Methods

Randomisation and allocation concealment: random allocation of the entire population of the urban and rural areas (population, 110,000; 20,400 households) into 28 discrete clusters (16 rural and 12 urban) on the basis of household characteristics, socioeconomic criteria, and geographic location. Each cluster was allocated to a community health worker who distributed the supplements on a cluster‐based allocation strategy of supplements ("either iron–folic acid or multiple micronutrients"). Distribution of the sealed, coded supplement bottles were independently controlled by the pharmacy at Aga Khan University.

Blinding of outcome assessment: medical officers, community health workers, social scientists, and data collection team remained blinded to the supplementation allocation.

Documentation of exclusion: 373 women (16.5%) were excluded.

Use of placebo control: no placebo given, women in the control group were given IFA.

Participants

2378 women from community settings in urban and rural Sindh (Pakistan) less than 16 weeks of gestation. Eligible women were women with a confirmed pregnancy at less than 16 weeks of gestation. Women who did not have a confirmed pregnancy on ultrasound scanning or women who were clearly advanced beyond 24 weeks of gestation were excluded.

Interventions

Multiple micronutrients comprised 30 mg of iron (ferrous fumarate) and 400 mcg of folic acid along with 800 mcg of retinol (retinyl acetate), 200 IU of vitamin D (ergocalciferol), 10 mg of vitamin E (α‐tocopherol acetate), 70 mg of ascorbic acid, 1.4 mg of vitamin B1 (thiamine mononitrate), 18 mg of niacin (niacinamide) 1.4 mg of vitamin B2, 1.9 mg of vitamin B6 (pyridoxine), 2.6 mcg of vitamin B12 (cyanocobalamin), 15 mg of zinc (zinc gluconate), 2 mg of copper, 65 mcg of selenium, and 150 mcg of iodine. Intervention was timed to start at less than 16 weeks' gestation. Comparison was iron (60 mg) and folic acid (400 mcg).

Outcomes

Maternal outcomes:

1. Blood Hb level as well as serum ferritin, zinc, and vitamin A.

2. Physical and clinical examination, including a morbidity assessment and measurement of fundal height.

3. Height, weight, and mid‐upper‐arm circumference.

Infant outcomes:

1. Birthweight.

2. Gestational age.

3. Neonatal death and cause of death.

Notes

Women's risk of spontaneous and recurrent miscarriage is unclear.

Womens' BMI, Hb, ferritin, zinc, and serum retinol at admission are reported.

Sample‐size calculation reported by 2 methods: 1. based on a potential 5% gain in birthweight, 2. based to estimate a difference in birthweight of 150 g between the 2 groups.

No intention‐to‐treat analyses performed.

Compliance: community health worker performed a tablet count every fourth nightly visit. Proportion of tablets consumed 75.65 in the intervention group and 76.7% in the control group.

Location: urban population (Bilal Colony, Karachi) and rural villages (Kot Diji district, rural Sindh), Pakistan.

Timeframe: unclear.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"We randomly allocated the entire population of the urban and rural area." Pg S497.

Allocation concealment (selection bias)

Low risk

"cluster‐based allocation strategy of supplements (either iron–folic acid or multiple micronutrients) by the community health workers was implemented. The allocation of either iron–folic acid or multiple micronutrient supplements and the distribution of the sealed, coded supplement bottles were independently controlled by the pharmacy at Aga Khan University, which maintained the allocation codes by individual community health workers." Pg S498.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

All pregnant women were allocated a unique code and a uniquely labelled and numerically coded specific supplement supply for the duration of pregnancy. Blinding is unlikely to have been broken. Pg S498.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"The field staff (medical officers, community health workers, social scientists, and data collection team) remained completely blinded as to the supplement allocation." Pg S498.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Approximately 16.5% of attrition with balanced number and similar reason for each group. S500 Figure1.

Selective reporting (reporting bias)

Unclear risk

No information about trial registration.

Other bias

High risk

The distribution of study participants across the urban and rural areas is unclear from the text and no adjustments were made for cluster design.

Methods

Randomisation and allocation concealment: unclear, no methodological details given, dubious as the number of women allocated to the treatment group was more than double that allocated to the placebo group. "Unselected patients were each given 200 capsules... these were given a code, unknown to us and contained either an inert powder or 100 mg each of ascorbic acid and hesperidin."

Blinding of outcome assessment: women and study investigators did not know the treatment codes.

Documentation of exclusion: none reported.

Use of placebo control: placebo given; however, all women received an additional multivitamin supplement.

Participants

406 women were recruited in the study. Eligible women were "unselected patients" in private obstetrics care, who were less than or equal to 10 weeks' pregnant, and were eligible regardless of whether they were currently bleeding or the number of previous pregnancies. Women greater than 10 weeks' gestation were excluded. 406 women were randomised to either vitamin C (n = 303) or placebo (n = 103), no losses to follow‐up were reported. 77 women in the study had more than 2 previous miscarriages and/or bleeding in the pregnancy, and 329 had 2 or fewer miscarriages and no bleeding in the pregnancy.

Interventions

All women were given 200 tablets, containing either 100 mg each of ascorbic acid and hesperidin or placebo (an inert powder).
The study lasted for 7 weeks. For the first 2 weeks, women were asked to take 8 tablets daily (i.e. daily 800 mg each of vitamin C and hesperidin or placebo). For the following 5 weeks, women took 4 tablets daily (i.e. daily 400 mg each of vitamin C and hesperidin or placebo). All women received a multiple vitamin supplement containing 50 mg vitamin C.

Outcomes

1. Spontaneous miscarriage.

2. Spontaneous miscarriage in women with 2 or fewer previous miscarriages and no bleeding in the current pregnancy.

3. Spontaneous miscarriage in women with more than 2 previous miscarriages and/or bleeding in the current pregnancy.

4. Spontaneous miscarriage in women who experienced recurrent miscarriage.

Notes

Women's risk of spontaneous and recurrent miscarriage is unclear, as there is no information about concurrent medical conditions or other risk factors for miscarriage. 9 of the 406 women were classified as experiencing recurrent miscarriage.
No information is available about women's nutritional status.
No sample‐size calculation reported.
Intention‐to‐treat analyses performed (no losses to follow‐up reported).
Compliance: no compliance information reported.
Location: Philadelphia, USA.
Timeframe: unclear.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No methodological details given.

Allocation concealment (selection bias)

Unclear risk

No methodological details given.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Women and study investigators did not know the treatment allocation.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Double‐blind study, but it is unclear who was blinded and if the code was broken before or after outcome assessment pg289.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No losses to follow‐up reported.

Selective reporting (reporting bias)

Unclear risk

Limited information about selection bias, stated that 'unselected patients' were included.

Other bias

Unclear risk

Limited methodological details provided including patient compliance.

Methods

Randomisation and allocation concealment: a computer‐generated randomisation list using blocks of 10 was given to the hospital pharmacy departments. Researchers allocated the next available number to participants and women collected the trial tablets from the pharmacy department.

Blinding of outcome assessment: women, caregivers and researchers were blinded to the treatment allocation until recruitment, data collection and laboratory analyses were complete.

Documentation of exclusion: 123 (43.5%) women were excluded, of which 70 women were withdrawn because their second Doppler scan was normal. Pregnancy outcome data were reported for all women randomised.

Use of placebo control: placebo control.

Participants

283 women were recruited into the study. Inclusion criteria: abnormal Doppler waveform in either uterine artery at 18‐22 weeks' gestation or a history in the preceding pregnancy of pre‐eclampsia necessitating delivery before 37 weeks' gestation, eclampsia or the syndrome of HELLP.
Exclusion criteria: heparin or warfarin treatment, abnormal fetal‐anomaly scan or multiple pregnancy.
Women were randomised at 18‐22 weeks' gestation; however, women with a previous history who were identified at an earlier stage were randomised at 16 weeks' gestation. Women with abnormal Doppler waveform analysis returned for a second scan at 24 weeks' gestation, those with a normal waveform at this time stopped treatment and were withdrawn from the study. The remaining women who had persistently abnormal waveforms, and those with a previous history or pre‐eclampsia remained in the study and were seen every 4 weeks through the rest of pregnancy. 1512 women underwent Doppler screening, 273 women had abnormal waveforms and of these, 242 women consented to the study. An additional 41 women who had a history of pre‐eclampsia consented. 283 women were randomised to either the vitamin C and E group (n = 141) or the placebo group (n = 142), 72 women had normal Doppler scans at 24 weeks' gestation and 24 women did not return for a second scan and were withdrawn. A further 27 women withdrew from the trial after 24 weeks' gestation for various reasons. In total, 160 women completed the trial protocol until delivery, 79 in the vitamin C and E group and 81 in the placebo group. Pregnancy outcome data were presented for all women randomised (n = 283) as well as only for those women completing the trial protocol (n = 160).

Interventions

Women randomised to the vitamin C and E group received tablets containing 1000 mg vitamin C daily and capsules containing 400 IU vitamin E daily.
Women randomised to the placebo group received tablets containing microcrystalline cellulose and soyabean oil, that were identical in appearance to the vitamin C tablets and vitamin E capsules. After 24 weeks' gestation women were seen every 4 weeks, and blood samples were taken at each visit.

Outcomes

1. Ratio of PAI‐1 to PAI‐2.

2. Incidence of pre‐eclampsia.

3. Placental abruption.

4. Spontaneous preterm delivery (< 37 weeks).

5. Intrauterine death.

6. Small‐for‐gestational‐age infants (on or below the 10th centile).

7. Mean systolic and diastolic blood pressure before delivery.

8. Gestational age at delivery (median, IQR).

9. Birthweight (median, IQR).

10. Birthweight centile (median, IQR).

Notes

Women's risk of spontaneous and recurrent miscarriage is unclear, women were at high risk of pre‐eclampsia.
No information is available about women's nutritional status.
Sample‐size calculation reported, based on a 30% reduction in PAI‐1.
Intention‐to‐treat analyses performed.
Compliance: "within the treated group, plasma ascorbic acid concentration increased by 32% from baseline values and plasma alpha‐tocopherol increased by 54%".
Location: London, UK.
Timeframe: unclear.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated random number list.

Allocation concealment (selection bias)

Low risk

Random number list used blocks of 10 and was held by the pharmacy department.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Women, caregivers and researchers were blinded until the analyses were completed.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"The code was revealed to the researchers once recruitment, data collection, and laboratory analyses were complete" pg811.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

123 (43.5%) women were excluded, of which, 70 women were withdrawn because their second Doppler scan was normal. Data were reported for all women randomised.

Selective reporting (reporting bias)

Low risk

Data reported for all outcomes in methods.

Other bias

Low risk

The study appears to be free of other sources of bias.

Methods

Randomisation and allocation concealment: unclear, "women agreed to their allocation on the basis of a random table".

Blinding of outcome assessment: unclear, women were aware of the "blind use of one of two kinds of tablets", but no other details given.

Documentation of exclusion: 49 women (1%) were lost to follow‐up and excluded.

Use of placebo control: "trace element control" given.

Participants

7765 women were recruited into the study. Women participating in the HOFPP who volunteered to take part, were not currently pregnant, and who conceived within 12 months of ceasing contraception. In the first 2 years of the HOFPP, women were also required to be aged < 35 years, and not to have had a previous pregnancy except a prior induced abortion. 7905 women were approached, of which 140 refused participation, 7765 were randomised and 5502 women had a confirmed pregnancy and were allocated to either multivitamins (n = 2819) or control (n = 2683). 49 women of the 5502 confirmed pregnancies were lost to follow‐up.

