Systematic Review: Covid-19 Pandemic Risk in Nutritional View on

Pregnant Mothers and Infants

Fahmil Usman

, Harsono Salimo

and Adi Magna Patriadi Nuhriawangsa

Clinical Nutrition, Graduate School, Universitas Sebelas Maret, Surakarta, Indonesia

Graduate School, Universitas Sebelas Maret, Surakarta, Indonesia

Keywords: Covid-19 Pandemic, Dietary Habit, Food, Nutrition.

Abstract: Covid-19 has made an impact on individual dietary habits and bad nutritional state, especially to the weakly

susceptible group of people such as children, pregnant and breastfeeding mothers, and has been the major

social health issue. The objective of this article is to discern the risk of Covid-19 pandemic and its impact on

the dietary habit, diet, and nutrition of pregnant mothers and infants. The method used is systematic review

from several references with such keywords in Google Scholar database and Pubmed Research Gate. Covid-

19 pandemic in Mexico caused the significant decrease of food security from 38.9% in 2018 to 24.9% in June

2020 in domestic dietary habits and food insecurity. The positive change of dietary habits includes the

consumption decrease of fried food, snacks, fast food, red meat, pastries, or sweet beverages, and the increase

of olive oil, vegetables, fruits, and nuts consumption. The negative change of dietary habits puts the mothers

and children nutritional health at risk, which is vulnerable due to mobility limitation, economic crisis, food

insecurity, and large-scale unemployment. It causes insufficient nutritional supply to such a weakly

susceptible group of people, incurring 28.000 and 168.000 death cases of mothers and newborn infants

respectively.

1 INTRODUCTION

Based on the report received by the World Health

Organization (WHO) in December 2019, cases of

pneumonia caused by severe acute respiratory

syndrome coronavirus 2 were grouped into four

(SARS-CoV-2) (WHO, 2020). In Indonesia,

coronavirus 2 (SARS-CoV-2) spread widely with

increasing positive cases with a total of 1.68 million

cases (Covid19, 2021). Positive cases of COVID-19

increases drastically so that it was designated as a

pandemic. Therefore, the government has issued

policies including social restriction, travel restriction,

even lockdown. They are predicted to trigger poor

economic conditions, decreased production and

consumption activities, job losses, increased

unemployment, and hampered economic growth

(Schneeweiss et al., 2020).

The COVID-19 pandemic has led to an increase

in food insecurity in the community which triggers

serious public health problems (Pedroso et al., 2020).

It causes changes in individual dietary habits and poor

nutritional status due to the stay-at-home policy.

Indeed, it affects lifestyle, including dietary habits,

irregular eating patterns, and physical activity

patterns covering physical and mental health (Naja &

Hamadeh, 2020). This pandemic is projected to have

a severe impact on food security, nutrition, and health,

particularly for vulnerable groups such as young

children, pregnant and breastfeeding mothers,

resulting in 28,000 maternal deaths and 168,000

stillbirth cases (Roberton et al., 2020).

The COVID-19 pandemic has changed the

socioeconomic order including the education, health,

food, and income sectors (Nicola et al., 2020). Low

income affects the ability of the household to afford

foods (Pechey & Monsivais, 2016). Less optimal

food intake has an impact on the nutritional status of

pregnant women, including the infant (Department of

Health and Ageing & National Health and Medical

Research Council, 2017). Pregnant women with

abnormal nutritional causes a higher risk of preterm

birth than those with normal nutritional status

(Grieger & Clifton, 2015). Poor quality and quantity

of food intake during pregnancy cause a high risk of

micronutrient deficiencies, such as Fe, vitamin B9,

iodine, zinc, vitamins A and D, riboflavin, B6 and

Usman, F., Salimo, H. and Nuhriawangsa, A.

Systematic Review: Covid-19 Pandemic Risk in Nutritional View on Pregnant Mothers and Infants.

