Chapter 1: Provide nutrition in pregnancy 2. Provide nutrition in lactation 3. Provide infant nutrition 4. Provide young child nutrition

Nutrition during pregnancy is a critical area of focus for Nutrition and Dietetics professionals in Kenya, where maternal and child health remains a priority for public health initiatives. Understanding the specific nutritional needs before and during pregnancy enables practitioners to design effective interventions that reduce risks of complications, promote healthy fetal development, and support maternal well-being. This chapter addresses the foundational principles of maternal nutrition, emphasizing preconception care and comprehensive nutritional assessments tailored for pregnant women within diverse Kenyan communities.

1.1 Nutritional needs before and during pregnancy

A woman's nutritional state in the months before conception and through the nine months of pregnancy shapes the growth of her baby, the course of the pregnancy and her own health after delivery. The dietitian works across this whole period: finding out what a woman needs, explaining why those needs rise, and measuring her nutritional status so that advice fits her. This topic first introduces the nutritional picture, then explains why preconception nutrition matters, and then sets out how needs are assessed, from body measurements to the individual nutrients that matter most.

1.1.1 Introduction to nutrition before and during pregnancy

Pregnancy builds a new person, a placenta and a larger uterus, expands the mother's blood volume and prepares the breasts for milk. All of this is paid for from the food the woman eats and from the stores her body already holds. Needs for energy, protein and many vitamins and minerals therefore rise, and a woman who starts pregnancy with small stores or a limited diet can struggle to meet them. For example, a woman who sells vegetables from a roadside stall may eat one large meal late in the evening, and in pregnancy that pattern can leave her short of energy and iron for much of the day.

Nutritional demands during pregnancy

Energy needs rise gradually: the increase is small in the first trimester and larger in the second and third, when the baby grows fastest. Protein is needed for the baby's tissues, the placenta and the mother's own expanding tissues. Iron, folate, iodine, calcium, zinc and vitamin D are needed in higher amounts because of cell division, red blood cell production and the development of the brain and bones. Iron deficiency is a leading cause of anaemia in pregnancy, which is why iron is checked and managed at antenatal visits. The exact reference amounts are given under Macronutrients and under each nutrient below.

Physiological changes influencing nutrition

Hormones of pregnancy change how the body handles food. Progesterone relaxes the muscle of the gut, which slows movement of food and can cause constipation and heartburn. Nausea and vomiting, often in the first trimester, reduce intake and may make some foods unpleasant. Appetite and taste often change, and the growing uterus presses on the stomach, so large meals become uncomfortable in late pregnancy. The body also absorbs some nutrients, such as iron and calcium, more efficiently as pregnancy advances. A dietitian uses these facts to suggest small frequent meals, dry foods on waking and fibre with fluids, so that advice works with the symptoms instead of against them.

Nutritional challenges specific to Kenyan settings

Many women in Kenya meet pregnancy with limited choice of food. Low household income, seasonal shortages, long distances to markets and diets built mainly on a staple cereal can restrict variety. Some families avoid certain foods in pregnancy because of local beliefs, for example avoiding eggs or some fruits for fear of a large baby, which removes useful sources of protein and vitamins. Infections such as malaria and intestinal worms use up or destroy the woman's nutrient stores. A dietitian listens to these beliefs without judgement, finds out where they come from and offers practical alternatives that the family can accept.

Role of nutrition education and counselling

Nutrition education gives a woman the knowledge she needs to choose food well, and counselling helps her to turn that knowledge into action at home. The antenatal clinic is the natural meeting point, because women attend it several times during pregnancy and are ready to listen. Good counselling uses local foods, short clear messages and demonstration, and it invites the husband, mother-in-law or other decision makers to take part, because they often control what is bought and cooked. Clear explanation of why iron and folic acid tablets are taken, and how to manage their side effects, also improves whether a woman keeps taking them.

