Born too soon in Malawi : Maternal nutrition as a predictor of preterm delivery and community and professional views on the care of the preterm infant

Ennenaikaisen syntymän ilmaantuvuus on Malawissa korkea, nykyisten arvioiden mukaan 18,1 %. Ennenaikaiseen syntymään voi Afrikassa vaikuttaa moni tekijä, kuten äidin raskautta edeltävä ja raskaudenaikainen ravinto. Äidin raskautta edeltävän ravitsemustilan ja vastasyntyneen terveyden (raskauden kesto ja vastasyntyneen koko: paino, pituus ja päänympärysmitta) välisestä yhteydestä on Malawista on vähän näyttöön perustuvaa tietoa Tällä tutkimuksella oli kolme tavoitetta. Ensimmäisenä tavoitteena oli kuvailla käsityksiä ennenaikaisista syntymistä, ennenaikaisesti syntyneiden lasten hoitokäytäntöjä ja ennenaikaisiin syntymiin liittyviä haasteita köyhässä malawilaisessa maaseutuyhteisössä. Toisena tavoitteena oli tutkia terveydenhuollon ammattilaisten näkemyksiä ennenaikaisesti syntyneiden lasten hoidosta ja hoitoa ohjaavien dokumenttien olemassaolosta malawilaisissa terveydenhuollon yksiköissä. Kolmantena tavoitteena oli määritellä äidin raskautta edeltävän ja raskaudenaikaisen ravitsemustilan ja vastasyntyneen terveyden välisen yhteyden voimakkuus. Käsityksiä ennenaikaisen syntymän syistä, ennenaikaisesti syntyneiden lasten hoitokäytännöistä ja ennenaikaiseen syntymään liittyvistä haasteista selvitettiin 20 syvähaastattelulla ja 14 fokusryhmähaastattelulla Mangochin alueen yhteisöissä. Haastateltavien mukaan ennenaikaista syntymää aiheuttavat raskaudenaikaiset sairaudet kuten verenpainetauti ja malaria sekä perinteiset sairaudet (likango and mwanamphepo) sekä raskaudenaikainen huono ravitsemus, monen lapsen synnyttäminen ja aikaisempi ennenaikaisen lapsen synnyttäminen. Tärkeimpinä ennenaikaisesti syntyneiden lasten kotihoitokäytäntöinä mainittiin lapsen pitäminen lämpimänä lämpimien vaatteiden ja peitteiden avulla sekä lämmittämällä taloa avotulella ja sulkemalla ovet ja ikkunat. Haastateltavat mainitsivat ennenaikaisesti syntyneiden lasten asianmukaiseen hoitoon liittyvinä haasteina tiedonpuutteen ja köyhyyden: sairaan lapsen hoitoon vieminen viivästyi ja köyhyys rajoitti mahdollisuutta lämpimien vaatteiden hankintaan. Terveydenhuollon ammattilaisille ja päättäjille tehtiin 16 syvähaastattelua, joilla selvitettiin ennenaikaisesti syntyneiden lasten hoitokäytäntöjä hoitoa ohjaavien dokumenttien olemassaoloa terveydenhuollon yksiköissä. Osa perusterveydenhuollossa työskentelevistä terveydenhuollon ammattilaisista kertoi, että hoitoa ohjaavia dokumentteja ei ollut joissain aluesairaaloissa ja terveyskeskuksissa, mutta yliopistosairaaloissa työskentelevät tiesivät että hoitoohjeita on. Päätöksentekijät uskoivat, että dokumentit olivat saatavilla kaikissa terveydenhuollon yksiköissä. Lisäksi selvisi, että Malawin terveysministeriö on tehnyt ohjeen, jossa selvitetään ennenaikaisesti syntyneiden lasten hoitokäytäntöä. Kolmas osatyö oli prospektiivinen kohorttitutkimus, joka tehtiin upotettuna satunnaistettuun, kontrolloituun iLiNS-DYAD-M -tutkimukseen, jossa mukaan otettiin 1391 naista, joilla oli normaali raskaus Mangochin alueella Malawissa. Äidin raskautta edeltävän painoindeksin sekä raskaudenaikaisen painonnousun ja vastasyntyneen terveyden välistä yhteyttä tutkittiin regressiomalleilla. Raskautta edeltävän painoindeksin ja raskauden keston välillä ei löydetty tilastollisesti merkitseviä eroja, mutta raskautta edeltävä painoindeksi oli yhteydessä lapsen syntymäpainoon ja pään ympärysmittaan. Raskaudenaikainen viikoittainen painonnousu ennusti vahvasti vastasyntyneen terveyttä, sillä se oli yhteydessä melkein kaikkiin tutkittuihin vasteisiin. Loppupäätelmänä voidaan todeta että paikallisten ennenaikaisia syntymiä koskevien käsityksiin kuuluvat äidin sairaudet, äidin käyttäytymiseen liittyvät tekijät ja sosiokulttuuriset tavat. Osallistujien mukaan heillä on paljon haasteita ennenaikaisesti syntyneiden lasten hoidossa sekä kotona että terveydenhuollon yksiköissä. Päättäjien mukaan terveydenhuollon yksiköissä on dokumentteja, jotka voisivat opastaa terveydenhuollon työntekijöitä ennenaikaisesti syntyneiden lasten hoidossa. Vähäinen raskaudenaikainen painonnousu on yhteydessä huonompaan vastasyntyneen terveyteen Malawissa.The incidence of preterm birth (PTB) remains high in Malawi and is currently