INTRODUCTION

In a holistic view of the physiological functions of the female human body, generating new life in your uterus is the most complex of cellular, hormonal and immunological engineering¹.

All the complexity in the formation and healthy development of the new being, from embryonic life to adult life, has the social factor as primordial, due to its direct relationship with the pregnant woman’s quality of life. This quality depends on the socioeconomic conditions in which one lives, interfering with the psychological factor and exposure to factors harmful to the fetus, such as smoking, alcohol consumption, poor sanitary conditions, low education and food with low nutritional value¹.

Brazil is a peripheral country, called “developing”, with around 30% of the population on low income². Like the entire world, Brazil was hit by COVID-19, a disease caused by the coronavirus SARS-COV 2, declared a pandemic by the World Health Organization (WHO) in March 2020, which caused the biggest health collapse of the last century , corroborating a greater awakening to the importance of seeking health promotion actions³.

Considering the effects of SARS-VOC2 on the human body, triggering an intense inflammatory and vascular response in the individual, compromising the immune system, pregnant women stood out as a high-risk subpopulation, as they have a fragile immune system and greater vascular risk⁴.

Brazil stood out in terms of maternal mortality due to SARS-VOC 2, with a mortality rate 2.5 to 4 times higher in relation to the general population, reaching a mortality rate of 12% in pregnant and postpartum women at the peak of the disease in 2021^5,6.

Adequate nutrition contributes to good maternal health, having great importance in the healthy development of the fetus⁷. Malnutrition (whether of adequate, high or suboptimal weight ) can generate serious events such as fetal or infant death (before or after birth until the first year of life) as well as morbidities of the fetus, from intrauterine life to adulthood, from intrauterine fetal growth restriction (IUGR) to endocrine, metabolic or morphological dysfunctions, such as thyroid disorders, diabetes, heart disease, neuropsychic disorders or other diseases⁸.

National Public Policies aimed at the recovery and prevention of nutritional problems are permanent actions of the Ministry of Health (MS) in recent decades, through the Secretariat of Primary Health Care (APS) with various programs and actions, highlighting in nutrition the Nutritional Disease Prevention and Control Program (PCAN), aimed at children and pregnant women⁹.

The scenario experienced in recent years is one of poor food quality, where a balanced diet containing minerals, vitamins, proteins and fatty acids, in addition to carbohydrates, is the exception. In pregnant women, nutritional demand increases not only in quantity, but above all in quality, to guarantee the fetus the adequate nutritional supply for its development^1,9.

The goals established around the world remain the same in plans to reduce maternal and child mortality, within the Sustainable Development Goals (SDGs) for 2030, with a Maternal Mortality Ratio (MMR) estimated at 30 deaths per 100,000 live births ( NV). This reality is distant in Brazil, before the pandemic the triple viral infection was 58 per 100,000 LB, increasing by 62% in COVID-19, reaching 107 deaths per 100,000 LB^10,11.

Therefore, such research is justified, in this context of maternal morbidity and mortality, in addition to essential knowledge, of a social context, whose professional practice experiences two divergent realities in public and private services, in something basic which is dietary supplementation for pregnant women.

The general objective is to analyze the quality and supply of dietary supplementation for pregnant women in Brazil, from 2019 to 2021.

METHODS

RESULTS

It was evident that 4,536,389 (four million five hundred and thirty-six thousand three hundred and eighty-nine) pregnant women were registered, totaling the three years analyzed.

An analysis of supplements offered in the public system in Brazil, iron and folic acid, was carried out in the pre -pandemic year of 2019 and in the pandemic years, 2020 and 2021. The distribution rates of iron and folic acid in the five Brazilian regions were evaluated separately.

Table 1 shows iron distribution rates, generally below recommended levels, with less than 25% of pregnant women having received it. Among Brazilian regions, the one with the highest percentage was the Northeast, with 24.39%.

It was observed that the pandemic year 2021 was the year with the highest rate of iron supply to pregnant women, 19.26%, in relation to the period studied.

