Investigating the nutritional and social determinants of favorable fetal growth conditions (FFGC) in pregnant women living in the Free State Province, South Africa

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Aim: The prevalence of adverse birth outcomes such as low birth weight and preterm birth are gradually increasing in South Africa (SA), while overall global prevalence rates have been declining. Poor birth outcomes are an indicator of a poor fetal environment, and a predictor of increased risk of certain health outcomes in adulthood, such as non-communicable diseases and obesity, as posited by the Developmental Origins of Health and Disease (DOHaD) theory. Current DOHaD research relies on low birth weight as the main indicator for assessing the fetal environment, but statisticians have developed a latent construct known as Favorable Fetal Growth Conditions (FFCG), that considers birth weight, birth length, and gestational age. This study was driven by the high rate of low birth weight (15%) in SA. Also, there is a gap in the literature related to the nutritional and social determinants of FFGC. Since Human Immunodeficiency Virus (HIV) is highly prevalent in SA, it was also important to explore if HIV status influenced how nutritional and social factors contributed to FFGC. The purpose of the study was three-fold. First, to assess the sociodemographic status, nutritional status, micronutrient quality, food security status, stress levels, social support, and birth outcomes of pregnant women in the Free State Province, SA. Secondly, to create a model that explored the relationships between these factors and determine if the model was valid for women with and without HIV. Third, to create a conceptual framework for the drivers of favorable fetal growth conditions in the Free State. Methods: A cohort study was conducted, where 682 women receiving antenatal care from Pelonomi Regional Hospital were enrolled, and interviews were conducted in either English, Sesotho, or Afrikaans. At baseline, information related to sociodemographic characteristics, stress, lifestyle, and social support was collected. Dietary intake was assessed using a quantified food frequency questionnaire (QFFQ). A 24-hour dietary recall was also conducted, and dietary diversity scores were calculated from this, based on nine food groups. Anthropometric measurements were collected to determine gestational body mass index (GBMI). Women were followed up until after giving birth, at which point they provided data related to their birth outcomes (such as birth weight, length, and gestational age of the infant) and HIV status. At the end of the study, 305 women provided this data. These participants formed the subsample that was used for further analysis. Descriptive statistics were carried out in R version 4.1.2 and structural equation modeling (SEM) was conducted in Lavaan version 0.6–5 in R version 4.1.2. Results: Based on the participants who provided both HIV status and birth outcome data at the end of the study, there was an HIV prevalence of 34.9%, 16.1% of the births were preterm, 14.4% had a low birth length, and 13.5% of the infants had a low birth weight. Significantly more women with HIV gave birth to a low-birth-weight infant (p=0.034) and had preterm (p=0.024) when compared to women who did not have HIV. A 1 unit increase in GBMI was associated with a 0.223 unit increase in FFGC (p<0.001) and a 1 unit increase in income level was associated with a 0.141 unit increase in FFGC (p=0.041). Higher household incomes were associated with higher dietary micronutrient quality (p=0.002), GBMIs (p=0.012), and food security (p=0.001), while higher stress was associated with lower household incomes (p=0.004) and higher levels of food insecurity (p<0.001). Social support was also associated with better household food security (p=0.008). These findings were applicable to all women, regardless of HIV status. Conclusion: Based on these findings, the main social determinant of FFGC was income, while GBMI was the main nutrition-related determinant of FFGC in women living in the Free State province, SA. Multisectoral community-based programs that address low household incomes and poverty can improve FFGC, GBMIs, dietary micronutrient quality, food security status, and reduce stress during pregnancy. Social support structures within the community can also be leveraged to improve food security.

Embargo status: Restricted until 09/2172. To request the author grant access, click on the PDF link to the left.

Maternal, Neonate, Health, Infant