Interventions

Women were provided with multivitamin or trace element 'control' from at least 28 days before conception continuing until at least the second missed menstrual period.
The multivitamin with folic acid contained 6000 IU vitamin A, 1.6 mg vitamin B1, 1.8 mg vitamin B2, 2.6 mg vitamin B6, 4.0 mcg vitamin B12, 100 mg vitamin C, 500 IU vitamin D, 15 mg vitamin E, 19 mg nicotinamide, 10 mg calcium pantothenate, 0.2 mg biotin, 0.8 mg folic acid, 125 mg calcium, 125 mg phosphorus, 100 mg magnesium, 60 mg iron, 1 mg copper, 1 mg manganese, 7.5 mg zinc.
The trace element control contained 7.5 mg vitamin C, 1 mg copper, 1 mg manganese and 7.5 mg zinc.

Outcomes

1. NTDs and other birth defects.

2. Miscarriage.

3. Ectopic pregnancy.

4. Termination of pregnancy.

5. Live births.

6. Stillbirths.

7. Multiple gestation.

8. Subgroup data are available on menstrual cycle, first trimester symptoms and sexual activity.

Notes

Women's risk of spontaneous and recurrent miscarriage is unclear.
Information on their dietary status is unknown.
No sample‐size calculation reported.
Partial intention‐to‐treat analyses performed.
Compliance: compliance was assessed by questioning, checking the tick‐off on the basal temperature chart and counting of unused tablets. 70% of women in the multivitamin group and 71% in the control group took the full course of the supplements, with an additional 20% and 21% in the multivitamin and control groups respectively receiving a partial course of supplementation.
Location: Hungary.
Time frame: 1 February 1984 to 30 April 1992.
The denominators used for this trial are the number of women randomised and with a confirmed pregnancy (i.e. 2819 for the multivitamin group and 2683 for the control group).

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Methodological details unclear.

Allocation concealment (selection bias)

Unclear risk

Methodological details unclear, 'women agreed to their allocation on the basis of a random table'.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Women were aware of the 'blind use of one of two kinds of tablets', but no other details given.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No details are given if outcome assessment was blinded.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

49 women (1%) excluded, partial intention‐to‐treat analyses performed.

Selective reporting (reporting bias)

Unclear risk

Denominators vary with serial publications.

Other bias

Unclear risk

Limited methodological details provided.

Methods

Randomisation and allocation concealment: block randomisation using blocks of 20, eligible women were "assigned the next numbered bottle of regimen". The study used a 2 by 2 factorial design and women were randomised to 1 of 4 groups. Tablets were indistinguishable and packaged in identically coded bottles.

Blinding of outcome assessment: women and study investigators were unaware of the treatment allocation, no information given about blinding of outcome assessors.

Documentation of exclusion: 64 women (6%) were lost to follow‐up and excluded.

Use of placebo control: placebo given.

Participants

1085 women were recruited into the study. Pregnant women between 12 and 27 weeks' gestation who were HIV‐1 infected, living in Dar es Salaam and intended to stay there for at least 1 year were eligible for the study. Women not HIV‐1 positive or moving out of Dar es Salaam were excluded. 13,879 pregnant women consented to be HIV‐1 tested, of which 1806 were positive, and 1085 were randomised. Of these, 3 women were not pregnant and 7 women died before delivery and were excluded from the trial. Of the remaining 1075 women, 54 women (5%) were lost to follow‐up by the time of delivery, leaving birth outcomes reported for 1021 women. Women were randomised to 1 of 4 groups: vitamin A (n = 269), multivitamins excluding vitamin A (n = 269); multivitamins including vitamin A (n = 270) or placebo (n = 267).

Interventions

Women were randomised to 1 of 4 groups:

1. vitamin A (30 mg beta‐carotene plus 5000 IU preformed vitamin A);

2. multivitamins excluding vitamin A (20 mg vitamin B1, 20 mg vitamin B2, 25 mg vitamin B6, 100 mg niacin, 50 mcg vitamin B12, 500 mg vitamin C, 30 mg vitamin E, 0.8 mg folic acid);

3. multivitamins including vitamin A, all formulated in 2 tablets; or

4. placebo.

All women received 400 mg ferrous sulphate and 5 mg folic acid daily, as well as 500 mg chloroquine phosphate weekly. At delivery, all women taking vitamin A were to receive an additional oral dose of 200,000 IU vitamin A and the others an extra dose of a placebo. Pill counts were conducted at each visit and new tablets were given out at each visit.

Outcomes

1. Miscarriage, defined as delivery before 28 weeks' gestation.

2. Stillbirth, defined as delivery of a dead baby at or after 28 weeks' gestation.

3. Fetal death, defined as either miscarriage or stillbirth.

4. Low birthweight, defined as birthweight less than 2500 g.

5. Very low birthweight, defined as birthweight less than 2000 g.

6. Preterm delivery, defined as delivery before 37 weeks.

7. Severe preterm birth, defined as delivery before 34 weeks.

8. Small‐for‐gestational age, defined as birthweight less than the 10th percentile for gestational age.

Notes

Women's risk of spontaneous and recurrent miscarriage was unclear, although may be increased due to their HIV‐1 positive status.
Women's nutritional status is also unclear.
Figures change with serial publications, particularly for secondary outcomes, and results are not reported separately for the individual 4 groups. Results are reported as: any multivitamins, multivitamin, any vitamin A or no vitamin A.
Sample‐size calculation performed allowing for 20% loss to follow‐up.
Intention‐to‐treat analyses performed.
Compliance: compliance assessed by the percentage of prescribed tablets absent from the returned bottles, and in plasma vitamin A concentrations in a subset of 100 women. Median compliance assessed using pill counts was 90% by the time of delivery.
Location: Tanzania.
Timeframe: April 1995 to July 1997.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Block randomisation using blocks of 20.

Allocation concealment (selection bias)

Unclear risk

Women assigned the 'next numbered bottle of regimen'.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Women and investigators were blinded.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Double‐blinded study, but unclear if ocutome assessors were blinded.

Incomplete outcome data (attrition bias)
All outcomes

High risk

64 women (6%) were lost to follow‐up and excluded, intention‐to‐treat analyses performed.

Selective reporting (reporting bias)

Unclear risk

Figures change with serial publications, particularly for secondary outcomes, and results are not reported separately for the individual 4 groups.

Other bias

Unclear risk

Limited methodological details provided.

Methods

Randomisation: unclear about sequence generation.

Allocation concealment: states a list was prepared according to the randomisation sequence in blocks of 20, tablets were bottled in identical coded bottles, eligible women were given the next numbered bottle.

Blinding of outcome assessment: women and research assistants who assessed the study outcomes were unaware of the intervention groups.

Documentation of exclusion: 49 women lost to follow‐up (multivitamin group: 23, placebo group: 26), no post‐randomisation exclusions.

Use of placebo control: placebo given.

Participants

8428 women were randomised in the study. Pregnant women between 12 and 27 weeks who had a negative test for HIV infection and planned to stay in the city until delivery and for 1 year thereafter recruited through antenatal clinics in Dar es Salaam. 8468 women were enrolled, however 40 women were then found to be ineligible. 8428 women were randomly assigned to receive either a multivitamin (n = 4214) or placebo (n = 4214) from the time of enrolment until 6 weeks after delivery. 6 women died before delivery and 43 were lost to follow‐up by the time of delivery.

Interventions

The supplements included 20 mg of vitamin B1, 20 mg of vitamin B2, 25 mg of vitamin B6, 100 mg of niacin, 50 mcg of vitamin B12, 500 mg of vitamin C, 30 mg of vitamin E, and 0.8 mg of folic acid.

The active tablets and placebo were similar in shape, size, and colour.

All women, irrespective of the assigned study regimen, were given daily doses of iron (60 mg of elemental iron) and folic acid (0.25 mg). They were also given malaria prophylaxis in the form of sulfadoxine‐pyrimethamine tablets at 20 weeks and 30 weeks of gestation.

Outcomes

1. Low birthweight (< 2500 g).

2. Preterm delivery (before 37 weeks' gestation).

3. Fetal death.

4. Birthweight below 2000 g.

5. Extremely preterm delivery (before 34 weeks).

6. Small‐for‐gestational age (birthweight below the 10th percentile for gestational age).

7. Fetal death and death in the first 6 weeks of life.

Notes

Women's risk of spontaneous and recurrent miscarriage was unclear.

Women's nutritional status is also unclear.

Intention‐to‐treat analyses performed.

Compliance: average compliance was 88%, no difference in compliances between the 2 groups.

Location: Tanzania.

Timeframe: August 2001 and July 2004.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Generation of sequence not reported, except that there were blocks of 20 in the sequence.

Allocation concealment (selection bias)

Low risk

Identical coded bottles prepared according to the randomisation list, eligible women were assigned the next numbered bottle.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Women and outcome assessors were blinded to allocation.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"Research assistants who assessed the study outcomes were unaware of the intervention groups." pg1424.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

49 (1%) women lost to follow‐up, balanced across groups, analyses by intention‐to‐treat.

Selective reporting (reporting bias)

Low risk

All pre‐specified outcomes appear to be reported.

Other bias

Low risk

The study appears to be free of other sources of bias.

Methods

Randomisation and allocation concealment: quasi‐randomised, alternate women were allocated to receive folic acid or placebo according to the order in which they attended antenatal clinic. No other methodological details were given.

Blinding of outcome assessment: women and investigators were blinded to the treatment allocation, until after the completion of the trial.

Documentation of exclusion: 21 women (28%) excluded from the analysis.

Use of placebo control: control tablet containing iron given.

Participants

75 women were recruited into the trial. Women were eligible if they were primigravida, less than 26 weeks' pregnant (range of gestation 10 to 26 weeks'), with haematocrit value (PCV) 27% or more, and who had not received treatment so far as was known. Women with Hb SC, Hb SS, Hb CC were excluded. Alternate patients were allocated to group A (placebo) or B (folic acid). 75 women were included (40 in group A and 35 in group B) initially; however, only 26 in group A and 28 in group B completed the trial. 16 women (10 in group A and 8 in group B) defaulted from the trial, 3 (2 in group A and 1 in group B) were anaemic on the second visit warranting folic acid treatment, 1 in group A self‐medicated with folic acid and 1 in group A 'aborted'.

Interventions

All women received antimalarials and iron supplements as per the standard antenatal care at the hospital.
Women in group B received 5 mg folic acid tablets on each attendance, which was fortnightly initially and weekly in the last trimester.
Group A received "one tablet of lactose base and colouring matter in the same manner".

Outcomes

1. PCV and reticulocyte index.

2. Serum folic acid concentration and 'megaloblastic score'.

3. Malarial infection.

4. Maternal morbidity (pyelonephritis, pre‐eclamptic toxaemia, septicaemia, puerperal psychosis).

5. Prematurity.

6. Birthweight (mean birthweight but no standard deviation).

7. Fetal mortality.

Notes

Results not reported as intention‐to‐treat; however, where possible, the review authors included data in the review as intention‐to‐treat.
Unclear of women's risk of spontaneous and recurrent miscarriage.
16 women in the trial showed evidence of folic acid deficiency at trial entry.
Sample‐size calculation: none reported.
No intention‐to‐treat analyses performed.
Compliance: no compliance information reported specifically; however, women were "seen to swallow" the tablets at their fortnightly and weekly visits.
Location: Nigeria.
Time frame: unclear.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Quasi‐randomised, alternate allocation.

Allocation concealment (selection bias)

High risk

Quasi‐randomised, alternate allocation.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Women and investigators blinded.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"The identity of the tablets was not known to investigators until after the completion of the trial." pg426.

Incomplete outcome data (attrition bias)
All outcomes

High risk

21 women (28%) excluded from the analysis.

Selective reporting (reporting bias)

Unclear risk

Results not reported as intention to treat; however, where possible, the review authors included data in the review as intention to treat.

Other bias

Unclear risk

Limited methodological details provided.

Methods

Randomisation and allocation concealment: women were "randomly allocated to one of five groups using a random number table", no other details given.

Blinding of outcome assessment: women and investigators were blinded to the treatment allocation, until after the completion of the trial.

