not finishing the necessary
pills.
IFA pills taken during pregnancy and self-reported by pregnant women was
positively associated with increased mean serum folate and RBC folate status in the
pregnant women before delivery, but this association was not statistically significant. The
mean serum folate increase was 7.9 ± 3.6 nmol/L, 8.9 ± 4.9 nmol/L and 10.2 ± 4.1
nmol/L (P = 0.175) while that of RBC folate was 463.1 ± 270 nmol/L, 488.8 ± 38.5
nmol/L and 488.8 ± 469.5 nmol/L (P = 0.949) for IFA intake of 45 pills, 45-89 pills, and

89

≥ 90 pills respectively. Serum folate is a biomarker of short-term consumption of folate
while RBC folate is a biomarker for long-term intake of folic acid. We are of the view
that diet of the pregnant women might have impacted the folate data, as it is readily
available in local vegetable and cereal diets than iron whose best source is meat and it is
not readily available to the population at large. Partly the national fortification program of
cereals with folic acid and vitamin B may also impact the results of the study. However,
that would only affect a third of the pregnant women who came from rural areas, as
fortified cereals are only found in cities accessible to urban dwellers and not rural and
peri-urban residents.
Maternal hemoglobin and folate status and low birth weight
We wanted to investigate if pregnant women who reported taking prenatal
supplements and showed improved hematological status, had any impact on the birth
outcomes, particularly birth weight, of the newborn. It was observed that the mean birth
weight was statistically different between the normal and LBW newborns, 3071.8 ± 388g
and 2115.6 ± 310 g, P = < 0.001 (n=179) in Table 9. Mean hemoglobin status between
mothers of normal and LBW newborns were 11.4 ± 1.6 g/dl and 9.4 ± 1.6 g/dl (P =
<0.001), respectively. However, the difference in serum and RBC folate between mothers
of normal and LBW newborns were not significant, 9.1 ± 4.4 nmol/L and 7.5 ± 3.6
nmol/L respectively (P = 0.230). The same was observed with RBC folate status between
normal and LBW 494.6 ± 413 nmol/L and 489.8 181.1 nmol/L respectively (P = 0.942).
These results indicate that overall maternal biomarker status is positively associated with
birth weight. This is in agreement with many other studies which show that maternal
hemoglobin has modifying effects on infant birth weight of women receiving prenatal
90

iron-containing supplements (Wang et al., 2016). In a randomized double blind
multicenter clinical trial (n= 18,775 participants) in China it was found supplementation
of iron and folic acid, folic acid alone or multiple micronutrient supplements (formulated
by the United Nations) impacted birth weight depending on hemoglobin status of the
pregnant woman. Folic acid did not show much impact on birth weight, perhaps this
could explain our results above, that although there is positive association, it was not a
statistically significant relationship. The supplement has to make significant change on
maternal hemoglobin levels, and hemoglobin will modify the birth weight of the newborn
(Wang et al., 2016), with more impact seen in those with better hemoglobin status at
baseline. Those getting folic acid supplements alone did not have significant better birth
outcomes but those with combined pills or multiple micronutrients. Another study
showed that supplementation did not just improve newborn anthropometric
measurements, but reduced the prevalence of anemia in mothers (Preziosi et al., 1997).
Steer found that low hemoglobin is associated with LBW (Steer, 2000).
Prenatal IFA supplements are associated with low risk of low birth weight
We examined the association between the number of prenatal IFA pills taken
during pregnancy and the risk of delivering a LBW newborn and found that pregnant
women who self-reported taking supplements consistently (at least two months) lowered
their risk of delivering a LBW newborn significantly. After establishing that IFA impacts
biomarkers of hematological status of pregnant women and that biomarkers of
supplement use (hemoglobin and folate) have modifying effects on birth weight, we
wanted to examine if birth outcomes could be linked to “self-reported” IFA use during
pregnancy. If self-reported use of IFA pills during pregnancy is validated to predict birth
91

outcomes in Malawi, then this could strengthen the messages taught in prenatal clinics for
the anemia prevention program. It could also help reduce the cost of a routine
hemoglobin check, which are rarely done, due to the lack of resources Malawi (only 30
out 213 women had their hemoglobin checked during prenatal care). We accepted the
hypothesis that self-reported intake of IFA reduces the risk of low birth weight. The
prevalence of LBW (Table 9) was 20.1%, 13.5% and 5.6% for IFA pill intake of < 45
pills, 45-89 pills, and ≥ 90 pills (P = 0.027) respectively. The more prenatal IFA pills
were taken by pregnant women the lower the risk of low birth weights. According to
Table 12 women who took 60 IFA pills or more had lower risk of delivering LBW (OR =
0.11, 95% CI: 0.02, 0.056, P = 0.008) compared with reference group who took ≤ 30 pills
(OR = 1.00). The risk of LBW was also lower for women who took ≥ 90 pills (OR =
0.19, 95% CI: 0.04, 1.01, P=0.051). These observations were made on pill numbers of 60
– 90 or more. The question is whether or not pregnant women should take 180 pills (6
months pill intake) as recommended by WHO because we are seeing improvements at 90
pills (3 months).
Similarly Nisar and friends (2016) in their study which used nationally
representative data of the Pakistan demographic and health survey (PDHS, 2002 – 2006)
found that self-reported of IFA pills of any amount during pregnancy was positively
associated with better perceived birth size and birth weight. Any amount of IFA pills
taken was associated with reduced risk of having a smaller than average newborn by 18%
(OR = 0.82, 95% CI: 0.71, 0.96) (Nisar and Dibley, 2016).
In another study in India, which also used national data set to examine the
relationship between self-reported intake of IFA pills in pregnancy and LBW risk, found

92

inverse association. They found that at population level in a context where the burden of
anemia is severe (prevalence ≥ 40%), IFA taken during pregnancy was significantly
associated with decreased LBW (OR = 0.77, 95% CI: 0.68, 0.86, P = < 0.001. They
concluded that measures to improve the implementation of prenatal supplementation
program, would likely help to address India’s burden of LBW (Balarajan et al., 2013).
The situation in India applies to Malawi because they are both developing countries with
existing food security challenges in its communities, have a high prevalence of anemia
and prenatal IFA supplements have proved to be effective.
The findings in Table 13 summarize the influences of IFA and status of maternal
biomarkers on newborn anthropometric z-scores. We used mother’s hemoglobin, serum
folate, and RBC as independent variables and the newborn anthropometric outcomes as
dependent variables, the regression coefficients of number of IFA pills, mother’s Hb,
serum folate, and RBC folate for predicting newborn anthropometry vs. the number of
IFA pills. Covariates were controlled and included age, residence, education, and house
hold income among others. An increase in mothers’ Hb of 1 g/dl corresponded to an
increase in the WHZ score of (β = 0.232, P = 0.045), when all covariates are constant.
Also an increase in mothers’ Hb of 1 g/dl corresponds to an increase in WAZ score of β =
0.130, P = 0.021. Higher serum folate levels were also significantly related to increased
WAZ and HCZ scores of β = 0.057, P = 0.043 and β = 0.119, P = 0.023 respectively.
However, mothers intake of IFA pills during pregnancy and RBC folate status of
pregnant woman were not significantly associated with newborn anthropometric
outcomes. This shows that hemoglobin and folate status of the mother is associated with
size of newborn at birth. Since it is known that prenatal supplements can correct

