Will individual participant data (IPD) be shared publicly (including data dictionaries)?  

•        Malnutrition in pregnancy:In  developing countries20% to 39%of women are with Low body mass index (<18.5 kg/m2)¹.South Asia had the highest proportion of underweight women with an estimated 24%.There were 270 000 deaths (95% UI 249 000–295 000) from nutritional deficiencies in 2017  representing 2·60% (2·37–2·86) of all deaths in that year ².In India 58.7% of Pregnant women (15-49 years) with anemia, 33.3% Women in reproductive age are undernourished, 42.2% Indian women who are underweight when they begin pregnancy(NFHS4). In Karnataka the prevalence of women with low BMI is 20% .Only 68.7 % of women received the mandatory of three antenatal check-up, Utilization of public health services is 26% only. ^3,4

•        Effect of Poor nutrition in pregnancy:  Higher risk of preterm delivery, Small for gestational age (SGA), Still birth, Low birth weight (LBW) - important secondary factor in 40%–80% of neonatal deaths,^5,6 Risk of maternal mortality, Anemia and Pregnancy-induced hypertension (PIH), Third trimester bleeding and premature rupture of membranes, Prolonged labour,  Postpartum hemorrhage and Puerperal endometritis⁷

•        Nutrition practices in Karnataka: Numerous food items which are nutritious and safe and available locally are either restricted or denied in Karnataka. During pregnancy food items like Ragi, papaya, mango, guava, pineapple, jackfruit, jaggery, sesame seeds, dates, all kinds of meat, eggs, milk and spices are reported to be avoided^8,9

•        Nutrition management in Karnataka: There are many programmes existing in Karnataka to manage malnutrition in pregnancy such as Supplementary feeding programmes- Mathru Pushtivardhini, Prasoothi Araike, Special nutrition programme, Integrated child development services scheme, Applied nutrition programme, Distribution of iron and folic acid tablets.¹⁰Although nutrition policies are on the books and interventions are in place, child malnutrition and maternal under-nutrition persist as severe public health problems. Quality of services should be maintained in existing programs, Knowledge gaps about nutrition and nutrition practice need to be filled¹¹

•        UNICEF and FIGO recommends Food/dietary supplements and Nutrition counselling to be offered to pregnant undernourished women.¹²Healthcare professionals should ensure appropriate gestational weight gain in relation to prepregnancy BMI .¹³Nutritional health education should be designed after studying the pregnant women’s’ nutritional habits and usual intake .

               Malnutrition is a modifiable risk factor. A healthy maternal dietary pattern during pregnancy reduces the risk of maternal and infant complications.  Low BMI pregnant women need help and nutritional support for appropriate weight gain during pregnancy. Improving the health and nutritional status requires a series of actions to raise the quality and increase the coverage of service. Midwives/Nurses play a vital role in early identification of malnutrition during pregnancy.  Hence the rresearcher is interested to prepare multigrain powder which is affordable and low cost,  to compensate the nutrition need of Low BMI pregnant women.(550 kcal energy and 27 gms of protein) and offer nutrition education. So this project helps in early identification of low BMI pregnant women and offers multigrain power and nutrition education to enhance weight gain during pregnancy and prevent the complications to mother and fetus.

    Objectives:

•        To evaluate the effectiveness of Nursing Interventions on Maternal outcomes and Fetal / Neonatal outcomes among low BMI antenatal women

•        To find the correlation between Maternal weight gain and fetal weight, crown to heel length and Birth weight among low BMI antenatal women

•        To determine the association of Maternal outcomes  and Fetal / Neonatal outcomes with Maternal variables among low BMI antenatal women

 Hypotheses :

•        H_1- There is a difference in the mean maternal outcomes and Fetal / Neonatal outcomes of antenatal women between the experimental group and the control group

•        H_2- There is a correlation between maternal weight gain and Fetal weight, Crown to heel length & Birth weight.

•        H_3- There is an association of maternal outcomes and Fetal  / Neonatal outcomes with maternal variables.

Ø  Detailed description of procedure:

Ethical clearance

Obtain permission to conduct study

Maternity hospitals (BBMP) will be identified

                                                                                                            Maternity hospital A (Control group)                          Maternity hospital B (Experimental group)          

All antenatal women attending antenatal OPD at selected Maternity hospital will be screened for BMI (height, weight and BMI will be calculated) during 1st trimester

Antenatal women with BMI 19 or below will be identified

Samples will be selected according to selection criteria after obtaining informed consent.

                                                                                                                            Control group                                                                              Experimental group

                                                                                                                         Pre-test                                                                                                       Pre-test

                                                                                                                          Routine care                                                                                    Nursing interventions

                                                                                                                           Post-test -26,30,34,38 weeks and at birth                           Pos-ttest -26,30,34,38 weeks and at birth

PILOT STUDY WILL BE CONDUCTED WITH 10 SAMPLES {5+5}

Nursing interventions: refers to Nutrition education and cooking demonstration video of multigrain porridge to Antenatal women with BMI of 19 or below.

Ø  Nutritional education will be imparted to pregnant women about weight gain during pregnancy, nutritional requirements, different food groups, sources of macro and micro nutrients, importance of nutritional supplementation, and food safety during pregnancy and avoidance of substances during pregnancy, in two sessions at 2 weeks interval.

Ø  Cooking demonstration video refers to preparation of porridge by using multigrain powder made from mixture of roasted    wheat, soya, jowar, ragi, foxtail millet, brown rice, groundnut, green gram, red gram and jaggery. 75 grams of powder will be mixed with water to prepare porridge. 2 serving of porridge (75gms morning+ 75 gms evening) gives 575 kcal energy with 20 gms of protein.

•      Participants  will be motivated to follow  the nursing interventions by SMS / Whatsapp

•      Reinforcement of Nutrition Education will be given according to the need

•      Antenatal women  who has faulty dietary practices will be counseled and educated intensively

Tools and techniques

•      Screening tool

•      Questionnaire on maternal variables

•      Questionnaire  on Knowledge regarding diet during pregnancy

•      Questionnaire  on Nutrition practice during pregnancy

•      Information sheet on maternal and fetal /neonatal outcomes

•      Questionnaire  on Antenatal care service utilization

Ø  Place of the study:

Antenatal Outpatient departments of BBMP Maternity hospitals such as

§  Srirampura Refferal hospital

§  Ganganagar BBMP maternity home

§  Hosahalli Refferal hospital

§  Kovindaraj nagar BBMP maternity home

Ø  Outcome measures:

Ø  Statistical methods:

Descriptive statistics

•       Frequency and percentage distribution will be used to describe sample characteristics , maternal outcomes , Nutrition Practices and Antenatal care services utilization

•      Mean, Mean difference and Standard Deviation will be used to interpret Maternal and Fetal /Neonatal outcomes between the groups

Inferential statistics

•      Independent t test will be performed to compare knowledge score between experimental and control group

•      Repeated measure ANOVA will be used to identify the difference in the score over time between the groups

•      Pearson correlation coefficient will be computed to correlate Maternal weight gain and Fetal weight, Crown to heel length & Birth weight.

•      Chi square test will be used to find the association of Maternal outcomes and Fetal / Neonatal outcomes with maternal variables.

•      Multi -variate analysis will be performed to find the relationship between Nutrition practices and maternal weight gain, birth weight of neonate.