1.1.2 Importance of preconception nutrition

The neural tube of the baby closes within the first four weeks after conception, often before a woman knows she is pregnant, and the baby's first organs form in the weeks that follow. Nutrition before conception is therefore not a preparation for pregnancy that can wait: it decides the conditions in which the baby's early development takes place. A woman who enters pregnancy well nourished, with adequate iron and folate stores and a healthy weight, is better placed to carry a healthy pregnancy. Preconception counselling is also a suitable time to correct deficiencies, because correction takes weeks to months.

Impact on maternal and fetal health outcomes

Women who are underweight before pregnancy have a higher risk of delivering a baby with low birth weight and of delivering preterm. Women who are overweight or obese have a higher risk of gestational diabetes, pre-eclampsia and a difficult delivery, and their babies are more often born large. Adequate folate before conception lowers the risk of neural tube defects such as spina bifida. Good iron stores protect the woman from anaemia, which would otherwise reduce oxygen delivery to the baby and weaken the mother at delivery. A woman's pre-pregnancy nutrition also affects how easily she conceives, since very low or very high body weight can disturb ovulation.

Correction of micronutrient deficiencies before conception

A woman who is planning pregnancy can have her iron status checked and treated with food and, where a clinician advises, iron tablets, so that stores are built before demand rises. Iodine intake can be improved through iodised salt, and vitamin A and zinc intake through a more varied diet. Intestinal worms and malaria that drain iron are treated by the health team before conception. The woman is advised to start a daily folic acid supplement before she stops contraception, and not to wait for a positive test. Correcting deficiencies in advance gives the body time to rebuild stores, which cannot be done quickly once pregnancy has begun.

Lifestyle and dietary modifications during preconception

Counselling in this period covers the pattern of eating and habits that carry into pregnancy. A woman is encouraged to eat a variety of foods from different groups daily, to include a source of iron or protein in the meals of the day, and to reach a healthy weight slowly by adjusting portions and activity, not by crash dieting. She is advised to stop alcohol and tobacco, to limit tea and coffee, and to check with a health worker before using herbal products. Food safety habits such as washing hands, cooking animal foods thoroughly and using pasteurised or boiled milk are also taught, since they protect the early pregnancy from infection.

Integration with reproductive health services

Preconception nutrition reaches more women when it is built into services that women already use. A family planning clinic can screen weight, measure the mid-upper arm and ask about diet when a woman asks to stop contraception. HIV care, chronic disease clinics and adolescent services can offer short nutrition messages and referral. Community health workers carry the same messages to homes, and midwives identify women who need a dietitian's input. Working together prevents a woman from receiving different advice from different workers and lets a dietitian follow her from before conception into antenatal care.

1.1.3 Assessment of nutritional needs before and during pregnancy

Assessment is how a dietitian finds out what a particular woman needs. It combines body measurements, laboratory tests, a clinical examination and a record of what she eats, and each of these answers a different question. Body measurements show whether her size and weight gain are healthy, laboratory tests show whether nutrients are reaching the blood, the clinical examination shows signs a measurement can miss, and the diet record shows why. No single method is enough, and the findings are read together and compared with the woman's circumstances. The same four methods are used again later to track progress, which is explained under monitoring and evaluating nutrition intervention.

1.1.3.1 Anthropometry

Anthropometry means measuring the body. In pregnancy the dietitian measures height once, weight at each visit, and mid-upper arm circumference where weight before pregnancy is not known. Measurements must be taken in the same way each time, with the same calibrated scale, the woman in light clothing and without shoes, so that changes are real and not caused by the method.

Body mass index (BMI) is the woman's weight divided by her height squared, and it is calculated using her weight before pregnancy or from the first visit in the first trimester. Example: a woman weighs 54 kg and is 1.55 m tall.

• Formula: BMI = weight (kg) ÷ height (m)²
• Substitution: BMI = 54 ÷ (1.55 × 1.55) = 54 ÷ 2.4025
• Result: 22.5 kg/m², which is in the normal range

BMI is read against the usual adult bands: below 18.5 kg/m² underweight, 18.5 to 24.9 normal, 25.0 to 29.9 overweight and 30.0 or above obese. These bands set the target for weight gain.