estimated at 18.1%. Various underlying factors could contribute to PTBs in Africa, including maternal nutrition before pregnancy and during pregnancy. In Malawi, evidence is lacking making it difficult to estimate the relationship between maternal pre-pregnancy nutrition and pregnancy outcomes (duration of pregnancy and size of the newborn including weight, length and head circumference). To address the existing gaps in knowledge on PTBs, the present study had three aims. The first aim was to describe the local perceptions of PTB, care practices for preterm infants, and challenges associated with PTB among people in a rural lowincome community in Malawi. The second aim was to investigate views of the health workers about the care of the preterm infants in the health facilities and existence of any treatment guidelines such as policy documents for delivery of care to the preterm infants in Malawian health facilities. Finally, the third aim was to determine the strength of association between maternal nutritional status before and during pregnancy as well as birth outcomes among women in Malawi. Twenty in-depth interviews and 14 focus group discussions (FGDs) were used to explore the perceived causes of PTB, care practices for preterm infants and challenges associated with PTB among community members in Mangochi district. Participants perceived that diseases such as hypertension, malaria and traditional diseases (likango and mwanamphepo) during pregnancy as well as poor diet during pregnancy, having many children and history of a PTB in the family causes/lead to PTBs. The main reported care practice for preterm infants in the community was keeping the infant warm through dressing the infant with many warm clothes and covering an infant with wrappers, making fire inside the house and closing doors and windows to keep the house warm. Some of the reported challenges included lack of knowledge on how to properly care for preterm infants and poverty which limited the caregivers to buy the infants warm clothes and delay in seeking medical care when needed. A total of 16 in-depth interviews with health care workers and policy makers were used to explore the care of preterm infants in the health facilities and existence of any treatment guidelines for delivery of care to the preterm infants in the health facilities. Some of the health workers reported that, policy and protocol guidelines for care of preterm infants were not available in some district hospitals and health centers, but those working in tertiary hospitals acknowledged availability of the policy and protocol guidelines. Additionally, policy makers believed that policy documents and protocol guidelines were available in all health facilities that would guide care of preterm infants. The analysis of documents also revealed that a policy document, produced by Ministry of Health (MOH) Malawi explaining care of preterm infants was available in Malawi. The third study was a prospective cohort study nested within the International Lipid- Based Nutrient Supplement trial in Malawi (iLiNS DYAD-M) that enrolled 1,391 women with uncomplicated pregnancies in a randomized, controlled trial in Mangochi District of Malawi. Regression analysis was used to investigate the association between maternal pre-pregnancy BMI and weight gain during pregnancy with birth outcomes (duration of pregnancy and size of the newborn including weight, length and head circumference). No significant statistical associations were observed between pre-pregnancy BMI and pregnancy duration, but pre-pregnancy BMI was associated with birth weight and head circumference. Gestational weekly weight gain (GWG) was a strong predictor for birth outcomes as it was associated with almost all measured outcomes. In conclusion, the local perceptions of PTBs in Mangochi district include; maternal diseases, maternal behavioral related issues and social cultural practices. Participants feel that they face many challenges to care for preterm infants in the community and in the health facilities. Policy makers believe that, treatment guidelines are available in health facilities that could guide service providers to care for preterm infants. Low GWG is strongly associated with increased risk of having infants with poor outcomes in Malawi

