Iodine status of pregnant women living in urban Johannesburg, South Africa

Maternal and Child Nutrition, Volume 18, No. 1, Year 2022

Interpretation

Adequate intake of iodine is important during pregnancy because of its essential role in foetal growth and neurodevelopment. Data on iodine status of South African pregnant women are scarce, and the salt reduction policy implemented in 2016 may decrease iodine intake of South Africans. This cross-sectional study assessed the iodine status of pregnant women residing in urban Johannesburg, South Africa. A total of 250 pregnant women were enrolled into the ‘Nutrition during Pregnancy and Early Development’ (NuPED) study and 312 pregnant women into the ‘Assessment of dried blood spot thyroglobulin in pregnant women to redefine the range of median urinary iodine concentration that indicates adequate iodine intake, South Africa’ (STRIPE-SA) study and were included in this analysis. Urinary iodine concentration (UIC) was analysed in a spot urine sample. Thyroglobulin (Tg) was measured in serum, and thyroid-stimulating hormone (TSH) and total thyroxine (tT4) were measured in dried blood spots. The median [interquartile range (IQR)] UIC of pregnant women was 144 (84–234) μg/L. Women in the first (n = 99), second (n = 262) and third (n = 174) trimester had a median UIC of 133 (81–316), 145 (84–236) and 156 (89–245) μg/L, respectively (p = 0.419). Median TSH, tT4 and Tg were 2.7 (2.3–3.2) mU/L, 202 (163–236) nmol/L and 9.2 (5.4–17.9) μg/L, respectively. Based on the median UIC, pregnant women residing in urban Johannesburg may be borderline iodine deficient. These findings highlight the need for ongoing monitoring of iodine status among vulnerable pregnant women, especially considering the recently introduced salt reduction policy in South Africa. This cross‐sectional study was performed in pregnant women who participated in two studies, namely the ‘Nutrition during Pregnancy and Early Development’ (NuPED) study (n = 250) and the ‘Assessment of dried blood spot thyroglobulin in pregnant women to redefine the range of median urinary iodine concentration that indicates adequate iodine intake, South Africa’ (STRIPE‐SA) study (n = 312). The NUPED study is a prospective cohort study designed to follow‐up women during pregnancy and their infants postnatally. Pregnant women who participated in the NuPED study were recruited from primary healthcare clinics in Johannesburg between March 2016 and December 2017. The protocol of the study was previously published (Symington et al., 2018). For the purpose of the current study, data collected from the women at enrolment (<18 weeks gestation) were included. The STRIPE‐SA study has a cross‐sectional design and was conducted in pregnant women of any gestational age from September 2018 to February 2019 attending antenatal care at the Rahima Moosa Mother and Child Hospital (RMMCH) in Johannesburg of the Gauteng Province. Data collection for both studies was performed at the antenatal clinic of RMMCH antenatal clinic. In both studies, pregnant women were included if they were between 18 and 39 years of age, born in South Africa or a neighbouring country, have lived in Johannesburg for at least 12 months, were able to communicate effectively in one of the local languages, non‐smoking, and expecting a singleton. In the NuPED study, pregnant women further had to be <18 weeks gestational age at recruitment. In the NuPED study, women were excluded from participation if they reported use of illicit drugs, had a known non‐communicable disease (NCDs) such as diabetes, renal disease, history of high blood cholesterol and hypertension, and had a known infectious disease such as tuberculosis and hepatitis, or known serious illness such as cancer, lupus or psychosis. In the STRIPE‐SA study, pregnant women were excluded if they had a major medical illness, thyroid disease, HIV, and/or were taking major chronic medication (including antiretroviral drugs), have received iodine‐containing X‐ray/CT contrast agent or iodine‐containing medication within the last year, and if they were taking kelp and/or seaweed supplements. The NuPED study included HIV positive women to allow generalisation of results to the wider South African population that has a high prevalence of HIV (~36% of women aged 30–34 years) (Shisana et al., 2014). Socio‐economic and demographic data were collected from participants through a structured interview conducted by trained fieldworkers. Data collected included date and country of birth, marital status, educational level, employment status and beneficiaries of social grants. Living standards data were collected to allow classification according to the Living Standards Measure (LSM) developed by the South African Audience Reference Foundation (SAARF) (Haupt, 2016). This measure is widely used in South Africa to describe the socio‐economic status of the population (Labadarios et al., 2011). Women with an LSM score of 1–4, 5–7 or 8–10 were considered having a low, medium or high living standard, respectively. HIV status data were obtained from clinical records with consent from the participants. In the STRIPE‐SA study, we collected information on the use of iodine‐containing dietary supplements in the last 6 months and the use of iodised salt. Anthropometric measurements included height and weight. All measurements were performed twice and recorded to the nearest 0.05 kg for weight and 0.1 cm for height. Standardised methods of