Vitamin A status of Rural Pregnant Women in a Southern Indian Backward District

Objective: The objective of this study was to assess the vitamin A status among rural pregnant women.

Study design: A community-based cross-sectional pilot study.

Methods: This study was carried out among 100 rural pregnant women from 30 randomly selected villages in a backward south Indian district of Medak, Telangana State, India, from October 2019 to Feb 2020. Serum retinol of all the pregnant women was estimated using the high-pressure liquid chromatography (HPLC) method and dietary intake of vitamin A was assessed using a one-day 24-hr re-call method of diet survey. All the subjects were examined for clinical examination for clinical signs of vitamin A deficiency (VAD).

Results: The prevalence of Bitot’s spot, an objective sign of VAD was 1% and none of the pregnant women reported night blindness. Mean serum retinol was 44µg/dl and 6% of the pregnant women had sub-clinical VAD. The intake of vitamin A was 170µg with 91% of pregnant women consuming inadequate dietary vitamin A i.e., <70% of Recommended Dietary Allowances (RDA) and 89% of them not consuming even 50% of their RDA.

Conclusions:  The rural pregnant women were subsisting on inadequate diets that are extremely poor in vitamin A. Therefore, the community in general and women of reproductive age as well as pregnant women and nursing mothers, in particular, should be counseled to consume vitamin A-rich foods through health and nutrition education using information, education, and communication (IEC) activities as well as behavioural change communication (BCC) methods.

Vitamin A is an essential micronutrient crucial for the normal functioning of the human body like vision, growth and development, reproduction, maintenance of epithelial tissue, and immunity [1]. Vitamin A deficiency (VAD) is the leading cause of preventable blindness worldwide and when combined with iron and iodine deficiencies, remains a major public health concern in the world today. Despite the implementation of several national nutrition programs especially supplementation bi-annual massive doses of vitamin A solution (MDVAS) to the children 6-59 months in India since the 1970s, it still has the highest prevalence of subclinical VAD in the   world [2]. Periodic nutrition surveys carried out in India revealed that the diets of rural and tribal children below five years as well as pregnant and lactating women were extremely poor in vitamin A and not changed much over four decades [3]. Vitamin A is required especially during the periods of rapid cell proliferation and differentiation, like pregnancy and early childhood making these two groups more vulnerable to vitamin A deficiency. There is very limited information in India on Vitamin A status during pregnancy despite the fact vitamin A is essential not just for the maintenance of ocular health of the mother and foetus, but also for the development of the skeleton, other organs, and maintenance of the immune system of the foetus [1,4]. There is an increased demand for micronutrients including vitamin A during pregnancy to meet the metabolic needs of both mother and foetus [5].

 Physiological changes in the pregnancy especially during the final phase, like an increase in circulating maternal blood along with the accelerated fetal growth and development, heightens the frequency of VAD in this phase [1]. VAD in the second trimester of pregnancy increases the risk of schizophrenia and associated spectrum disorders in children by three times [6]. An association has also been reported between the newborn growth and Apgar scores with the concentrations of vitamin A compounds in the mother and child [7] and vitamin A content of breast milk is also reported to be lowered in lactating mothers with VAD.

Between 1995 and 2005, Globally VAD has affected about 19 million pregnant women, especially in low-income countries like South and Southeast Asia of whom 9.8 million are suffering from night blindness [8] Community-based studies on vitamin A status of pregnant women were not readily available in India. Therefore, taking into consideration the serious implications of VAD, it was considered important to assess the vitamin A situation of pregnant women in India.

A community-based cross-sectional pilot study was carried out from October 2019 to Feb 2020 with the objective to assess the vitamin A status among rural pregnant women in a backward district of Medak, Telangana state, Southern India. For this community-based study, a purposive sample of 100 pregnant women of all three trimesters (First-8%: Second-51% & Third-41%) was covered from 30 randomly selected villages to assess the vitamin A status. All the pregnant women underwent clinical examination for the ocular manifestation of clinical signs of vitamin A deficiency and history of night blindness was obtained from all the participants. Venous blood samples (3ml) were collected from all the pregnant women, and sub-clinical vitamin A i.e, serum retinol was estimated using the high-pressure liquid chromatography (HPLC) method. Likewise, dietary intakes of various foods consumed by pregnant women during the previous day were assessed using a one-day 24-hr re-call method of diet survey and dietary intake of vitamin A was calculated using Indian food composition tables (IFCT). Median, as well as percent intake of vitamin A as against the Recommended Dietary Allowances (RDA), was calculated. All the study participants were informed of the purpose of the study and informed written consent was obtained from all the pregnant women. Data analyses were performed using SPSS version 23.0.

The prevalence of Bitot’s spot, the objective sign of VAD was observed in 1% of the pregnant women although none of them reported night blindness. Using the cut-off point 0.5 % of Bitot’s spot, VAD in these pregnant women was noted to be a public health problem. The mean serum retinol value of pregnant women was 44µg/dL (1.54µmol/L), and the prevalence of sub-clinical VAD (serum retinol <20>Table 1). No significant differences were observed between the dietary intakes of vitamin A and the gestational period.

Table 1: Prevalence (%) of vitamin A intakes and its deficiency among rural pregnant women.

This community-based study, perhaps for the first time carried out among rural pregnant women in India. Though, the prevalence of sub-clinical VAD in this rural study (6%) is lower than the hospital-based study [9] among urban pregnant women (27%), the diets were grossly deficient in vitamin A as against the RDA. It could be attributed to poor intake of animal sourced foods rich in vitamin A due to poverty, traditional food habits and prevailing customs. In India, the consumption of papaya is avoided during pregnancy because it is believed to cause abortion. Likewise, pregnant women consume less green leafy vegetables fearing that they could cause diarrhea. Poor bioavailability with a conversion factor of beta carotene to retinol 6:1 has an overriding part in the development of VAD among communities, especially that of India which are predominantly dependent on plant-based diets.  Adequate vitamin A levels during pregnancy are of paramount importance not just for the health of pregnant mothers but also for their fetuses. The risk of vitamin A deficiency is higher for young children whose mothers are vitamin A deficient and maternal vitamin A deficiency results in reduced fetal stores and lower levels of vitamin A in breast milk, [10] and may also have negative consequences on mothers' overall health.

Hence, sustainable interventions like health and nutrition education through information, education, and communication (IEC) activities and a well-designed behavioural change communication (BCC) method must be mandated to motivate and aid increase in knowledge of consumption of vitamin A-rich foods for improved vitamin A status and also in achieving dietary diversification which results in better outcomes during pregnancy and to reduce the associated morbidity of the newborn. The community is also encouraged to cultivate a variety of leafy non-leafy vegetables rich in micronutrients in general and vitamin A in particular in kitchen gardens at home to mitigate the burden of multiple micronutrient deficiencies.

Acknowledgments: The authors would like to extend their gratitude to Mr. C.Sai Babu, Ms. D.Neeraja, Ms. Vijaya Pushpa Latha, Ms. Keerthi and Mr. N.Srinivas for their support and co-operation in the completion of the study.

Ethical Approval: National Institute of Nutrition (NIN) institutional ethics committee (IEC).

Funding & Sponsorship: Indian Council of Medical Research.

Competing interests:  None.