Perceptions and experiences of community members on caring for preterm newborns in rural Mangochi, Malawi: a qualitative study

Background The number of preterm birth is increasing worldwide, especially in low income countries. Malawi has the highest incidence of preterm birth in the world, currently estimated at 18.1 percent. The aim of this study was to explore the perceived causes of preterm birth, care practices for preterm newborn babies and challenges associated with preterm birth among community members in Mangochi District, southern Malawi. Methods We conducted 14 focus group discussions with the following groups of participants: mothers (n = 4), fathers (n = 6) and grandmothers (n = 4) for 110 participants. We conducted 20 IDIs with mothers to preterm newborns (n = 10), TBAs (n = 6) and traditional healers (n = 4). A discussion guide was used to facilitate the focus group and in-depth interview sessions. Data collection took place between October 2012 and January 2013. We used content analysis to analyze data. Results Participants mentioned a number of perceptions of preterm birth and these included young and old maternal age, heredity, sexual impurity and maternal illness during pregnancy. Provision of warmth was the most commonly reported component of care for preterm newborns. Participants reported several challenges to caring for preterm newborns such as lack of knowledge on how to provide care, poverty, and the high time burden of care leading to neglect of household, farming and business duties. Women had the main responsibility for caring for preterm newborns. Conclusion In this community, the reported poor care practices for preterm newborns were associated with poverty and lack of knowledge of how to properly care for these babies at home. Action is needed to address the current care practices for preterm babies among the community members.BioMed Central open acces

Leveraging routine viral load testing to integrate diabetes screening among patients on antiretroviral therapy in Malawi

Background People living with HIV are at an increased risk of diabetes mellitus due to HIV infection and exposure to antiretroviral therapy (ART). Despite this, integrated diabetes screening has not been implemented commonly in African HIV clinics. Our objective was to explore the feasibility of integrating diabetes screening into existing routine HIV viral load (VL) monitoring and to determine a group of HIV patients that benefit from a targeted screening for diabetes. Methods A mixed methods study was conducted from January to July 2018 among patients on ART aged≥18 y and healthcare workers at an urban HIV clinic in Zomba Central Hospital, Malawi. Patients who were due for routine VL monitoring underwent a finger-prick for simultaneous point-of-care glucose measurement and dried blood spot sampling for a VL test. Diabetes was diagnosed according to WHO criteria. We collected demographic and medical history information using an interviewer-administered questionnaire and electronic medical records. We conducted focus group discussions among healthcare workers about their experience and perceptions regarding the integrated diabetes screening program. Results Of patients undergoing routine VL monitoring, 1316 of 1385 (95%) had simultaneous screening for diabetes during the study period. The median age was 44 y (IQR: 38–53); 61% were female; 28% overweight or obese; and median ART duration was 83 mo (IQR: 48–115). At baseline, median CD4 count was 199 cells/mm3 (IQR: 102–277) and 50% were in WHO clinical stages I or II; 45% were previously exposed to stavudine and 88% were virologically suppressed (<1000 copies/mL). Diabetes prevalence was 31/1316 (2.4%). Diabetes diagnosis was associated with age ≥40 y (adjusted OR [aOR] 7.44; 95% CI: 1.74 to 31.80), being overweight and/or obese (aOR 2.46; 95% CI: 1.13 to 5.38) and being on a protease inhibitor-based ART regimen (aOR 5.78; 95% CI: 2.30 to 14.50). Healthcare workers appreciated integrated diabetes screening but also reported challenges including increased waiting time, additional workload and inadequate communication of results to patients. Conclusions Integrating diabetes screening with routine VL monitoring (every 2 y) seems feasible and was valued by healthcare workers. The additional cost of adding diabetes screening into VL clinics requires further study and could benefit from a targeted approach prioritizing patients aged ≥40 y, being overweight/obese and on protease inhibitor-based regimens