DOI: 10.5220/0010759200003235

In Proceedings of the 3rd International Conference on Social Determinants of Health (ICSDH 2021), pages 70-76

ISBN: 978-989-758-542-5

B12, that have adverse effects on both the mother and

infant (Haider et al., 2011; Torheim et al., 2010).

Health problems in pregnant women such as

anemia and chronic energy deficiency (CED) are

caused by a lack of food intake for a long period due

to lack of access to food which mostly occurs in low-

income households (Pechey & Monsivais, 2016). The

health of pregnant women and maternal, newborns,

and children health services become the main

concerns of health problems, particularly in low- and

middle-income countries during COVID-19

(Roberton et al., 2020). A systematic review and

meta-analysis concluded that the risk of preterm birth

increases by 29% in thin women and increases by 64%

of Low Birth Weight (LBW). This condition

decreases the children's intelligence (cognitive),

increases the risk of degenerative diseases when

become adults (Han et al., 2011), growth delay, and

infectious diseases (Fitri, 2018).

The nutritional status disorder in pregnant women

and infants may occur as a result of the COVID-19

pandemic which causes changes in diet, food access,

and income. Therefore, this present study aims to

identify the risks of the COVID-19 pandemic and

nutritional problems in pregnant women and infants.

2 METHODS

This study used a systematic review method. This

method aims to identify, review, evaluate, and

interpret all available and interesting research topics.

The researcher searched research articles both

international and national using the Google Scholar

and Pubmed Researchgate databases.

The researcher used several keywords to search

the relevant research articles. The keywords were the

impact of the COVID-19 pandemic on the economy,

food, and nutrition; the impact of COVID-19 on

foods; the impact of COVID-19 on diet, and the

impact of COVID-19 on nutrition. Then, the

researcher filtered the total articles that have been

obtained through inclusion criteria. The inclusion

criteria were published in 2020-2021 and nationally

and internationally accredited. The data were

analyzed by explaining each research article that

discusses the impact of the COVID-19 pandemic on

the economy, food, and nutrition.

In the identification process, the obtained articles

were re-checked. This process found 165 titles

(Google scholar 60 articles and Pubmed Researchgate

105 articles) based on keywords. The next step was

screening based on the inclusion criteria and the

appropriate theme, getting 30 articles for the literature

review, and explaining 5 articles according to the

theme.

Figure 1. Article Selection Flowchart.

3 RESULTS AND DISCUSSION

3.1 COVID-19 Relation to Nutrition

Based on a survey conducted in America during the

COVID-19 pandemic, many low-income Americans

were most likely to get sick and die from COVID-19.

It is followed by job loss or drastically reduced

income which tend to increase poverty rates.

Therefore, it causes difficulty in purchasing foods and

food insecurity (Parolin & Wimer, 2020). Food

insecurity is a condition of limited access or

insufficient nutritious foods to meet the daily needs.

People who experience food insecurity can lead to

hunger in which it is maybe due to lack of financial

resources or low income which make them unable to

buy purchase foods or no access to food which causes

stress, a physical and mental health problem which is

dangerous in the short and long term (Fang & Cao,

2014). COVID-19 has destabilized access and

availability of food around the world resulting in

massive unemployment and loss of income, as well as

food insecurity (Bauer, 2020).

Food insecurity, disturbing food production, and

consumption facilities, food availability, and food

prices amid the COVID-19 pandemic were due to

significant changes in the food sector during the

COVID-19 pandemic, particularly to adjust the

protocol during production to support the quality and

quantity of food safety. It occurred as a result of the

implementation of social/physical distancing or

large-scale social restriction policies (PSBB) in

Geogle scholar

60 article

Pubmed Researchgate

105 article

105 Articles excluded

do not match the theme

60 articles

according to the

theme

30 articles included in the

literature review

5 the article has an explanation that

fits the theme

Systematic Review: Covid-19 Pandemic Risk in Nutritional View on Pregnant Mothers and Infants

several areas. Therefore, it is important to adjust to

policy strategies related to food to ensure food

security and safety in Indonesia. The COVID-19

pandemic has disrupted food production in terms of

agricultural machinery and equipment, subsidies for

fertilizers and seeds, and other production support

facilities. Thus, increasing production is a priority

and needs to be monitored by the Ministry of

Agriculture and the Agriculture Service to ensure the

proper distribution of facilities and assistance as well

as the socialization of the safe production protocols.