93

biomarker status, therefore compliance to prenatal supplements can impact newborn size
at birth. This shows that compliance to prenatal supplements can actually reduce risk of
LBW, infant mortality and stunting prevalence in Malawi.
Malawi has other nutrition programs that are aimed at improving the nutrition
status of the population in general. These include improving food security by supporting
production (farm inputs subsidy), industrial and bio-fortification of commonly consumed
foods and encouraging locals to explore other foods to diversify diets rich in iron, vitamin
A and other essential nutrients. However, the above approaches are long term as food
security cannot be completely achieved without improvement of the economic status of
the people. This leaves prenatal supplementation as the best short-term solution to the
high prevalence of anemia. The biggest challenge that we were able to identify in this
study was sustained intake of the IFA pills for longer than 3 months. Most pregnant
women reported negligence, reduced supply of IFA supplements and late start of prenatal
clinic attendance as major reasons for poor compliance (table 11 and 12). Now that we
have demonstrated that self-reported intake of prenatal supplements is a valid tool to
predict hematological status of biomarkers and birth out comes of a pregnant woman, it is
high time a monitoring mechanism was put in place to evaluate the pregnant women
about their compliance to IFA every time they go for prenatal clinics. Perhaps the
monitoring mechanism could combine with pill counting (Young et al., 2000) to ensure
compliance is being achieved and pregnant women adhere to IFA pills supplements. Pill
counting has been employed successfully to improve adherence to ant-retroviral drugs in
the treatment of HIV/AIDS. Another method being used in Malawi is directly observed
treatment (DOT), where a patient takes drugs under the observation of medical

94

practitioner or a trusted guardian. DOT is being used in the treatment of tuberculosis (the
first two weeks) and malaria prophylaxis in pregnant women at the prenatal clinic. An
effective monitoring and evaluation mechanism would make Malawi realize more
benefits from IFA supplementation program and make it more successful in lowering
prevalence of low birth weight. Education of pregnant women on the benefits of IFA on
their newborns would yield positive results because negligence was one of the major
reasons for poor compliance. Lowering the risk of LBW has long term benefits such as
reducing infant and child mortality, reducing stunting prevalence, which in turn has
economic returns and improve national development (Win, 2016).
Summary and Conclusion
This research examined compliance to prenatal IFA in relation to LBW in
Malawi. The results show that self-reported compliance to prenatal supplement use by
pregnant women is associated with reduced risk of low birth weight. The mechanism
being that prenatal supplements improve hematological status of hemoglobin and folate,
which have direct impact on the developing fetus.
The total number of pregnant women involved in the study was n = 213, 70%
were young (below 35 y ), the majority were fairly literate (went to primary and
secondary school) and they came from all corners of the district (i.e., rural, peri-urban
and urban). The majority had very low household income, living with less than a dollar a
day, only 11% were doing skilled labor and the rest were housewives and subsistence
farmers. The average number of prenatal care clinic visits were 3.3, with most attendance
in second trimester, received and took IFA supplements, however about 40% had anemia
(hemoglobin < 11 g/dl).
95

We had hypothesized that women who self-reported taking prenatal supplements
(complying) would have better biomarker status (improved hemoglobin and folate). This
hypothesis is hereby being accepted based on results in Figure 5, 6, 7, and Table 8 and 9
which indicate a positive association between self-reported IFA supplements pills taken
during pregnancy and hemoglobin and folate status before delivery. There was a
statistically significant association between IFA intake and hemoglobin, although there
was not a statistically significant association between both serum and RBC folate and
IFA taken during pregnancy, mean folate status improved tremendously from those that
<45 pills to those that took >90 pills. The implication of this finding is that it confirms
that IFA supplementation still has the potential to fight anemia in pregnant women in
Malawi and to reduce the prevalence of anemia (currently at 33%).
We also hypothesized that pregnant women with better biomarker status (less
anemic) would have better birth outcomes (lower risk of delivering a LBW newborn).
This hypothesis is also accepted based on results illustrated in Table 11. We observed
that IFA biomarker status was much higher in women who delivered a normal weight
newborn compared with those who had a LBW new born. The association was
statistically significant for hemoglobin but not folate (Hemoglobin: 11.4 g/dl versus 9.4
g/dl P= < 0.001, serum folate: 9.1 nmol/L versus 7.5 nmol/L P=0.230, RBC folate: 494.6
nmol/L versus 489.8 nmol/L P=0.942). Again, these findings have the implication that
improving maternal IFA biomarker status impacts newborn health, and reduces the risk
of low birth weight. Routine checking of hemoglobin during prenatal clinics would
facilitate prompt correction of anemic women and reduce the risk of delivering a LBW
newborn. As seen in this study, 30 out 213 women only had hemoglobin checked in

96

prenatal clinic during pregnancy. The rest of the women just hoped that they were not
anemic until they were enrolled in the study and had hemoglobin checked. In the absence
of such a service then emphasis would be put on ensuring that all pregnant women are
compliant to taking IFA supplements.
Finally we had hypothesized that self-reported compliance to prenatal iron and
folic acid intake would be associated with lower risk of giving birth to a LBW newborn.
Results in Table 7, 9, and Figure 9 indicate that the more IFA pills pregnant women took
the better the birth outcome. The average birth weight increased from 2884.2 g, 2903.9 g
and 3188.9 g (P = 0.002) with IFA pill intake of < 45, 45-89, ≥ 90 pills respectively. A
multivariate analysis of odds ratio showed that women who took more than 60 pills
reduced the risk of LBW significantly (OR = 0.11, 95% CI: 0.02, 0.056, P = 0.008). On
this basis again the hypothesis is accepted. The implication of these findings is that selfreported intake of prenatal IFA can be used to predict birth outcomes. In other words,
self-reported intake of IFA can be used as a monitoring tool for the prenatal
supplementation program in Malawi, to enforce compliance in the interest of reducing
LBW prevalence. However, the question still stands is whether we should stick to the
WHO guidelines of a minimum of 180 pills (6 months intake) of IFA during pregnancy
considering that >90 pills already shows significant difference.
Therefore, self-reported IFA intake (compliance) in pregnancy is a predictor of
birth weight. Compliance can be improved if the Malawian government improves the
supply of IFA pills in clinics, through education make every pregnant woman attend
prenatal clinics early in pregnancy, and possibly adding pill count to the questions asked
at follow up before supplying the next consignment of IFA pills.