For iron, coverage was adequate in only one of the 27 states. In 2019, the highest coverage rate was 11.2%, having been 9.97% in 2020 and a better offer, although still low, of 19.26% in 2021, the second year of the pandemic.

The categorization of iron distribution (table 2) was not adequate in 98.8% of Brazilian regions.

Regarding the distribution of folic acid to pregnant women, this presented an overall rate of less than 20%. It was observed that the year of the 2021 pandemic was the one with the highest supply rate in relation to the period studied, at 15.28% (table 3).

Therefore, more than 75% of pregnant women were left without access to folic acid, with maximum coverage below 16%, being 8% in 2019, 7.6% in 2020 and 15.28% in 2021.

However, the distribution of folic acid to pregnant women in Brazil, in Primary Health Care, was not adequate in 100% of Brazilian states, as shown in table 4.

What was observed in Brazil in general was the inadequacy of micronutrient intake throughout the period studied, from pre -pandemic to pandemic (tables 3 and 5).

In the comparative analysis between the pre -pandemic (2019) and pandemic (2020 and 2021) periods, there was a significant and strong correlation in the distribution of iron using the Spearman method (table 5).

However, this correlation using the Pairwise method , with significance values adjusted by the Bonferroni correction , showed that between 2019 and 2020 there was no significant difference (p=1.00), but only between the years 2019 and 2020 with 2021 (p<0.05), due to the higher iron distribution rate in the pandemic year 2021 (table 6).

For folic acid distribution, the correlation coefficient between the pre -pandemic and pandemic years was weaker, but significant between the years 2019 and 2020 (p=0.001). Between 2019 and 2021, there was no significant correlation, according to the Spearman method (table 7).

Friedman’s hypothesis test (table 9) showed no association in the distribution of folic acid in the years 2019 to 2021 (p=0.060). Therefore, folic acid supply was not significantly different between years.

DISCUSSION

The present study highlighted the quality and supply of dietary supplementation for pregnant women with disabilities in Brazil. In Brazilian regions, only iron and folic acid are prescribed as minerals offered in PHC prenatal care.

Observing the results, it is necessary to reflect on important points in the literature, in parallel with the findings and possible improvements in the Brazilian scenario.

The low distribution of supplements in almost all states was the exception of the state of Pernambuco, in the Northeast region, which economically has populations with lower income². And, on the contrary, more developed regions, such as the Southeast, presented the least satisfactory rates. This discrepancy is possibly due to greater concern and care with health promotion actions on the part of professionals who deal with care in more economically needy regions.

The results of low supplementation have no causal relationship with the pandemic. The pre-pandemic numbers for 2019 were more unsatisfactory compared to the years 2020 and 2021 (pandemic). This fact reveals chronic deficiencies in the health system and its management, and may be related to failures ranging from professional training to the importance of promotion actions, as well as management planning to the supervision of results, which aims to improve in the face of failures. This entire basic health management chain needs to be reevaluated for changes and improvements.

Looking at Brazil’s Food and Nutrition Surveillance System (SISVAN), created more than 30 years ago and still in force, these results bring reflections on possible flaws in the system. It should be noted that the objectives of SISVAN are “health promotion and prevention actions and updated situational diagnosis of food and nutritional problems relevant to public health”⁹.

Given this duty of the State to promote, diagnose and prevent health problems for the population, possible causes of inadequate coverage of iron and folic acid supplementation in Brazil include failures at various points such as: in health education actions for women of childbearing age, pregnant women and their families, about the importance of supplementation for the mother and fetus; in the National Policy for Permanent Education in Health (PNEPS), which aims to periodically update health professionals, who in Primary Care range from community agents, to technicians, nurses, pharmacists, nutritionists, doctors and everyone in this cycle of assistance to pregnant women , certainly contributing to greater effectiveness in guidance, prescription, dispensing, use and supervision; in administrative management, from planning to execution, from purchase to exit and monitoring results and maternal and child indicators of morbidity and mortality, among other possible factors.

Focusing on this nutritional care, the National Food and Nutrition Policy – PNAN was created in 1999, updated in 2021, which aims to monitor, promote and prevent food and nutrition, as well as management and qualification of the work team⁹.