Therefore, the government has to pay attention to

good food distribution and the national food logistics

system (Hirawan & Verselita, 2020; Khairunnisa,

2020).

A study reveals that if the COVID-19 pandemic

continues, food insecurity will continue to occur in

low-income households in which vulnerable groups

such as small children, adolescents, pregnant women,

and breastfeeding mothers need to be highly

protected. In the future, health will depend on food,

nutrition, and social protection systems and to ensure

that every community can access food and have food

security, sufficient economy, and good nutrition

status to protect them from malnutrition and other

nutritional problems due to related food, nutrition,

health, and socioeconomic problems (Pérez-

Escamilla et al., 2020). It means that households with

low income have unstable quality and quantity of

foods, disrupted food security and nutrition. Further,

if they are experienced by pregnant women, they can

cause nutritional problems which directly affect the

nutrition status of the infant (Myrnawati & Anita,

2016).

Poor families are vulnerable to malnutrition

because of their low ability to access good food

(Sebataraja et al., 2014). In some countries,

experiencing a decline or economic crisis becomes

one of the causes of the low birth weight of <2500

grams (LBW) (Martinson & Reichman, 2016). An

epidemiological case-control study revealed that the

income of pregnant women and food insecurity are

the causes of low birth weight (LBW) (Altenhöner et

al., 2016).

3.2 The Risk of COVID-19 Pandemic

3.2.1 COVID-19 and Food Insecurity

A previous study by Chiwona-Karltun et al., (2021)

has assessed the impact of the spread of COVID-19

on economic and food insecurity. Based on the

collected qualitative data from 12 countries in South

Sahara revealed that the lockdown policy during the

COVID-19 pandemic created anxiety of household

food security, health, economic and human rights, or

welfare problems. The lockdown has affected food

security as the stay-at-home policy threatens food

production which relies on agriculture as the main

economic activity.

Food insecurity occurs particularly in poor

households and rural or remote communities (Malapit

et al., 2020). The main contributing factors to food

security are poverty, conflict, climate changes,

ecosystem challenges, and economic decline. A

country can maintain its food security through the

availability of natural resources, and appropriate

policies on natural resources as well as the

implementation of the policy (Carletto et al., 2013).

An online survey has measured the risk of

COVID-19 on low-income adults in the United States

in the middle of March 2020 in which it can be

accessed through Smartphone or computer/laptop.

The survey was adjusted to the age, gender, ethnicity

of the total population. A total of 1,497 participants

completed the survey. It concludes that the COVID-

19 pandemic affects the household’s income and food

access as well as causing social and economic chaos

(Wolfson & Leung, 2020). Another study Ahn &

Norwood (2021) has measured food insecurity during

the COVID-19 pandemic and it concludes that food

insecurity increases three points in each household

compared to the previous year. A study conducted in

Mexico revealed that the household’s food security

decreases from 38.9% in 2018 to 24.9% in June 2020

(Gaitán-Rossi et al., 2021). Therefore, it is important

to rethink the dysfunctional food security system in

which now the world depends and reconfigure the

type of cross-sectoral program, policy, and

mechanism needed to ensure food security and

nutrition for all, including youth, children, pregnant

women, and breastfeeding mothers (UNICEF, 2020).

