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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 26-30

Association between household food security and pregnancy complications


1 Deputy of Health, Qazvin University of Medical Science, Qazvin, Iran
2 Department of Midwifery, School of Nursing and Midwifery, Hamadan University of Medical Science, Hamadan, Iran
3 Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Qazvin, Iran

Date of Web Publication24-Jul-2018

Correspondence Address:
Dr. Zainab Alimoradi
Qazvin University of Medical Science, Bahonar Blv. Postal Code: 34197-59811 Qazvin
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SHB.SHB_3_18

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  Abstract 


Introduction: Despite the importance of the family food insecurity during pregnancy, there was no research in this regard in Iran, where generally has a modest food security status. The present study was designed to investigate the prevalence of household insecurity in pregnant women and found its relationship with pregnancy complications such as preeclampsia, gestational diabetes, and anemia during pregnancy. Methods: This cross-sectional study was conducted between December 2016 and December 2017. Samples were women after childbirth referred to health centers for postpartum care in the Qazvin province. The household food security status (using Household Food Insecurity Access Scale) and pregnancy outcomes including preeclampsia, diabetes during pregnancy, and anemia during pregnancy were investigated. Results: Overall food insecurity was observed in 32.3% of participants. The increased chance of having a total pregnancy complication rate was 64% (odds ratio [OR] [95% confidential interval [CI]] = 1.64 [1.06–2.54]) in food insecure group compared to food secure participants. Specifically, gestational hypertension was 24% (OR [95% CI] = 1.24 [0.58–2.69]), preeclampsia was nearly four times (OR [95% CI] = 3.88 [1.18–12.83]), gestational anemia was 24% (OR [95% CI] = 1.24 [0.58–2.71]), and gestational diabetes was 63% (OR [95% CI] =1.63 [0.81–3.30]). Conclusion: Food insecurity might increase the likelihood of pregnancy complications. Since the pregnant women's diet plays an important role in maternal and fetal health, the assessment of maternal nutritional status and household conditions regarding access to food supplies and the ability to supply diverse and balanced foods during pregnancy is important.

Keywords: Anemia, food insecurity, gestational diabetes, logistic regression, preeclampsia, pregnancy outcome


How to cite this article:
Hoseini KS, Kazemi F, Alimoradi Z, Oskoei SS, Alijani H, Zolghadr S. Association between household food security and pregnancy complications. Soc Health Behav 2018;1:26-30

How to cite this URL:
Hoseini KS, Kazemi F, Alimoradi Z, Oskoei SS, Alijani H, Zolghadr S. Association between household food security and pregnancy complications. Soc Health Behav [serial online] 2018 [cited 2019 Nov 13];1:26-30. Available from: http://www.shbonweb.com/text.asp?2018/1/1/26/237422




  Introduction Top


Food insecurity and hunger can have adverse effects on physical, psychological, and social health of individuals.[1] The importance of food insecurity is especially high for women, because they suffer from poor health outcomes associated with food insecurity more than men.[2] Pregnancy in the life of a woman is a period of physical, behavioral, psychosocial changes, and specific nutritional needs, which can have a direct impact on the development of the fetus and the future health of women.[2] It is a unique time for weight-related expectations for women which is a particular challenge in relation to food insecurity for women.[3] The results of some studies on the consequences of household food insecurity in pregnancy indicate a relationship between the birth weight of the child, an increase in birth defects and nutritional status of pregnant women.[4],[5] In a study in the United States, maternal food insecurity has been associated with an increased risk of specific birth defects such as cleft palate, large vessels displacements, tetralogy of Fallot, and spina bifida.[5] While pregnancy is often seen as a period of women's life that can improve their health behaviors, about half of women are overweight or obese in this period.[6] Prepregnancy overweight is associated with poor nutrition and overweight,[2],[6] gestational diabetes,[7] gestational hypertension, preeclampsia,[8] and postnatal anemia.[9],[10] Many of these conditions may be exacerbated in case of food insecurity in the family.[2] Therefore, the study by Laria et al.[2] showed that life in unsafe conditions is significantly associated with high prepregnancy obesity. The relative status of food security was also significantly associated with gestational diabetes. This study showed that life in unsafe families during pregnancy increased the risk of weight gain and related complications during pregnancy.

