THE Government of India in 1975 launched the Integrated Child Develop-ment Services (ICDS) in a planned manner to cover all the blocks. These services were also planned to cover urban slums. This is the largest direct nutrition and health input program in the world for children and pregnant and lactating women. Inspite of several implementation and regular food supply problems, ICDS has succeeded in reaching over 80% of rural India, particularly in poor and difficult areas.

In earlier reports from the same study area, it was documented that still births and perinatal, early neonatal and infant mortalities were significantly lower for mothers in supplemented area of the ICDS block(1,2). The present report had the objectives of investigating the impact of ICDS services on maternal weight gain in pregnancy, birth weight, period of gestation and caloric intake.

The present study was undertaken in a rural ICDS block (Harahua - 28 villages; population 33770) and the adjoining non-ICDS (Kashi Vidhyapeth block - 21 villages; population 32307). For evaluating the impact of supplementation, the supplemented women of block Harahua were compared against those who did not receive the supple-mentation during pregnancy, as other ICDS inputs were similar in both the groups. The study however had some weaknesses: (a) quality, composition and required amount for supplement could not be controlled, (b) the criteria for selection of women was based on socio-economic status and caste (4-5% more from the scheduled caste group and lower socio-economic families in nutrition supple-mentation group), and (c) sharing of supple-mented food in these families could not be checked personally except by verbal enquiry.

After considerable persuasion, Govern-ment of Uttar Pradesh agreed to provide nutrition supplement to all pregnant women in the ICDS study area. The supplementation however reached only 34.4% pregnant women in the ICDS area, was irregular, was of poor quality, and inadequate in amount. Besides the nutrition supplement to pregnant women, preschool children received non-formal education and nutrition supple-mentation in the ICDS block. The women in addition received education on health and diet and were provided antenatal check up.

The data for the study were collected from 1987 to 1993. The details for method of registration, data collection are given in earlier reports(1-3). The iron-folate supple-mentation was negligible in both the blocks.

(a) Anthropometeric measurements: Maternal height, weight and mid-arm circumference were measured as per standard techniques using Chattilon weighing scale (USA), anthropometeric rod and fibre glass tape, respectively. Birth weight was recorded on a modified Tansi scale(1-3). Abdominal girth was measured by fibre glass tape at the level of umblicus by crossover technique. Pre-pregnancy weight, mid-arm circumference and height measurements were available for these study women.

(b) Hemoglobin estimation and dietary assessment: Hemoglobin was estimated by cyanmethemoglobin method. Dietary survey was done by 24 h recall method using standard utensils. These estimations were undertaken in all pregnant women.

During pregnancy women were examined at 16±2, 28±2 and 36±2 weeks of gestation and also within 48 h of delivery for estimation of gestational age at term and birth weight.

Means, standard deviation, ANOVA and multiple regression analysis were performed using SPSS package.

A comparison of age, education, gravidity, parity, interpregnancy interval and number of living children in the ICDS and non-ICDS blocks is depicted in Table I.

The mean weight gain during pregnancy was 6.4 ± 1.0, 6.3 ± 0.9 and 6.3 ± 1.1 kg for the supplemented and unsupplemented women of ICDS area and non-ICDS area, respectively (Table II). Gain in weight of >6.0 kg was observed in 72.3%, 69.5% and 62.3%, women respectively in the three groups. Even in the third trimester of pregnancy, 27.4% women remained <45.0 kg in the non-ICDS area as compared to 13.8% and 12.7% in the supplemented and the unsupplemented groups of ICDS area, respectively (p <0.05).

The total increase in abdominal girth was about 21 cm in the ICDS and 15 cm in the non-ICDS areas. These differences were significant (p <0.001). The change in midarm cirumference during pregnancy was not significant in all the three groups.

At 28 weeks, the mean hemoglobin decreased by 0.5 and 0.4 g/dl amongst the ICDS (supplemented and unsupplemented, respectively) and 0.2 g/dl in non-ICDS women. At 36 weeks there was further fall of 0.1 and 0.4 g/dl in the supplemented and the unsupplemented groups of ICDS area, whereas the non-ICDS women showed no fall. These hemoglobin changes were signi-ficantly (p <0.001) different (Table II).

The dietary intake between 16-28 weeks did not change in any of the groups. The average caloric intake was 1650 kcal per day and protein intake around 52 g per day. By about 36 weeks of pregnancy, ICDS supple-mented women received 1676 ± 200 kcal/day as compared to 1654 ± 198 kcal/day for the unsupplemented ICDS group.

In the ICDS block birth weight for supplemented women was significantly higher by 58 g as compared to unsupple-mented women. The birth weight in unsupplemented ICDS area was 25 g higher as compared to non ICDS area. ICDS supple-mented group of women had a significantly smaller proportion of low birth weight babies (14.4%) compared to ICDS unsupplemented (20.4%) and non-ICDS women (26.3%). The prevalence of preterm births was 2.0, 2.4 and 4.3% in the supplemented and unsupple-mented ICDS area and non-ICDS area respectively (p <0.001).