For the woman above, a gain of 11.5 to 16 kg means that at the end of pregnancy her weight should lie between 54 + 11.5 = 65.5 kg and 54 + 16 = 70 kg. Gain that is well below the target, or that rises sharply in a few weeks, is investigated for undernutrition, fluid retention or a complication.

Mid-upper arm circumference (MUAC) is measured on the left arm, halfway between the tip of the shoulder and the elbow, with a non-stretchable tape held snug but not tight. It is useful in clinics without good scales and at outreach visits because it changes little during pregnancy. A reading below 23 cm is taken as a sign of undernutrition and the woman is referred for nutrition support. Height is also noted: a woman shorter than 145 cm is flagged to the midwife because of the higher chance of a difficult delivery.

1.1.3.2 Biochemical assessments

Biochemical assessments measure nutrients, or the effects of nutrient shortage, in blood and urine. A key test in pregnancy is haemoglobin, the iron-carrying protein in red blood cells. It is measured by a small portable haemoglobinometer at the clinic or by a full blood count in the laboratory. Haemoglobin is normally lower in pregnancy because the blood plasma expands more than the red cells, so pregnancy-specific cut-offs are used.

A level below 7.0 g/dL is severe anaemia and needs urgent referral to a clinician. Example: a woman at 33 weeks has a reading of 10.6 g/dL. This is below the third trimester cut-off of 11.0 g/dL, so she is anaemic, and a reading from 10.0 to 10.9 g/dL in the third trimester is mild anaemia, which is managed with food advice and iron tablets as the clinic directs.

Other tests that the health team may order include serum ferritin, which shows the size of iron stores and falls before haemoglobin does, and tests for vitamin B12 and folate when anaemia does not respond to iron. A screening test for blood sugar, usually between 24 and 28 weeks, identifies gestational diabetes. Urine tests for protein and sugar are taken at antenatal visits, and a positive result is reported to the clinician. A dietitian reads these results with the diet record, but a diagnosis and medicine are decided by the clinician.

1.1.3.3 Clinical monitoring

Clinical monitoring looks for physical signs and symptoms of nutrient shortage or of a pregnancy problem. It is done by looking, asking and examining, and it needs no equipment. It also identifies women who need urgent referral.

• Pallor: a pale inner lower eyelid, tongue, nail beds or palms suggests anaemia and prompts a haemoglobin test.
• Swelling: swelling of the feet in the evening is common in late pregnancy, but swelling of the face and hands needs blood pressure and urine checks.
• Blood pressure: raised blood pressure after 20 weeks is a warning sign of pre-eclampsia and is referred to the clinician.
• Signs of deficiency: cracks at the corners of the mouth may point to B vitamins, a swelling at the front of the neck to iodine shortage, bleeding gums to vitamin C and thin hair and a poor-healing skin to protein or zinc shortage. These signs are not specific, so they are confirmed with the diet record and tests.
• Symptoms: persistent vomiting, tiredness, breathlessness on small effort, loss of appetite and constipation affect intake and are recorded.
• Danger signs: severe headache, blurred vision, vaginal bleeding, severe pallor and reduced baby movements are referred to the clinician immediately.

The dietitian records each finding at each visit so that changes between visits can be seen.

1.1.3.4 Dietary assessments

Dietary assessment finds out what a woman eats and whether it can meet her needs. It explains the findings of the other three methods: a low haemoglobin, for example, may be explained by a diet with little iron-rich food and tea taken with meals. Several methods are used, and the choice depends on time and on how well the woman can recall.

• 24-hour recall: the woman describes everything eaten and drunk in the previous day, from waking to sleeping, including portions, cooking method and snacks. It is quick but reflects one day only, so it is repeated on another day.
• Food frequency questionnaire: a list of foods is read out and the woman says how often she eats each in a week or month. It shows long-term habits, such as how often she eats meat, fish, eggs or green vegetables.
• Diet history: a longer interview about usual eating pattern, meal times, food beliefs, appetite changes and food supply at home. It gives the fullest picture and suits the first visit.
• Dietary diversity score: the foods eaten in a day are grouped into ten food groups: grains, white roots and tubers and plantains; pulses; nuts and seeds; dairy; meat, poultry and fish; eggs; dark green leafy vegetables; other vitamin A-rich fruits and vegetables; other vegetables; and other fruits. A woman who eats foods from five or more groups has a diet more likely to supply enough micronutrients.
• Food records: the woman, or a family member who can write, records food as it is eaten for three days, which gives detail but needs literacy and effort.