Despite the importance of the family food insecurity during pregnancy, there was no research in this regard in Iran, where generally has a modest food security status. Therefore, the present study was designed to investigate the prevalence of household insecurity in pregnant women and find its relationship with pregnancy complications such as preeclampsia, gestational diabetes, and anemia during pregnancy.


  Methods Top


This cross-sectional study was conducted between December 2016 and December 2017. Samples were women after childbirth referred to health centers for postpartum care in the Qazvin province. Inclusion criteria were the desire to participate in the study and a lack of history of chronic medical problems such as diabetes and cardiovascular diseases. The participants who did not fill out completely questionnaires were excluded from the study. The sample size was 860 women according to the study by Laria et al.,[2] and given 10% prevalence of anemia in the food insecurity group, α = 0.05, and 20% error rate.

All 100 health centers in six provinces of Qazvin were recruited. According to the number of pregnancy cases in each county, quota sampling was performed. After specifying the required number of samples in each city, according to the number of reported pregnancies from each health center, the number of samples from each center was determined. Sampling was conducted in all health centers until the required number of samples was reached.

The household food security status and pregnancy outcomes including preeclampsia, diabetes during pregnancy, and anemia during pregnancy were investigated. The household food insecurity access scale (HFIAS) was used to examine the household food security situation. This scale reflected the household's feelings about food insecurity and the family. The questions of the HFIAS not only directly referred to nutrition quality but also covered households' perceptions of changes in food quality, regardless of the actual dietary composition. This scale was consisted of nine items with a 4-point Likert scale (no = 0, rarely = 1, sometimes = 2, and often = 3). According to this questionnaire, women were divided into four categories of secure food (0–1), mild insecure (7–2), moderate insecure (8–14), and severe insecure (15–27).[11] Validation of the Farsi version of the HFIAS was assessed by Mohammadi et al.[12] Content and criterion validity, factor analysis, and internal reliability (Cronbach's alpha = 0.55) of the questionnaire were somewhat satisfactory. The test-retest reliability of the HFIAS questionnaire in the present study was assessed within a 2-week interval on a sample of 30 women after childbirth. The intraclass correlation coefficient was reported as 0.90 indicating the excellent reliability of this instrument. In this study, women were ranked according to their scores in the groups: secure food (0–1) and insecure food (2–15).

Demographic and pregnancy outcomes were assessed using a researcher-made questionnaire. Data were collected using pregnancy file and birth certificate. Demographic variables were age, education level, occupation of the mother, the level of education and occupation of the spouse, and the household economic status. Pregnancy data were the number of pregnancies, wanted or unwanted pregnancies, prepregnancy body mass index (BMI) and weight gain during pregnancy, and the presence or absence of pregnancy complications including pregnancy-preeclampsia, pregnancy-induced diabetes, and pregnancy anemia. In this study, gestational hypertension was considered when blood pressure was more than 140/90 mmHg without proteinuria in pregnancy; preeclampsia was considered when blood pressure was ≥140/90 mmHg after the 20th week of pregnancy with proteinuria; gestational diabetes was considered if after 20th weeks of pregnancy, 2 out of 3 measures of glucose tolerance test with 75 g oral glucose was disrupted; anemia during pregnancy was considered when hemoglobin was <10 mg/dl in the second trimester and <11 mg/dl in the third trimester of pregnancy.[13] The content validity of this questionnaire was approved by five midwifery and gynecology faculty members.


