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Discussion

Numerous studies have been reported of the relation between maternal nutrition and fetal growth, breast milk production and infant growth, but the effect of reproduction on the mother-infant pair as an entity has received limited attention (Krasovec & Anderson, 1991).

Table 9. Maternal weight changes (kg) over two consecutive reproduction cycles

	Body mass index categories
	< 170 (n = 31)		17.0-18.4 (n = 64)		³ 18.5 (n = 122)
Weight (kg) at specified periods	Mean	SD	Mean	SD	Mean	SD
First reproduction cycle
Pre-pregnant	37.7	3.1	40.3	2.7	45.2	4.6
Post-partum at
1 month	39.9	4.1	41.9	3.1	45.2	5.1
at 6 months	39.6	3.8	40.9	3.5	45.0	5.1
at 12 months	38.8	3.6	40.9	3.2	44.7	4.7
Second reproduction cycle
Pre-pregnant	38.4	3.6	41.8	3.6	45.0	4.8
Post-partum
at 1 month	40.4	4.2	41.7	3.7	45.3	6.1
at 6 months	40.1	3.8	41.1	3.5	45.1	5.5
at 12 months	40.3	3.8	41.3	3.5	45.2	5.1

Using infant outcomes, there is evidence that pregnant and lactating women can be in energy balance on surprisingly low energy intakes, admittedly 'not always compatible with an optimum quality of life' of the infant (Prentice, 1984). Are there limits to the maternal body's capacity to support fetal and infant growth? If so, to what level will a woman deplete her own energy reserves in the reproductive process?

BMI has been used in this analysis in an attempt to get a better understanding of the maternal-infant relation during pregnancy and lactation. CED, defined by BMI, was very common in the study population (38%) and according to a survey conducted in 1991, also in East Java province (27% unpublished data). Such a situation is not exceptional for the Third World (James & Ralph, 1992). Considering the population of women as a whole, one can only agree with the general point of view that fetal growth and breast milk production were remarkably well protected, in spite of low energy intakes and reserves. The negative effects of chronic undernutrition on infant outcomes emerged only after separation of women by BMI categories. It clearly illustrates how average values can mask the issues of concern.

The functional significance of the proposed BMI cut-offs is confirmed in our population. There was strong predictive value of pre pregnant BMI for birth weight, and post-partum BMI influenced infant growth.

The relation between Pre-pregnant and postpartum BMI and maternal weight changes in the corresponding periods is remarkable. Although the variation was very large, the trend was consistent. Maternal BMI was found to determine the response to reproductive stress in such a way that in CED women pregnancy and lactation promoted weight gain of the women to the detriment of fetal and infant growth. Apparently there are limits to maternal depletion. Contrary to conventional wisdom, maternal weight gain during pregnancy and lactation among Madurese women was an indication of a poor maternal energy status and predictive for a poor infant outcome!

The similarity in maternal weight changes during pregnancy and post-natally in the cross-sectional and longitudinal sample indicates that CED is a problem among women of reproductive age, irrespective of physiological state and primarily as a result of habitual low energy intakes. In spite of a very long birth interval of about 30 months the severe and moderate CED women never recuperated to reach a BMI level of 18.5. What is observed is a change of maternal energy reserves in waves: when very depleted, they are replenished. If body reserves have reached a certain level of BMI ~18.5, the maternal body subsidizes fetal growth and breast milk production. In fact, the problem of CED is more serious than the observed prevalence suggests. The whole female population goes through this undulating process!

There are very few studies for comparison. In the Gambia pregnant women save so much energy by a lower BMR that being pregnant appears to benefit their own energy balance (Durnin, 1987) and during lactation there was evidence of a competition between repletion of maternal subcutaneous fat and milk production (Paul, Mueller & Whitehead, 1979). Most comparable to EJPS is the Winkvist study (1992). Winkvist examined weight changes over two consecutive pregnancies among Pakistanis and did a secondary analysis of data from the well-known supplementation study in Guatemala. The net weight change during one reproductive cycle was defined as the difference between maternal weight at 1 month after the first and second newborn. The largest positive maternal weight gain occurred in the low initial weight group. It was associated with the largest negative difference in mean birth weight between two consecutive births.

Through which processes would CED women replete their energy stores at the expense of the fetus and infant? The homeostatic mechanism that regulates the partitioning of dietary energy during reproduction in the human is poorly understood. In animal studies the partitioning of nutrients between mother and offspring seems to depend on prior maternal nutritional status (Young & Young, 1985; Glore & Layman, 1985; Sadurskis et al., 1991). Path models, used to analyse the effect of the Dutch winter (1944/45; Stein et al., 1975) suggest that under famine conditions there may be a shift in the role of the placenta with the passage of nutrients from the mother to the fetus being reduced to the advantage of the mother (Susser, 1991).

Finally, communities in developing countries are not homogeneous and the observations in EJPS will certainly not have universal validity. Although the Indian data showed the same validity of the BMI cut-offs for birth weight (Naidu et al., 1991), the percentage of low birth weight in each category was far higher than in EJPS. In a comparable study in the Philippines weight changes during lactation did not differ across the range of post-partum weight and BMI, although the maternal weight and height distribution was similar to that in EJPS (Adair et al., 1990). In Senegal maternal height rather than fat reserves was significantly correlated with birth weight (Briend, 1985). Work still remains to be done on the relation of maternal nutrition to weight gain and to outcome at birth in humans.

If the observations in EJPS, suggesting a preferential partitioning of energy to the CED mother, are confirmed in other communities, they may explain the modest effect or absence of an effect of energy supplementation to undernourished pregnant and lactating mothers on the selected infant outcomes.

One can at least conclude that weight monitoring of mothers is as essential as growth monitoring of young children. Indeed, by concentrating solely on child malnutrition one has distorted the picture of food needs in developing countries (Ferro-Luzzi et al., 1992).

Acknowledgement - The financial support for this research by the Netherlands Directorate for International Technical Cooperation (DGIS), the Hague is gratefully acknowledged.

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Discussion

Waterlow: What is the significance of 2.5 kg as a cut-off point for low birth weight? If by a supplementation programme you get an increase in birth weight of 100g, say, from 2.7 to 2.8 has this any significance in the outcome for the child? Kusin: In our population the risk cut-off point is 2.4 kg. Above this, mortality is all the same.

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