97

Recommendations and future studies
In this study, we have demonstrated that self-reported compliance to prenatal IFA
intake is associated with improved biomarker status before delivery (hemoglobin) and
reduced risk of LBW. We also showed that taking ≥ 60 IFA pills or more is significantly
associated with reduced risk of LBW. Therefore, we recommend that self-reported
compliance be used as a monitoring and evaluation tool in prenatal clinics to ensure
adherence to IFA intake as it will improve birth outcomes. Self-reported compliance to
IFA intake is a valid tool to assess and predict hematological status in the pregnant
women before delivery and newborn health at birth. We hereby also recommend that
extensive education to be carried out in communities and prenatal clinics to pregnant
women and women of child bearing age, so that they understand the importance of taking
prenatal IFA supplements. Given the challenging levels of compliance to WHO
recommendation of taking prenatal IFA through out pregnancy or at least a minimum of
180 pills, we suggest that prenatal clinics ensure that women take at least 60 – 90 pills of
IFA since this has the potential to reduce risk of LBW.
However, more studies need to be done to find optimum minimum level of IFA
intake, which gives similar beneficial results in Malawi women. Since ours was a cross
sectional study, we recommend a longitudinal study which will take into account the
changes in availability of food due to seasonality of food security in Malawi. A
longitudinal population study may also show what happens to the infants who were born
small, from mothers with low hemoglobin and folate status in terms of infant mortality
and linear growth in general. We also recommend that such studies should include dietary
recalls to account for differences in dietary exposure among pregnant women.

98

APPENDICES

99

Appendix A: Literature Review Articles
Table 14. Summarized literature review of selected articles.
Author
Objective
Design of the Study Subject and Parameter

(Hjertholm et
al.,
2017)Hjertholm
et. al 2017

Major Findings

To examine the

Cross sectional

Dietary intake (macronutrients

Milk, vitamin C and fat were

association

study in rural

and 11 micronutrients of 203

positively associated with birth

between maternal

Malawi

pregnant at 28 and 35 weeks

weight while carbohydrate had

dietary during

gestation and neonatal

negative association

pregnancy intake

anthropometry measured at

and infant birth

birth (n=132). Used 3 day

size

interactive 24HR recall

To examine the

Cross sectional

Any use of Iron and folic acid

The risk of LBW was reduced by

impact of antenatal

study using the

use and maternal perception of

18% for IFA users and starting IFA

IFA

Pakistan

birth size and birth weight.

in first trimester significantly

(Nisar and

supplementation on demographic and

They used multivariate logistic

reduced the risk of LBW in 19% of

Dibley, 2016)

perceived birth size health survey

regression analysis and

babies and 11% attributable risk of

and birth weight in

(PDHS) 2006-2007,

adjusted for 13 confounders

smaller birth weight for non-use of

Pakistan over a 5-

n=5962

IFA

year

100

Table 14. (cont’d).
Author
Objective

Design of the Study

Subject and Parameter

Major Findings

(Owens et al.

Multiple

Randomized, double

Subjects supplemented with

Placental vascular function was

2015)

micronutrient

blind, placebo

UNICEF/WHO/United Nations

modifiable by preconception multiple

supplementation

controlled clinical

University multiple

micronutrient supplementation

and placental

trial in Gambia, (n

micronutrient preparation

(UNIMMAP)

function

=1137, and 415

(UNIMMAP) or placebo.

pregnancies).

Placental transport capacity at
birth scanned.

(Abass et al.,

Determine

2014)

Case control in a

50 cases with birth weight of

Low maternal and cord blood serum

association between hospital in Sudan

less then 2500g and 50 controls

zinc was associated with LBW in

low plasma zinc

with birth weight above 2500g,

babies

and low birth

checked serum zinc levels

weight
(Rwebembera Relationship

Case control study in 84 cases with birth weight of

Low maternal and cord blood serum

et al., 2006)

between infant

a Hospital in

less then 2000g and 84 controls

zinc was associated with LBW OR

weight and

Tanzania

with birth weight above 2000g,

2.6 (CI 1.36 – 5.73)

maternal zinc status

checked serum zinc levels

101

Table 14. (cont’d).
Author
Objective

Design of the Study

(Kishosha et

To determine

Case control study in 46 cases and 46 controls. Blood

Mean serum selenium level in goiter

al., 2011)

association of low

Uganda

samples were taken to

patients (77.25ug/l (SD 16.78) lower

determine selenium

than in the non-goiter controls (95.50

concentration

ug/l (SD 24.47), p<0.005.

selenium and goiter

Subject and Parameter

Major Findings

(Gebremedhin Coverage and

Cross-sectional

414 pregnant women and 1,573

Coverage was only 35% of women.

et al., 2014)

compliance for

study in 8 random

women one post delivery. Data;

Only 3.5% took iron for 91 days as

using prenatal iron

districts in Ethiopia

multi-stage sampling and using

recommended by WHO. The odds of

a structured questionnaire

receiving iron supplements increased

supplements in
eight rural districts

with increased antenatal attendance;

of Ethiopia

1, 2, 3, 4, had 0.04, 0.33, 0.50 and
0.60 respectively.

(Preziosi et

Iron

Randomized placebo 197 pregnant women received

Neonatal length and Apgar scores

al., 1997)

supplementation on

controlled clinical

100mg iron from 28 week

improved by iron supplements. Iron

the iron status of

trial in Niger

gestation until delivery. Four

decreased anemia.

mothers and infant

blood samples taken from entry

health.

day, during labor, cord and heel
of baby, and anthropometric

102

Table 14. (cont’d).
Author
Objective

Design of the Study

Subject and Parameter

Major Findings

(Makrides et

Assessing effect of

Randomized, double

430 women followed up to 6

No significant differences in

al., 2003)

prenatal IDA and

blind, placebo

months postpartum after a low

gestational age at birth, birth weight,

iron deficiency

controlled clinical

dose iron supplement of 20 mg

birth length, birth head

from low dosage

trial using iron

given from 20 weeks gestation

circumference, Apgar scores, or the

(20 mg/d) of iron,

supplementation in

level of neonatal care required

and side effects

Australia

between the iron- supplemented and
placebo groups.

