Inadequate feeding and care may contribute to high rates of stunting and underweight among children in rural families in India. This cluster‐randomized trial tested the hypothesis that teaching caregivers appropriate complementary feeding and strategies for how to feed and play responsively through home‐visits would increase children's dietary intake, growth and development compared with home‐visit‐complementary feeding education alone or routine care. Sixty villages in Andhra Pradesh were randomized into three groups of 20 villages with 200 mother–infant dyads in each group. The control group (CG) received routine Integrated Child Development Services (ICDS); the complementary feeding group (CFG) received the ICDS plus the World Health Organization recommendations on breastfeeding and complementary foods; and the responsive complementary feeding and play group (RCF&PG) received the same intervention as the CFG plus skills for responsive feeding and psychosocial stimulation. Both intervention groups received bi‐weekly visits by trained village women. The groups did not differ at 3 months on socioeconomic status, maternal and child nutritional indices, and maternal depression. After controlling for potential confounding factors using the mixed models approach, the 12‐month intervention to the CFG and RCF&PG significantly ( P < 0.05) increased median intakes of energy, protein, Vitamin A, calcium (CFG), iron and zinc, reduced stunting [0.19, confidence interval (CI): 0.0–0.4] in the CFG (but not RCF&PG) and increased ( P < 0.01) Bayley Mental Development scores (mean = 3.1, CI: 0.8–5.3) in the RCF&PG (but not CFG) compared with CG. Community‐based educational interventions can improve dietary intake, length (CFG) and mental development (RCF&PG) for children under 2 years in food‐secure rural Indian families.
Eight World Health Organization (WHO) feeding indicators (FIs) and Demographic and Health Survey data for children <24 months were used to assess the relationship of child feeding with stunting and underweight in 14 poor countries. Also assessed were the correlations of FI with country gross national income (GNI). Prevalence of underweight and stunting increased with age and ≥50% of 12–23‐month children were stunted. About 66% of babies received solids by sixth to eighth months; 91% were still breastfeeding through months 12–15. Approximately half of the children were fed with complementary foods at the recommended daily frequency, but <25% met food diversity recommendations. GNI was negatively correlated with a breastfeeding index ( P < 0.01) but not with other age‐appropriate FI. Regression modelling indicated a significant association between early initiation of breastfeeding and a reduction in risk of underweight ( P < 0.05), but a higher risk of underweight for continued breastfeeding at 12–15 months ( P < 0.001). For infants 6–8 months, consumption of solid foods was associated with significantly lower risk of both stunting and underweight ( P < 0.001), as was meeting WHO guidance for minimum acceptable diet, iron‐rich foods (IRF) and dietary diversity ( P < 0.001); desired feeding frequency was only associated with lower risk of underweight ( P < 0.05). Timely solid food introduction, dietary diversity and IRF were associated with reduced probability of underweight and stunting that was further associated with maternal education ( P < 0.001). These results identify FI associated with growth and reinforce maternal education as a variable to reduce risk of underweight and stunting in poor countries.
Improving the nutritional status of infants and young children in developing countries depends to a significant extent on adoption of optimal nutrition‐related practices within the context of the household. Most policies, research and programmes on child nutrition in non‐Western societies focus narrowly on the mother–child dyad and fail to consider the wider household and community environments in which other actors, hierarchical patterns of authority and informal communication networks operate and influence such practices. In particular, the role and influence of senior women, or grandmothers , has received limited attention. Research dealing with child nutrition from numerous socio‐cultural settings in Africa, Asia and Latin America reveals three common patterns related to the social dynamics and decision‐making within households and communities. First, grandmothers play a central role as advisers to younger women and as caregivers of both women and children on nutrition and health issues. Second, grandmother social networks exercise collective influence on maternal and child nutrition‐related practices, specifically regarding pregnancy, feeding and care of infants, young children and sick children. Third, men play a relatively limited role in day‐to‐day child nutrition within family systems. The research reviewed supports the need to re‐conceptualize the parameters considered in nutritional policies and programmes by expanding the focus beyond the mother–child dyad to include grandmothers given their role as culturally designated advisers and caregivers.