Multiple regression analysis revealed that weight gain in pregnancy, length of gestation and caloric intake in the third trimester made significant contribution to birth weight in both the blocks ICDS and non-ICDS (Table III). In addition pre-pregnancy height and hemoglo-bin at 36 weeks made significant contribution to birth weight in ICDS block only.

The present study was designed to evaluate the effects of interventions provided by the Government of India in the Integrated Child Development Services on maternal nutrition and pregnancy outcome during the years 1987-93. This is an important research question as these services have already being extended to cover all the blocks and urban slum areas without any improvement in quality of nutrition supplement and in the delivery system. Furthermore, the nutritional status of women in various parts of India is similarly poor, with lower weight gain in pregnancy(4,5). In several other studies low weight gain during pregnancy has been observed in undernourished women, e.g 6.4 kg in Gambia(6), 7.6 kg in Taiwan(7,8) and 5.5 kg in East Java(9). In Bangla Desh(10) urban high class gained 6.7 kg and low social class gained 5.5 kg. Nutrition intervention in most of these studies improved weight gain in pregnancy and marginally improved the birth weight(11).

The pregnant women of rural Varanasi in this study showed only marginal increase in energy intake and poor weight gain. Hemo-globin concentration between the 16 and 36 weeks reduced by 6% in the supplemented, 6.9% in unsupplemented area, with negligible change in the non-ICDS group. Paintain et al.(12) reported hemoglobin decrease by 1.7%, 12.5% and 10% by 5, 8 and 9 month of gestation, respectively. These findings suggest that the ICDS group women could increase blood volume only to around 1/3 of the expected and the non-ICDS group had negligible expansion. The fall in hemoglobin in second half of pregnancy is important for reducing preterm and low birth weight deliveries(13).

As per the ICDS guidelines women should receive 450-500 kcal with 20 g protein in the later half of pregnancy; this should provide around 45,000-50,000 kcal extra supplement in pregnancy. This is neither reflected in their dietary intake nor in weight gain during pregnancy. The possibility of food sharing in these poor families remains an important possibility for these observations. Inspite of very low level of supplementation as compared to the unsupplemented group, the positive achievements were: (a) lower percentage of low birth weight deliveries (14.4% vs 20.4%); (b) more newborns weighed >3000g (16.2% vs 11.0%); (c) 100 g extra gain in maternal weight; and (d) the gestational age increased by 0.3 week (p <0.001). A comparison of unsupplemented ICDS group with non-ICDS women showed 44.2% reduction in preterm births and 23.1% reduction in low birth weights. These achievements were due to other inputs in the ICDS. The ICDS to a large extent can be compared to the Women-Infant-Child (WIC) supplementation program of the USA(14,15) providing milk, cheese, eggs, iron fortified cereal, beans, butter and 100% fruit juice (900 kcal/day). In WIC supplemented group (pregnancies = 1154673; during 1972-80) there was increase in birth weight by 23.9 g and gestational age by 0.2 day; reduction in pregnancy wastage (fetal mortality reduced by 2.3/1000), small for gestational age births (reduced by 1.1%) and maternal weight increased by 70g. Among women receiving nutrition supplement during second preg-nancy, birth weight increased by 136 g. In contrast, the present study on rural women had several well known factors predisposing for a small size baby: short stature, under-weight mothers and low mid-arm circum-ference (early as well as current under-nutrition). The normal pregnancy contributes 20% extra weight over the pre-pregnancy weight. For the mean height of the present study women, the expected weight should have been around 49 kg, which at term with 20% increase would be 59 kg. The study women however had a mean weight of 42.5 kg (around 86.7% of the expected). To approach the desired weight of 59 kg the gain should be 16.5 kg (deficit + required pregnancy gain). This will require 460-490 kcal/day extra from 12th week of gestation or before for ideal pregnancy outcome. The present study women gained an average weight of 6.3 kg (baby = 2.7 kg + placenta 0.4 kg + uterus + blood 3-4 kg) thus maintaining a deficit balance(16,17). Earlier studies in the same area revealed that treatment of anemia in pregnant women had also resulted in better birth weight(18).

To conclude the present study demons-trated that nutrition supplement to pregnant women in ICDS area improved weight gain in pregnancy and birth weight with reduction in pre-term and low birth weight deliveries. To lesser extent such effect was also observed in unsupplemented ICDS, possibly contributed by the other inputs.

The USAID consultant Prof. D. Rush Jean Mayer, USDA Human Nutrition Research Center on Aging 711 Washington St. Boston U.S.A. provided critical guidance. The study could not have been possible without the administrative and scientific contribution from Dr. Badri Saxena, former Additional Director General (ADG) ICMR, New Delhi. Thanks are due to Dr. Padam Singh, ADG, ICMR for statistical discussions. We were grateful to Shri A.K. Bansal, Biostatistics Division University College Medical Sciences, Delhi for help in statistical analysis. The infrastructural facilities were provided by the Banaras Hindu University, Varanasi.

Contributors: KNA coordinated the study (interpretation/monitoring). DKA supervised and monitored field work. She also undertook preliminary analysis. AA and SA did examina-tion of women and paper writing. SR. RP and TBS were responsible for field data entry.

Funding: Indian Council of Medical Research and United States Agency for International Development Delhi.
Competing interests: None stated.