(Hill et al.,

Factors that affect

Field

Semi-structured questionnaire

Knowledge low, taking medicines

2007)

adoption and

trial/community

administered during interviews

when healthy was new concept.

adherence to

survey in Ghana

and focus groups. 4-month

Supplements accepted when motive

capsule given to 60 women.

explained. Factors affecting adoption:

weekly vitamin A
supplementation in

perceived side effects, vitamins are

Ghana, (individual,

family planning; supplements are for

cultural)

the childless or pregnant,
forgetfulness, herbal medicines and
IEC

103

Table 14. (cont’d).
Author
Objective

Design of the Study

Subject and Parameter

Major Findings

(Thirukkanesh To determine the

Cross-sectional

118 mostly third trimester

49.2% complied with mineral and

and Zahara,

compliance of

study in Malaysia

pregnant women aged >28, 62

vitamin supplements, not different

2010)

vitamin and mineral

urban and 56 rural. Used self-

between rural and urban in

supplementation of

reported questionnaire and

compliance. Lower hemoglobin in

women in prenatal

hemoglobin from prenatal

non-compliant groups

clinics in urban and

records

rural areas
(Steer, 2000)

Association of

Systematic review

A presentation at a symposium

Low hemoglobin (<80g/L) is

maternal

article

Maternal nutrition in 1998 in

associated with low birth weight,

Hemoglobin

Paris; new developments and

SGA, and preterm birth >84g/L is

concentration and

implications

considered optimal

birth outcomes

104

Table 14. (cont’d).
Author
Objective

Design of the Study

Subject and Parameter

Major Findings

(Kalimbira

Assess maternal

A cross-sectional

629 women were randomly

22%, 28% and 33% in central,

et al., 2009)

knowledge and

study in northern,

selected in all the 3 regions of

northern and southern respectively

practices related to

central and southern

the country and interviewed

reported taking iron supplements for

anemia and iron

Malawi

using a pre-tested questionnaire

one month only. 43% non-

supplementation in

compliance due to nausea

rural areas
(Young et

Comparing the

A simply

413 pregnant women, first

Initial hemoglobin for daily and

al., 2000)

effectiveness of

randomized clinical

group got 60mg iron/0.25 folate

weekly supplemented groups

weekly and daily

trial at a prenatal

daily (n=211) and second got

105.7g/L and 104.4g/L. Final was

iron supplement and unit in a hospital in

120mg iron/0.50 folate weekly

107.5g/L and 105.6 respectively, no

compliance

(n=202). Initial and later final

significant difference. Self-reported

Hemoglobin and compliance

and pill count compliance was higher

checked at 10th week

in weekly supplemented group, also

northern Malawi

had less side effects

105

Appendix B: Architect i System for Folate Analysis
ARCHITECT i Systems reagents:
ARCHITECT Folate Reagent Kit (1P74-25, 1P74-35) 100 tests.
• Microparticle -1 Bottle (6.6 mL per 100℃test bottle) Anti-Folate Binding Protein
(mouse, monoclonal) coupled to microparticles affinity-bound with Folate Binding
Protein (bovine), in TRIS buffer with protein stabilizers (human serum albumin and
caprine). Minimum concentration: 0.08% solids. Preservatives: Sodium azide and
antimicrobial agents.
• Conjugate - 1 Bottle (29.0 mL per 100-test bottle) Pteroic Acid (PTA) - acridinium
labeled conjugate in MES buffer with protein stabilizer (porcine). Minimum
concentration: 4 ng/mL. Preservative: antimicrobial agents.
• Assay specifc diluent -1 Bottle (5.7 mL per 100-test bottle/25.3 mL per 500-test
bottle) Folate Assay Specific Diluent containing borate buffer. Preservatives: sodium
azide and antimicrobial agents.
• Pretreatment 1 - Bottle (50.2 mL per 100-test bottle) Folate Pre-Treatment Reagent 1
containing potassium hydroxide.
• Pretreatment 2 - 1 Bottle (6.6 mL per 100-test bottle) Folate Pre-Treatment Reagent 2
containing dithiothreitol (DTT) in acetic acid buffer with EDTA.
• Specimen diluent - 1 Bottle (5.5 mL per 100-test bottle) Folate Specimen Diluent
containing TRIS buffer with protein stabilizer (human serum albumin). Preservative:
sodium azide.
ARCHITECT Folate (1P74-50)
• Manual Diluent -1 Bottle (4 mL) containing TRIS buffer with protein stabilizer
106

(human serum albumin). Preservative: sodium azide.
• Folate RBC Lysis Diluent (L2) - 1 Bottle (12.5 mL) containing citric acid and
guanidine hydrochloride. Preservative: antimicrobial agent.
• Folate Lysis Reagent (L1) - 4 Bottles (285-385 mg each) containing ascorbic acid and
guanidine hydrochloride.
• Pre-Trigger Solution - containing 1.32% (w/v) hydrogen peroxide.
• Trigger Solution - containing 0.35 N sodium hydroxide.
• Wash Buffer - containing phosphate buffered saline solution. Preservative:
antimicrobial agents.
The specimens were mixed thoroughly by low speed vortexing for 10 times. To ensure
consistency in results, specimens were transferred to a centrifuge tube and centrifuged before
testing because they were frozen and thawed, also if they contained fibrin, red blood cells in
serum, or other particulate matter.
Procedure for the Determination of Folate in Red Blood Cells (RBC)
NOTE: Hematocrit of EDTA specimen is determined first and used later to calculate the
corrected value of RBC folate if the results fall out of range.
Part 1: Reconstitution of Folate Lysis Reagent (L1)
Reconstitution was done using one bottle of Folate Lysis Reagent (L1) by adding 30
mL distilled or deionized water.
• The reagent bottle was capped and mixed by inverting 10 times and let stand for 15
minutes.
Part 2: Preparation of Red Blood Cell Hemolysate
NOTE: The assay was initiated on the final hemolysate within 2 hours as recommended for

107

ARCHITECT i system.
• The reconstituted Folate Lysis Reagent (L1) was inverted an additional
10 times. Pipetted 1.0 mL into a suitable sample tube with a cap (example: 2 mL tube).
• Mixed whole blood tube by inverting 10 times to ensure a homogeneous sample.
•100 μL of whole blood sample was added to the sample tube containing the 1.0 mL of
the reconstituted Folate Lysis Reagent (L1).
• Capped the tube and mixed by inverting 10 times or vortexing and allow to stand at
room temperature (15-30 °C) for 90 minutes ± 5 minutes). Protect from light.
• Pipetted 100 μL ARCHITECT Folate RBC Lysis Diluent (L2) into a new sample tube
(or ARCHITECT sample cup). Then add 100 μL of hemolyzed sample.
• Mix by swirling or vortexing and initiate assay on this sample within 2 hours.
Running the assay on ARCHITECT i system (Folate and Folate RBC Assays)
After preparing hemolysate and serum samples above, analysis preceded on the
ARCHITECT i system.
Inverted the microparticle bottle 30 times until microparticle re-suspend. Once the
microparticles have been re-suspended, the cap was removed and discarded. Wearing
clean gloves, removed a septum from the bag and placed it septum on the bottle. The
ARCHITECT Folate Reagent Kit was Loaded on the ARCHITECT i System. When
running a serum or plasma specimen/control, Folate II (assay 685 “UNDILUTED”)
was selected on the ARCHITECT i system. When running a whole blood specimen or
whole blood control, Folate RBC (assay number 686, “RBC DIL”) was selected on the
ARCHITECT i system.