the International Society for the Advancement of Kinanthropometry (Marfell‐Jones et al., 2012) were used with a calibrated digital scale for weight (Seca Robusta 813) and a mobile stadiometer for height (Leicester Height Measure). Midstream spot urine samples (10–40 ml) were collected into clean plastic cups between 07:00 and 12:00 noon, and approximately, 5 ml was decanted into iodine‐free screw‐capped cups. The research team ensured that the urine samples were not used for any routine assessment using dipsticks to avoid potential contamination with iodine. Samples were aliquoted and stored on‐site at −20°C for a maximum of 7 days. Thereafter, samples were transported on dry ice to Centre of Excellence for Nutrition (CEN) laboratories in Potchefstroom, South Africa, for storage at −80°C until analysis. Dried blood spots (DBS) were collected on Whatman 903 filter paper cards (Whatman Inc., USA). Whole blood was collected in the NuPED study by venous blood collection into an EDTA‐coated vacutainer (Becton Dickinson, Woodmead, South Africa) and in the STRIPE‐SA study by capillary blood collection via finger prick. Blood samples were spotted onto filter paper cards. Each filter paper card had six circles (spotting areas), and 50 μl of whole blood was spotted on each circle. The filter paper cards were allowed to dry at room temperature for 24 h, placed in zip lock bags with a desiccant and stored at −20°C for a maximum of 7 days before transportation on dry ice to CEN laboratories for storage at –80°C before shipment on dry ice to the Swiss Newborn Screening Laboratory, University Children's Hospital in Zurich, Switzerland for analysis. In the NuPED study, a serum sample was prepared from venous blood collected into a serum separator vacutainer tube (Becton Dickinson, Woodmead, South Africa) to obtain a serum sample, which was also stored on‐site at –20°C for a maximum of 7 days before transportation on dry ice to CEN laboratories for storage at –80°C before analysis. UIC in spot urine samples was measured in duplicate using the Pino modification of the Sandell–Kolthoff reaction with spectrophotometric detection at CEN (Jooste & Strydom, 2010; Pino et al., 1996). All analyses were done using nanopure grade water, and all laboratory glassware and plasticware were acid washed before use. Internal and external controls were used to ensure the quality of the analysis. Iodine concentrations in spot urine samples are expressed as median concentrations (μg/L). The median UIC cut‐off of <150 μg/L is used to define iodine deficiency in pregnant women (WHO, 2013b). Thyroid‐stimulating hormone (TSH) and total thyroxine (tT4) in DBS samples were measured at the Swiss Newborn Screening Laboratory, University Children's Hospital in Zurich, Switzerland. DBS‐TSH and DBS‐tT4 were analysed with the use of a time‐resolved dissociation‐enhanced lanthanide fluorescence immunoassay (DELFIA) on the genetic screening processor (GSP) and related kits (PerkinElmer, Turku, Finland), or with the use of a fluoro‐enzymatic immunoassay (FEIA) on the screening system NS2400 and related kits (Labsystem Diagnostics, Vantaa, Finland). Thyroglobulin (Tg) was analysed in serum samples using the Q‐Plex™ Human Micronutrient Array (7‐plex, Quansys Bioscience, Logan, UT, USA) (Brindle et al., 2017) at the CEN. This fully quantitative chemiluminescent multiplex assay also includes Tg (Brindle et al., 2017). Tg was analysed for the NuPED participants and not for the STRIPE‐SA study. Analysis of Tg with this method was not within the scope of the STRIPE‐SA study. Data processing and statistical analysis of data were performed using SPSS version 26 (IBM, Armonk, NY, USA). Raw data were captured in Microsoft Access, and 20% of all data were randomly checked for correctness. All UIC data were captured in Excel Windows XP (Microsoft, Seattle, WA, USA). Baseline data from the NuPED study (<18 week's gestation) were pooled with the STRIPE‐SA data. Data were tested for outliers and normality using Q–Q plots, histograms and Shapiro–Wilk test. All data were non‐normally distributed and are expressed as medians [interquartile range (IQR)]. Categorical data are expressed as frequencies and percentages. Women were categorised by trimesters (first, second and third trimester), and the Kruskal–Wallis test was used to determine between‐group differences. Women were further grouped according to UIC status [(UIC < 150 μg/L and UIC ≥ 150 μg/L) and (UIC < 100 μg/L and UIC ≥ 100 μg/L)], and Mann–Witney U tests were performed to determine differences between groups. The Spearman's correlation was used to determine associations between continuous maternal characteristic and outcome variables. Analysis of covariance (ANCOVA) was performed to determine differences in TSH, tT4 and Tg between UIC categories [(UIC < 150 μg/L and UIC ≥ 150 μg/L) and (UIC < 100 μg/L and UIC ≥ 100 μg/L)], while controlling for maternal age and gestational age. TSH, tT4 and Tg were log‐transformed for univariate analysis. This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Human Research Ethics Committee of the North‐West University and the University of the Witwatersrand, Johannesburg. Permission to perform both the NuPED and STRIPE‐SA studies was given by the CEO of RMMCH, the RMMCH research review committee, the Gauteng Department of Health and the Johannesburg Health District's District Research Committee. Written informed consent was obtained from all participants before enrolment.