In 2005, the National Iron Supplementation Program (PNSF) was created to guarantee the preventive supply of iron and folic acid to all pregnant women, offering folate from the beginning of pregnancy and ferrous sulfate from 20 weeks, maintaining it until 3 months after childbirth (puerperium) or after abortion. In 2013 it was updated, ceasing to be a federal program and decentralizing it to States and Municipalities; indicating starting folic acid during preconception, at least 30 days before becoming pregnant, for the best prevention of malformations of the Central Nervous System-CNS; prolonging the use of folate throughout pregnancy, acting against anemia and other possible formation problems, in addition to the CNS and bringing forward the use of iron to the beginning of pregnancy and not just after the 20th week, when anemia may already be present¹⁴.

The importance of these nutrients available for years in the care policy for pregnant women in Brazil is highlighted, which are iron and folic acid.

Iron is an important metal in the formation of hemoglobin, the most important protein in red blood cells or red blood cells. There are 2 types of iron, heme iron and non-heme iron. Heme iron is best absorbed and is found in meat, especially red meat. Non-heme is present in vegetables, among others¹⁵.

Iron deficiency leads to a drop in hemoglobin, which can have several reasons, including low food intake. This drop in hemoglobin is called anemia, which in iron deficiency is called iron deficiency anemia. Hemoglobin is responsible for transporting oxygen to all cells in the body. Failure in oxygenation leads to inflammation and cell death, reflected in various diseases throughout the body, from growth deficits, fatigue, tiredness, heart problems, among others. And specifically in pregnancy, it can be associated with maternal pre-eclampsia, fetal growth restriction, premature births and hemorrhages, due to various vascular and coagulation disorders. For the diagnosis of anemia, the laboratory standard evaluated is a hemoglobin concentration below 11 g/dl and ferritin, which signals hepatic iron reserves^16-20.

According to the WHO, 38% of pregnant women in 2011 had anemia, around 80% due to iron deficiency. The use of iron was the initial milestone in supplementation in the last century, 1990, given the serious situation of malnutrition and anemia in children under 5 years of age, when formulas or flour enrichment were introduced in several countries, which in Brazil occurred in 2005, through the PNSF^14,18.

The second nutrient recommended for years in the national policy for assistance to pregnant women is folic acid, or vitamin B9, also called folate in its active form or methylfolate. Food sources of folate are dark green leaves (which gave rise to the name), whole grains, beans, mushrooms, chicken and beef liver, eggs, fruits, among others¹⁶.

Folate deficiency can cause anemia, worsened immunity and other problems related to growth and formation by acting as a coenzyme in cellular reactions, cell division, protein metabolism and DNA synthesis. Its greatest importance in prevention is related to CNS malformations, with spina bifida and anencephaly being the most prevalent (90% of cases)^18,21-23.

CNS malformations begin between the third and fifth week of gestation and supplementation with ideal folate is started preconception due to the precocity of the malformation. This supplementation reduces the risk of serious defects by 50 to 70 percent. Unfortunately, many women’s accession occurs late and the neural tube defect may already be present. Less than half of pregnant women know that the use of folic acid should be started during preconception, as well as continued throughout pregnancy^18,20.

Such supplementation studied in 56 countries, estimated that 65,380 cases of spina bifida and anencephaly were avoided, where early folate supplementation reduced at least 23% of CNS malformations²⁰.

Regarding the dose of folate to be used, there is no consensus. For years and still in Brazil and other countries, the 5 mg dose has been used, as it is the standard dose distributed in tablet form in Primary Care. More recent studies, the WHO itself and the Brazilian Federation of Gynecology and Obstetrics (FEBRASGO) demonstrate efficacy with smaller doses and the use of the active form methylfolate, at an average dose of 0.4 to 0.6 mg, although there is no standard^21,22.

A study in Malaysia of doses of iron and folic acid in CNS protection identified that the dose with the best neuroprotective effect was seven times higher than the currently recommended dose of 2.8 mg of folate per day²³.

Thus, iron and folic acid are of great importance in the prevention of maternal-fetal diseases, but the PNSF during pregnancy has existed for 18 years and there is no update regarding the nutritional quality to be supplemented.

