Maternal Nutritional Status at Postnatal Care

Export Indicator

The number and proportion of HIV-positive women who have a MUAC of less than 220 mm at the first postnatal visit. HIV-positive women is defined as all women with a confirmed HIV-positive test result. MUAC is defined as the circumference of the left, uppe
What it measures

The purpose of this indicator is to measure the impact of nutrition
support during pregnancy on HIV-positive women. Changes in this indicator are meaningful, as
nutrition intervention would be expected to reduce the number/percentage of women with
low MUAC. Women that have a MUAC less than 220 mm at this visit can be assumed to be in an
undernourished state.

According to the WHO guidelines for treatment of HIV-positive adults and adolescents, weight
loss is one of the considerations used to determine clinical staging of HIV.2 Malnutrition
significantly increases the mortality risk for HIV-infected individuals, both those on treatment
and those that are not.3 For case management, nutrition assessment that includes
anthropometric measurement can provide data for clinical staging and can identify patients at
higher mortality risk whose health status may benefit from medical or nutrition interventions,
such as counseling and therapeutic or supplementary feeding. At the facility, regional, and
national levels, monitoring the number and proportion of undernourished individuals can be
used to determine the extent to which PLHIV in care and treatment services may need nutrition
care services.4 It also serves to inform the development of strategies for nutrition interventions
in care and support services. This information can also be used for planning and resource
allocation for food and nutrition support. This indicator can also be used to determine whether
the objective of integrating nutrition care services to reduce malnutrition among PLHIV is being
achieved.

Interpretation. MUAC provides a measure of acute nutritional status in adults. Maternal
nutritional status following delivery is assumed to reflect the mother’s nutritional experience
during pregnancy, her general health and well-being, and her physical preparedness to
breastfeed and care for a baby. A reduction in the prevalence of acute malnutrition following
pregnancy among HIV-infected women indicates that nutritional support and possibly other
interventions have been effective in preventing malnutrition during pregnancy among HIV-
infected girls/women. If the mother’s MUAC is below 220 mm at this assessment, she is often
eligible for nutrition support where such services are available.

Uses. This indicator is an outcome that measures whether or not malnourished HIV-positive
pregnant women were identified at ANC and whether or not they received adequate nutritional
support, if it was deemed necessary at the time. If a program or region has an increased
prevalence of women with a MUAC other areas of food and nutrition programming to ensure that HIV-positive pregnant women
are getting nutritional care and support services earlier in their pregnancy. Other areas may also need to be addressed, such as the need for increased service provision, treatment,
improved counseling, and training for clinic staff.

This indicator can also inform program managers if HIV-positive mothers are in need of
additional nutritional care and support after delivery of their infant. Regardless of the method
of infant feeding (breastfeeding or replacement feeding), both mother and infant benefit if the
mother is in good nutritional status after delivery.

Finally, this indicator can be used to inform maternal nutrition programs nationally and globally.
It can be used to advocate for increased funding and program resources to improve maternal
health. However, at the global level, care must be taken with interpretation. If countries and
programs use individually determined indicator cutoffs (other than MUAC not be strictly comparable across programs.

Rationale

Uses. At the national or program level, this indicator can be used to track progress toward safer
infant-feeding practices among HIV-infected women and their exposed infants, and to assess
the results of infant feeding counseling during the antenatal and peripartum period. The
indicator also contributes to assessment of the quality of counseling on infant feeding (with low
rates of mixed feeding likely to indicate adequate counseling and support).

At the health facility level, the indicator is useful to monitor the extent to which women are
choosing the safest infant feeding practices. Nutrition education efforts could be tailored to
provide women the knowledge to make informed decisions about feeding practices and skills to
feed their infants as safely as possible, regardless of the practice they choose. The indicator can
also be used to help programs or facilities plan for ARV requirements based on the number of
women who are breastfeeding at 3 months.

Numerator

The number of HIV- positive women that have a MUAC less than 220 mm at the first postnatal visit (which should take place within 6 weeks of delivery) at any point in the reporting period

Denominator

All HIV-positive women that attend a postnatal visit within 6 weeks of delivery and receive a MUAC assessment during the same period

Calculation

Numerator / Denominator

Method of measurement

The numerator for this indicator will include the number of HIV-
positive women that have a MUAC less than 220 mm at the first postnatal visit (which should
take place within 6 weeks of delivery) at any point in the reporting period. The denominator will include all HIV-positive women that attend a postnatal visit within 6 weeks of delivery and
receive a MUAC assessment during the same period.