AI Digest

Study Justification:

– Adequate iodine intake is crucial during pregnancy for fetal growth and neurodevelopment.
– Data on iodine status of pregnant women in South Africa are limited.
– The salt reduction policy implemented in 2016 may impact iodine intake in South Africa.
– This study aimed to assess the iodine status of pregnant women in urban Johannesburg.

Highlights:

– The study included 250 pregnant women from the NuPED study and 312 pregnant women from the STRIPE-SA study.
– Median urinary iodine concentration (UIC) of pregnant women was 144 μg/L.
– There was no significant difference in UIC among trimesters.
– Median levels of thyroid-stimulating hormone (TSH), total thyroxine (tT4), and thyroglobulin (Tg) were within normal ranges.
– Based on the median UIC, pregnant women in urban Johannesburg may be borderline iodine deficient.
– Ongoing monitoring of iodine status among vulnerable pregnant women is necessary, especially considering the salt reduction policy.

Recommendations:

– Continuously monitor iodine status among pregnant women in urban Johannesburg.
– Assess the impact of the salt reduction policy on iodine intake.
– Implement interventions to ensure adequate iodine intake during pregnancy.
– Provide education and awareness programs for pregnant women and healthcare providers regarding the importance of iodine during pregnancy.

Key Role Players:

– Researchers and scientists involved in the study.
– Healthcare providers and antenatal care clinics.
– Government health departments and policymakers.
– Nutritionists and dietitians.
– Community health workers and educators.

Cost Items for Planning Recommendations:

– Research and data collection expenses.
– Laboratory analysis and testing.
– Training and education programs for healthcare providers.
– Development and distribution of educational materials.
– Monitoring and surveillance systems.
– Implementation of interventions and programs.
– Evaluation and assessment of the impact of interventions.
Please note that the provided cost items are general categories and not actual cost estimates. The actual costs would depend on various factors and would need to be determined through detailed planning and budgeting.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is cross-sectional, which limits the ability to establish causality. However, the study included a relatively large sample size of 562 pregnant women and used standardized measurements and laboratory methods. To improve the strength of the evidence, future studies could consider using a longitudinal design to establish temporal relationships and include a control group for comparison. Additionally, conducting a systematic review or meta-analysis of multiple studies on iodine status in pregnant women in South Africa would provide a more comprehensive assessment of the evidence.