Documentation of exclusion: 18 women (9%) were excluded due to anaemia at enrolment, 'defaulting', or being 'mentally subnormal', these women were replaced by other women chosen by an investigator. A further 42 women were excluded before delivery and another 30 failed to attend the postnatal clinic, birth outcomes were available for 160 women (80%).

Use of placebo control: no placebo control.

Participants

228 women met the eligibility criteria; however 200 pregnant women were recruited into the study. Women were allocated to 1 of 5 groups; 40 women were allocated to each group.

Eligible women included:

1. Hausa women living in Zaria and planning to deliver in Zaria;

2. pregnant for the first time;

3. at less than 24 weeks' gestation, as estimated by the height of the fundus uteri;

4. the wives of unskilled or semiskilled men.

Women were excluded if they had already taken any antimalarial treatment or haematinics during the pregnancy, or had the following complications: hydatiform mole, Hb SC disease, overt anaemia or proteinuria.

The mean gestational age of women at enrolment was 18.5 weeks.

Interventions

Women were allocated to 1 of 5 groups:

• group 1: no active treatment (control);

• group 2: antimalarials only (600 mg chloroquine/day + 100 mg proguanil/day);

• group 3: iron + antimalarials (60 mg iron/day + 600 mg chloroquine/day + 100 mg proguanil/day);

• group 4: folic acid + antimalarials (1 mg folic acid/day + 600 mg chloroquine/day + 100 mg proguanil/day);

• group 5: iron + folic acid + antimalarials (1 mg folic acid/day + 60 mg iron/day + 600 mg chloroquine/day + 100 mg proguanil/day).

Outcomes

Maternal outcomes

1. Anaemia (severe and mild/moderate) before 28 weeks', between 28‐36 weeks', and after 36 weeks' gestation.

2. Gestation age.

3. Mode of delivery.

4. Complications of pregnancy (abortion, hypertension, pre‐eclampsia or eclampsia, hydramnios, abdominal pain).

Infant outcomes

1. Fetal distress.

2. Birthweight.

3. Apgar score at 2 minutes.

4. Fetal complications.

Laboratory outcomes

1. Hb concentration, red cell indices and WBC at first attendance, 28 weeks, 36 weeks, at delivery (form mother and infant) and 6 weeks postpartum.

Not all outcomes were reported for each individual treatment group. Miscarriage was reported for the combined groups 4 and 5, therefore for the purpose of this review the groups 4 and 5 are combined (folic acid + iron) and compared with group 2 and group 3 (iron + antimalarials). The authors reported that 8 women had hypertension without other signs, 21 women had pre‐eclampsia and 6 developed eclampsia, with no association between these outcomes and treatment group. No other details were provided, including the breakdown of these outcomes by treatment group.

Notes

Women's risk of spontaneous and recurrent miscarriage was unclear.

Women were at high risk of anaemia. Information about other nutritional indices was not provided.

Intention‐to‐treat analyses not performed, however, where possible, the review authors included data in the review as intention‐to‐treat.

Compliance: 72 women (36%) were classed as defaulters.

Location: Nigeria.

Timeframe: unclear.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

A random number table was used but no details provided of how it was generated.

Allocation concealment (selection bias)

Unclear risk

No details provided about the allocation.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Neither the researchers nor the patients were aware of the treatment allocation until after the completion of the study.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"Neither the researchers nor the patients were aware of the treatment allocation until after the completion of the study." pg 214.

Incomplete outcome data (attrition bias)
All outcomes

High risk

228 women met the entry criteria, but only 200 were included in the trial. 18 women were excluded and replaced by other women.

Selective reporting (reporting bias)

High risk

Not all outcomes are reported by treatment group. In serial publications up to 70% of the data were excluded.

Other bias

Unclear risk

Limited methodological details provided.

Methods

Randomisation and allocation concealment: women were randomly assigned to receive either 400 mg of vitamin C daily or not in addition to their standard antenatal vitamin. Randomisation was obtained by a computer‐generated, block design sequence to receive vitamin C or not in a 1:1 ratio. No other methodological details given.

Blinding of outcome assessment: unclear, no details given.

Documentation of exclusion: 16 women (4%) did not complete the trial after randomisation.

Use of placebo control: no placebo control.

Participants

400 women 4 to 12 gestational weeks of pregnancy confirmed serologically by B‐HCG reagent test along with referred last menstrual period not exceeding the past 3 months, aged at least 18. Women with referred pregnancy of more than 3 months by last menstrual period, concomitant HIV infection status, active or recent (< 2 weeks) sexually transmitted disease infection, medical record of any severe organ disease such as heart, liver or renal failure at the time of assessment, diagnosis of pregnancy during inpatient admission for any other reason, recent history of multivitamin supplementation (< 12 weeks) for any reason, except for pregnancy, and patients incapable to read and write.

Interventions

Chewable tablet of synthetic form of L‐ascorbic acid or vitamin C 400 mg administered daily 2 tablet 2 times a day, from first trimester until delivery. Comparison received no vitamin C in addition to their standard antenatal vitamin.

All women received ferrous sulphate 200 mg, folic acid 5 mg and vitamin B‐complex 60 mg once daily tablets. Nutritional counselling was provided to all women.

Outcomes

1. Prevention of hospitalisations during pregnancy.

2. Overall hospitalisations rate.

3. Weight gain during pregnancy (normal < 16 kg).

4. Term pregnancy (≥ 37 gestational weeks).

5. Preterm delivery.

6. miscarriage (< 24 gestational weeks).

7. Low birthweight (< 2500 g).

8. Gestational systolic blood pressure.

Notes

Women's risk of spontaneous or recurrent miscarriage is unclear, as is their dietary intake.

Sample‐size calculation based on at least 30% of women not hospitalised during pregnancy in the control group and at least 50% of women not hospitalised in the intervention group.

Analyses were not based on intention‐to‐treat.

Compliance: no details of any compliance assessments were given.

Location: Kyeibuza, Uganda.

Timeframe: August 2007 and January 2009.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Patients presented to the health centre, those who met the inclusion criteria were randomly assigned...randomization was obtained by a computer‐generated, block design sequence to receive vitamin C or not in a 1:1 ratio." pg 3.

Allocation concealment (selection bias)

Unclear risk

No description for allocation concealment in the text. Probably not done.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No information on participant or personnel blinding provided.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No information on outcome assessor blinding provided.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Drop‐out rates for each group were not clearly described and no information was provided on the reason of exclusion and attrition.

Selective reporting (reporting bias)

Unclear risk

Although expected outcomes were reported, the study protocol was not available to see if all prespecified outcomes were reported as planned.

Other bias

Low risk

The study appears to be free of other sources of bias.

Methods

Randomisation and allocation concealment: unclear, "patients were randomly assigned to the control group or the study group". No other methodological details given.

Blinding of outcome assessment: unclear, no details given.

Documentation of exclusion: 28 women (19%) in the control group were excluded, no details given for the exclusion.

Use of placebo control: no placebo control.

Participants

150 women were recruited into the study. Women with a luteal phase defect, as described by a peak serum P level < 120 mg/mL in the mid‐luteal phase measured at 3 time points, were eligible and invited to participate. Luteal phase defects were ascertained in 2 consecutive menstrual cycles, and the third cycle was the intervention cycle. Women receiving IVF‐ET treatment were excluded. 313 women were considered for enrolment in the study, 150 (48%) were randomised. 28 women were withdrawn from the control group, leaving 122 women in the study, who were allocated to vitamin C (n = 76) or control (n = 46). 5 women in the control group and 19 women in the vitamin C group became pregnant during the study period.

Interventions

Women in the intervention group took 750 mg vitamin C per day from the first day of the third menstrual cycle until a urinary pregnancy test was positive. Pregnancy rate was checked up until 6 months after the study cycle was started. Women in the control group received no supplementation and no treatment was given in the third cycle.

Outcomes

1. Serum P concentrations.

2. Serum E2 (oestrogen) concentrations.

3. Pregnancy rate.

4. Miscarriage.

Notes

Women's risk of spontaneous or recurrent miscarriage was unclear according to criteria specified in the review.
Their dietary intake of vitamin C is unknown.
No sample‐size calculation was reported.
Analyses were not based on intention to treat.
Compliance: no details of any compliance assessments were given.
Country: Japan.
Time frame: January 1997 to December 2000.
The denominators used for this trials are the number of women randomised and with a confirmed pregnancy (i.e. 19 for the vitamin group and 5 for the control group).

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Methodological details unclear.

Allocation concealment (selection bias)

Unclear risk

Methodological details unclear.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Methodological details unclear.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No methodological details are given.

Incomplete outcome data (attrition bias)
All outcomes

High risk

28 women (19%) in the control group excluded.

Selective reporting (reporting bias)

Unclear risk

No details of exclusion of women in the control group given.

Other bias

High risk

No placebo control.

Methods

Randomisation and allocation concealment: unclear, "containers of vitamin or placebo capsules were given a random number" and "the key to random numbers was kept at the ICMR Headquarters". No other methodological details were given.

Blinding of outcome assessment: "double blind" mentioned in the text, but no details given.

Documentation of exclusion: 187 women (40%) were excluded from the analysis.

Use of placebo control: placebo control.

Participants

466 women were recruited into the study. Women who had previously given birth to a child with an open NTD, and planned to have another child were eligible and invited to participate. This was regardless of their parity, number of previous births with an NTD, age, consanguinity, and socioeconomic status. Women who had previously given birth to a child with closed spina bifida, or with a history of diabetes or abnormal fasting and post‐prandial blood sugar, history of epilepsy, congenital anomalies indicative of a genetic syndrome in the previous NTD, history of vitamin intake in the 3 months prior to enrolment, and pregnancy were excluded. 466 women were enrolled and randomised to either vitamin (n = 231) or placebo (n = 235), of these women, 90 were lost to follow‐up immediately and 71 did not conceive until the final follow‐up. Of the remaining 305 women who were known to become pregnant (vitamin n = 152, placebo n = 153), pregnancy outcomes were unknown for 26 women. In the paper, 279 of the initial 466 women were included in the analysis; however, in this review results are presented for main outcomes on an intention‐to‐treat basis (i.e. n = 466).

Interventions

The folic acid containing multivitamin included 120 mg ferrous sulphate, 240 mg calcium phosphate, 4000 IU vitamin A, 400 IU vitamin D, 2.5 mg vitamin B1, 2.5 mg vitamin B2, 2 mg vitamin B6, 15 mg nicotinamide, 40 mg vitamin C, 4 mg folic acid, 10 mg zinc.
The placebo tablets contained the following trace elements: 120 mg ferrous sulphate and 240 mg calcium phosphate. Both capsules were identical in appearance and women were provided with the tablets from at least 28 days before conception and continuing until at least the second missed menstrual period.

Outcomes

1. Recurrence of NTDs.

2. Live births.

3. Stillbirths.

4. Spontaneous and induced abortion.

5. Multiple birth.

Notes

The risk profile of women in the trial for spontaneous and recurrent miscarriage is unclear, as is the dietary intake of participants.
Sample‐size calculation performed, assuming a 20% drop out rate. The trial was terminated after publication of the MRC trial in 1991.
Compliance: compliance was assessed at 3‐monthly visits, by checking a diary card maintained by the woman and the number of capsules returned. If the total number of missed days in 3 months did not exceed 10 days, and the total number of missed days at a stretch did not exceed 3, compliance was taken as satisfactory. Women not meeting the above criteria were excluded if they became pregnant in that particular quarter. No compliance data are specifically reported.
Analyses not based on intention‐to‐treat.
Country: India.
Time frame: 1988 to 1991.
The denominators used for this trial are based on the number of women randomised (i.e. 231 for the vitamin group and 235 for the placebo group). There was not enough information to accurately confirm the number of women that did or did not become pregnant due to the large number of losses to follow‐up.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Containers 'given a random number'.