  Statistical Analysis Top


Data analysis was performed using the STATA software v. 12 (Copyright 1985-2011, StataCorp, USA). To determine the relationship between the household security status and pregnancy complications, the logistic regression models were used with single-variable and multivariate tests. In the regression models, food security was defined as a dual-state variable of secure and insecure, and the secure food group entered the regression model as a reference group. In addition, the complications of pregnancy were defined in a dual-state variable (yes or no). The analysis of multivariate analysis was conducted through adjusting age, occupation and education of the women, occupation and education of the spouse, number of pregnancies, BMI, weight gain, pregnancy status, and economic status. Multivalued variables are defined as dummy. Findings were evaluated and interpreted at a significant level below 0.05.

Ethical considerations

The research proposal was approved by the Committee for Research on Social determinants of health affiliated with Qazvin University of Medical Sciences. This proposal was also approved by the Ethics Committee of the University and received the code number IR. QUMS. REC.1396.77. After obtaining written informed consent from eligible pregnant women who were willing to participate in the study, the questionnaires were completed through the interviewing method. In addition, data related to the complications of pregnancy and childbirth was collected based on the pregnancy file and birth certificate.


  Results Top


In this study, a total of 860 women after childbirth with an average age of 27.84 years (standard deviation = 5.95) participated. Demographic characteristics of the participants were presented in [Table 1].
Table 1: Sociodemographic and reproductive attributes of participants

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The household food security status showed that 67.7% and 32.3% had secure and insecure food conditions, respectively. In terms of pregnancy complications, 4.3% had gestational hypertension, 2% had preeclampsia, 5.1% had gestational diabetes, and 4.4% had anemia. A total of 15.8% of the women experienced one of varieties of pregnancy complications. The results of multivariate analysis indicated that in the household insecure group, the chance of getting all pregnancy complications increased compared to the other group. The increased chance of having a total pregnancy complication rate was 64% (odds ratio [OR] [95% confidential interval [CI] = 1.64 [1.06–2.54]). The increase in the chance of having a pregnancy complication in the food insecurity group compared to the food secure group was as follows:

Gestational hypertension was 24% (OR [95% CI] = 1.24 [0.58–2.69]). Preeclampsia was nearly four times that of (OR [95% CI] = 3.88 [1.18–12.83]). Pregnancy anemia was 24% (OR [95% CI] = 1.24 [0.58–2.71]), and gestational diabetes was 63% (OR [95% CI] = 1.63 [0.81–3.30]). Increasing the chance of a pregnancy complication and preeclampsia were statistically significant (P< 0.05). The multivariate analysis of the relationship between pregnancy complications and the food security situation in the logistic regression model was presented in [Table 2].
Table 2: Results of multivariate analysis of logistic regression for association of pregnancy complication with household food security status

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  Discussion Top


Given the importance of nutrition role on pregnancy outcomes, household food security from the point of access was an indicator of the nutritional status of pregnant women as demonstrated in the present study. Therefore, its relationship with pregnancy complications was studied. The results of this study showed that food insecurity significantly increased the likelihood of pregnancy complications. Increasing the chance of pregnancy-induced hypertension, preeclampsia, anemia, and diabetes during pregnancy was noticeably significant in the food insecure group, which was statistically significant only for preeclampsia. The highest incidence was seen in the prevalence of preeclampsia, which was nearly four times higher. The association between food insecurity and cardiovascular risk factors, hypertension, diabetes, cholesterol, and obesity has also been reported in other studies.[14],[15],[16]

The results of this study in the increase of the chances of preeclampsia are consistent with the results of Morales et al.[17] that revealed the association between food insecurity and cardiovascular health in pregnant women. They referred pregnant women to midwifery care clinics that had insecure food conditions to receive a food plan for their families. In their study, blood pressure and blood glucose were compared in three groups: The group referred for the food plan that enrolled in the program, the referred group that did not register, and the group that was not referred. Blood pressure and baseline blood glucose were not different in all three groups; however, the women who enrolled in the food program for families had better blood pressure than the other two groups. However, no difference was observed in the trend of gestational blood glucose in the three groups. Their study results showed that the program could improve cardiovascular health in pregnant women.[18] The difference between the present study and Morales et al.'s [17] study was in the status of gestational diabetes. In the present study, the increased risk of gestational diabetes in the food insecure group was increased by 63%; however, in the study Morales et al.,[17] no differences in the blood glucose levels of the groups were found. One of the possible reasons for this difference may be the mediating role of poor health behaviors or inappropriate food intake such as excessive intake of fats during pregnancy. The possible relationship between food insecurity and gestational diabetes is important, because gestational diabetes is associated with fetal problems such as macrosomia, shoulder dystocia, and birth injuries and maternal complications including the increased risk of type II diabetes at higher ages.[13]