Example: a woman reports maize porridge for breakfast, ugali with sukuma wiki and a small piece of fish for lunch, and rice with beans for supper. The groups counted are grains, dark green leafy vegetables, meat, poultry and fish, and pulses, giving a score of 4 out of 10, which is below the minimum of 5. The dietitian then asks about fruit, eggs, milk and nuts and plans additions.

The recall is then compared with the needs for individual nutrients. The sections below set out what the dietitian looks for.

1.1.3.4.1 Key nutritional needs

Needs rise because the body is building new tissue and expanding the blood volume, which increases considerably during pregnancy. The need for energy and protein rises, and the need for several vitamins and minerals rises more, in proportion, than the need for energy. This means that a pregnant woman needs foods that are rich in nutrients, not just more of the same food. A diet built around a staple cereal with little variety will tend to fall short of iron, folate, zinc and iodine even when the woman is eating enough to feel full.

• Energy and protein: needs for both rise in the second and third trimesters, as set out under Macronutrients.
• Iron, folic acid, iodine, zinc and vitamin D: each is treated in its own section below, because each has its own sources, risks and signs.
• Calcium: needed for the baby's bones and teeth. When the diet supplies too little, the mother's own bone is used. Milk, yoghurt, small fish eaten with their bones and dark green leafy vegetables supply it.
• Vitamin A: supports vision, growth and immunity. It is taken from orange-fleshed sweet potato, carrot, pumpkin, mango and green leafy vegetables. Large daily amounts of liver or high-dose vitamin A tablets are avoided, because too much preformed vitamin A can harm the developing baby.
• Vitamin B12: found naturally in animal foods, so women who eat no meat, fish, eggs or milk need special attention.
• Fluids: a woman drinks enough clean, safe water to keep her urine pale, and more in hot weather or when she is vomiting.

Some foods and habits are advised against. Alcohol has no safe level in pregnancy and tobacco harms growth, so both are avoided. Tea and coffee are taken in moderation and away from meals. Raw or undercooked meat, eggs and fish and unpasteurised milk can carry organisms that harm the baby, so animal foods are cooked thoroughly and milk is boiled or pasteurised. A woman is also asked to check with a health worker before taking herbal remedies.

1.1.3.4.2 Iron

Iron is part of haemoglobin, which carries oxygen in the blood, and of enzymes that support growth and brain development. The need for iron rises sharply in pregnancy because the mother makes more red blood cells and the baby and placenta store iron; over the whole pregnancy the extra requirement is about 1,000 mg. Few women have stores large enough to meet this from the body alone, so iron has to come from food and from tablets. Iron deficiency leads to anaemia, tiredness, poor resistance to infection, and a higher risk of preterm birth, low birth weight and heavy blood loss at delivery.

Iron from food comes in two forms.

• Haem iron: found in meat, chicken, liver and fish, and well absorbed.
• Non-haem iron: found in beans, lentils, cowpeas, dark green leafy vegetables, finger millet and fortified flour, and absorbed less well.

Absorption of non-haem iron improves when a food rich in vitamin C, such as orange, guava, mango, tomato or lemon, is eaten at the same meal, or when a little meat or fish is added. It is reduced by tea and coffee taken with meals and by phytates in unrefined cereals and pulses, which can be lowered by soaking, fermenting or germinating the grain. Cooking in an iron pot adds a small amount of iron to food.

World Health Organization guidance recommends a daily iron supplement of 30 to 60 mg of elemental iron with folic acid throughout pregnancy, starting as early as possible, and the national antenatal programme issues the tablets at the clinic. Side effects such as constipation, nausea and dark stools are common, and women are advised that these are harmless, that the tablet is better taken in the evening or with a fruit, and that they should not stop without advising the health worker. Women are also told to keep tablets away from children.