Allocation concealment (selection bias)

Unclear risk

'Key to random numbers were kept at the ICMR headquarters' but no other details given.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Double‐blind mentioned in the text but no details given.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Unclear of outcome assessors were unaware of treatment allocation.

Incomplete outcome data (attrition bias)
All outcomes

High risk

187 (40%) women excluded.

Selective reporting (reporting bias)

Unclear risk

Difficult to assess given the high losses to follow‐up.

Other bias

Unclear risk

Limited methodological details provided.

Methods

Randomisation and allocation concealment: randomised controlled trial, but no other information provided.

Blinding of outcome assessment: unclear.

Documentation of exclusions: unclear, no information provided.

Use of placebo: placebo control.

Participants

Women with a history of 2 or more early pregnancy losses, with no identifiable cause for the losses.

Interventions

Vitamin C 1000 mg and vitamin E 400 IU versus placebo.

Outcomes

Miscarriage.

Notes

Updated 27/11/2013: the trial was stopped in October 2009 due to poor recruitment and lack of funding.

Women's risk of spontaneous and recurrent miscarriage is unclear.
Sample‐size calculation: not done.
No intention‐to‐treat analyses: not done.
Compliance: unclear.
Location: UK.
Timeframe: recruitment planned from 2000 to 2001, but trial stopped in 2009.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Could not be assessed because the trial was stopped.

Allocation concealment (selection bias)

Unclear risk

Could not be assessed because the trial was stopped.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Could not be assessed because the trial was stopped.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Could not be assessed because the trial was stopped.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

Could not be assessed because the trial was stopped.

Selective reporting (reporting bias)

Unclear risk

Could not be assessed because the trial was stopped.

Other bias

Unclear risk

Could not be assessed because the trial was stopped.

Methods

Randomisation and allocation concealment: cluster‐randomised. 270 centres in the Salarhi district, Nepal, were involved which included 30 subdistricts each with 9 wards. Each ward was assigned to 1 of 3 treatment groups. "Wards were assigned by a random draw of numbered chits, blocked on subdistrict."

Blinding of outcome assessment: women and study investigators were not aware of the treatment codes. Maternal mortality was assessed by study investigators blinded to treatment allocation, no details were given for other outcomes.

Documentation of exclusions: 157 (1%) women were lost to follow‐up and excluded.

Use of placebo: placebo control.

Participants

15,832 women were recruited into the study. All married women of child bearing age in the Salarhi district, Nepal, were eligible and invited to participate in the study. Women migrating into the study area, or women that were never pregnant or refused participation, or women who migrated before being pregnant, were excluded from the analysis. Eligible women were identified from census data and marriage registers. 44,646 women were recruited, of which 1136 (2.5%) were excluded as they either emigrated before becoming pregnant, died or refused consent. During the study period 15,832 women identified themselves as being pregnant, and 157 women were lost to follow‐up in the postpartum period. Results are reported for 17,373 pregnancies, allocated to the following groups: vitamin A (n = 6070), beta‐carotene (n = 5650) or placebo (n = 5653). Denominators for the treatment groups vary for the measures of early infant mortality, due to losses to follow‐up after birth.

Interventions

The 3 treatment groups consisted of a weekly single oral supplement of either:

1. 23,300 IU preformed vitamin A as retinyl palmitate;

2. 42 mg of all trans beta‐carotene;

3. placebo.

All capsules contained mg dl‐alpha‐tocopherol as an antioxidant. Women took the tablets prior to conception, during pregnancy and postpartum, for a total of 3.5 years.

Outcomes

1. Fetal loss, defined as any reported miscarriage, stillbirth or maternal death during pregnancy. The outcomes were based on self‐reports, and women who reported to be pregnant for >= 6 weeks but then no longer reported being pregnant were considered to have had a miscarriage.
Serial publications also reported neonatal death.

Notes

Women's risk profile for spontaneous or recurrent miscarriage was unclear, as was their dietary intake of vitamin A.
Compliance: women were distributed the capsules in their home on a weekly basis, receipt of capsules was noted only if the distributor observed the woman swallowing the capsule. Over half of the women who became pregnant during the study received over 80% of their intended supplements, and 75% of pregnant women received at least half of their eligible doses.
There were serial publications of this study causing the study numerators and denominators to vary between published versions, and multiple pregnancy figures reported did not include higher order pregnancies.
Sample‐size calculation performed.
Partial intention‐to‐treat analyses, and the risk ratios and confidence intervals were adjusted to account for any cluster‐design effect.
Country: Nepal.
Timeframe: April 1994 to September 1997.
The denominators used for this trial are the number of women randomised who identified themselves as pregnant (i.e. 6070 for the vitamin A group, 5650 for the beta‐carotene group and 5653 for the placebo group).

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Cluster‐randomised, unclear how sequence was generated.

Allocation concealment (selection bias)

Unclear risk

Each ward was assigned to the treatment groups based on 'a random draw of numbered chits, blocked on subdistrict'.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Women and investigators blinded to treatment allocation.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

"This committee and the data analysts were unmasked to the treatment codes, but the codes were made available to study investigators only at the end of the trial."

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

157 women (1%) were lost to follow‐up and excluded, partial intention‐to‐treat analysis performed.

Selective reporting (reporting bias)

Unclear risk

Denominators vary in several publications of this trial.

Other bias

High risk

Some women were pregnant more than once during the study period, however the denominators reported are the total number of pregnancies during the study period, not the total number of women randomised, which incorrectly assumes that each data point included is independent from the next.

Methods

Randomisation and allocation concealment: block randomisation, stratified by hospital, using "consecutively numbered, opaque, sealed envelopes".

Blinding of outcome assessment: women and study investigators were initially blinded to the treatment allocation, however the tablet preparations were changed after 55 women were randomised and after this only participants were blinded.

Documentation of exclusion: 3 women (1%) were lost to follow‐up and excluded.

Use of placebo control: 3 treatment regimens were assessed, no placebo control.

Participants

354 women were recruited into the study. Women with a previous NTD defined as anencephalus, iniencephalus, encephalocoele, and spina bifida aperta, who were not pregnant when contacted but were planning a future pregnancy, were eligible and invited to participate. Women were identified from case registers at the participating hospitals. Women with conditions likely to result in impaired absorption from the gastrointestinal tract were excluded.
435 women were approached, of which 354 (84%) consented and were randomised to either F (n = 115 ), MV (n = 119) or MF (n = 120). 16 women did not become pregnant, and 75 women withdrew; however, their pregnancy outcome status was known, and 18 of these women subsequently became pregnant after withdrawing. 3 women were lost to follow‐up. 281 women (93 in the F group, 93 in the MF group and 95 in the MV group) became pregnant in the study period and their pregnancy outcome was known.

Interventions

Indistinguishable trial tablets were initially made by Beecham and Glaxo, however Beecham withdrew their support after 55 women had been randomised. After this time a commercially available pregnavite Forte F was used (MF tablet) and Antigen Pharmaceuticals produced a white multivitamin tablet without folic acid. This was associated with a loss of blinding. Women were randomised to 1 of 3 treatments:

1. folic acid alone (F);

2. multivitamin with folic acid (MF);

3. multivitamin with no folic acid (MV).

The F and MF resulted in a daily dose of 0.3 mg folic acid. The MF and MV resulted in a daily dose of 4000 IU vitamin A, 400 IU calciferol, 1.5 mg thiamine hydrochloride, 1.5 mg riboflavine, 1 mg pyridoxine hydrochloride, 15 mg nicotinamide, 40 mg ascorbic acid, 480 mg calcium phosphate, and 252 mg ferrous sulphate. Women took the tablets for at least 2 months prior to conception and until the date of the 3rd missed period.

Outcomes

1. Recurrence risk of NTDs.

2. Spontaneous abortion.

3. Ectopic pregnancy.

4. Livebirth.

5. Stillbirth.

6. Congenital malformations excluding NTDs.

Notes

The trial was stopped after there were poor recruitment rates and birth rates. A sample‐size calculation required 462 women to show a reduction in NTDs from 5% to 1%. Data from 106 women who were already pregnant at time of recruitment are also included.
The risk profile of women in the trial for spontaneous and recurrent miscarriage is unclear, as is their dietary intake.
Compliance: compliance was assessed on tablet counts and blood tests; however, the results are not presented.
Intention‐to‐treat analyses were performed.
Location: Republic of Ireland.
Timeframe: December 1981 to January 1988.
The denominators used for this trial are the number of women randomised who became pregnant in the study period and their pregnancy outcome was known (i.e. 93 in the F group, 93 in the MF group and 95 in the MV group).

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Block randomisation stratified by hospital site.

Allocation concealment (selection bias)

Low risk

Consequtively numbered, opaque sealed envelopes used.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Only participants were blinded.

Blinding of outcome assessment (detection bias)
All outcomes

High risk

Only participants were blinded.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

3 women (1%) lost to follow‐up and excluded. Intention‐to‐treat analyses performed.

Selective reporting (reporting bias)

Unclear risk

Compliance data not reported.

Other bias

High risk

The trial was stopped after there were poor recruitment rates and birth rates.

Methods

Randomised controlled trial of vitamin A, iron and folic acid supplementation versus iron and folic acid only, during pregnancy, to improve infant outcomes born to women infected with HIV in Malawi.

Randomisation and allocation concealment: "treatment assignment was determined by use of a computer's random‐number generator" and "mothers were assigned an original study identification number at enrolment and were given the next sequentially numbered opaque bottle with supplements". "Treatment assignment was concealed by pre packing study supplements in sequentially numbered series assigned to study identification numbers."

Blinding of outcome assessment: unclear, not specifically stated, but participants were blind to their treatment allocation.

Documentation of exclusion: 63 (9%) women were lost to follow‐up and 14 (2%) pairs of twins were excluded.

Use of placebo control: control tablets containing iron and folic acid were given.

Participants

Pregnant women between 18 and 29 weeks' gestation and infected with HIV. The average gestation of participants was 23 weeks. 693 women were enrolled and allocated to either vitamin A (n = 340) or control (n = 357), of which pregnancy outcomes were known for 623 women. 63 women were lost to follow‐up and 14 sets of twins were excluded due to their higher risk of low birthweight and infant mortality.

Interventions

All women received orally administered daily doses of 30 mg iron and 400 mcg folic acid during the study. Women in the intervention group received 10,000 IU vitamin A (3 mg retinol equivalent) orally, in addition to the iron and folic acid supplements. Women were asked to take the tablets from enrolments until delivery. Tablet counts were conducted every 4 weeks. All women received 30 mg retinol equivalents at 6 weeks postpartum, according to standard postpartum care in Malawi.

Outcomes

1. Infant Hb level at 6 weeks and 12 months of age.

2. Percentage of infants with anaemia at 6 weeks of age and at 12 months, defined as a Hb level of < 110 g/L.

3. Birthweight.

4. Percentage of infants < 2500 g at birth.

5. Weight and length at 6 weeks, 14 weeks and 6 months of age.

6. Transmission of HIV to the infant, infant mortality at < 6 weeks of age, at 12 months and at 24 months.

7. Stillbirth and spontaneous abortion (undefined).

Notes

Women's risk of spontaneous and recurrent miscarriage is unclear, although may be increased due to their HIV status.
50% of women in the vitamin A group and 51% of women in the control group had deficient levels of vitamin A (defined as plasma vitamin A < 0.70 umol/L) at trial entry.
Sample‐size calculation performed.
No intention‐to‐treat analyses were performed.
Compliance: more than 95% of women in both groups took > 90% of study supplements, as ascertained by tablet counts.
Location: Malawi.
Timeframe: November 1995 to December 1996.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated random number list.

Allocation concealment (selection bias)

Low risk

Sequentially number opaque bottles used.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Not specifically stated but women were blinded.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Unclear of outcome assessors were unaware of treatment allocation.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

63 women (9%) lost to follow‐up and 14 pairs of twins (2%) excluded. No intention‐to‐treat analyses performed.