MUAC measures the circumference of the left upper arm in millimeters (mm). It is taken at a
point midway between the tip of the shoulder and the elbow. MUAC is a proxy measure of
nutrient reserves in muscle and fat that are not affected by pregnancy and are independent of
height. It can be used to classify the nutritional status of women who are pregnant or up to 6
months post-partum and of non-pregnant/post-partum clients whose height or weight cannot
be measured (e.g., the client cannot stand or no weighing or measuring equipment is available).

Country or individual programs that currently use a different cutoff for malnutrition than mm can continue to do so, as this will facilitate collection of the indicator in a broader number
of settings. This will, however, limit the value of the indicator for global and inter-program
comparison. To the extent possible, individual programs should ensure that the same cutoff is
used across all program facilities.

Data collection method. PNC registers will be the source of data for this indicator. The PNC
registers should contain a column for maternal HIV status as well as a column for MUAC that
indicates the MUAC measurement and whether or not the MUAC is from those registers should be aggregated with data that are included with the reporting of
other indicators from this register.

Frequency of measurement and reporting. This indicator should be collected on a quarterly or
semiannual basis to ensure high-data quality and to allow for review if there is a question about
the data validity. For country-level reporting, this indicator should be reported annually.

Disaggregation. This indicator will not require disaggregation.

Measurement frequency

Periodic

Disaggregation
Explanation of the numerator
Explanation of the denominator
Strengths and weaknesses

Strengths. A prominent strength associated with this indicator is that it directly measures the
nutritional status of women receiving PMTCT services. MUAC is an internationally utilized
measure for assessing nutritional status.5 Another strength of this indictor is that because the
indicator generally will not require additional data collection (since it relies on components
already collected by many national systems), minimal additional effort and cost will be needed
for collection. Finally, the indicator requires only two elements within the postnatal register:
the HIV status of mothers and their nutritional status as assessed by MUAC. These two
elements are already commonly incorporated into postnatal registers in numerous countries.
Provision of national figures would require only the integration of these two elements into
monthly summary reporting mechanisms.

Weaknesses. Weaknesses include the fact that there are not yet standardized cutoffs for MUAC
to categorize the nutritional status of adults: Different countries and programs use different
cutoffs to classify malnutrition among pregnant and lactating women. Also, MUAC, like all
anthropometric data, can be subject to inter-observer error and measurement error.
Furthermore, some conditions, such as lipodystrophy, may alter an individual’s normal fat
distribution and affect the validity of MUAC measurements for determining nutritional status.

Another consideration is that use of a cutoff (i.e., low MUAC) for assessing nutritional status
prevents assessment of nutritional improvement below the “satisfactory” level. A low MUAC
value following pregnancy does not necessarily mean that the individual did not benefit from
nutritional care and support, since the individual mother’s nutritional status may have
improved with nutritional care and support even if that improvement was not sufficient to
produce a normal MUAC value.

Finally, this indicator only measures those women who come to their postnatal care visit within
the first 6 weeks and it is thus likely to suffer from selection bias. The attendance rate of these
visits also varies between countries and within countries, so the size of this bias is likely to vary between countries and within countries. The usefulness of this indicator for inter- and intra-
country comparisons is limited.

Resources required. To collect data for this indicator, programs will require registers at
postnatal facilities that capture maternal HIV status and maternal nutritional status as
measured by MUAC. These are the only two elements required to calculate this indicator from
registers. If the indicator is to be reported at the national level, monthly summary forms must
also include the indicator.

At the health facility level, implementers will need to ensure that there are staff present at
facilities that have been trained to accurately measure and record MUAC. MUAC tapes will also
be required.

MUAC is currently collected in many postnatal care settings, including the MUAC of HIV-positive
mothers. Collection of MUAC data for HIV-positive mothers does not differ, either technically or
in terms of reporting challenges, except in ensuring that facilities are able to distinguish their
HIV-positive clients from non-PLHIVs. For this reason, we count the indicator as effectively field-
tested.

Further information

Egge, K. and S. Strasser. 2005 Measuring the Impact of Targeted Food Assistance on HIV/AIDS-
Related Beneficiary Groups: M&E Indicators for Consideration. C-SAFE Learning Spaces
Initiative http://www.ifpri.org/pubs/books/oc50/oc50ch16.pdf