The results of this study in the increase of the chances of anemia during pregnancy were consistent with the findings of the Park and Eicher-Miller's study.[19] They examined the relationship between iron deficiency and food insecurity in 1045 pregnant women in the USA. The mean dietary iron intake was similar in two secure and insecure groups. The mean of iron supplementation in the food secure group was lower. Iron deficiency was 2.90 times higher according to the ferritin level than in the insecure group; however, other indicators of iron deficiency were not related to food insecurity. Since no relationship was found between the poverty income ratio and iron intake or iron deficiency, they concluded that household food security was a more appropriate indicator for identifying women in need of direct interventions to improve their access to or educate them about iron-rich foods and supplements.

The relationship between gestational hypertension, diabetes, and anemia during pregnancy with food insecurity was also studied by Laraia et al.[2] In their unadjusted models, marginal food insecurity was associated with the second-trimester anemia and diabetes; however, food insecurity was associated with pregnancy-related hypertension. In their adjusted models, no such a relationship was observed. Moreover, they revealed that the chance of gestational diabetes in both groups of insecure and marginal insecure, even after controlling demographic variables was still doubled. After placing insecurity and marginal insecurity in one category, the chance of gestational diabetes was higher (2.38, 95% CI = 0.99–5.73). They concluded that life at any level of food insecurity increased the chance of developing gestational diabetes. The findings of the present study in terms of increasing the chances of pregnancy, diabetes mellitus, and anemia during pregnancy were in-line with the study of Laraia et al.[2] It is worth noting that in present study and Laraia et al.'s,[2] an increased risk of these complications were observed; however, no statistically significant differences were reported. Such a finding may be due to factors such as hypertension, diabetes, and anemia in pregnancy besides diet and weight gain. For example, in the present study, the chance of anemia in the food insecurity group was 24% higher; however, this finding was not statistically significant. A possible reason for this finding is the greater impact of pregnancy anemia on hemodilution, undernutrition, nausea and vomiting, and a lack or poor intake of supplements.[9] Furthermore, for gestational diabetes, in addition to prepregnancy weight and maternal weight gain, poor health behaviors, or poor food intake such as high levels of fats during pregnancy should also be considered.[17] The etiology of gestational hypertension is influenced by factors such as abnormal placental thromboembolism, genetic factors, maternal immunological tolerance to fetal tissues, and inadequate maternal adaptation to cardiovascular physiological changes. However, nutritional factors such as the use of a diet rich in fruits and vegetables with antioxidant activities can affect the incidence of gestational hypertension and preeclampsia.[13] As in the present study, an increase in the odds of pregnancy complications was no significant; however, in the insecure group with less access to a diverse and balanced diet for all micronutrients, the prevalence of preeclampsia was significantly increased about four times.


  Conclusion Top


Since the pregnant women's diet plays an important role in maternal and fetal health, the assessment of maternal nutritional status and household conditions regarding access to food supplies and the ability to supply diverse and balanced foods during pregnancy are important. The results of this study showed the importance of the family food security status on pregnancy complications. Therefore, assessing the food security status as a quick and easy method can help assess pregnant women regarding the nutritional status. Identifying individuals at risk and designing educational interventions to get acquainted with food sources and cheaper and more accessible substitutes in different food groups can be an effective step to reduce the impact of food insecurity on the health of pregnant women. On the other hand, provision of nutritional supplements to insecure food families can be an effective intervention to increase the health of pregnant women and fetus and to reduce related complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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