Studies during the pandemic are suggested to

focus on nutrition and foods including (1) adapt and

continue the provision of supplementary foods at

school and food assistance program for households

with children, youth, pregnant women, and

breastfeeding mothers during quarantine; (2) develop

an equal fast-response and effective system to prevent

or reduce food insecurity based on the complex

adaptive framework (Barnhill et al., 2018) which

discusses food system, nutrition, health care, and

social protection as well as the complex correlation

between each of them; provide special attention to

households with children, youth, pregnant women,

and breastfeeding mothers; and (3) monitor and use

effective surveillance system to identify and target

the provision of healthy and nutritious foods for

ICSDH 2021 - International Conference on Social Determinants of Health

vulnerable families such as families with children,

youth, pregnant women, and breastfeeding mothers.

Based on the evidence from the UNICEF 2020 report

which summarizes the impact of the COVID-19

pandemic on health, such as the number of children

under 5 years old visiting community health centers

in Vietnam dropping by 48%, in Indonesia more than

50% of households are reported to be unable to meet

the nutritional needs of their families. Philippines

more than 80% experienced a decline in household

income, the study aims to protect the food security

and nutrition, as well as health and welfare of families

with children, youth, pregnant women, and

breastfeeding mothers (WHO, 2000).

3.2.2 Changes in Diet

Lifestyles tend to drastically change during a

pandemic as a result of government policies that

require people to stay at home. A previous study

concerning the changes in diet during the COVID-19

pandemic found that the COVID-19 pandemic highly

affects the economy, food industry, and diet (Rahmah,

2017). Changes in diet before and during the COVID-

19 pandemic can be seen clearly (Eftimov et al.,

2020).

The study is in line with a previous study by

Ammar et al in which lifestyle changed dramatically

during the COVID-19 pandemic (Ammar et al., 2020).

It is an online study conducted in April 2020

involving 1,047 participants to investigate the effects

of social restrictions on physical activity and dietary

behavior across continents from Europe, North Africa,

West Asia, and North America. It was reported that

the restrictions have an adverse effect on physical

activities in which respondents decreased their

physical activity during the pandemic. Besides, the

stay-at-home policy is associated with unhealthy

dietary patterns as participants reported an increased

frequency of eating unhealthy foods, eating out of

control, snacking between meals, and increased

number of meals per day (Ammar et al., 2020). The

behavior change is likely due to the anxiety and

boredom of staying at home in which people tend to

eat more, change lifestyle patterns, and reduce diet

quality (Naja & Hamadeh, 2020).

On the other hand, studies concerning dietary

behaviors in the Spanish adult population revealed

healthier dietary behaviors (for example, reduced

intake of fried foods, snacks, fast food, red meat,

pastries, or sugary drinks, but an increase in olive oil,

vegetables, fruits or nuts) during the quarantine due

to COVID-19 pandemic compared to previous

behaviors (Rodríguez-Pérez et al., 2020). It is in line

with a study by Eftimov et al., (2020).

The quarantine results in positive and negative

changes in diet and lifestyle. It is crucial to identify

groups that are at higher risk for unhealthy lifestyles

during the COVID-19 pandemic and to create

targeted recommendations to maintain health and to

prevent chronic disease (Górnicka et al., 2020) as

well as maintain weight or nutritional status. Changes

in diet also affect nutritional status during the

pandemic (Górnicka et al., 2020) as an indicator of

causing long-term effects of other chronic health

(Yousafzai et al., 2013).

Changes in diet, especially in pregnant women,

have the potential to have a low birth weight baby,

pre-term birth, and stillbirth which will further

increase nutritional problems such as stunting and

malnutrition (Bianchi et al., 2016; Danielewicz et al.,

2017)(Bianchi et al., 2016; Danielewicz et al., 2017).

Therefore, the government and health workers should

play an important role in formulating policies in

providing dietary counseling, monitoring the

development of pregnant women who may be at risk

due to unbalanced diet and lifestyles (Iordachescu et

al., 2020).

3.2.3 The Impact of the COVID-19

Pandemic and Nutritional Problems in

Pregnant Women and Infant

The health of pregnant women, infant, and children

especially in low-middle-income countries become

the main concern during COVID-19. It is maybe

partly due to worry about insufficient health services,

limited availability of transportation, and health

facilities. Maternal and Child Health Services (MCH)

has become the key factor of drastic decline in

maternal and infant mortality, as well as malnutrition

in recent decades (Roberton et al., 2020).