The World Health Organization and UNICEF define non‐oedematous severe acute malnutrition (SAM) either by a mid‐upper arm circumference (MUAC) less than 115 mm or by a weight‐for‐height z‐score (WHZ) less than –3. The objective of this study was to assess whether there was any benefit to identify malnourished children with a high risk of death to combine these two diagnostic criteria. Data of a longitudinal study examining the relationship between anthropometry and mortality in rural Senegal and predating the development of community‐based management of SAM were used for this study. First, the receiver operating characteristic (ROC) curves of MUAC and of WHZ to predict mortality were drawn, and then the points corresponding to WHZ less than –3 and/or MUAC less than 115 mm were positioned in relation to these curves. MUAC had the highest ROC curve, which indicates that it identifies high‐risk children better than WHZ. Both points representing WHZ less than –3 and/or MUAC less than 115 mm were below the MUAC ROC curve. It is concluded that to identify high‐risk malnourished children, there is no benefit in using both WHZ less than –3 and/or MUAC less than 115 mm, and that using MUAC alone is preferable.
Improving infant and young child feeding practices will help South Asian countries achieve the Millennium Development Goal of reducing child mortality. This paper aims to compare key indicators of complementary feeding and their determinants in children aged 6–23 months across five South Asian countries – Bangladesh, India, Nepal, Pakistan and Sri Lanka. The latest Demographic and Health Survey and National Family Health Survey India data were used. The analyses were confined to last‐born children aged 6–23 months – 1728 in Bangladesh, 15 028 in India, 1428 in Nepal, 2106 in Sri Lanka and 443 infants aged 6–8 months in Pakistan. Introduction of solid, semi‐solid or soft foods, minimum dietary diversity, minimum meal frequency and minimum acceptable diet, and their significant determinants were compared across the countries. Minimum dietary diversity among children aged 6–23 months ranged from 15% in India to 71% in Sri Lanka, with Nepal (34%) and Bangladesh (42%) in between. Minimum acceptable diet among breastfed children was 9% in India, 32% in Nepal, 40% in Bangladesh and 68% in Sri Lanka. The most consistent determinants of inappropriate complementary feeding practices across all countries were the lack of maternal education and lower household wealth. Limited exposure to media, inadequate antenatal care and lack of post‐natal contacts by health workers were among predictors of inappropriate feeding. Overall, complementary feeding practices among children aged 6–23 months need improvement in all South Asian countries. More intensive interventions are necessary targeting the groups with sup‐optimal practices, while programmes that cover entire populations are being continued.
Breast milk fatty acid (FA) composition varies greatly among individual women, including in percentages of the long‐chain polyunsaturated FAs (LCPUFA) 20:4n‐6 (arachidonic acid, AA) and 22:6n‐3 (docosahexaenoic acid, DHA), which are important for infant neurological development. It has been suggested that owing to wide variation in milk LCPUFA and low DHA in Western diets, standards of milk FA composition should be derived from populations consuming traditional diets. We collected breast milk samples from Tsimane women at varying lactational stages (6–82 weeks). The Tsimane are an indigenous, natural fertility, subsistence‐level population living in Amazonia Bolivia. Tsimane samples were matched by lactational stage to samples from a US milk bank, and analysed concurrently for FA composition by gas‐liquid chromatography. We compared milk FA composition between Tsimane ( n = 35) and US ( n = 35) mothers, focusing on differences in LCPUFA percentages that may be due to population‐typical dietary patterns. Per total FAs, the percentages of AA, DHA, total n‐3 and total n‐6 LCPUFA were significantly higher among Tsimane mothers. Mean percentages of 18:2n‐6 (linoleic acid) and trans FAs were significantly higher among US mothers. Tsimane mothers' higher milk n‐3 and n‐6 LCPUFA percentages may be due to their regular consumption of wild game and freshwater fish, as well as comparatively lower intakes of processed foods and oils that may interfere with LCPUFA synthesis.