When assessing iron, the dietitian asks how often the woman eats meat, fish, eggs or liver, when she drinks tea in relation to meals, whether she is taking her tablets and what side effects she has, and compares these answers with her haemoglobin.

1.1.3.4.3 Iodine

Iodine is needed to make thyroid hormones, which control the body's metabolism and are essential for the development of the baby's brain and nervous system. The baby depends entirely on the mother's thyroid hormone in the first part of pregnancy, so the woman's iodine intake matters from conception. Deficiency in pregnancy can cause goitre, an underactive thyroid in the mother, miscarriage, stillbirth and, in the baby, impaired brain development and, when severe, congenital iodine deficiency disorder. World Health Organization guidance gives a recommended intake of 250 micrograms a day in pregnancy.

The usual source of iodine in the Kenyan diet is iodised salt, and sea fish, milk and eggs supply smaller amounts. Iodine is lost when salt is exposed to heat, sunlight and moisture, so iodised salt is stored in a closed container away from the stove and added toward the end of cooking. Some foods, such as cassava, sorghum and raw cabbage, contain substances that reduce the use of iodine by the thyroid, and this matters when iodine intake is low; soaking, cooking and fermentation lower their effect.

During assessment the dietitian asks which salt the household buys, how it is stored and when it is added, and looks for a swelling at the front of the neck. A woman with a goitre or with a diet that lacks iodised salt is referred to the clinician. Iodine tablets are not given by the dietitian on her own, and large doses are avoided because too much iodine can also disturb the thyroid.

1.1.3.4.4 Vitamin D

Vitamin D helps the body absorb calcium and phosphorus and is needed for the baby's bones and teeth and for the immune system. Skin makes vitamin D when it is exposed to sunlight, and this is a major source for many people. Kenya lies on the equator, so sunlight is usually adequate, but a woman who spends the day indoors, covers her arms and face fully, lives with heavy air pollution or has dark skin may make less. A short time outdoors with the face and arms exposed on several days a week, avoiding burning, helps.

Food sources are smaller: oily fish, egg yolk, liver and foods fortified with vitamin D. Low vitamin D in the mother can lead to low calcium in the newborn, poor bone development and rickets in the infant, and to bone pain and softening in the mother. The World Health Organization does not recommend routine vitamin D tablets in pregnancy, so a supplement is given when a clinician finds deficiency or risk. The dietitian asks about time outdoors, clothing, food sources and bone pain, and refers women with signs of deficiency.

1.1.3.4.5 Macronutrients

Macronutrients are carbohydrate, protein and fat, the nutrients that supply energy and body-building material. Their needs rise during pregnancy, but a woman does not need to eat for two. Adequate weight gain, as shown under Anthropometry, is a useful guide to whether energy intake is enough.

• Energy: World Health Organization and Food and Agriculture Organization estimates for women who gain weight as recommended are an extra 85 kcal a day in the first trimester, 285 kcal in the second and 475 kcal in the third. Example: a woman who needed 1,900 kcal a day before pregnancy needs about 1,900 + 85 = 1,985 kcal in the first trimester, 1,900 + 285 = 2,185 kcal in the second and 1,900 + 475 = 2,375 kcal in the third. This baseline is hypothetical, because the true figure depends on her size and activity. Women who are undernourished or who work physically hard need more.
• Protein: protein is needed for the baby, placenta, uterus and the mother's extra blood. The extra amount is small in the first trimester and rises later, about 9 g a day more in the second and 31 g more in the third than for a non-pregnant woman. Sources include fish, eggs, milk, meat, beans, lentils, cowpeas, groundnuts and soya.
• Carbohydrate: carbohydrate is the body's usual source of energy and the brain's fuel. The recommended intake in pregnancy is at least 175 g a day. Better sources are whole grains, sweet potato, cassava, plantain and legumes, which also supply fibre, rather than sugary drinks and sweets.
• Fat: fat supplies concentrated energy and the essential fatty acids needed for the baby's brain and eyes, including the omega-3 fat DHA found in oily fish. Cooking oil, groundnuts, avocado, eggs and fish supply fat.
• Fibre: fibre from whole grains, beans, fruits and vegetables, taken with enough water, prevents the constipation that hormones cause.