Selective reporting (reporting bias)

Low risk

All pre‐specified outcomes appear to be reported.

Other bias

Unclear risk

Insufficient information to assess whether an important risk of other bias exists.

Methods

Randomisation and allocation concealment: participants were randomly allocated in a 1:1 ratio to receive 1000 mg vitamin C and 400 IU vitamin E. A randomisation sequence generated in advance by Victoria Pharmaceuticals using PRISYM ID software (version1.0009) was used. The randomisation sequence was stratified by centre with balanced blocks of 8 patients and was held by Victoria Pharmaceuticals. Individual sealed envelopes containing treatment allocations were given to trial pharmacists in every centre allowing treatment groups to be revealed in a clinical emergency.

Blinding of outcome assessment: diagnosis was independently confirmed by 3 senior clinicians, who were unaware of treatment allocation.

Documentation of exclusion: only 1 loss to follow‐up was reported.

Use of placebo control: matched placebo control.

Participants

762 pregnant women between 8 and 22 weeks' gestation with type‐1 diabetes attending 25 antenatal metabolic clinics across Northern Ireland, Scotland, and northwest England. Participants were women with type 1 diabetes preceding pregnancy, presentation between 8 weeks' and 22 weeks' gestation, singleton pregnancy, and age 16 years or older. Women with chronic hypertension were included in the trial.

Women were excluded if they did not give consent, were enrolled in another research study, were being treated with warfarin, or were known to misuse drugs Women taking vitamin supplements were excluded only if these contained 500 mg or more vitamin C or 200 IU or more vitamin E daily.

Interventions

1000 mg vitamin C and 400 IU vitamin E versus matched placebo started between 8 and 22 weeks' gestation and taken until delivery.

Outcomes

1. Pre‐eclampsia.

2. Placental and endothelial function (established by PAI‐1 to PAI‐2 ratio).

3. Gestational hypertension.

4. Birthweight (centile as calculated from customised birthweight charts).

5. Miscarriage.

6. Maternal death.

7. Obstetric complications and other adverse outcomes.

8. Fetal malformation.

9. Gestational age at delivery.

10. Admission to a neonatal care unit.

Notes

Women's risk profile for spontaneous and recurrent miscarriage: women with chronic hypertension were included.

Multivitamin supplementation at randomisation was reported at trial entry. Other information about nutrition status are not provided.

Sample‐size calculation: based on 40% reduction in pre‐eclampsia.

Modified intention to treat was used for analysis of the primary endpoint.

Compliance: unused tablets and capsules were collected during delivery admission or at the 6‐week postnatal trial visit, or were returned in postage prepaid envelopes.

Location: Northern Ireland, Scotland, northwest England.

Tiimeframe: April 2003 to June 2008.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated randomisations by Victoria Pharmaceuticals using PRISYM ID software (version1.0009).

Allocation concealment (selection bias)

Low risk

Supplements were identical in appearance. The randomisation sequence was stratified by centre with balanced blocks of 8 patients, and was held by Victoria Pharmaceuticals.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Treatment allocation was masked from all trial personnel and participants until trial completion.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

Diagnosis were independently confirmed by 3 senior clinicians, who were unaware of treatment allocation.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Only 1 loss to follow‐up in placebo group, but the reason is unclear.

Selective reporting (reporting bias)

High risk

Fewer outcomes were stated in the trial registration.

Other bias

Low risk

The study appears to be free of other sources of bias.

Methods

Randomisation and allocation concealment: third party randomisation, "randomisation was carried out through the Clinical Trials Service Unit in Oxford". Randomisation was stratified by centre.

Blinding of outcome assessment: women, caregivers and study investigators were blinded to the treatment allocation.

Documentation of exclusion: 164 women (9%) excluded.

Use of placebo control: placebo control.

Participants

1817 women were recruited into the study. Women who had a previous pregnancy affected by a NTD, and were planning another pregnancy and not already taking supplements were eligible for the study. Women whose affected child had Meckel's syndrome and those women with epilepsy were excluded. 1817 women were randomised to either F (n = 449), MV (n = 453), MF (n = 461) or P (n = 454), of which, 1195 were informative pregnancies that is, where the outcome of NTD or not was definitely known (F n = 298, MV n = 302, MF n = 295, P n = 300). Results for pregnancy loss are reported for both informative and not informative pregnancies. 164 women were excluded as they may have been pregnant at the time of randomisation.

Interventions

Women were randomised into 1 of 4 groups:

1. 4 mg, 240 mg di‐calcium phosphate and 120 mg ferrous sulphate (F);

2. 4000 IU vitamin A, 400 IU calciferol, 1.5 mg thiamine hydrochloride, 1.5 mg riboflavine, 1 mg pyridoxine hydrochloride, 15 mg nicotinamide, 40 mg ascorbic acid, 240 mg di‐calcium phosphate and 120 mg ferrous sulphate (MV);

3. folic acid combined with the multivitamins specified above (MF);

4. placebo containing 240 mg di‐calcium phosphate and 120 mg ferrous sulphate only (P).

Women took the tablets prior to conception and attended the site every 3 months to collect additional supplies and again during the 12th week of pregnancy. No special dietary advice was given to women.

Outcomes

1. NTD and other birth defects.

2. Spontaneous abortions.

3. Ectopic pregnancy.

4. Termination or pregnancy.

5. Livebirth.

6. Stillbirth.

7. Multiple pregnancy.

8. Subsequent publications report on blood folic acid and zinc concentrations.

Notes

The trial was stopped early after there were 1195 informative pregnancies, according to prespecified stopping rules. The aim of the study was to obtain information on at least 2000 informative pregnancies unless a sufficiently clear result emerged sooner.
Women's risk profile for spontaneous and recurrent miscarriage was unclear, as was their nutritional status.
Compliance: compliance based on self‐reports, and data were available for women with an informative pregnancy only, where 79 (6%) women reported they stopped taking their capsules before their last scheduled visit.
Intention‐to‐treat analyses are reported in this review including not informative pregnancies (i.e. n = 1817).
Location: multi‐national study co‐ordinated from the UK.
Timeframe: July 1983 to April 1991.
The denominators used for this trial are the number of women randomised, i.e. (449 for the F group, 453 for the MV group, 461 for the MF and 454 for the P group). There was no information provided about any women randomised that did not become pregnant in the study period.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Third party randomisation, "randomisation was carried out through the Clinical Trials Service Unit in Oxford".

Allocation concealment (selection bias)

Low risk

Third party randomisation, "randomisation was carried out through the Clinical Trials Service Unit in Oxford".

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Women, caregivers and investigators blinded to treatment allocation.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No details are given if outcome assessment was blinded.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

164 women (9%) excluded, intention‐to‐treat analyses performed.

Selective reporting (reporting bias)

Unclear risk

No information provided about any women randomised that did not become pregnant in the study period.

Other bias

High risk

The trial was stopped early after there were 1195 informative pregnancies, according to prespecified stopping rules.

Methods

Randomisation and allocation concealment: 1 of the authors 'randomly allocated 1200 participant numbers by computer into 2 groups in permuted blocks of 50'. Every identification number was allocated a supplement container, which was then packed by a team member not otherwise involved in the trial. After enrolment, another author allocated participants sequential identification numbers with the corresponding supplement containers.

Blinding of outcome assessment: double‐blind stated but no other details given.

Documentation of exclusion: 61 women (5%) withdrew or were lost to follow‐up, however data on miscarriage were reported for those who withdrew due to miscarriage.

Use of placebo control: control of iron and folic acid supplements given which looked identical to the intervention supplements.

Participants

1200 women were recruited into the study. Women were eligible if they were: less than 20 completed weeks, had a singleton pregnancy, no notable fetal abnormality, no existing maternal illness of a severity that could compromise the outcome of pregnancy, and lived in an area of Dhanusha or the adjoining district of Mahottari accessible for home visits.

Maternal illnesses that led to exclusion were: recently treated recurrent cysticercosis, need for chlorpromazine or anticoagulant drugs with changing doses, and symptomatic mitral stenosis or multivalvular heart disease. Fetal exclusions were: twin pregnancies, anencephaly, occipital meningocele, encephalocele, duodenal atresia and a grossly dilated pelvicalyceal system.

Interventions

Intervention group: vitamin A 800 mcg, vitamin E 10 mg, vitamin D 5 mcg, vitamin B1 1.4 mg, vitamin B2 1.4 mg, niacin 18 mg, vitamin B6 1.9 mg, vitamin B12 2.6 mcg, folic acid 400 mcg, vitamin C 70 mg, iron 30 mg, zinc 15 mg, copper 2 mg, selenium 65 mcg, and iodine 150 mcg.

Control group: iron 60 mg and folic acid 400 mcg.

Supplementation began at a minimum of 12 weeks’ gestation and continued until delivery.

Outcomes

1. Birthweight.

2. Gestational duration.

3. Infant length and head circumference.

4. Miscarriage defined as cessation of confirmed pregnancy before 23 weeks’ gestation.

5. Stillbirth defined as delivery of an infant showing no signs of life (movement, breathing, or heartbeat) after 23 weeks’ gestation.

6. Early neonatal death defined as death of a live born infant in the first 7 days after birth.

7. Late neonatal death as death of a live born infant after 7 but within 28 days.

Notes

Women's risk of spontaneous and recurrent miscarriage was unclear.

Women's nutritional status is also unclear, however, women are presumable at high risk of under‐nutrition as the paper states that in Nepal 'deficiencies of several micronutrients have been well described in individual studies and in a national sample'.

Intention‐to‐treat analyses performed.

Compliance: median 'adherence' was 98% in the control group and 97% in the intervention group.

Location: Nepal.

Timeframe: August 2002 to October 2003.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated in permuted blocks of 50.

Allocation concealment (selection bias)

Unclear risk

1 of the authors allocated participants with sequential identification numbers, but unclear if this person was involved in the recruitment of participants.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Double‐blind stated in the text but no other details given.

Blinding of outcome assessment (detection bias)
All outcomes

High risk

The allocation code was broken for the analysis. Pg 956.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

61 women (5%) withdrew or were lost to follow‐up, however data on miscarriage were reported for those who withdrew due to miscarriage. Intention‐to‐treat analyses performed.

Selective reporting (reporting bias)

Low risk

All pre‐specified outcomes appear to be reported.

Other bias

Low risk

The study appears to be free of other sources of bias.

Methods

Randomisation and allocation concealment: "women enrolled at the antenatal clinic were divided into two main groups by placing them alternatively on separate lists".

Blinding of outcome assessment: unclear, no information given on blinding of participants, carers or outcome assessors.

Documentation of exclusion: 622 women (11%) were excluded.

Use of placebo control: no placebo given.

Participants

5644 women were recruited into the study. All women attending the antenatal clinics and who were less than or equal to 24 weeks' gestation and who were in 'good health' were eligible for the study. Women who were more than 24 weeks' gestation and women who suffered from any disease or physical abnormality were excluded from the study. After enrolment, women who had twin births and who miscarried at an early stage were also excluded.
5644 women were initially enrolled in the study of which 5022 (89%) remained in the study. Of the 622 (11%) women withdrawn from the trial, 494 were evacuated from the London area (due to World War 2), 39 women had twin births and 89 women miscarried at an early stage. 5022 women remained in the study and were allocated to either multivitamins (n = 2510) or control (n = 2512). Women were further divided into primiparae and multiparae, and various age groups.

Interventions

Women allocated to the treatment group were given daily vitamin C 100 mg, ferrous iron 0.26 g, calcium 0.26 g, minute quantities of iodine, manganese and copper, adsorbate of vitamin B1 containing all factors of the B complex and halibut liver oil 0.36 g containing vitamin A (52,000 IU per g) and vitamin D (2500 IU per g).
Women allocated to the control group received no placebo.

Outcomes

1. Toxaemia classified into subgroups based on: hypertension only, albuminuria with or without hypertension, or hypertension with albuminuria (pre‐eclampsia).