Improving the screening and treatment of hypertension in people living with HIV: An evidence-based policy brief by Malawi’s Knowledge Translation Platform

No Abstrac

Born too soon in Malawi : Maternal nutrition as a predictor of preterm delivery and community and professional views on the care of the preterm infant

Ennenaikaisen syntymän ilmaantuvuus on Malawissa korkea, nykyisten arvioiden mukaan 18,1 %. Ennenaikaiseen syntymään voi Afrikassa vaikuttaa moni tekijä, kuten äidin raskautta edeltävä ja raskaudenaikainen ravinto. Äidin raskautta edeltävän ravitsemustilan ja vastasyntyneen terveyden (raskauden kesto ja vastasyntyneen koko: paino, pituus ja päänympärysmitta) välisestä yhteydestä on Malawista on vähän näyttöön perustuvaa tietoa Tällä tutkimuksella oli kolme tavoitetta. Ensimmäisenä tavoitteena oli kuvailla käsityksiä ennenaikaisista syntymistä, ennenaikaisesti syntyneiden lasten hoitokäytäntöjä ja ennenaikaisiin syntymiin liittyviä haasteita köyhässä malawilaisessa maaseutuyhteisössä. Toisena tavoitteena oli tutkia terveydenhuollon ammattilaisten näkemyksiä ennenaikaisesti syntyneiden lasten hoidosta ja hoitoa ohjaavien dokumenttien olemassaolosta malawilaisissa terveydenhuollon yksiköissä. Kolmantena tavoitteena oli määritellä äidin raskautta edeltävän ja raskaudenaikaisen ravitsemustilan ja vastasyntyneen terveyden välisen yhteyden voimakkuus. Käsityksiä ennenaikaisen syntymän syistä, ennenaikaisesti syntyneiden lasten hoitokäytännöistä ja ennenaikaiseen syntymään liittyvistä haasteista selvitettiin 20 syvähaastattelulla ja 14 fokusryhmähaastattelulla Mangochin alueen yhteisöissä. Haastateltavien mukaan ennenaikaista syntymää aiheuttavat raskaudenaikaiset sairaudet kuten verenpainetauti ja malaria sekä perinteiset sairaudet (likango and mwanamphepo) sekä raskaudenaikainen huono ravitsemus, monen lapsen synnyttäminen ja aikaisempi ennenaikaisen lapsen synnyttäminen. Tärkeimpinä ennenaikaisesti syntyneiden lasten kotihoitokäytäntöinä mainittiin lapsen pitäminen lämpimänä lämpimien vaatteiden ja peitteiden avulla sekä lämmittämällä taloa avotulella ja sulkemalla ovet ja ikkunat. Haastateltavat mainitsivat ennenaikaisesti syntyneiden lasten asianmukaiseen hoitoon liittyvinä haasteina tiedonpuutteen ja köyhyyden: sairaan lapsen hoitoon vieminen viivästyi ja köyhyys rajoitti mahdollisuutta lämpimien vaatteiden hankintaan. Terveydenhuollon ammattilaisille ja päättäjille tehtiin 16 syvähaastattelua, joilla selvitettiin ennenaikaisesti syntyneiden lasten hoitokäytäntöjä hoitoa ohjaavien dokumenttien olemassaoloa terveydenhuollon yksiköissä. Osa perusterveydenhuollossa työskentelevistä terveydenhuollon ammattilaisista kertoi, että hoitoa ohjaavia dokumentteja ei ollut joissain aluesairaaloissa ja terveyskeskuksissa, mutta yliopistosairaaloissa työskentelevät tiesivät että hoitoohjeita on. Päätöksentekijät uskoivat, että dokumentit olivat saatavilla kaikissa terveydenhuollon yksiköissä. Lisäksi selvisi, että Malawin terveysministeriö on tehnyt ohjeen, jossa selvitetään ennenaikaisesti syntyneiden lasten hoitokäytäntöä. Kolmas osatyö oli prospektiivinen kohorttitutkimus, joka tehtiin upotettuna satunnaistettuun, kontrolloituun iLiNS-DYAD-M -tutkimukseen, jossa mukaan otettiin 1391 naista, joilla oli normaali raskaus Mangochin alueella Malawissa. Äidin raskautta edeltävän painoindeksin sekä raskaudenaikaisen painonnousun ja vastasyntyneen terveyden välistä yhteyttä tutkittiin regressiomalleilla. Raskautta edeltävän painoindeksin ja raskauden keston välillä ei löydetty tilastollisesti merkitseviä eroja, mutta raskautta edeltävä painoindeksi oli yhteydessä lapsen syntymäpainoon ja pään ympärysmittaan. Raskaudenaikainen viikoittainen painonnousu ennusti vahvasti vastasyntyneen terveyttä, sillä se oli yhteydessä melkein kaikkiin tutkittuihin vasteisiin. Loppupäätelmänä voidaan todeta että paikallisten ennenaikaisia syntymiä koskevien käsityksiin kuuluvat äidin sairaudet, äidin käyttäytymiseen liittyvät tekijät ja sosiokulttuuriset tavat. Osallistujien mukaan heillä on paljon haasteita ennenaikaisesti syntyneiden lasten hoidossa sekä kotona että terveydenhuollon yksiköissä. Päättäjien mukaan terveydenhuollon yksiköissä on dokumentteja, jotka voisivat opastaa terveydenhuollon työntekijöitä ennenaikaisesti syntyneiden lasten hoidossa. Vähäinen raskaudenaikainen painonnousu on yhteydessä huonompaan vastasyntyneen terveyteen