Abstract

This cross‐sectional study was performed in pregnant women who participated in two studies, namely the ‘Nutrition during Pregnancy and Early Development’ (NuPED) study (n = 250) and the ‘Assessment of dried blood spot thyroglobulin in pregnant women to redefine the range of median urinary iodine concentration that indicates adequate iodine intake, South Africa’ (STRIPE‐SA) study (n = 312). The NUPED study is a prospective cohort study designed to follow‐up women during pregnancy and their infants postnatally. Pregnant women who participated in the NuPED study were recruited from primary healthcare clinics in Johannesburg between March 2016 and December 2017. The protocol of the study was previously published (Symington et al., 2018). For the purpose of the current study, data collected from the women at enrolment (<18 weeks gestation) were included. The STRIPE‐SA study has a cross‐sectional design and was conducted in pregnant women of any gestational age from September 2018 to February 2019 attending antenatal care at the Rahima Moosa Mother and Child Hospital (RMMCH) in Johannesburg of the Gauteng Province. Data collection for both studies was performed at the antenatal clinic of RMMCH antenatal clinic. In both studies, pregnant women were included if they were between 18 and 39 years of age, born in South Africa or a neighbouring country, have lived in Johannesburg for at least 12 months, were able to communicate effectively in one of the local languages, non‐smoking, and expecting a singleton. In the NuPED study, pregnant women further had to be <18 weeks gestational age at recruitment. In the NuPED study, women were excluded from participation if they reported use of illicit drugs, had a known non‐communicable disease (NCDs) such as diabetes, renal disease, history of high blood cholesterol and hypertension, and had a known infectious disease such as tuberculosis and hepatitis, or known serious illness such as cancer, lupus or psychosis. In the STRIPE‐SA study, pregnant women were excluded if they had a major medical illness, thyroid disease, HIV, and/or were taking major chronic medication (including antiretroviral drugs), have received iodine‐containing X‐ray/CT contrast agent or iodine‐containing medication within the last year, and if they were taking kelp and/or seaweed supplements. The NuPED study included HIV positive women to allow generalisation of results to the wider South African population that has a high prevalence of HIV (~36% of women aged 30–34 years) (Shisana et al., 2014). Socio‐economic and demographic data were collected from participants through a structured interview conducted by trained fieldworkers. Data collected included date and country of birth, marital status, educational level, employment status and beneficiaries of social grants. Living standards data were collected to allow classification according to the Living Standards Measure (LSM) developed by the South African Audience Reference Foundation (SAARF) (Haupt, 2016). This measure is widely used in South Africa to describe the socio‐economic status of the population (Labadarios et al., 2011). Women with an LSM score of 1–4, 5–7 or 8–10 were considered having a low, medium or high living standard, respectively. HIV status data were obtained from clinical records with consent from the participants. In the STRIPE‐SA study, we collected information on the use of iodine‐containing dietary supplements in the last 6 months and the use of iodised salt. Anthropometric measurements included height and weight. All measurements were performed twice and recorded to the nearest 0.05 kg for weight and 0.1 cm for height. Standardised methods of the International Society for the Advancement of Kinanthropometry (Marfell‐Jones et al., 2012) were used with a calibrated digital scale for weight (Seca Robusta 813) and a mobile stadiometer for height (Leicester Height Measure). Midstream spot urine samples (10–40 ml) were collected into clean plastic cups between 07:00 and 12:00 noon, and approximately, 5 ml was decanted into iodine‐free screw‐capped cups. The research team ensured that the urine samples were not used for any routine assessment using dipsticks to avoid potential contamination with iodine. Samples were aliquoted and stored on‐site at −20°C for a maximum of 7 days. Thereafter, samples were transported on dry ice to Centre of Excellence for Nutrition (CEN) laboratories in Potchefstroom, South Africa, for storage at −80°C until analysis. Dried blood spots (DBS) were collected on Whatman 903 filter paper cards (Whatman Inc., USA). Whole blood was collected in the NuPED study by venous blood collection into an EDTA‐coated vacutainer (Becton Dickinson, Woodmead, South Africa) and in the STRIPE‐SA study by capillary blood collection via finger prick. Blood samples were spotted onto filter paper cards. Each filter paper card had six circles (spotting areas), and 50 μl of whole blood was spotted on each circle. The filter paper cards were allowed to dry at room temperature for 24 h, placed in zip lock bags with a desiccant and stored at −20°C for a maximum of 7 days before transportation on dry ice to CEN laboratories for storage at –80°C before shipment on dry ice to the Swiss Newborn Screening Laboratory, University Children's Hospital in Zurich, Switzerland for analysis. In the NuPED study, a serum sample was prepared from venous blood collected into a serum separator vacutainer tube (Becton Dickinson, Woodmead, South Africa) to obtain a serum sample, which was also stored on‐site at –20°C for a maximum of 7 days before transportation on dry ice to CEN laboratories for storage at –80°C before analysis. UIC in spot urine samples was measured in duplicate using the Pino modification of the Sandell–Kolthoff reaction with spectrophotometric detection at CEN (Jooste & Strydom, 2010; Pino et al., 1996). All analyses were done using nanopure grade water, and all laboratory glassware and plasticware were acid washed before use. Internal and external controls were used to ensure the quality of the analysis. Iodine concentrations in spot urine samples are expressed as median concentrations (μg/L). The median UIC cut‐off of <150 μg/L is used to define iodine deficiency in pregnant women (WHO, 2013b). Thyroid‐stimulating hormone (TSH) and total thyroxine (tT4) in DBS samples were measured at the Swiss Newborn Screening Laboratory, University Children's Hospital in Zurich, Switzerland. DBS‐TSH and DBS‐tT4 were analysed with the use of a time‐resolved dissociation‐enhanced lanthanide fluorescence immunoassay (DELFIA) on the genetic screening processor (GSP) and related kits (PerkinElmer, Turku, Finland), or with the use of a fluoro‐enzymatic immunoassay (FEIA) on the screening system NS2400 and related kits (Labsystem Diagnostics, Vantaa, Finland). Thyroglobulin (Tg) was analysed in serum samples using the Q‐Plex™ Human Micronutrient Array (7‐plex, Quansys Bioscience, Logan, UT, USA) (Brindle et al., 2017) at the CEN. This fully quantitative chemiluminescent multiplex assay also includes Tg (Brindle et al., 2017). Tg was analysed for the NuPED participants and not for the STRIPE‐SA study. Analysis of Tg with this method was not within the scope of the STRIPE‐SA study. Data processing and statistical analysis of data were performed using SPSS version 26 (IBM, Armonk, NY, USA). Raw data were captured in Microsoft Access, and 20% of all data were randomly checked for correctness. All UIC data were captured in Excel Windows XP (Microsoft, Seattle, WA, USA). Baseline data from the NuPED study (<18 week's gestation) were pooled with the STRIPE‐SA data. Data were tested for outliers and normality using Q–Q plots, histograms and Shapiro–Wilk test. All data were non‐normally distributed and are expressed as medians [interquartile range (IQR)]. Categorical data are expressed as frequencies and percentages. Women were categorised by trimesters (first, second and third trimester), and the Kruskal–Wallis test was used to determine between‐group differences. Women were further grouped according to UIC status [(UIC < 150 μg/L and UIC ≥ 150 μg/L) and (UIC < 100 μg/L and UIC ≥ 100 μg/L)], and Mann–Witney U tests were performed to determine differences between groups. The Spearman's correlation was used to determine associations between continuous maternal characteristic and outcome variables. Analysis of covariance (ANCOVA) was performed to determine differences in TSH, tT4 and Tg between UIC categories [(UIC < 150 μg/L and UIC ≥ 150 μg/L) and (UIC < 100 μg/L and UIC ≥ 100 μg/L)], while controlling for maternal age and gestational age. TSH, tT4 and Tg were log‐transformed for univariate analysis. This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Human Research Ethics Committee of the North‐West University and the University of the Witwatersrand, Johannesburg. Permission to perform both the NuPED and STRIPE‐SA studies was given by the CEO of RMMCH, the RMMCH research review committee, the Gauteng Department of Health and the Johannesburg Health District's District Research Committee. Written informed consent was obtained from all participants before enrolment.

