Which Anthropometric Indicators Identify a Pregnant Woman as Acutely Malnourished and Predict Adverse Birth Outcomes in the Hum

Currently there is no consensus on how to identify pregnant women as acutely malnourished and when to enroll them in nutritional programmes. Médecins Sans Frontières Switzerland undertook a literature review with the purpose of determining values of anthropometric indicators for acute malnutrition that are associated with adverse birth outcomes (such as low birth weight (LBW)), pre-term birth and intra-uterine growth retardation (IUGR). A literature search in PUBMED was done covering 1 January 1995 to 12 September 2012 with the key terms maternal anthropometry and pregnancy. The review focused on the humanitarian context. Mid-upper-arm circumference (MUAC) was identified as the preferential indicator of choice because of its relatively strong association with LBW, narrow range of cut-off values, simplicity of measurement (important in humanitarian settings) and it does not require prior knowledge of gestational age. The MUAC values below which most adverse effects were identified were <22 and <23 cm. A conservative cut-off of <23 cm is recommended to include most pregnant women at risk of LBW for their infants in the African and Asian contexts. Background Acute malnutrition is particularly important in humanitarian emergencies where sudden change of food availability or high disease burden can cause this form of malnutrition, and consequently excessive mortality in adults1 2. There is little information available to identify and treat acute malnutrition among pregnant women (PW)3. Yet, the impact of acute malnutrition on PW is substantial and maternal malnutrition is a major cause of low birth weight (LBW)4 5. Currently there is neither consensus on which anthropometric measurement should be used to identify acute malnutrition during pregnancy nor which cut-off value should be used. In emergencies or protracted crises PW are included in nutritional programmes, most frequently supplementary feeding programmes (SFP); criteria for inclusion vary. Some programmes use the normal body mass index (BMI) cut-off value of 18.5 kg/m for adult women, assuming it is applicable for PW 6. Mid-upper arm circumference (MUAC) is often used too, but no universal cut-off points have been identified7. Various national nutritional protocols use the following MUAC cut-off values for inclusion of PW into SFPs: MUAC <18.5 cm (Zimbabwe 2008), <21.0 cm (Burkina Faso, Burundi 2002, DRC 2008, Guinea 2005, Madagascar 2007, Malawi 2007, Mali 2007, Niger 2006, Senegal 2008), <22.0 cm (Mozambique 2008), <22.5 cm (Zambia 2009)7, <23.0 cm (Indonesia 1996)8 and ≤23 cm (Sri Lanka 2006)9. According to the SPHERE Guidelines10, MUAC may be used as a screening tool for PW, e.g. as a criterion for entry into a feeding programme. The guidelines state that cut-off points for risk vary by country and range from 21 cm to 23 cm. SPHERE suggests <21 cm as an appropriate cut-off for selection of PW at risk for growth retardation during emergencies. Some nutritional protocols enroll PW based on ,