During the pandemic, pregnant women tend to

have unstable emotions, changes in diet with

increased food intake and decreased physical activity.

Thus, they tend to eat a lot of snacks which can cause

obesity, especially those living in severely affected

areas. Obesity increase risk of chronic conditions

such as cardiovascular disease (Zhang et al., 2020).

During the pandemic, changes in nutritional status

can happen to anyone, including pregnant women

who are affected, in which they experienced changes

in diet, economic decline, and household food

insecurity (Huizar et al., 2021; Mehta, 2020). The

health of pregnant women is determined by the

nutritional status and the fulfillment of nutritional

intake. Pregnant women need sufficient nutritional

Systematic Review: Covid-19 Pandemic Risk in Nutritional View on Pregnant Mothers and Infants

intake to maintain normal nutritional status. If their

nutritional intake is not balanced, it can cause

nutritional deficiencies and will result in poor

nutritional status (Khasanah, 2020). Lack of

nutritional intake during pregnancy can affect the

growth of the fetus (Kartikasari et al., 2013).

Malnutrition during pregnancy can cause risks and

complications for the mother, such as anemia,

bleeding, abnormal maternal weight, infectious

diseases, and low birth weight (Rukmana &

Kartasurya, 2014).

A study Panthi et al. (2020) focusing on women

and children in Nepal during the COVID-19

pandemic revealed that malnutrition in women and

children is a prolonged hunger causing malnutrition

due to food insecurity, job loss, economic crisis, and

limited access to health services (Ministry of Health

et al., 2017). It is associated with a high rate of

stunting, an increase in infants with low birth weight

(LBW) due to insufficient nutritional intake during

pregnancy. LBW will increase the morbidity and

mortality of children resulting in future generations

with lower physical and cognitive potential. The

COVID-19 pandemic and stay-at-home policy can be

a risk factor for malnutrition (Panthi et al., 2020).

Another study Abadi & Putri (2020) on

macronutrient consumption in pregnant women with

chronic energy deficiency found lack of food intake

such as energy, protein, fat, and carbohydrates during

the COVID-19 pandemic. Anggraini et al (2021)

stated that pregnant women need optimal food intake

to maintain their health and the fetus during the

pandemic. They need more

intake of supplements, iron, Vitamin C, and

macronutrient containing carbohydrates, protein and

fat, to meet their nutritional needs. Further, they are

suggested eating breakfast, eating high-fiber foods,

increasing fluid intake, and applying a healthy diet

regularly (Anggraini & Anjani, 2021).

This pandemic has the potential to increase the

prevalence of maternal and newborn mortality

(Roberton et al., 2020). Malnutrition in pregnant

women, especially with anemia and underweight, can

increase the number of stunting if it is not managed

properly and even can cause overweight and obesity

in all age groups due to limited physical activity and

increased consumption of processed foods containing

high levels of sugar, salt, and fat (UNICEF, 2020).

4 CONCLUSIONS

The COVID-19 pandemic has impact of an economic

crisis, changes in diet, and mass unemployment and a

decline in household food security. In Mexico during

the COVID-19 pandemic, food security decreased

from 38.9% in 2018 to 24.9% in June 2020 in

households. Food insecurity is an indirect risk to

health, including the nutritional status of mothers and

children which will have an impact on increasing the

prevalence of nutritional problems such as stunting,

LBW, Chronic Energy Deficiency, and obesity. This

pandemic is projected to have an impact on

vulnerable groups including young children, pregnant

and lactating mothers, resulting in 28,000 maternal

deaths and 168,000 newborns.

On the other hand, in some other people, changes

in the diet tend to improve due to afraid of the

pandemic so that they prefer consuming healthy

foods such as olive oil, vegetables, fruit, or nuts.

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