Women with a history of poor weight gain, a low BMI or a food-insecure household are noted at assessment, because they may need extra support covered under nutrition intervention.

1.1.3.4.6 Folic Acid

Folate is a B vitamin needed to make DNA and new cells, and folic acid is its stable form used in tablets and fortified foods. Folate is needed particularly while the neural tube forms in the first month after conception. Too little folate in that period raises the risk of neural tube defects, in which the spine or brain does not close fully. Spina bifida and anencephaly are examples. Deficiency in the later months can also cause a type of anaemia in which the red cells are large.

World Health Organization guidance recommends 400 micrograms of folic acid daily, starting before conception and continuing through the first 12 weeks, and it is also included in the daily iron and folic acid tablet through pregnancy. Women who have had a baby with a neural tube defect, who take certain medicines for epilepsy or who have diabetes may be prescribed a higher dose by a clinician. A dietitian does not set this dose.

Food sources of folate include dark green leafy vegetables such as sukuma wiki and amaranth, beans, cowpeas, groundnuts, citrus fruit, avocado and liver. Folate is easily destroyed by long cooking and by discarding the cooking water, so vegetables are cooked briefly and lightly. Fortified maize and wheat flour sold in Kenya also supply folic acid and are recognisable by the fortification mark on the packet. Because a pregnancy is often recognised after the neural tube has closed, women of child-bearing age are encouraged to eat folate-rich foods regularly.

1.1.3.4.7 Zinc

Zinc is needed for cell division, protein making, wound healing and immunity, and so for the growth of the baby and the mother's resistance to infection. Needs are higher in pregnancy. Low zinc status is associated with poor growth and a weaker immune response, although routine zinc tablets in pregnancy are not recommended.

Good sources are meat, fish, shellfish, eggs and milk, from which zinc is well absorbed. Beans, lentils, nuts, seeds and whole grains also contain zinc, but phytates in them reduce absorption, so soaking, fermenting and germinating these foods help. A diet based mainly on unrefined cereals with few animal foods is at risk of low zinc. High doses of iron tablets taken together with zinc can reduce absorption of both, which is one reason supplements are taken as advised and not in larger amounts.

At assessment, the dietitian asks how often the woman eats animal foods, which cereals she uses and whether she soaks or ferments grains. Signs such as slow wound healing, hair loss and frequent infections are not specific, so they are noted and followed with the diet record, and the dietitian refers a woman who may need a supplement to the clinician.

Socioeconomic and environmental factors

Assessment is not complete without the setting in which the woman lives. The dietitian asks about household income, who buys and cooks food, the number of people the household feeds, the season, access to a market, water and sanitation, workload and the distance to the clinic. For example, a woman living in a crowded urban settlement with an irregular income may rely on cheap street food and have no space to cook, so advice to cook beans slowly is unrealistic until a cheaper, faster alternative such as roasted groundnuts or boiled eggs is offered. Food beliefs and the support of the family are also noted. These findings let the dietitian propose changes that the woman can afford and carry out, and they identify women who need referral for social support.

Chapter Summary

This chapter covers the essential aspects of providing nutrition during pregnancy, starting with the nutritional needs before and during this critical period. It highlights the significance of preconception nutrition and various methods to assess nutritional status, including anthropometry, biochemical tests, clinical monitoring, and dietary assessments. Pregnancy-related complications such as gestational diabetes, anemia, pre-eclampsia, and others are explored, emphasizing their impact on maternal and fetal health. The chapter then outlines the development of a nutrition intervention plan, detailing steps involved and types of interventions like supplementation, diet planning, deworming, and education. It proceeds to discuss how to effectively carry out these nutrition interventions using appropriate tools and resources. Finally, the chapter explains the importance of monitoring and evaluating nutrition interventions through various methods and indicators, while addressing challenges encountered in ensuring successful outcomes.