Malawissa.The incidence of preterm birth (PTB) remains high in Malawi and is currently estimated at 18.1%. Various underlying factors could contribute to PTBs in Africa, including maternal nutrition before pregnancy and during pregnancy. In Malawi, evidence is lacking making it difficult to estimate the relationship between maternal pre-pregnancy nutrition and pregnancy outcomes (duration of pregnancy and size of the newborn including weight, length and head circumference). To address the existing gaps in knowledge on PTBs, the present study had three aims. The first aim was to describe the local perceptions of PTB, care practices for preterm infants, and challenges associated with PTB among people in a rural lowincome community in Malawi. The second aim was to investigate views of the health workers about the care of the preterm infants in the health facilities and existence of any treatment guidelines such as policy documents for delivery of care to the preterm infants in Malawian health facilities. Finally, the third aim was to determine the strength of association between maternal nutritional status before and during pregnancy as well as birth outcomes among women in Malawi. Twenty in-depth interviews and 14 focus group discussions (FGDs) were used to explore the perceived causes of PTB, care practices for preterm infants and challenges associated with PTB among community members in Mangochi district. Participants perceived that diseases such as hypertension, malaria and traditional diseases (likango and mwanamphepo) during pregnancy as well as poor diet during pregnancy, having many children and history of a PTB in the family causes/lead to PTBs. The main reported care practice for preterm infants in the community was keeping the infant warm through dressing the infant with many warm clothes and covering an infant with wrappers, making fire inside the house and closing doors and windows to keep the house warm. Some of the reported challenges included lack of knowledge on how to properly care for preterm infants and poverty which limited the caregivers to buy the infants warm clothes and delay in seeking medical care when needed. A total of 16 in-depth interviews with health care workers and policy makers were used to explore the care of preterm infants in the health facilities and existence of any treatment guidelines for delivery of care to the preterm infants in the health facilities. Some of the health workers reported that, policy and protocol guidelines for care of preterm infants were not available in some district hospitals and health centers, but those working in tertiary hospitals acknowledged availability of the policy and protocol guidelines. Additionally, policy makers believed that policy documents and protocol guidelines were available in all health facilities that would guide care of preterm infants. The analysis of documents also revealed that a policy document, produced by Ministry of Health (MOH) Malawi explaining care of preterm infants was available in Malawi. The third study was a prospective cohort study nested within the International Lipid- Based Nutrient Supplement trial in Malawi (iLiNS DYAD-M) that enrolled 1,391 women with uncomplicated pregnancies in a randomized, controlled trial in Mangochi District of Malawi. Regression analysis was used to investigate the association between maternal pre-pregnancy BMI and weight gain during pregnancy with birth outcomes (duration of pregnancy and size of the newborn including weight, length and head circumference). No significant statistical associations were observed between pre-pregnancy BMI and pregnancy duration, but pre-pregnancy BMI was associated with birth weight and head circumference. Gestational weekly weight gain (GWG) was a strong predictor for birth outcomes as it was associated with almost all measured outcomes. In conclusion, the local perceptions of PTBs in Mangochi district include; maternal diseases, maternal behavioral related issues and social cultural practices. Participants feel that they face many challenges to care for preterm infants in the community and in the health facilities. Policy makers believe that, treatment guidelines are available in health facilities that could guide service providers to care for preterm infants. Low GWG is strongly associated with increased risk of having infants with poor outcomes in Malawi