What was different with children, whose public supplementation policy has already undergone successive changes, from the supply of iron and folic acid, followed by vitamins A and D to multivitamin and mineral supplementation, now distributed in public schools in Brazil in sachets. , in the 2014 NutriSUS program^9,18.

The approximate standard of dietary reference intake (DRI) for pregnant women, both American and another developed by Freitas in 2010, ratifies the need for an adequate intake of multivitamins and minerals, in addition to macronutrients, such as fatty acids, in addition to carbohydrates and proteins, with greater maternal demand compared to non-pregnant women^25,26.

In the analysis of the variables in this research, the results reveal this supplementary deficiency in Brazil, both in distribution and quality, as in addition to iron and folic acid, several other micronutrients have their value in the pregnancy process¹⁹.

Vitamins such as A, C, E, D, all the others in the B complex (B1, B2, B3, B5, B6, B7 and B12), in addition to folic acid (B9), as well as other minerals in addition to iron (Iodine, Zinc, Selenium, Magnesium and Calcium) are essential in cellular metabolism and vascular protection, from the formation process, homeostasis to the prevention of oxidative and epigenetic damage. The adequate supply of these and other micro and macronutrients (omega 3, 6, proteins and others) has an important association in reducing maternal and fetal damage, such as pre-eclampsia, gestational diabetes, maternal depression, premature birth and neuroendocrine and neuropsychic disorders from childhood to adult life, whether resulting from prematurity or just poor fetal nutrition in this pregnancy process of formation and healthy development of human organs and systems^27-33,36.

It is worth highlighting the fact that many women already begin their pregnancy with nutritional deficiencies, whether due to poor diet or even iron losses due to menstrual cycles and, therefore, nutritional assessment and supplementation are of great importance not only at the beginning of pregnancy, but also in preconception.

This research clarifies the importance of supplementation with various micronutrients for maternal health, ratified by the Brazilian Federation of Gynecology and Obstetrics and WHO, popularly called “multivitamin”^19,21-26.

Considering the doses of vitamins and minerals to be supplemented during pregnancy, there is no consensus, but it is reiterated that maternal needs are greater than those of non-pregnant women and that supplementation is carried out under medical and nutritional supervision, with individualized management. , assessing the needs of each pregnant woman^21,25,26.

And a last important consideration concerns public spending. The lack of “multivitamin” supplementation in this class can bring several complications in the short and long term, maternal, fetal and postnatal child, leading to high costs in expenses with complications, from surgeries and non-surgical treatments, intrauterine life, childbirth and the lifelong³⁷.

Therefore, the importance of supplementation during pregnancy rich in macro and micronutrients, in the prevention of maternal, fetal and child diseases, is in contrast to the numbers obtained in this research, of inadequate supplementation in Brazil.

This study has as a limitation the obtaining of secondary data, registered in government databases, and the numbers worked in this research may be underreported in the system.

CONCLUSION

The present study showed that in Brazil the quality and supply of dietary supplementation for pregnant women are deficient.

The lack of quality in the nutritional supply to pregnant women in the public health network in Brazil has occurred since before the pandemic, with only iron and folic acid being offered for more than fifteen years, contradicting a broader recommendation for supplementation that already exists nationally and worldwide.

Regarding the distribution of supplements in Primary Health Care, inadequacy was evident, with a low distribution of supplements in almost all national states, with the exception of only the state of Pernambuco, in the northeast region.

Dietary supplementation in a peripheral country like Brazil becomes essential, as it is safe and accessible, combined with multidisciplinary care, including consultation with a nutritionist in the low-risk team. Such actions are important from preconception to the entire pregnancy period.

The analysis of the results obtained in comparison with the literature and the socioeconomic reality of Brazil, aims to expand discussions and knowledge, and can also contribute to the implementation of safe and effective practices in promoting maternal and fetal health, stimulating necessary changes in management in health in the country.

This study has as a limitation the obtaining of secondary data, recorded in the database of the Brazilian government system E-gestor, which depends on the inclusion of information in the system.