In India, poor feeding practices in early childhood contribute to the burden of malnutrition as well as infant and child mortality. This paper aims to use the newly developed World Health Organization (WHO) infant feeding indicators to determine the prevalence of complementary feeding indicators among children of 6–23 months of age and to identify the determinants of inappropriate complementary feeding practices in India. The study data on 15 028 last‐born children aged 6–23 months was obtained from the National Family Health Survey 2005–2006. Inappropriate complementary feeding indicators were examined against a set of child, parental, household, health service and community level characteristics. The prevalence of timely introduction of complementary feeding among infants aged 6–8 months was 55%. Among children aged 6–23 months, minimum dietary diversity rate was 15.2%, minimum meal frequency 41.5% and minimum acceptable diet 9.2%. Children in northern and western geographical regions of India had higher odds for inappropriate complementary feeding indicators than in other geographical regions. Richest households were less likely to delay introduction of complementary foods than other households. Other determinants of not meeting minimum dietary diversity and minimum acceptable diet were: no maternal education, lower maternal Body Mass Index (BMI) (<18.5 kg/m 2 ), lower wealth index, less frequent (<7) antenatal clinic visits, lack of post‐natal visits and poor exposure to media. A very low proportion of children aged 6–23 months in India received adequate complementary foods as measured by the WHO indicators.
Breastfeeding is a practice which is promoted and scrutinized in the UK and internationally. In this paper, we use interpretative phenomenological analysis to explore the experiences of eight British first‐time mothers who struggled with breastfeeding in the early post‐partum period. Participants kept audio‐diary accounts of their infant feeding experiences across a 7‐day period immediately following the birth of their infant and took part in related semi‐structured interviews a few days after completion of the diary. The overarching theme identified was of a tension between the participants' lived, embodied experience of struggling to breastfeed and the cultural construction of breastfeeding as ‘natural’ and trouble‐free. Participants reported particular difficulties interpreting the pain they experienced during feeds and their emerging maternal identities were threatened, often fluctuating considerably from feed to feed. We discuss some of the implications for breastfeeding promotion and argue for greater awareness and understanding of breastfeeding difficulties so that breastfeeding women are less likely to interpret these as a personal shortcoming in a manner which disempowers them. We also advocate the need to address proximal and distal influences around the breastfeeding dyad and, in particular, to consider the broader cultural context in the UK where breastfeeding is routinely promoted yet often constructed as a shameful act if performed in the public arena.
Inappropriate complementary feeding increases the risk of undernutrition, illness and mortality in infants and children. This study uses a subsample of 1428 children of 6–23 months from Nepal Demographic and Health Survey (NDHS), 2006. The 2006 NDHS was a multistage cluster sample survey. The complementary feeding indicators were estimated according to the 2008 World Health Organization recommendations. The rate of introduction of solid, semi‐solid or soft foods to infants aged 6–8 months was 70%. Minimum meal frequency and minimum dietary diversity rates were 82% and 34%, respectively, and minimum acceptable diet for breastfed infants was 32%. Multivariate analysis indicated that working mothers and mothers with primary or no education were significantly less likely to give complementary foods, to meet dietary diversity, minimum meal frequency and minimum acceptable diet. Children living in poor households were significantly less likely to meet minimum dietary diversity and minimum acceptable diet. Mothers who had adequate exposure to media, i.e. who watch television and who listen to radio almost every day, were significantly more likely to meet minimum dietary diversity and meal frequency. Infants aged 6–11 months were significantly less likely to meet minimum acceptable diet [adjusted odds ratio (OR) = 3.13, confidence interval (CI) = 2.16–4.53] and to meet minimum meal frequency (adjusted OR = 4.46, CI = 2.67–7.46). In conclusion, complementary feeding rates in Nepal are inadequate except for minimum meal frequency. Planning and promotion activities to improve appropriate complementary feeding practices should focus on illiterate mothers, those living in poor households, and those not exposed to media.