108

Table 15. Summary descriptive statistics.

Appendix C: Descriptive Statistics

Category

Variable

Newborn
characteristics

Birth weight (g)
Birth length (cm)
Head Circumference (cm)
APGAR Score 1minute
APGAR score 5 minute
Weight for height Z-scores
Height for age Z-scores
Weight for age Z-scores
BMI for age Z-scores
Head circ Z-scores
Age
Maternal WT- 1 (kg)
Maternal WT- 2 (kg)
Maternal height (cm)
Gravidity
Parity
Gestation age
Number of IFA
Number of ANC visits

Pregnancy & antenatal
care

n

Mean

Median

Std. Dev.

Minimum

Maximum

213
209
210
209
209
176
208
213
207
210
213
185
141
185
212
212
189
205
207

2919.2
47.8
34.4
8.1
9.7
-0.671
-0.8
-0.9
-0.7
0.2
25.2
59.3
65.6
154.7
2.7
1.6
36.8
53.6
3.3

3000.0
48.4
35.0
8.0
10.0
-0.67
-0.6
-0.7
-0.6
0.4
24.0
58.0
64.0
154.0
2.0
1.0
37.0
60.0
3.0

514.3
3.6
2.1
1.4
1.2
1.5846
1.7
1.2
1.5
1.7
6.4
9.9
11.1
5.9
1.7
1.6
1.8
36.6
1.1

1300.0
32.5
25.0
0.0
0.0
-6.5
-5.7
-5.0
-6.4
-7.5
14
38.0
48.6
141.0
1.0
0.0
28.0
0
0

4100
57
40
10
10
3.8
4.22
1.57
3.95
5.17
43
100
110
170.5
9
8
41
160
6

109

Table 15. (Cont’d)
Maternal IFA status

Hb- 1 (g/dl)
29
9.3
Hb- 2 (g/dl)
199
11.1
Serum folate (nmol/L)
101
8.8
RBC Folate (nmol/L)
101
493.9
Placenta weight
Placenta weight (g)
171
570.7
Economic status
Annual HH income ($)*
154
884.8
*USD $1= MK721 (Malawi kwacha), roughly at the time of the survey

110

9.3
11.2
8.0
391.0
565.0
499.3

1.7
1.7
4.4
388.6
141.5
1677.5

4.3
6.9
2.0
138.0
222.0
69.3

12.9
15.5
31
2317
1029
13,869.3

Appendix D: Consent Form (English)
Research participant information and consent form
You are being asked to participate in a research study. Researchers are required to
provide a consent form to inform you about the research study, to convey that
participation is voluntary, to explain risks and benefits of participation, and to empower
you to make an informed decision. You should feel free to ask the researchers any
questions you may have.
Study Title: Compliance to prenatal supplements as a determinant of LBW in Malawi
Researcher and Title: Won Song, Professor of Human Nutrition
Department and
Institution: Food Science and Human Nutrition, Michigan State University
Address and Contact Information: Phone; +1 517 6143636 song@anr.msu.edu
1. PURPOSE OF RESEARCH
• You are being asked to participate in a research study of Compliance to prenatal
supplements as a determinant of LBW in Malawi
• You have been selected as a possible participant in this study because you are pregnant
and coming for delivery of your baby in this hospital. 

• From this study, the researchers hope to learn how compliance to prenatal supplements
affects the health of the newborn baby at birth. The results shall also be used to write a
thesis to meet requirements of Masters study at Michigan State University. 

• Your participation in this study will take about 15 minutes. 

2. WHAT YOU WILL DO
• 
You will be asked a few questions on prenatal supplements use and your medical
record on antenatal care will be abstracted. We will use part of the blood sample routinely
drawn by midwives and doctors during admission to maternity ward (for grouping and
111

cross matching to keep blood in the bank for you in case you need a transfusion during
labor).
• Upon delivery of your baby the midwife will collect a blood sample from the umbilical
cord after it is cut and the placenta will be weighed. This will happen after making sure
you are fine and will not be done by the same midwife responsible for your care and
newborn.
• After your baby has received the initial care the research midwife will also abstract the
medical record of your newborn specifically APGAR scores, weight, length and head
circumference. If you choose not to participate in the study your care will not change,
you will still have access to midwives and doctors. 

3. POTENTIAL BENEFITS

The potential benefits to you for taking part in this study are that you will know the
health status of your child if you choose to know the results and at the end we would like
to give your newborn a gift (incentive) of a wrapper.
However, your participation in this study may contribute to the understanding if how the
Malawi government’s prenatal micronutrient supplementation to all pregnant women is
working in terms of compliance. And it will add knowledge on how early malnutrition
may start showing symptoms in newborns. 

4. POTENTIAL RISKS

There are no risks to you or your baby for participating in the study, as it does not
involve new procedures apart from those already routinely done in clinical practice. We
shall collect the placenta for weighing and cord blood at the point when the nurse would
throw away the placenta and cord. However, if some measurements were not done
thoroughly on newborn, the researchers may want to repeat and that may lead to a short
separation of you and your newborn. But we shall try our best to keep you or your
guardian close while measurements are done.

112


5. PRIVACY AND CONFIDENTIALITY 

• The data for this study are being collected confidentially. Information about you will be
kept confidential to the maximum extent allowable by law. Only the research team, and
the Michigan State University Human Research Protection program shall have access to
the data. The data shall be stored at the Food and Nutrition Database Research Center in
the department of Food Science and Human Nutrition at Michigan State University for a
minimum of 3 y .
The results of this study may be published or presented at professional meetings, but the
identities of all research participants will remain confidential.
6. YOUR RIGHTS TO PARTICIPATE, SAY NO, OR WITHDRAW
• Participation is voluntary. Refusal to participate will involve no penalty or loss of
benefits to which you are otherwise entitled. You may discontinue participation at any
time without penalty or loss of benefits to which you are otherwise entitled. 