Reaching adolescents in rural areas : Exploratory study on factors contributing to low utilisation of family planning services among adolescents in Mangochi district - Malawi

It is widely acknowledged that providing family planning services to adolescents would not encourage them to indulge in sexual behaviors but would rather help them with information on how to protect themselves if sexually active from unwanted pregnancies and sexually transmitted infections including HIV/AIDS. Despite the universal knowledge of at least one modern method of family planning among adolescents in Malawi, use of these methods remains negligible and virtually no in-depth studies have targeted adolescents to explore the situation. The purpose of this study was to explore the contributing factors to low utilization of family planning services among adolescents in Lungwena area of Mangochi District in Southern Region of Malawi. Qualitative methods using focus group discussions, individual interviews, key informant interviews plus some general participant observations and limited discourse analysis were used to obtain data for this study. The study found that adolescents’ utilization of family planning services in Lungwena area is mainly affected by lack of community acceptance to acknowledge adolescents sexual activity. However, norms of the society and messages adolescents are exposed to, through some cultural practices, peers and parents confuse adolescents in the understanding of family planning services in general. As such adolescents are challenged with numerous reproductive health problems in this society. In addition, lack of proper knowledge pertaining to family planning methods, individual perceived barriers and barriers associated with delivery of services inhibit adolescents’ to use the available family planning services. This is the first study that has used qualitative methods to explore adolescents’ low utilization of family planning services in Mangochi District. Findings suggest that equipping adolescents with proper knowledge and sensitizing the community on unmarried adolescents reproductive health needs would help adolescents to utilize the available family planning services hence protect them from the sexual health problems found by this study

Lipid based nutrient supplements during pregnancy may improve foetal growth in HIV infected women - A cohort study.