Suboptimal and inappropriate complementary feeding practices are one of the major causes of child undernutrition in the first 2 years of life in South Asian countries including Bangladesh. The aim of this study was to use the newly developed World Health Organization infant feeding indicators to identify the potential risk factors associated with inappropriate complementary feeding practices. We used data for 1728 children aged 6–23 months obtained from nationally representative data from the 2007 Bangladesh Demographic and Health Survey to assess the association between complementary feeding and other characteristics using multivariate models. Only 71% of infants were consuming soft, semi‐solid and solid food by 6–8 months of age. In the multivariate analysis, mothers who had no education had a higher risk for not introducing timely complementary feeds [adjusted odds ratio (AOR) = 2.14; 95% confidence interval (CI): 1.08–4.23, P = 0.03], not meeting the minimum dietary diversity (AOR = 1.69; 95% CI: 1.14–2.54, P = 0.01), minimum acceptable diet (AOR = 1.70, 95% CI: 1.09–2.67, P = 0.02) and minimum meal frequency (AOR = 1.73; 95% CI: 1.20–2.49, P = 0.003) than the mothers who had secondary or higher education. Infants born in Sylhet, Chittagong and Barisal division had higher risks for not meeting minimum dietary diversity, meal frequency and acceptable diet ( P < 0.001). The poorest two quintiles had poor levels of minimum meal frequency but dietary quality improved with age. In Bangladesh addressing the fourth Millennium Development Goal (MDG) target will require substantial improvement in complementary feeding practices. Appropriate Infant and Young Child feeding massages should to be development and delivered through existing health system.
Inappropriate complementary feeding increases risk of undernutrition, illness and mortality in infants and children. This paper aimed to determine the factors associated with inappropriate complementary feeding practices in Sri Lanka. The Sri Lanka Demographic and Health Survey 2006–2007 used a stratified two‐stage cluster sample of ever‐married women 15–49 years, and included details about foods given to children aged 6–23 months during the last 24 h. The new World Health Organization indicators for infant and young child feeding (IYCF) – (introduction of solid/semi‐solid or soft foods; minimum dietary diversity; minimum meal frequency; and minimum acceptable diet) were calculated for 2106 children aged 6–23 months. These indicators were examined against explanatory variables with multivariate analyses to identify factors associated with inappropriate practices. Eighty‐four per cent of infants aged 6–8 months were introduced to complementary food. The proportion of infants aged 6–8 months who consumed eggs (7.5%), fruits and vegetables other than those rich in vitamin A (29.6%) and flesh foods (35.2%) was low. Of children aged 6–23 months, minimum dietary diversity was 71%, minimum meal frequency 88% and minimum acceptable diet 68%. Children who lived in tea estate sector had a lower dietary diversity and minimum acceptable diet than children in urban and rural areas. Other determinants of not receiving a diverse or acceptable diet were lower maternal education, shorter maternal height, lower wealth index, lack of postnatal visits, unsatisfactory exposure to media and acute respiratory infections. In conclusion, complementary feeding indicators were adequate except in the 6–11 months age group. Subgroups with inappropriate feeding practices should be the focus of IYCF promotion programs.
Although exclusively breastfed infants are at increased risk of vitamin D (vit D) deficiency if vit D supplementation is lacking and sun exposure is limited, assessment of both risk factors in the first year of life is lacking. We evaluated the contribution of vit D intake and sunlight exposure to vit D status in 120 healthy, breastfeeding mother–infant dyads, who were followed up for 1 year. Vitamin D intake and skin sunlight exposure were evaluated using questionnaires. Serum 25‐hydroxyvitamin D, parathyroid hormone (PTH) and alkaline phosphatase levels were determined post‐natally in mothers at 4 weeks and in infants at 4, 26 and 52 weeks. Vitamin D supplementation was low (<20%) and sunlight exposure was common (93%) in study infants. At 4 weeks, 17% of mothers were vit D deficient (<50 nmol L −1 ) and 49% were insufficient (50–<75 nmol L −1 ), while 18% of infants were severely vit D deficient (<25 nmol L −1 ) and 77% were deficient (<50 nmol L −1 ). At 26 weeks, winter/spring birth season and shorter duration of months of exclusive breastfeeding were protective of vit D deficiency in infants. Vitamin D deficiency in infants decreased to 12% at 52 weeks with sunlight exposure. Serum PTH levels were significantly higher in severely vit D deficient than sufficient infants. Vitamin D deficiency was widespread in early post‐partum breastfeeding mothers and infants, and declined to one in eight infants at 52 weeks due mostly to sunshine exposure. When sunlight exposure is limited or restricted, intensified vit D supplementation of breastfeeding mothers and infants is needed to improve vit D status.