Materials

N/A

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide pregnant women with access to information and resources related to maternal health, including nutrition, prenatal care, and iodine intake. These apps can also offer reminders for appointments and medication, as well as connect women with healthcare providers through telemedicine.

2. Community Health Workers: Train and deploy community health workers to provide education and support to pregnant women in urban areas. These workers can conduct home visits, organize group sessions, and provide personalized guidance on maternal health practices, including the importance of iodine intake.

3. Telemedicine Services: Establish telemedicine services that allow pregnant women to consult with healthcare providers remotely. This can help overcome barriers to accessing healthcare, such as transportation issues or long waiting times at clinics. Pregnant women can receive guidance on iodine intake and have their questions answered by healthcare professionals.

4. Iodine Supplementation Programs: Implement targeted iodine supplementation programs for pregnant women in urban areas. This can involve distributing iodine supplements, such as iodized salt or iodine-containing prenatal vitamins, to ensure adequate iodine intake during pregnancy.

5. Public Awareness Campaigns: Launch public awareness campaigns to educate pregnant women and the general population about the importance of iodine intake during pregnancy. These campaigns can use various media channels, such as television, radio, social media, and community events, to disseminate information and promote healthy behaviors.

6. Collaboration with Salt Producers: Collaborate with salt producers to ensure the availability and affordability of iodized salt in urban areas. This can involve working with salt manufacturers to increase the production and distribution of iodized salt, as well as advocating for policies that promote the use of iodized salt in food processing.

7. Integration of Maternal Health Services: Integrate maternal health services with existing healthcare facilities and programs in urban areas. This can include incorporating maternal health screenings and interventions into routine primary care visits, antenatal care clinics, and family planning services.

