Effect of Maternal Multiple Micronutrient Supplementation on Fetal Loss and Infant Death in Indonesia: A Double-Blind Cluster-Randomized Trial

In developing countries such as Indonesia, maternal nutrient supplementation generally is limited to providing iron and folic acid (IFA). The use of multiple micronutrients (MMN) has been slowed by a lack of persuasive evidence that they reduce fetal losses and infant deaths. The Supplementation with Multiple Micronutrients Intervention Trial, or SUMMIT, was designed as a double-blind cluster-randomized study, conducted in Lombok, Indonesia to determine whether MMN improves obstetrical outcomes when compared with IFA. Both infant and maternal mortality rates were comparatively high in this province. A total of 262 midwives were randomly assigned to distribute IFA or MMN to 31,290 pregnant women in the setting of governmental prenatal care services. Participants took supplements on a daily basis from enrollment up to 90 days postpartum. In the study group, micronutrients included iron, folic acid, retinol, vitamins D and E, ascorbic acid, vitamins B1, B6, and B12, niacin, zinc, copper, selenium, and iodine. Compliance rates approximated 85% in both the IFA and MMN groups. Compared with infants whose mothers received IFA, those whose mothers received MMN supplements experienced an 18% reduction in early infant mortality (up to 90 days postpartum). When mothers were undernourished (with a mid-upper arm circumference less than 23.5 cm) or anemic (with a hemoglobin less than 110 gm/liter), early infant mortality declined by 25% and 38%, respectively. Fetal losses and neonatal deaths combined were reduced by 11%, and significant effects were observed in undernourished and anemic women. When analyzing a cohort of 11,101 infants who were weighed within an hour after birth, the risk of low birth weight (less than 2500 gm) was decreased 14% in the MMN group. For infants whose mothers were anemic when enrolled in the study, the risk of low birth weight was decreased by 33%. These results suggest that, in developing countries, maternal MMN supplementation can reduce infant deaths and for this reason become a valued addition to prenatal care programs. Supplements appear to be particularly helpful to women who are undernourished or anemic.