Policies and guidelines have recommended that structured programmes to support breastfeeding should be introduced. The objective of this review was to consider the evidence of outcomes of structured compared with non‐structured breastfeeding programmes in acute maternity care settings to support initiation and duration of exclusive breastfeeding. Quantitative and qualitative studies were considered. Primary outcomes of interest were initiation of breastfeeding and duration of exclusive breastfeeding. Studies that only considered community‐based interventions were excluded. An extensive search of literature published in 1992–2010 was undertaken using identified key words and index terms. Methodological quality was assessed using checklists developed by the Joanna Briggs Institute. Two independent reviewers conducted critical appraisal and data extraction; 26 articles were included. Because of clinical and methodological heterogeneity of study designs, it was not possible to combine studies or individual outcomes in meta‐analyses. Most studies found a statistically significant improvement in breastfeeding initiation following introduction of a structured breastfeeding programme, although effect sizes varied. The impact on the duration of exclusive breastfeeding and duration of any breastfeeding to 6 months was also evident, although not all studies found statistically significant differences. Despite poor overall study quality, structured programmes compared with standard care positively influence the initiation and duration of exclusive breastfeeding and any breastfeeding. In health care settings with low breastfeeding initiation and duration rates, structured programmes may have a greater benefit. Few studies controlled for any potential confounding factors, and the impact of bias has to be considered.
Identification of factors that predict a woman's infant feeding choice is important for breastfeeding promotion programmes. We analysed a subsample of children under 2 years of age from the most recent Sri Lanka Demographic and Health Survey (SLDHS) to assess breastfeeding practices and factors associated with suboptimal practices. SLDHS 2006–2007 used a stratified two‐stage cluster sample of ever‐married women aged 15–49 years. Breastfeeding indicators were estimated for the last‐born children ( n = 2735). Selected indicators were examined against independent variables through cross‐tabulations and multivariate analyses. Of the sample, 83.3% initiated breastfeeding within 1 h of birth. Continuation rates declined from 92.6% in first year to 83.5% in second year. Exclusive breastfeeding (EBF) rate under 6 months of age was 75.8%, with median duration being 4.8 months. Delayed initiation of breastfeeding was associated with low birthweight [odds ratio (OR) = 2.24] and caesarean delivery (OR = 3.30), but less likely among female infants (OR = 0.75), mothers from ‘estate’ sector (OR = 0.61) or richer wealth quintile (OR = 0.60). Non‐EBF was associated with children from urban areas (OR = 1.72) and estate sector (OR = 4.48) and absence of post‐natal visits by a public health midwife (OR = 1.89). A child was at risk for not currently breastfeeding if born in a private hospital (OR = 3.73), delivered by caesarean section (OR = 1.46) or lived in urban areas (OR = 2.80) or estate sector (OR = 3.23). Those living in estates (OR = 11.4) and not receiving post‐natal home visits (OR = 2.62) were more likely to discontinue breastfeeding by 1 year. Breastfeeding indicators in Sri Lanka were higher compared with many countries and determined by socio‐economic and health care system factors.