• You have the right to say no. 

• You may change your mind at any time and withdraw. 

• You may choose not to answer specific questions or to stop participating at any time. 

• Choosing not to participate in this study will not make any difference in the quality of
any treatment you may 
receive during labor and delivery of your baby.

7. COSTS AND COMPENSATION FOR BEING IN THE STUDY

There are no costs on your side for taking part in the study and therefore there is no
compensation that you will get for being in this study.

8. CONTACT INFORMATION

If you have concerns or any questions about this study, such as scientific issues, how to
do any part of it, or to report an injury, please contact the researcher: Dr. Won Song. 469
113

Wilson RD Trout Building RM 135, Michigan State University, MI 48824, or email
song@anr.msu.edu or Phone; +15173533332

If you have questions or concerns about your role and rights as a research participant,
would like to obtain information or offer input, or would like to register a complaint
about this study, you may contact, anonymously if you wish, the Michigan State
University’s Human Research Protection Program at 517-355-2180, Fax 517-432- 4503,
or e-mail irb@msu.edu or regular mail at 408 West Circle Drive, Olds Hall Room 207,
MSU, East Lansing, MI 48824.
9. DOCUMENTATION OF INFORMED CONSENT

Your signature line below means that you voluntarily agree for you and your child to
participate in this research study. Signature________________
 Date

_____/_____/________
Your signature below means that you voluntarily agree for your child to participate in this
research. 

Signature__________________________Date 
_____/_____/_________ Signature of
Assenting Child (15-17)____________Date______/_____/____ 

You will be given a copy of this form to keep. 

This consent form was approved by a Michigan State University Institutional
Review Board. Approved 07/13/16 – valid through 07/12/17. This version supersedes
all previous versions. IRB # 16-837. 


114

Appendix E: Consent Form (Chichewa Version)
Kalata wa chivomelezo cholowa kafukufuku
Mukupemphedwa kutengapo gawo pa kafukufuku. Ochita kafukufuku amayenera kupereka
chikalata ichi chofotokoza za ubwino ndi kuipa kotangapo gawo pa kafukufuku kuonenetsetsa
kuti kutengapo gawo kwanu ndi chiganizo chomwe mwapanga mosakakamizidwa koma
mwaufulu wanu. Choncho ndinu omasuka kufunsa funso lililonse lomwe mungakhale nalo kwa
ochita kafukufuku.
Mutu wa kafukufuku: Kulondoloza kwa mankhwala ochulukitsa magazi operekedwa ku sikelo,
ndi zotsatira zake pa ana operewera sikelo

Mwini kafukufuku ndi udindo wake: Won Song, Professor wa zamadyedwe
athanzi Komwe
akuchokera: Food Science and Human Nutrition, Michigan State University
Keyala ndi nambala ya lamnya: +1 517 614 3636, song@anr.msu.edu
1. CHOLINGA CHA KAFUKUFUKU
• Mukufunsidwa kutengapo gawo pa kafukufuku wa Kulondoloza kwa mankhwala ochuluktsa
magazi operekedwa ku sikelo, ndi nthanzi la nsengwa/matenda posiyanitsa ndi kulemera kwa
nsengwa, malilidwe, kulemera ndi msinkhu wa mwana pobadwa ku Malawi.
• Mwasankhidwa chifukwa chakuti ndinu oyembekezera ndipo mwabwera kudzachilira mu
chipatala chino. 

• Ochita kafukufuku uyu akufuna kudziwa Kulondoloza kwa mankhwala ochulukitsa magazi
operekedwa ku sikelo, ndi nthanzi la nsengwa/matenda posiyanitsa ndi kulemera kwa nsengwa,
malilidwe, kulemera ndi kwa mwana pobadwa ku Malawi kuno. Zomwe zimayimira thanzi la
mwana pamapeto pake. Zotsatira za kafukufuku zigwiritsidwa ntchito pokwaniritsa zofunikira pa
maphunziro a ukadaulo ku sukulu ya 
ukachenjede ya Michigan State University ku America. 

• Kafukufuku adzatenga pafupifupi theka la ola. 

2. ZOMWE TIDZACHITE 

Mudzafunsidwa mafunso ochepa za mankhwala amagazi aku sikelo ndiponso tidzafuna
tilembeko zina zomwe zili m’buku lanu la kuchipatala. Tidzafuna tiyezeso kudziwa kuchuluka
kwa magazi ndi mchere mmagazi anu omwe a nurse adzatenge kutumiza kwa oyeyeza.
Pamene mwana wanu wabadwa Namwino/mzamba adzatenga magazi pang’ono ku nsengwa
komanso kuyeza pa sikelo nsengwayo. Mwananso akadzamaliza kulandira thandizo loyambilira
tidzamuyesa sikelo, msinkhu, kukula kwa mutu ndi kulemba momwe analilira pobadwa.
Dziwani kuti ngati mutasankha kusatengapo gawo pakafukufuku uyu, thandizo lomwe a
mzamba/Namwino kapena a dotolo adzapereke kwa inu silidzasintha chifukwa simunalowe
mkafukufuku.
115


3. PHINDU LOLOWA MU KAFUKUFUKU
Phindu lotengapo gawo pa kafukufuku uyu ndi lakuti mudzadziwa thanzi la mwana wanu
potengera momwe mumalondolozera mankhwala ochulukitsa magazi ku sikelo ngati
mungasankhe kumva zotsatirazo. Komanso tidzafuna kupereka ka mphatso kangachepe kwa
mwana wanu imene ili chitenje.
Komabe dziwani kuti kutengapo gawo kwanu mukafukufuku uyu kudzathandiza ngakhale Boma
kudziwa momwe azimayi oyembekezera akulondolozera mankhwala amagazi operekedwa ku
sikelo ndiponso kuwonjezera nzeru ndi ukadaulo kuti tidziwe ngati ana akudadwa a thanzi
kapena onyetchera kale poyelekeza ndi momwe amayi anamwera mankhwala a magazi asachile.