2. Maternal sepsis.

3. Length of gestation (categorised as less than 40 weeks, 40 weeks, and greater than 40 weeks).

4. Percentage of women breastfeeding.

5. Stillbirth.

6. Neonatal mortality (defined as death before 8 days).

7. Birthweight (pounds) (only reported for primiparae and multiparae separately).

Notes

Women risk status for spontaneous and recurrent miscarriage is unclear.
Dietary intake at trial entry: "vitamin C shortage affected about half the women".
Intention‐to‐treat analyses: not performed.
Compliance: unclear, no information provided.
Sample‐size calculation: unclear. "It was decided that the investigation should include a minimum of 5000 pregnant women". No other details given.
Location: England.
Timeframe: 1938 to 1939.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

High risk

Quasi‐randomistion using alternate separate lists.

Allocation concealment (selection bias)

High risk

No allocation concealment.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No information about blinding provided.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No information about blinding provided.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

622 women (11%) excluded, intention‐to‐treat analyses not performed.

Selective reporting (reporting bias)

Unclear risk

Limited methodological details provided.

Other bias

Unclear risk

Limited methodological details provided.

Methods

Randomisation and allocation concealment: the randomisation (computer‐generated sequence) was blocked—i.e., balanced—by centre in groups of 2 to 10 individuals.

Blinding of outcome assessment: none of the trial staff or any other person involved in the trial knew the allocated treatment of any woman until after completion of the study.

Documentation of exclusion: 9 (0.4%) women were excluded.

Use of placebo control: placebo control.

Participants

2404 women with clinical risk factors for pre‐eclampsia

Inclusion criteria:

gestational age 14+⁰–21+⁶ weeks; one or more of the following risk factors: pre‐eclampsia in the pregnancy preceding the index pregnancy, requiring delivery before 37 completed weeks’ gestation, diagnosis of HELLP syndrome in any previous pregnancy, eclampsia in any previous pregnancy; essential hypertension requiring medication, type 1 or type 2 diabetes, multiple pregnancy; abnormal uterine artery doppler waveform primiparity with BMI at first antenatal appointment of 30 kg/m² or more.

Exclusion criteria:

women unable or unwilling to give written informed consent or women who were being treated with warfarin. Women taking vitamin supplements that contained doses of vitamin C of 200 mg or more or of vitamin E of 40 IU or more daily were excluded.

Interventions

Women were assigned to 1000 mg vitamin C and 400 IU vitamin E (RRR α tocopherol; n = 1199) or matched placebo (n = 1205) daily from the second trimester of pregnancy until delivery.

Outcomes

Primary outcomes

1. Pre‐eclampsia,

Secondary outcomes:

1. Low birthweight (<2·5 kg).

2. Small size for gestational age.

3. Preterm birth (≤37+⁰ weeks’ gestation).

4. Gestational age at delivery.

5. Smaller than 10^th centile for gestation.

6. Use of health‐care resources.

Notes

Women risk status for spontaneous and recurrent miscarriage: history of chronic hypertension, BMI, pre‐eclampsia, multiple pregnancy, diabetes, and other risk factors reported.
Dietary intake at trial entry: use of supplements reported.
Intention‐to‐treat analyses: not performed.
Compliance: 80% (n = 1653) of women took at least 50% of their tablets, 65% (n = 1345) took 80% or more, and 32% (n = 661) took all of their tablets; 6% (n = 125) did not take any tablets.
Sample‐size calculation: expected incidence of pre‐eclampsia in the placebo group of at least 15% and in the treatment group of at least 30%

Location: 25 hospitals, UK.
Timeframe: August 2003 to June 2005.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated random sequence Pg 1146

Allocation concealment (selection bias)

Unclear risk

Although paper states that supplementation and placebo looked and tasted the same, (Pg 1146) there is no clear description of how women were allocated to treatment group

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

“none of the trial staff or any other person involved in the trial knew the allocated treatment of any woman until after completion of the study” Pg 1146

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Unclear from text if outcome assessors were blinded

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Very low loss to follow‐up rates. In the supplementation group 3 (0.25%) losses to follow‐up and in the placebo group 6 (0.5%).

Selective reporting (reporting bias)

Unclear risk

A large number of outcomes reported in the publication, but not pre‐specified in the registered trial.

Other bias

Low risk

The study appears to be free of other sources of bias.

Methods

Randomisation and allocation concealment: community‐based, individually‐randomised, placebo‐controlled and double‐blinded study. Pregnat women were randomly allocated in a 1:1:1:1 ratio in blocks of 12 based on a list of treatment numbers derived from a pseudo‐random number generated with SAS software.

Blinding of outcome assessment: all investigators, field and laboratory staff and participants were blinded to the treatment code until all field data had been collected and preliminary data analysis by coded groups had been completed.

Documentation of exclusions: 75 women (3.5%) were excluded.

Use of placebo control: placebo control.

Participants

2173 women at a gestational age of ,17 weeks were included in the study. Women at a gestational age of >=17 weeks were not eligible.

Interventions

Women were allocated to one of the three intervention groups:

1. 2400 retinol equivalents of vitamin A as retinyl palmitate,

2. 20 mg of zinc sulfate, or

3. the same dose of vitamin A and zinc sulfate.

Comparison group: placebo.

All capsules also contained 2mg dl‐alpha‐tocopherol as antioxidant and 350 mg of soyabean oil, 20 mg of beeswax and 8 mg of lecithin as capsule filler.

Outcomes

1. Birthweigh.

2. Birth length.

3. Neonatal morbidity.

4. Infant mortality.

Notes

Women's risk of spontaneous and recurrent miscarriage was unclear.

Women's nutritional status is unclear

Intention‐to‐treat analyses not performed.

Sample‐size calculation not performed

Compliance: consumption of 70% of supplements.

Location: Indonesia.

Timeframe: September 1995 to December 1999.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Pregnant women were randomly allocated in a 1:1:1:1 ratio in blocks of 12 based on a list of treatment numbers derived from a computer‐generated pseudo‐random number

Allocation concealment (selection bias)

Unclear risk

Treatment allocations was prepared and held at the University of Newcastle ....Supplements were coded with treatment numbers and women were assigned a treatment number in sequence based on date they consented to participate in the study. However, supplements were packed in plastic strips in identical opaque capsules..page 16 ‐ 17.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

All investigators, field and laboratory staff and participants were blinded to the treatment code until all field data had been collected and preliminary data analysis by coded groups had been completed page 17

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

All investigators, field and laboratory staff and participants were blinded to the treatment code until all field data had been collected and preliminary data analysis by coded groups had been completed page 17

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Drop‐out rate appears balanced between groups and reasons for loss to follow‐up were provided.

Selective reporting (reporting bias)

Low risk

Study protocol unavailable but outcomes predefined outcomes were reported

Other bias

Unclear risk

Overall, 70% of supplements were consumed, but it is unclear in text where there was more or less compliance.

Methods

Randomisation and allocation concealment: the randomisation scheme was generated by a computer program in permuted blocks of 4. Randomisation numbers were sealed in opaque envelopes. At each inclusion, the consulting physician opened the next sealed envelope and transmitted the randomisation number to a pharmacist managing the allocation sequence and the packaging of drugs at a central location.

Blinding of outcome assessment: the consulting physicians, pharmacist and women were blinded to allocation.

Documentation of exclusions: 107 women were lost to follow‐up (however their pregnancy outcome was reported). Post randomisation 26 twins were excluded (multivitamin group: 15; iron/folic acid group: 11 twins (including 1 set of triplets). Only singleton pregnancies were included in the analysis because fetal loss and anthropometric measures at birth in multiple pregnancies are not primarily nutrition‐related. 3 women died before delivery and 1 woman underwent a therapeutic abortion.

Use of placebo control: no placebo.

Participants

1374 women were recruited to participate, however 52 women were randomly assigned twice for consecutive pregnancies, resulting in data for 1426 pregnancies. Women had a pregnancy confirmed by urine testing and were randomly assigned to receive either IFA (n = 712) or UNIMMAP (n = 714) daily until 3 months after delivery. Women were recruited between 5 to 36 weeks’ gestation; 34.6% (n = 493) of the participants were recruited in the first trimester of pregnancy, mean gestational age at enrolment was 17.3 weeks (SD 7.8 weeks).

Interventions

UNIMMAP: vitamin A 800 mcg, vitamin D 200 IU, vitamin E 10 mg, vitamin B‐1 1.4 mg, vitamin B‐2 1.4 mg, niacin 18 mg, folic acid 400 mcg, vitamin B‐6 1.9 mg, vitamin B‐12 2.6 mcg, vitamin C 70 mg, zinc 15 mg, iron 30 mg, copper 2 mg, selenium 65 mcg, iodine 150 mcg.

IFA (control): folic acid 400 mcg, Iron 60 mg.

In a case of maternal illness, appropriate treatments were provided according to national guidelines. Severely anaemic women (Hb < 70 g/L, without dyspnoea) received ferrous sulphate (200 mg) + folic acid (0.25 mg) twice daily, for 3 months, regardless of their allocation group. All participants also received 400 mg albendazole in the second and third trimesters. If malaria occurred despite chemoprophylaxis, quinine (300 mg, 3 times/day) was given for 5 days. Vitamin A (200,000 IU) was given to all women after delivery, in accordance with national recommendations.

Outcomes

1. Gestational duration.

2. Birthweight, birth length, and Rohrer ponderal index at birth (weight(g)X100/length3(cm)).

3. Low birthweight (< 2500 g).

4. Small‐for‐gestational age (birthweight below the 10th percentile).

5. Large‐for‐gestational age (birthweight above the 90th percentile of the study population).

6. Thoracic circumference, head circumference, mid upper arm circumference.

7. Hb concentration in mothers during the third trimester, Hb and sTfR concentrations in cord blood.

8. Preterm birth (< 37 weeks’ gestation).

9. Stillbirth (delivery of an infant showing no sign of life after a gestational age of 28 weeks).

10. Perinatal death.

Notes

Women's risk of spontaneous and recurrent miscarriage was unclear. 18% of women in each group had experienced a previous fetal loss.

Women's nutritional status is unclear, although women are presumable at risk as the purpose of the trial is to correct MMN deficiencies.

Intention‐to‐treat analyses not performed, however the review included details of losses to follow‐up where the outcome was known.

Compliance: unclear, states that there was no difference in compliance between the 2 groups.

Location: Burkino Faso.

Timeframe: March 2004 to October 2006.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated with permuted blocks of 4.

Allocation concealment (selection bias)

Low risk

Randomisation numbers were kept in sealed opaque envelopes.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Consulting physicians, pharmacist and women were blinded to the intervention.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Authors claim the study had double‐blind design, but it is unclear if the assessors were blinded.

Incomplete outcome data (attrition bias)
All outcomes

High risk

Data were reported for singletons only.

Selective reporting (reporting bias)

Unclear risk

As above ‐ data only reported for singletons.

Other bias

High risk

Some women were pregnant more than once during the study period, however the denominators reported are the total number of pregnancies during the study period, not the total number of women randomised, which incorrectly assumes that each data point included is independent from the next.

Methods

Randomisation and allocation concealment: women were randomly assigned to receive capsules containing a combination of 1000 mg of vitamin C (ascorbic acid) and 400 IU of vitamin E (RRR‐alpha‐tocopherol acetate) or matching placebo (mineral oil). The simple urn method, with stratification according to clinical centre, was used by the data co‐ordinating centre to create a randomisation sequence. No further methodological details are provided.

Blinding of outcome assessment: medical charts were reviewed by at least 3 reviewers who were unaware of the treatment assignments.

Documentation of exclusions: 183 women (1.8%) were lost to follow‐up and for 2 women had been removed after randomisation.

Use of placebo control: placebo given.