8. Data Monitoring and Evaluation: Establish a comprehensive data monitoring and evaluation system to track the iodine status of pregnant women in urban areas. This can help identify areas of improvement, measure the impact of interventions, and inform evidence-based decision-making for future maternal health initiatives.

It is important to note that the specific context and needs of pregnant women in urban Johannesburg should be considered when implementing these innovations.

AI Innovations Description

Based on the description provided, the recommendation to improve access to maternal health in relation to iodine status of pregnant women in urban Johannesburg, South Africa is as follows:

1. Increase awareness and education: Implement targeted educational campaigns to raise awareness among pregnant women and healthcare providers about the importance of adequate iodine intake during pregnancy. This can include providing information about iodine-rich foods, the benefits of iodized salt, and the potential risks of iodine deficiency.

2. Strengthen antenatal care services: Ensure that antenatal care services include routine screening for iodine deficiency and monitoring of iodine status during pregnancy. This can be done through urine or blood tests to assess urinary iodine concentration and thyroid function.

3. Improve availability of iodized salt: Collaborate with government agencies, salt producers, and retailers to ensure the widespread availability of iodized salt in urban Johannesburg. This can involve promoting the use of iodized salt in households, restaurants, and food processing industries.

4. Enhance nutrition support: Provide nutritional counseling and support to pregnant women, emphasizing the importance of a balanced diet that includes iodine-rich foods such as seafood, dairy products, and iodized salt. This can be done through the integration of nutrition education into antenatal care services and the provision of affordable and accessible nutritious food options.

5. Monitor and evaluate iodine status: Establish a system for regular monitoring and evaluation of iodine status among pregnant women in urban Johannesburg. This can involve conducting periodic surveys or studies to assess the prevalence of iodine deficiency and the effectiveness of interventions.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to better iodine status among pregnant women in urban Johannesburg, South Africa.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Implement comprehensive education programs targeting pregnant women and healthcare providers to raise awareness about the importance of adequate iodine intake during pregnancy. This can include information on the role of iodine in foetal growth and neurodevelopment, as well as the potential risks of iodine deficiency.

2. Improve access to iodine supplements: Ensure that pregnant women have easy access to iodine supplements, either through healthcare facilities or community distribution programs. This can help to bridge the gap between dietary iodine intake and recommended levels.

3. Strengthen antenatal care services: Enhance antenatal care services by incorporating routine screening for iodine deficiency and providing appropriate interventions for pregnant women identified as iodine deficient. This can include regular monitoring of urinary iodine concentration and thyroid function, as well as personalized supplementation recommendations.

4. Collaborate with salt producers: Collaborate with salt producers to ensure that iodized salt is readily available and affordable in urban Johannesburg. This can involve advocacy efforts to promote the use of iodized salt in food processing and cooking at both household and commercial levels.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population of pregnant women in urban Johannesburg who would benefit from improved access to maternal health services, particularly in relation to iodine intake.

2. Collect baseline data: Gather relevant data on the current status of iodine intake and maternal health outcomes among the target population. This can include information on urinary iodine concentration, thyroid function, and other relevant indicators.

3. Develop a simulation model: Create a simulation model that incorporates the potential impact of the recommended interventions on improving access to maternal health. This model should consider factors such as the increase in awareness and education, the availability of iodine supplements, the strengthening of antenatal care services, and the collaboration with salt producers.

4. Input data and parameters: Input the collected baseline data and relevant parameters into the simulation model. This can include information on the size of the target population, the effectiveness of the interventions, and the timeframe for implementation.

5. Run simulations: Run multiple simulations using the model to assess the potential impact of the recommended interventions on improving access to maternal health. This can involve varying the parameters to explore different scenarios and outcomes.

6. Analyze results: Analyze the results of the simulations to determine the potential benefits and challenges associated with implementing the recommended interventions. This can include evaluating changes in iodine intake, maternal health outcomes, and overall access to maternal health services.

7. Refine and iterate: Based on the analysis of the simulation results, refine the model and interventions as needed. This can involve adjusting parameters, exploring alternative strategies, or identifying additional factors that may influence the outcomes.

8. Communicate findings: Present the findings of the simulation study to relevant stakeholders, including policymakers, healthcare providers, and community organizations. This can help to inform decision-making and facilitate the implementation of effective interventions to improve access to maternal health.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available data.

Author

Dima Health

Statistics:

Citations: 3

Identifiers:

DOI: 10.1111/mcn.13236

ISSN: 17408695

Research Areas:

Cancer, Environmental, Food Security, Genetics and Genomics, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

South Africa

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female