4. KUIPA KOLOWA MUKAFUKUFUKU
Palibe vuto lilonse lomwe lingaoneke kwa inu kapena kwa mwana wanu chifukwa mwalowa
mukafukufuku ameneyu chifukwa sitidzatenga magazi owonjezera pamwamba pa omwe
amatengedwa kale kwa inu.
Mwana sitidzamubaya kapena kumutenga magazi koma kungomuyeza chabe sikelo ndi msinkhu.
Ndipo tidzatenga magazi mu nsengwa pamene azamba akufuna kutawa atamaliza
kukuthandizani.
Komabe pa nthawi yomwe tikuyesa mwana sikelo ndi msinkhu mudzasiyana naye mwana
mwakanthawi tiphindi pang’ono. Ife tidzyesetsa kuti inu kapena okuyang’anirani akhale pafupi
kuonetsetsa ndi kuwonerana zonse zomwe zikuchitika pa mwanayo.
5. KUKUSUNGIRANI CHINSINSI PA KAFUKUFUKU
Kafukufuku ndi wa chinsinsi. Wochita kafukufuku sadzapanga zoti zomwe inu mwanena
ziululike monga mwamalamulo a dziko. Amene adzadziwa za zomwe inu mwatiuza ndi ochita
kafukufuku okha ndi omwe anapereka chilolezo kuti kafukufufku achitike.
Zotsatira zidzasungidwa ku Food and Nutrition Database Research Center gawo la sayansi ya
zakudya ndi madyedwe athanzi ku sukulu ya ukachenede ya Michigan State University ku
America.
Dziwaninso kuti zotsatira zitha kudzaulutsidwa mmisonkhano ya akatswiri aza manyedwe
athanzi ndi kusindikizidwa, koma dzina lanu silidzatchulidwa kapena kulumizidwa ndi zotsatira
zanu kuti mudziwike ayi.
6. UFULU OLOWA, KUKANA NDI KUTULUKA MKAFUKUFUKU
• Kulowa mkafukufuku uyu ndu ufulu wanu. Simudzalandira chilango chifukwa chokana
kutengapo gawo pakafukufuku, kapena kutaya mwayi uliwonse. Mutha kusiya popnda
kukukanizani thandizo lilonse liene mukuyenera kulandira ngati chilango chifukwa chosalowa
mukafukufuku ayi. 

• Dziwani kuti muli ndi ufulu okana. 

• Dziwani kuti muli ndi ufulu otuluka. 

• Mutha kusankha kusayankha mafunso ena kapenanso kusiya kuyankha mafunso nthawi
116

iliyonse 

• Thandizo lanu silidzatengera kulowa kapena kukana kulowa kafukufuku ayi.

7. MALIPIRO KAPENA CHIPEPESO MKAFUKUFUKU 

Inu simudzataya kapena kuwononga/kugwiritsa ntchito ndalama yanu kapena kanthu kalikonse
(ngati malipiro) chifukwa mwalowa mkafukufuku ayi. Ndiponso zindikilani kuti simudzalandira
malipiro kapena chipepeso chilichonse chifukwa cholowa mu kafukufuku ameneyu.

8. KEYALA NDI MLAMNYA ZA MPHUNZITSI WA KAFUKUFUKU
Ngati mutakhala ndi mafunso kapena nkhawa zili zonse pa kafukufuku ameneyu, ngakhale
panthawi yomwe mwatuluka mchipatala chonde lumikizanani ndi mkulu wakafukufuku yemwe
ali Mphunzitsi wanga pa keyala ndi lamnya izi: Dr. Won Song. 469 Wilson RD Trout Building
RM 139, Michigan State University, MI 48824, kapena email song@anr.msu.edu or Phone;
+1517 353 3636. 

Ngati mutakhala ndimafunso kapena nkhawa zina zokhudzana ndi gawo kapena ufulu wanu
mukafukufukuyu ndipo mukufuna kumva zambiri kapena kuthandizapo, ngakhale kupereka
dandaulo pa kafukufuku ameneyu, mukhoza kulemba kalata kapena kuchita lamnya pa keyala
ndi nambala ya lamnya zili mmusimu; Michigan State University’s Human Research Protection
Program pa 517-355-2180, Fax 517-432-4503, kapena e-mail irb@msu.edu or regular mail at
408 West Circle Drive, Olds Hall Room 207, MSU, East Lansing, MI 48824. 

9. UMBONI WA CHIVOMELEZO
kusainila kwanu mmusimu zitanthauza kuti mwavomereza mwaufulu popanda kukakamizidwa
kuti inu ndi mwana wanu mulowe mkafukufuku.

Tikitilani______________________

Tsiku_____/____/_______ 


kusainila kwanu mmusimu zitanthauza kuti mwavomereza mwaufulu popanda kukakamizidwa
kuti mwana wanu alowe 
mkafukufuku.
Tikitilani (zaka zosakwanira 18)_____________

Tsiku_____/_____/_______

Mudzalandira kalata iyi kuti inunso musunge.
This consent form was approved by a Michigan State University Institutional Review
Board. Approved 07/13/16 – valid through 07/12/17. This version supersedes all previous
versions. IRB # 16-837.

117

Appendix F. Survey Instrument
Name of interviewer …………………………………….
Date of interview ……………………………………….

Official use
Code:………….

SECTION A: PERSONAL IDENTIFICATION / BASIC CHARACTERISTICS (From the
chart)
ID
Question
Response
Chart Ask
Test
Name of patient
A1
√
A2

Age of patient

√

A3

Height

√

A4

Booking visit weight

√

A5

Number of prenatal visits

√

A6

Area of residence/village

√

A7

Gravidity

√

A8

Parity

√

A9

Education; highest level of
school Attained

A10

Occupation

A11

Annual income of household
head

(1)
(2)
(3)
(4)
(5)

Junior primary (grade 1-4)
Senior primary (5-8)
Secondary
College
Never been to school

√

√
√
MK………………………..

SECTION B: ANTENATAL AND NUTRITION CARE
Gestation age at
B1
(1) First trimester (Why?)
first visit
………………………………………
……………
(2) Second trimester
118

√

B2
B3

B4
B5
B6

B7

Use of
contraceptives prior
to this pregnancy
History of major
illness in this
pregnancy
History of
transfusion in this
pregnancy
Booking visit
Hemoglobin (from
health passport)
Screened for the
following diseases:

Vaccinated against
tetanus or other

(3) Third trimester (why?)
………………………………………
……………
(1) Hormonal
(2) Physical
(3) None
(1) Yes required hospital admission
(2) Yes, but just received prescription
(3) Yes it resolved on itself
(4) None
(1) Yes
(2) No
Hemoglobin…………………. g/dl
1.
2.
3.
4.
5.
(1)
(2)
(3)

Malaria…………. (Yes/No)
HIV………………. (Yes/No)
Syphilis…………. (Yes/No)
UTI……………….. (Yes/No)
Helminthes……. (Yes/No)
Yes
No
Other ………………………

√
√

√
√

√
√

SECTION C: MICRONUTRIENT SUPPLEMENTATION AND COMPLIANCE
FACTORS
Did you receive
(1) Yes
C1
iron and folate
(2) None (why?)
√
supplements
…………………………………….
C2

C3

C4

How long did you
take supplements?