Participants

10,154 pregnant women who had a singleton fetus with a gestational age of less than 16 weeks 0 days at the time of screening attending 16 clinical centres and the independent data coordinating centre of the MFMU Network. Women were eligible for inclusion if they had not had a previous pregnancy that lasted beyond 19 weeks 6 days.

Women were not eligible if they had elevated systolic or diastolic blood pressure, proteinuria, were taking or had taken antihypertensive medication, or were taking more than 150 mg of vitamin C or more than 75 IU of vitamin E daily. Other exclusion criteria were diabetes that was present before the pregnancy, treatment with antiplatelet drugs or non‐steroidal anti‐inflammatory agents, uterine bleeding within the week before recruitment, uterine malformation, serious medical condition, known fetal anomaly or aneuploidy, in vitro fertilisation resulting in the current pregnancy, or abuse of illicit drugs or alcohol.

Interventions

A combination of 1000 mg of vitamin C (ascorbic acid) and 400 IU of vitamin E daily administered from enrolment until delivery. The control group received placebo.

Outcomes

1. Pregnancy‐associated hypertension.

2. Serious adverse outcomes in the mother or her fetus or neonate. Pre‐eclampsia.

3. Other maternal and neonatal outcomes.

Notes

Women's risk of spontaneous and recurrent miscarriage was unclear.

Use of prenatal vitamins or multivitamins, daily dose of vitamin C and E were reported at trial entry.

Sample size calculation was based on a 30% reduction in the rate of the primary outcome.

Intention‐to‐treat analysis was performed.

Compliance: monthly, participants returned unused study drugs from the previous month.

Location: UK.

Timeframe: July 2003 to February 2008.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"The simple urn method, with stratification according to clinical center, was used by the data coordinating center to create a randomization sequence." pg 1283, last pgh.

Allocation concealment (selection bias)

Unclear risk

Text says participants "were randomly assigned to receive capsules containing...". No details on how participants were allocated to groups. pg 1283 last pgh.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

"Neither the participants nor the investigators were aware of the treatment assignments." pg 1283, last pgh.

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"Deidentified medical charts of all women with pregnancy‐associated hypertension were reviewed centrally by at least three reviewers who were unaware of the treatment assignments." pg 1284.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Vitamin C and E = 95/5088 missing and in placebo = 90/5066 missing. Reasons for missing similar between groups.

Selective reporting (reporting bias)

Low risk

Relevant outcomes reported as pre‐specified in the protocol.

Other bias

Low risk

The study appears to be free of other sources of bias.

Methods

Randomisation and allocation concealment: computer‐generated random number list with balanced variable blocks and stratification for collaborating centre and gestational age (< 18 weeks versus 18 weeks or more), allocation occurred via a central telephone randomisation service. The treatment packs contained 4 sealed, opaque, white plastic bottles of either the antioxidants vitamin C and vitamin E or the placebo and were prepared by a researcher not involved in recruitment or clinical care.

Blinding of outcome assessment: women, caregivers and investigators were blinded to allocation.

Documentation of exclusion: no losses to follow‐up.

Use of placebo control: placebo given.

Participants

1877 women were recruited into the study. Eligible women included those: with a nulliparous singleton pregnancy, between 14 and 22 weeks of gestation and with normal blood pressure at the first measurement in pregnancy and again at trial entry.

Women who had any of the following were excluded: known multiple pregnancy, known potentially lethal fetal anomaly, known thrombophilia, chronic renal failure, antihypertensive therapy, or specific contraindications to vitamin C or E therapy such as haemochromatosis or anticoagulant therapy.

Women were allocated to the vitamin C and E group (n = 935) or placebo (n = 935).

Interventions

Women allocated to the vitamin C and E group took 4 coated tablets of a combination of 250 mg of vitamin C (as ascorbic acid) and 100 IU of vitamin E (as d‐alpha‐tocopherol succinate) each day from trial entry until delivery (total daily dose of vitamin C: 1000 mg; vitamin E: 400 IU).

Women were advised not to take any other antioxidant supplements, although a multivitamin preparation that provided a daily intake of no more than 200 mg of vitamin C or 50 IU of vitamin E was permitted.

Outcomes

1. Pre‐eclampsia.

2. A composite measure of death or serious outcomes in the infant.

3. Small‐for‐gestational age.

4. Serious infant complications occurring before hospital discharge.

5. For women included a composite of any of the following until 6 weeks postpartum: death, pulmonary edema, eclampsia, stroke, thrombocytopenia, renal insufficiency, respiratory distress syndrome, cardiac arrest, respiratory arrest, placental abruption, abnormal liver function, preterm prelabour rupture of membranes, major postpartum haemorrhage, postpartum pyrexia, pneumonia, deep‐vein thrombosis, or pulmonary embolus requiring anticoagulant therapy.

Notes

Women were at low risk of spontaneous and recurrent miscarriage based on the review criteria.

The majority of women participating had a baseline dietary intake of vitamin C and E above the Australian recommended daily amount.

Intention‐to‐treat analyses performed.

Compliance: there was no difference in compliance between the vitamin group (67%) and the placebo group (70%).

Location: Australia.

Timeframe: December 2001 and January 2005.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated random number list.

Allocation concealment (selection bias)

Low risk

Allocation occurred via a central telephone randomisation service. Tablets were provided in sealed opaque bottles.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Women, caregivers and investigators were blinded.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No information provided about blinding of outcome assessment.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No losses to follow‐up.

Selective reporting (reporting bias)

Low risk

All pre‐specified outcomes reported.

Other bias

Low risk

The study appears to be free of other sources of bias.

Methods

Generation of random number sequence: a computer‐generated random number sequence.

Randomisation and allocation concealment: central allocation (randomisation by an independent third party who had no conflict of interest in the study).

Blinding of outcome assessment: treatment allocations were blinded to both the investigator and the patient until the study was finished.

Documentation of exclusion: none reported.

Use of placebo control: no, comparisons were between antioxidants versus iron and folic acid.

Participants

60 women between 8 and 12 weeks' gestation were eligible for randomisation (supplementation group: n = 29; folic acid group: n = 31).

Setting: at the antenatal clinic of the Department of Obstetrics and Gynecology, University of Indonesia between March 2003 and June 2004.

Eligibility criteria: pregnant women with low antioxidant status.

Exclusion criteria:

1. history or current use of anti‐hypertensive medication or diuretics;

2. use of vitamins C > 150 mg and/or E > 75 IU per day;

3. known placental abnormalities;

4. current pregnancy as a result of in vitro fertilisation;

5. regular use of platelet active drugs or non‐steroidal anti‐inflammatory drugs;

6. known fetal abnormalities;

7. documented uterine bleeding within a week of screening;

8. uterine malformations;

9. history of medical complications.

Interventions

Supplementation group: received antioxidant supplements daily ‐ vitamins A (1000 IU), B6 (2.2 mg), B12 (2.2 mcg), C (200 mg), E (400 IU), folic acid (400 mcg), N‐acetylcysteine (200 mg), Cu (2 mg), Zn (15 mg), Mn (0.5 mg), Fe (30 mg), calcium (800 mg), and selenium (100 mcg).

Folic acid group: received Fe 30 mg and folic acid 400 mcg daily.

Timing of the intervention: early pregnancy (8 to 12 weeks).

Outcomes

1. Pre‐eclampsia.

2. Abortion.

3. Hypertension.

4. Intrauterine growth restriction.

5. Intrauterine fetal death.

Notes

Women's risk of spontaneous and recurrent miscarriage was unclear.

Participating women had low antioxidant status at enrolment, as defined as superoxide dismutase level below 164U/mL. No nutritional information provided.

Intention‐to‐treat analyses performed.

Compliance: unclear, no information reported.

Location: Indonesia.

Timeframe: March 2003 and June 2004.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated random number sequence.

Allocation concealment (selection bias)

Low risk

Central allocation (randomisation by an independent third party who had no conflict of interest in the study).

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

Treatment allocations were blinded to both the investigator and the patient until the study was finished.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Authors claim the study had a double‐blind design, but it is unclear if the assessors were blinded. Treatment allocations were blinded to both the investigator and the patient until the study was finished.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No missing data.

Selective reporting (reporting bias)

Low risk

All pre‐specified outcomes were reported, no apparent evidence of selective reporting.

Other bias

Unclear risk

At baseline, the control group appears to have a 2 mmHg higher systolic blood pressure than the intervention group, this figure was of borderline statistical significance, P = 0.059.

Methods

Randomisation and allocation concealment: unclear, women were allocated to groups based on "random assignment". Randomisation was stratified on pre‐pregnancy weight, weight gain during pregnancy, previous low birthweight infant and protein intake. No other methodological details given.

Blinding of outcome assessment: unclear, women were allocated to 2 forms of treatment or control, where both treatments were given as a canned beverage and the control group were given standard oral multivitamins. No information is given on blinding of outcome assessors.

Documentation of exclusion: 237 women (22%) were excluded.

Use of placebo control: no placebo, the control group received standard prenatal multivitamin supplements.

Participants

1051 women were recruited into the study. Women eligible were black, English speaking, and not greater than 30 weeks' gestation. They also had 1 of the following criteria: low pre‐pregnant weight (under 110 pounds at conception); low weight gain at the time of recruitment; at least 1 previous low birthweight infant; a history of protein intake of less than 50 g in the 24 hours preceding recruitment. Women were not eligible if they were known to be seeking a termination, had specific chronic health disorders, if they admitted to recent use of narcotics or heavy use of alcohol, or weighed >= 140 pounds at conception.
The mean gestation at enrolment ranged from 16‐18 weeks for the treatment groups.
1225 women were invited to join the study, of which 1051 (84%) consented. Of these, 237 (22%) were excluded and 814 women (77%) remained active in the study until delivery and were allocated to 1 of 3 groups: supplement (n = 263), complement (n = 272) or control (n = 279).

Interventions

Women were randomised to 1 of 3 groups:

1. high protein supplement (daily 40 g animal protein, 470 calories, 1000 mg calcium, 100 mg magnesium, 60 mg iron, 4 mg zinc, 2 mg copper, 150 mcg iodine, 6000 IU vitamin A, 400 IU vitamin D, 30 USPU vitamin E, 60 mg vitamin C, 3 mg vitamin B1, 15 mg vitamin B2, 15 mg niacin, 2.5 mg vitamin B6, 1 mg pantothenic acid, 200 mcg biotin, 350 mcg folic acid, 8 mcg vitamin B12);

2. balanced protein‐energy complement (6 g animal protein, 250 mg calcium, 12 mg magnesium, 40 mg iron, 0.084 mg zinc, 0.15 mg copper, 100 mcg iodine, 4000 IU vitamin A, 400 IU vitamin D, 60 mg vitamin C, 3 mg vitamin B1, 15 mg vitamin B2, 10 mg niacin, 3 mg vitamin B6, 1 mg pantothenic acid, 350 mcg folic acid, 3 mcg vitamin B12);

3. control (250 mg calcium, 0.15 mg magnesium, 117 mg iron, 0.85 mg zinc, 0.15 mg copper, 100 mcg iodine, 4000 IU vitamin A, 400 IU vitamin D, 60 mg vitamin C, 3 mg vitamin B1, 2 mg vitamin B2, 10 mg niacin, 3 mg vitamin B6, 1 mg pantothenic acid, 350 mcg folic acid, 3 mcg vitamin B12).

Women received the high protein or balanced protein‐energy supplements in the format of a drink. Women in the control group received a standard oral prenatal multivitamin supplement.