Supplementation with lipid‐based nutrient supplements (LiNS) is promoted as an approach to prevent child undernutrition and growth faltering. Previous LiNS studies have not tested the effects of improving the underlying diet prior to providing LiNS. Formative research was conducted in rural Zimbabwe to develop feeding messages to improve complementary feeding with and without LiNS. Two rounds of Trials of Improved Practices were conducted with mothers of infants aged 6–12 months to assess the feasibility of improving infant diets using (1) only locally available resources and (2) locally available resources plus 20 g of LiNS as Nutributter®/day. Common feeding problems were poor dietary diversity and low energy density. Popular improved practices were to process locally available foods so that infants could swallow them and add processed local foods to enrich porridges. Consumption of beans, fruits, green leafy vegetables, and peanut/seed butters increased after counselling ( P < 0.05). Intakes of energy, protein, vitamin A, folate, calcium, iron and zinc from complementary foods increased significantly after counselling with or without the provision of Nutributter ( P < 0.05). Intakes of fat, folate, iron, and zinc increased only (fat) or more so (folate, iron, and zinc) with the provision of Nutributter ( P < 0.05). While provision of LiNS was crucial to ensure adequate intakes of iron and zinc, educational messages that were barrier‐specific and delivered directly to mothers were crucial to improving the underlying diet.
Exclusive breastfeeding (EBF) has the potential to significantly reduce infant mortality, but is frequently not practiced in low‐income settings where infants are vulnerable to malnutrition and infections including human immunodeficiency virus (HIV). This study explores mothers' experiences of infant feeding after receiving peer counselling promoting exclusive breast or formula feeding. This qualitative study was embedded in a cluster randomized peer counselling intervention trial in South Africa that aimed to evaluate the effect of peer counselling on EBF. Participants were selected from the three districts that were part of the trial reflecting different socio‐economic conditions, rural–urban locations and HIV prevalence rates. Seventeen HIV‐positive and ‐negative mothers allocated to intervention clusters were recruited. Despite perceived health and economic benefits of breastfeeding, several barriers to EBF remained, which contributed to a preference for mixed feeding. The understanding of the promotional message of ‘exclusive’ feeding was limited to ‘not mixing two milks’: breast or formula and did not address early introduction of foods and other liquids. Further, a crying infant or an infant who did not sleep at night were given as strong reasons for introducing semi‐solid foods as early as 1 month. In addition, the need to adhere to the cultural practice of ‘cleansing’ and the knowledge that this practice is not compatible with EBF appeared to promote the decision to formula feed in HIV‐positive mothers. Efforts to reduce barriers to EBF need to be intensified and further take into account the strong cultural beliefs that promote mixed feeding.
This study aimed to document whether food insecurity was associated with beliefs and attitudes towards exclusive breastfeeding (EBF) among urban Kenyan women. We conducted structured interviews with 75 human immunodeficiency virus (HIV)‐affected and 75 HIV‐status unknown, low‐income women who were either pregnant or with a child ≤24 months and residing in Nakuru, Kenya to generate categorical and open‐ended responses on knowledge, attitudes and beliefs towards EBF and food insecurity. We facilitated six focus group discussions (FGD) with HIV‐affected and HIV‐status unknown mothers ( n = 50 women) to assess barriers and facilitators to EBF. Of 148 women with complete interview data, 77% were moderately or severely food insecure (FIS). Women in FIS households had significantly greater odds of believing that breast milk would be insufficient for 6 months [odds ratio (OR), 2.6; 95% confidence interval (95% CI), 1.0, 6.8], that women who EBF for 6 months would experience health or social problems (OR, 2.7; 95% CI, 1.0, 7.3), that women need adequate food to support EBF for 6 months (OR, 2.6; 95% CI, 1.0, 6.7) and that they themselves would be unable to follow a counsellor's advice to EBF for 6 months (OR, 3.2; 95% CI, 1.3, 8.3). Qualitative analysis of interview and FGD transcripts indicated that the maternal experience of hunger contributes to perceived milk insufficiency, anxiety about infant hunger and a perception that access to adequate food is necessary for successful breastfeeding. The lived experience of food insecurity among a sample of low‐income, commonly FIS, urban Kenyan women reduces their capacity to implement at least one key recommended infant feeding practices, that of EBF for 6 months.
