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Effects of alternative maternal micronutrient supplements on low birth weight in rural Nepal: double blind randomised community trial

BMJ 2003; 326 doi: (Published 15 March 2003) Cite this as: BMJ 2003;326:571
  1. Parul Christian, associate research professor (pchristi{at},
  2. Subarna K Khatry, project directorb,
  3. Joanne Katz, professorc,
  4. Elizabeth K Pradhan, research associatea,
  5. Steven C LeClerq, research associatea,
  6. Sharada Ram Shrestha, deputy project directorb,
  7. Ramesh K Adhikari, project pediatrician consultantb,
  8. Alfred Sommer, deand,
  9. P West Keith Jr, professora
  1. a Division of Human Nutrition, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, USA
  2. b Nepal Nutrition Intervention Project-Sarlahi (NNIPS), Nepal Netra Jyoti Sangh, PO Box 335, Tripureswor, Kathmandu, Nepal
  3. c Division of Disease Prevention and Control, Johns Hopkins Bloomberg School of Public Health
  4. d Johns Hopkins Bloomberg School of Public Health
  1. Correspondence to: P Christian
  • Accepted 12 December 2002


Objective: To assess the impact on birth size and risk of low birth weight of alternative combinations of micronutrients given to pregnant women.

Design: Double blind cluster randomised controlled trial.

Setting: Rural community in south eastern Nepal.

Participants: 4926 pregnant women and 4130 live born infants.

Interventions: 426 communities were randomised to five regimens in which pregnant women received daily supplements of folic acid, folic acid-iron, folic acid-iron-zinc, or multiple micronutrients all given with vitamin A, or vitamin A alone (control).

Main outcome measures: Birth weight, length, and head and chest circumference assessed within 72 hours of birth. Low birth weight was defined <2500 g.

Results: Supplementation with maternal folic acid alone had no effect on birth size. Folic acid-iron increased mean birth weight by 37 g (95% confidence interval −16 g to 90 g) and reduced the percentage of low birthweight babies (<2500 g) from 43% to 34% (16%; relative risk=0.84, 0.72 to 0.99). Folic acid-iron-zinc had no effect on birth size compared with controls. Multiple micronutrient supplementation increased birth weight by 64 g (12 g to 115 g) and reduced the percentage of low birthweight babies by 14% (0.86, 0.74 to 0.99). None of the supplement combinations reduced the incidence of preterm births. Folic acid-iron and multiple micronutrients increased head and chest circumference of babies, but not length.

Conclusions: Antenatal folic acid-iron supplements modestly reduce the risk of low birth weight. Multiple micronutrients confer no additional benefit over folic acid-iron in reducing this risk.

What is already known on this topic

What is already known on this topic Deficiencies in micronutrients are common in women in developing countries and have been associated with low birth weight and preterm delivery

What this study adds

What this study adds In rural Nepal maternal supplementation with folic acid-iron reduced the incidence of low birth weight by 16%

A multiple micronutrient supplement of 14 micronutrients, including folic acid, iron, and zinc, reduced low birth weight by 14%, thus conferring no advantage over folic acid-iron


  • Funding This study was carried out under cooperative agreement HRN-A-00-97-00015-00 between Office of Health and Nutrition, US Agency for International Development (USAID), Washington, DC, and the Center for Human Nutrition (CHN), Department of International Health, and the Sight and Life Research Institute, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA. It was a joint undertaking between the CHN and the National Society for the Prevention of Blindness, Kathmandu, Nepal, under the auspices of the Social Welfare Council of His Majesty's Government of Nepal. The study was funded by USAID and received additional support from the Unicef Country Office, Kathmandu, Nepal, and Bill and Melinda Gates Foundation. The supplements were provided by Roche, Brazil, and manufactured by NutriCorp International, C E Jamieson, Canada. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

  • Competing interests None declared.

  • Ethical approval The study was approved by the National Health Research Council of the Ministry of Health of Nepal and the Committee for Human Research at the Johns Hopkins Bloomberg School of Public Health. A data safety and monitoring committee approved the trial's continuation midway through the trial. Informed consent was obtained from the participants at each interview.

  • Accepted 12 December 2002
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