Outcomes

1. Total weight gain, average weight gain and early weight gain during pregnancy.

2. Duration of gestation (presented as cumulative rates of delivery from life tables for each treatment group).

3. Preterm birth < 37 weeks.

4. Fetal death (before < 20 weeks' gestation and >= 20 weeks' gestation).

5. Neonatal death (according to gestation at delivery).

6. Birthweight (mean).

7. Somatic measures of infant growth at 1 year of age.

8. Psychological measures at 1 year of age.

Notes

Women's risk of spontaneous and recurrent miscarriage is unclear, as there is no information about concurrent medical conditions or other risk factors for miscarriage. Women in the trial had a low caloric intake at trial entry, and unexpectedly, an adequate protein intake. No other specific nutritional information is reported.
Sample‐size calculation reported: 250 women were required in each treatment group to show a 125 g difference in birthweight. A 25% loss to follow‐up was incorporated into the sample size.
Intention‐to‐treat analyses not performed.
There were 9 sets of twins amongst the 3 treatment groups.
Compliance: "on average, about three quarters of the prescribed amount of beverage was probably ingested".
Location: New York City, USA.
Timeframe: 1969 to 1976.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No methodological details given beyond reporting of 'random assignment'.

Allocation concealment (selection bias)

Unclear risk

No methodological details given beyond reporting of 'random assignment'.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

No information provided about blinding of participants and personnel. Unlikely as participants were given canned beverages or multivitamins.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No information provided about blinding of outcome assessment.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

237 women (22%) excluded, no intention‐to‐treat analysis.

Selective reporting (reporting bias)

Unclear risk

Unclear if all pre‐specified outcomes reported.

Other bias

Unclear risk

Limited methodological details provided.

Methods

Randomisation and allocation concealment: unclear, women were "randomly assigned on an individual basis, to double‐blind, weekly supplementation until delivery".

Blinding of outcome assessment: unclear, double‐blind stated in text but no details given.

Documentation of exclusion: 42 women (17%) were lost to follow‐up and excluded.

Use of placebo control: control tablets containing iron and folic acid were given.

Participants

243 women were recruited into this study. Pregnant women between 16 and 20 weeks' gestation, aged between 17 and 35 years old, with a parity < 6 and Hb level between 80‐140 g/L, were eligible for this study. Women were randomised to receive either vitamin A plus iron and folic acid (n = 122) or iron and folic acid only (n = 121). Of these 22 (18%) and 20 (17%) women in vitamin A plus iron and folic acid and the iron and folic acid groups respectively, dropped out between enrolment and the follow‐up at 4 months.

Interventions

Women were randomised to a weekly supplementation with 120 mg ferrous sulfate and 500 mcg folic acid, with or without vitamin A (2400 retinol equivalents). Women were asked to take the trial tablets from between 16 and 20 weeks' gestation until birth.

Outcomes

1. Stillbirth.
2. Concentrations of Hb, serum ferritin and serum transferrin receptors, at or near term.
3. Concentrations of iron and vitamin A in breast milk.
4. Hb and serum vitamin A concentrations in the mother and infant at 4 months postpartum.
5. General health, growth and development measures in the first year of life.

Notes

Women risk status for spontaneous and recurrent miscarriage is unclear.
At baseline, between 13% and 17% of women had marginal vitamin A deficiency 44% to 50% of women were anaemic.
Sample‐size calculation performed allowing for a 50% drop‐out during the study period.
Intention‐to‐treat analyses were not performed.
Compliance: adherence to the tablet intake was assessed through interview during a postnatal home visit, which revealed that the median tablet intake was 50 tablets (i.e. 25 weeks), while only 17% of the subjects took more than 90 tablets.
Location: Indonesia.
Serial publications of this data report different denominators.
Time frame: November 1997 to May 1998.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

No information provided about sequence generation.

Allocation concealment (selection bias)

Unclear risk

Women were 'randomly assigned on an individual basis' but no other details given.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Double‐blind used in the text but no details provided.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Authors claim the study had double‐blind design, but it is unclear who were blinded. No further information was available.

Incomplete outcome data (attrition bias)
All outcomes

Unclear risk

42 women (17%) were lost to follow‐up and excluded, no intention‐to‐treat analyses performed.

Selective reporting (reporting bias)

Unclear risk

Serial publications of this study report different denominators.

Other bias

Unclear risk

Limited methodological details provided.

Methods

Generation of random number sequence: the randomisation sequence was constructed by the data co‐ordinating centre (DCC) as permuted blocks of random size, stratified by clinical centre, and implemented via a program residing on the clinical centres study computer.

Randomisation and allocation concealment: central allocation.

Blinding of outcome assessment: all clinicians and clinical investigators were blinded to group assignment.

Documentation of exclusion: none reported.

Use of placebo control: placebo control.

Participants

739 eligible women between 12^0/7 and 19^6/7 weeks of gestation were enrolled in the study (treatment: 371; placebo: 368).

Setting: 4 Brazilian clinical centres: 1 primary clinical centre (Recife) and 3 additional clinical sites (Campinas, Botucatu, and Porto Alegre); each site’s major teaching hospital serves a primarily urban low‐income population.

Eligibility criteria: women between 12^0/7 and 19^6/7 weeks of gestation and diagnosed with nonproteinuric chronic hypertension or a prior history of pre‐eclampsia in their most recent pregnancy that progressed beyond 20 weeks' gestation.

Exclusion criteria:multifetal gestation, allergy to vitamin C or vitamin E, requirement for aspirin or anticoagulant medication, 24‐hour urinary protein ≥ 300 mg, pre‐pregnancy diabetes mellitus, known fetal anomaly incompatible with life.

Loss to follow‐up: 32 women (treatment 16; placebo 16).

Interventions

Intervention group: daily treatment with both vitamin C (1000 mg) and E (400 IU) until delivery or until the diagnosis of pre‐eclampsia.

Control group: daily placebo until delivery or until the diagnosis of pre‐eclampsia.

Timing of the intervention: between 12^0/7 and 19^6/7 weeks of gestation.

Outcomes

1. Pre‐eclampsia (women were followed through the 14th day postpartum for the occurrence of pre‐eclampsia).

2. Severity of pre‐eclampsia.

3. Gestational hypertension.

4. Abruptio placentae.

5. Premature rupture of membranes.

6. Preterm birth.

7. Small‐for‐gestational age.

8. Low birthweight infant.

Notes

25 inclusion/exclusion criteria violations (23 enrolled outside 12‐19 weeks’ gestation; 2 twin gestations ‐ 1 lost to spontaneous abortions, 1 delivered liveborn in treatment group); all 25 women remained in their assigned study groups.

26 women had early treatment terminations (treatment 19; placebo 7), but remained in follow‐up.

Women's risk of spontaneous and recurrent miscarriage was unclear.

Women's nutritional status is also unclear.

Intention‐to‐treat analyses performed.

Compliance: average compliance was 85%, and similar between treatment groups.

Location: Brazil.

Timeframe: July 2, 2003 and November 23, 2006.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated sequence number.

Allocation concealment (selection bias)

Low risk

Central allocation.

Blinding of participants and personnel (performance bias)
All outcomes

Low risk

All clinicians and clinical investigators were blinded to group assignment.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Authors claim the study had double‐blind design, but it is unclear who was blinded. No further information was available.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Small numbers of missing data, balanced across groups (32 women; treatment 16; placebo 16).

Selective reporting (reporting bias)

Low risk

All pre‐specified outcomes were reported, no apparent evidence of selective reporting.

Other bias

Low risk

The study appears to be free of other sources of bias.

Methods

Randomisation and allocation concealment: "randomisation was undertaken by computer‐generated numbers". Roche Pharmaceutical supplied numbered containers with either vitamin C or matching placebo, and they retained the study code until completion of the study. No other methodological details given.

Blinding of outcome assessment: "double blind" stated, Roche Pharmaceuticals retained the code until completion of the study.

Documentation of exclusion: none reported.

Use of placebo control: placebo control.

Participants

200 women were recruited into the study. Women with a history of a previous mid‐trimester abortion (defined as spontaneous expulsion of the uterine contents between 13 and 26 weeks' gestational age), or previous preterm labour, and less than 26 weeks' gestation were eligible and invited to participate. Women with iatrogenic causes of their previous preterm labour such as previous induction of labour before term for severe pre‐eclampsia, were excluded. 203 consecutive women were approached, of which 200 (98.5%) consented and were randomised to either vitamin C (n = 100) or placebo (n = 100). No losses to follow‐up were reported.

Interventions

Twice daily tablet of either 250 mg vitamin C or placebo, from trial entry until 34 weeks' gestation. All women were tested for bacterial vaginosis and all women with positive cultures for Mycoplasma hominis (and between 22 and 32 weeks' gestation) were treated with erythromycin for 7 days.

Outcomes

1. Preterm labour, defined as spontaneous onset of labour and delivery before 37 completed weeks.

2. The secondary outcome was perinatal outcome, a composite endpoint including birthweight, gestational age at delivery, perinatal mortality, duration of admission in the neonatal intensive care unit and neonatal complications.

The age of fetal viability was considered to be 28 weeks' gestation.

Notes

Results are from an interim analysis performed when 100 participants were recruited into each arm. Recruitment was stopped after the interim analysis revealed few differences between the 2 groups. Unclear if there was a sample‐size calculation performed. Women's risk profile spontaneous and recurrent miscarriage is unclear, although they are clearly at high risk of preterm birth. It is also unclear if multiple births were included.
6% of women had an inadequate dietary intake of vitamin C, defined as an intake < 67% of the recommended dietary allowance (70 mg per day).
Compliance: women were requested to bring the containers to each visit and the remaining tablets were counted to improve and control compliance; however, no compliance data were reported.
Country: South Africa.
Timeframe: unclear.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Computer‐generated sequence number.

Allocation concealment (selection bias)

Low risk

Roche pharmaceuticals supplied numbered study containers and kept the study code until completion of the study.

Blinding of participants and personnel (performance bias)
All outcomes

Unclear risk

Authors claim the study had double‐blind design, but it is unclear who was blinded. Allocation was double‐blind and Roche Pharmaceuticals retained the code until completion of the study.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Authors claim the study had double‐blind design, but it is unclear who was blinded. allocation was double‐blind and Roche Pharmaceuticals retained the code until completion of the study.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

No losses to follow‐up reported.

Selective reporting (reporting bias)

Unclear risk

Recruitment stopped after an interim analysis.

Other bias

High risk

Results are from an interim analysis performed when 100 participants were recruited into each arm.

Methods

Generation of random number sequence: computer‐generated number; 262 clustered unit of randomisation (all pregnant women served by the same midwife received supplements with the same midwife identification number).

Randomisation and allocation concealment: central allocation.

Blinding of outcome assessment: all study scientists and personnel, government staff, and enrollees were unaware of the allocation.

Documentation of exclusion: 1748 loss to follow‐up before delivery (IFA: 853; MMN: 895); 1128 loss to follow‐up after delivery (IFA: 553; MMN: 575). 10,549 pregnant women excluded post‐randomisation because of trial termination (IFA group: 5057; MMN group: 5492).

Use of placebo control: no placebo, comparisons were between multiple micronutrients and iron and folic acid.

Participants

41,839 pregnant women of any gestational age living on Lombok, Nusa Tenggara Barat Province, Indonesia. Women were allocated to IFA (n = 20,543) or MMN (n = 21,296).

Interventions

MMN group: the MMN was the UNIMMAP formulation containing 30 mg iron (ferrous fumarate) and 400 mcg folic acid along with 800 mcg retinol (retinyl acetate), 200 IU vitamin D (ergocalciferol), 10 mg vitamin E (alpha tocopherol acetate), 70 mg ascorbic acid, 1.4 mg vitamin B1 (thiamine mononitrate), 18 mg niacin (niacinanide), 1.9 mg vitamin B6 (pyridoxine), 2.6 mcg vitamin B12 (cyanocobalamin), 15 mg zinc (zinc gluconate), 2 mg copper, 65 mcg selenium, and 150 mcg iodine ‐ 1 capsule daily up to 3 months after birth.

IFA group: the IFA contained 30 mg iron (ferrous fumarate) and 400 mcg folic acid ‐ 1 capsule daily up to 3 months after birth.

Timing of the intervention: any time during pregnancy.

Outcomes