Poor breastfeeding outcomes among late preterm infants ( LPI s) have been attributed to inadequate breast milk transfer stemming from physiological immaturities. However, breastfeeding is more than a biological phenomenon, and it is unclear how mothers of LPI s manage other factors that may also impact the breastfeeding course. Using grounded theory methods and incorporating serial post‐partum interviews with several novel data collection techniques, we examined breastfeeding establishment over a 6–8‐week‐period among 10 late preterm mother‐infant dyads recruited from a maternity hospital in Pittsburgh, Pennsylvania, USA . We found that breastfeeding in the LPI population was a fluctuating, cascade‐like progression of trial and error, influenced by a host of contextual factors and events and culminating with breastfeeding continuation (with or without future caveats for duration or exclusivity of breastfeeding) or cessation. The trajectory was explained by the basic psychosocial process W eighing W orth against U ncertain W ork , which encompassed the tension among breastfeeding motivation, the intensity of breastfeeding work and the ambiguity surrounding infant behaviour and feeding cues. Several sub‐processes were also identified: P laying the G ame , L etting H im be the J udge vs. A ccommodating B oth of U s and Q uestioning W orth vs. H olding out H ope . If valid, our theoretical model indicates a need for earlier, more extensive and more qualified breastfeeding support for mothers of LPI s that emphasizes the connection between prematurity and observed feeding behaviours.
Observational studies suggest association between low concentrations of omega‐3 family fatty acids and greater risk for post‐partum depression (PPD). The objective was to investigate the effect of unbalanced dietary intake of omega‐6/omega‐3 ratio >9:1 in the prevalence for PPD. The study comprises a prospective cohort with four waves of follow‐up during pregnancy and one following delivery. PPD was evaluated according to the Edinburgh Post‐partum Depression Scale (PPD ≥ 11) in 106 puerperae between 2005 and 2007, in Rio de Janeiro, Brazil. Independent variables included socio‐demographic, obstetric, pre‐pregnancy body mass index (BMI) and dietary intake data, which were obtained by means of a food frequency questionnaire in the first trimester of pregnancy. Statistical analysis involved calculation of PPD prevalence and multivariate Poisson regression with robust variance. PPD prevalence amounted to 26.4% [ n = 28; confidence interval (CI) 95%: 18.0–34.8], and higher prevalences of PPD were observed in women who consumed an omega‐6/omega‐3 ratio >9:1 (60.0%) and in those with pre‐pregnancy BMI <18.5 kg/m 2 (66.7%). These variables held as factors associated to PPD in the multivariate model, elevating the chances of occurrence of the outcome in 2.50 (CI 95%: 1.21–5.14) and 4.01 times (CI 95%: 1.96–8.20), respectively. Analyses were adjusted for age, schooling, pre‐pregnancy BMI, lipids consumption and time elapsed since delivery. It verified an association between omega‐6/omega‐3 ratio above 9:1, the levels recommended by the Institute of Medicine, and the prevalence of PPD. These results add to the evidence regarding the importance of omega‐6 and omega‐3 fatty acids in the regulation of mental health mechanisms.
Iron supplementation for women of reproductive age is a main part of an interdisciplinary strategy recommended for the control and prevention of iron deficiency and the treatment of mild‐to‐moderate iron‐deficiency anaemia. This systematic review reports the findings from a meta‐synthesis of qualitative data concerning the experiences and perceptions of iron supplementation among women of reproductive age and health service providers worldwide. Qualitative systematic review methods were used to conduct a search of published literature, define inclusion and exclusion criteria, appraise quality of studies and extract data on the use of iron supplementation among women of reproductive age. Coding, thematic analysis, reciprocal translation and line of argument synthesis were used to synthesize data. Twelve studies spanning 17 countries met inclusion criteria and were included in the analysis. Seven domains emerged from the review: cultural norms and societal values including explanatory models and medical pluralism; political and socio‐economic circumstances; education and communication; social organization and social relationships; health care access and supplement supply; food and nutrition availability; and adherence. In addition, 16 sub‐domains are highlighted. Connecting review findings to a conceptual framework of social determinants of health highlights salient issues that policy makers must consider when adapting global iron supplementation recommendations to the local context.