Which type of salt
do you commonly
use?

Have you ever

(1) Less than a week (Why?)
………………………………………..
(2) Less than a month (Why?)
………………………………………
…
(3) Two months or more
(1) Closed container, packet or bottle
from shops (Why)
………………………………………
……
(2) Sold by vendors at the market opened
and exposed to the sun
Yes / No
119

√

√

√

C5
C6
C7

C8

heard about iodine?
Mention any
importance of
iodine?
Did you receive
anti-malaria
prophylaxis (SP)?
Did you receive
anti-helminthes
prophylaxis
(albendazole)?

Are you on longterm drug treatment
for any chronic
disease?

(1) Correct response
(2) Wrong response
(3) Don’t know

√
√
√

(1)
(2)
(3)
(4)

Tuberculosis treatment
Anti-retroviral
Steroids
Other
(specify)………………………………

SECTION D: PLACENTAL WEIGHT, NEWBORN APGAR SCORES &
ANTHROPOMETRICS
Placental weight
…………………………………….. gs
D1
D2

APGAR scores

√

√

At 1 minute ………………….. /10
At 5 minutes ……………….. / 10

√

D3

Birth weight

…………….. g

√

D4

Birth length

…………… cm

√

D5

Head
Circumference
Chest
circumference

…………… cm

√

…………… cm

√

D6

SECTION E: LABORATORY ANALYSIS OF MATERNAL
Maternal blood
Iodine
E1
E2

Iron

(1) TSH…………….
(2) T3………………
(1) Hemoglobin……………. g/dl
(2) Ferritin ………………… ug/L
END OF QUESTIONNAIRE

120

√
√

Appendix G: Survey Tool (Chichewa Version)
Dzina la Ofunsa Mafunso …………………………………….
Tsiku ……………………………………….

GAWO A: ZOKHUDZA AMAYI
ID
Funso
Yankho

Official use
Code:………….

A1

Dzina la Amayi

Onani
m’buk
u
√

A2

Zaka za Amayi

√

A3

Mudzi/kochokera

√

A4

Sikelo yoyambilira

√

A5

Ku sikelo munapita
kangati?
Msinkhu wa amayi

√

√

A8

Pakati ndi miyezi
ingati?
Anaberekapo kangati?

A9

Maphunziro

A6
A7

A10
A11

Amagwira Ntchito
yanji?
Pa chaka banja lanu
mumapeza ndalama
zingati?

Funs
ani

√

√
(6) Kufika sitandade 4 (grade 14)
(7) Kufika sitandade 8 (5-8)
(8) Sekondale
(9) Kufika sukulu ya
ukachenjede
(10) Sanapiteko ku sukulu

√

√
√
MK………………………..

121

Ye
za
ni

GAWO B: ZA KU SIKELO NDI MADYEDWE ATHANZI
Sikelo munayamba
B1
(4) Isanapitilire miyezi itatu
muli ndi pakati
(Chifukwa chiani?)
miyezi ingati?
………………………………
……………………
(5) Miyezi yosapitilira isanu ndi
umodzi
(6) (chifukwa?)
………………………………
……………………
Mumagwiritsa kulera (4) Obaya/mapilitsi/noropulanti
B2
uti musanatenge
(hormonal)
mimba iyi?
(5) Lupu (physical methods)
(6) Palibe sindinatenge kulera
Munadwala matenda (5) Eya anatigoneka
B3
anji mimba iyi?
(6) Eya tinangolandira
mankhwala
(7) Eya zinasiya zokha
(8) palibe
Munalandira magazi
(3) Eya
B4
mimba iyi?
(4) Ayi
B5
B6

B7

Magazi poyamba
sikelo (onani buku)
Ku sikelo
anakuyezani matenda
awa:

Katemera wa
kafumbata

Mulingo…………………. g/dl
6. malungo………….
(eya/ayi)
7. HIV……………….
(eya/ayi)
8. Chindoko ………….
(eya/ayi)
9. Likodzo………………
(eya/ayi)
10. Njoka za mmimba…….
(eya/ayi)
(4) Eya
(5) Ayi
(6) Wina ……………………

GAWO C: KULONDOLOZA MANKHWALA OCHULUKITSA
MAGAZI NDI MICHERE YOFUNIKA M’THUPI
Munalandira
(3) Eya
C1
mankhwala
(4) Ayi (chifukwa?)
ochulukitsa magazi
………………………………
…….

122

√

√

√

√
√
√

√

√

C2

C3

C4
C5
C6
C7

C8

Munamwa
mankhwala amagazi
nthawi yayitali
bwanji?

(4) Osapitilira sabata (chifukwa?)
………………………………
………..
(5) Osapitilira
mwenzi(chifukwa?)
………………………………
…………
(6) Miyezi iwiri kapena kupitilira

Kodi kawirikawiri
(3) Ku golosala wa
mchere wanu
m’botolo/mpaketi (chifukwa)
mumagula kuti, ndipo
……………………………
wosungidwa motani?
………………
(4) Kwa mavenda/woyeza
Munabvapo za
(1) Eya
mchere wa ayodini? (2) Ayi
Tchulani ubwino wa
(4) Yankho lokhoza
ayodine?
(5) Yankho lolakwa
(6) Sadziwa
Munalandira
mankhwala a
√
malungo (SP)?
Munalandira
mankhwala a njoka
√
za mmimba
(albendazole)?

√

Muli pa mankhwala
aliwonse omwa
nthayi yaitali?

√

(5)
(6)
(7)
(8)

Eya a TB
Eya ma ARV
Eya a asima (steroids)
Ena
(tchulani)……………………
…………

GAWO D: NSENGWA/MATENDA NDI MWANA
Sikelo ya nsengwa
…………………………………
D1
(placenta)
….. Magalamu
D2

√

Malilidwe a mwana
(APGAR scores)

√
√

√

Mphindi imodzi
………………….. /10
Mphindi zisanu
……………….. / 10
123

√

D3

Sikelo ya mwana

…………….. g

√

D4

Msinkhu

…………… cm

√

D5

Kukula kwa mutu

…………… cm

√

D6

Kukula kwa
pachifuwa

…………… cm

√

GAWO E: ZOTSATIRA ZA MMAGAZI (TO BE COMPLETED IN THE LAB)
ZOTSATIRA ZA MAGAZI A MAYI
Mchere wochulukitsa (1) Hemoglobin………………..
E1
magazi
g/dl
(2) Serum folate
……………………... ug/L
(3) RBC folate

MAFUNSO ATHERA APA

124

√

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125

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