ObjectivesBoth maternal HIV infection and antiretroviral therapy are associated with adverse birth outcomes. The role of antenatal nutrient supplements with regard to adverse birth outcomes in HIV infected women exposed to antiretroviral therapy is not well known. We assessed the association between HIV and birth outcomes and explored whether antenatal lipid-based nutrient supplements (LNS) modulated this association.MethodsWe analysed a nested cohort of pregnant Malawian women who received daily LNS, multiple micronutrients (MMN) or iron and folic acid (IFA). Birth weight, length-for-age z-score (LAZ) and weight-for-age z-score (WAZ) were analysed as continuous outcomes and proportion of stunting and small-for-gestational age (SGA) as dichotomous outcomes.Results134 HIV infected (46 LNS, 39 MMN, 49 IFA) and 833 HIV uninfected (271 LNS, 287 MMN, 275 IFA) women were included. Maternal HIV infection was associated with a lower mean birth weight (-129g (-209, -48), P = 0.002); LAZ (-0.34 (-0.54, -0.13), P = 0.002) and WAZ (-0.21 (-0.40, -0.02), P = 0.041) and a higher risk of stunting (RR (95% confidence interval), 1.87 (1.24, 2.83), P = 0.003) and SGA (1.66 (1.21, 2.26), P = 0.001) in the newborn. If the women received LNS, HIV was not associated with LAZ (mean difference (95%); -0.02 (-0.35, 0.31), P = 0.918) or newborn stunting (RR (95% CI), 0.84 (0.34, 2.03), P = 0.691). However HIV tended to be associated with LAZ if the women received MMN (-0.42 (-0.80, -0.03), P = 0.053); and was significantly associated with LAZ if the women received IFA (-0.52 (-0.89, -0.14), P = 0.021) and with newborn stunting if they received MMN (2.40 (1.15, 4.98), P = 0.029) or IFA (2.40 (1.26, 4.59), P = 0.024).ConclusionsFurther research to investigate the impact of LNS on various aspects of foetal growth in HIV infected women is warranted

Lipid based nutrient supplements during pregnancy may improve foetal growth in HIV infected women - A cohort study.

ObjectivesBoth maternal HIV infection and antiretroviral therapy are associated with adverse birth outcomes. The role of antenatal nutrient supplements with regard to adverse birth outcomes in HIV infected women exposed to antiretroviral therapy is not well known. We assessed the association between HIV and birth outcomes and explored whether antenatal lipid-based nutrient supplements (LNS) modulated this association.MethodsWe analysed a nested cohort of pregnant Malawian women who received daily LNS, multiple micronutrients (MMN) or iron and folic acid (IFA). Birth weight, length-for-age z-score (LAZ) and weight-for-age z-score (WAZ) were analysed as continuous outcomes and proportion of stunting and small-for-gestational age (SGA) as dichotomous outcomes.Results134 HIV infected (46 LNS, 39 MMN, 49 IFA) and 833 HIV uninfected (271 LNS, 287 MMN, 275 IFA) women were included. Maternal HIV infection was associated with a lower mean birth weight (-129g (-209, -48), P = 0.002); LAZ (-0.34 (-0.54, -0.13), P = 0.002) and WAZ (-0.21 (-0.40, -0.02), P = 0.041) and a higher risk of stunting (RR (95% confidence interval), 1.87 (1.24, 2.83), P = 0.003) and SGA (1.66 (1.21, 2.26), P = 0.001) in the newborn. If the women received LNS, HIV was not associated with LAZ (mean difference (95%); -0.02 (-0.35, 0.31), P = 0.918) or newborn stunting (RR (95% CI), 0.84 (0.34, 2.03), P = 0.691). However HIV tended to be associated with LAZ if the women received MMN (-0.42 (-0.80, -0.03), P = 0.053); and was significantly associated with LAZ if the women received IFA (-0.52 (-0.89, -0.14), P = 0.021) and with newborn stunting if they received MMN (2.40 (1.15, 4.98), P = 0.029) or IFA (2.40 (1.26, 4.59), P = 0.024).ConclusionsFurther research to investigate the impact of LNS on various aspects of foetal growth in HIV infected women is warranted