FNU Nutrition Intervention Program for Preeclampsia Capstone

*PRESENT AS ONE COHESIVE FINAL CAPSTONE PAPER. USE THE CONTENT FROMCAPSTONE I,II,III COMBINED. YOUR TITLE PAGE SHOULD YOUR REFLECT THE HEALTH
PROBLEM. DO NOT WRITE I, II, OR III.
NOTE: DO NOT PROPOSE A CHANGE THAT REQUIRES IRB APPROVAL OR DIRECT HUMAN
SUBJECT INVOLVEMENT.
CAPSTONE: PART III
1. Implementation/Conclusion
– Implement the change you are proposing- This should be a continuation of Part I and Part II
2. Describe the practice change; is it in the community, organizational, clinic setting and so forth
3. Discuss how you would implement and assess the change; this should include time frame,
setting, participants, barriers, external and internal factors.
4. How would you evaluate the change process?
-The change must be measurable
-How would you measure or evaluate? Is there a tool to measure?
5. The literature review must support your change and implementation. Use leadership
qualities and skills that will be utilized for successful completion of the project.
6. Discuss who will be invited to the proposal: who are the stakeholders?
-How will you present the information to your stakeholders?
OVERALL: The conclusion should have your Part I, II, II all put together in a thorough APA format.
-Use appropriate APA 7th Ed. format along with Syllabus outline
-Scholarly, peer-reviewed, and research articles cited should be within the last five years.
-This section should be 3-4 pages long (not including the title and reference page).
-The final Capstone project should be a minimum of 8 pages and maximum of 12 pages.
-Use proper in-text citations with a properly formatted reference list.
-All papers must be written in the 3rd person.
Capstone Poster Presentation
Preeclampsia: Nutrition Intervention Program
Yanay Lara
Florida National University
Capstone Project
Carmen Lazo
March 8th, 2023
Preeclampsia: Nutrition Intervention Program
Introduction
Preeclampsia is a severe pregnancy complication that affects approximately 5 to 8% of
pregnancies, resulting in fetal and maternal mortality and morbidity. It is a top cause of preterm
birth and low birth weight, and its high incidence and severity pose a significant public health
problem. This paper proposes an evidence-based nutrition intervention program for expecting
mothers in outpatient settings to decrease the possibilities of preeclampsia or eclampsia during
pregnancy.
Problem Significance
The impact of preeclampsia on the patient, community, and cost of care is significant.
According to the World Health Organization, preeclampsia is a leading cause of maternal and
fetal mortality and morbidity worldwide, resulting in approximately 76,000 maternal deaths and
500,000 infant deaths yearly. The cost of caring for patients with preeclampsia is also high, with
hospitalization, medication, and laboratory testing contributing to the cost burden. Additionally,
the long-term effects on the quality of life for both mother and child can be substantial.
Problem Description
Preeclampsia is characterized by proteinuria and high blood pressure in urine after the
twentieth pregnancy week. Eclampsia is a severe form of preeclampsia that can cause seizures,
coma, and even death.
PICOT Statement
In pregnant women (P) attending outpatient clinics, will a nutrition intervention program
(I) compared to standard care (C) decrease the incidence and severity of preeclampsia and
eclampsia (O) during pregnancy (T)?
Data and Statistics
Preeclampsia is a significant cause of fetal and maternal mortality and morbidity
worldwide. According to the World Health Organization, approximately 76,000 maternal deaths
and 500,000 infant deaths are attributable to preeclampsia and other hypertensive disorders of
pregnancy every year.
Purpose Statement and Proposed Program
This project aims to develop an evidence-based nutrition intervention program for
expecting mothers attending outpatient clinics to decrease the incidence and severity of
preeclampsia and eclampsia during pregnancy. The proposed program will focus on improving
maternal nutrition through dietary and lifestyle modifications, education, and support.
Proposed Outcome
The proposed outcome is to reduce the severity and incidence of eclampsia and
preeclampsia during pregnancy in the targeted population. This outcome will be measured by
comparing the severity and incidence of eclampsia and preeclampsia in the intervention group
with the standard care group using objective clinical criteria.
PICOT
This study investigates whether a nutrition intervention program can decrease the
incidence and severity of preeclampsia and eclampsia during pregnancy. The following elements
will be discussed in detail:
P – Population: The population for this study will consist of pregnant women attending
outpatient clinics. Pregnant women diagnosed with preeclampsia or eclampsia will be excluded
from the study.
I – Intervention: The intervention for this study will be a nutrition intervention program.
This program will include individualized nutrition counseling and education sessions with a
registered dietitian. The sessions will cover healthy eating habits, meal planning, and appropriate
weight gain during pregnancy.
C – Comparison intervention: The comparison group for this study will receive standard
care, which may include routine prenatal care, such as regular check-ups with a healthcare
provider and standard dietary advice.
O – Outcome: The primary outcome of this study will be a decrease in the incidence and
severity of preeclampsia and eclampsia during pregnancy. This will be measured by assessing
the incidence and severity of preeclampsia and eclampsia in both the intervention and
comparison groups.
T – Timing: The timing of this study will be during pregnancy. The nutrition intervention
program will begin as early as possible during pregnancy and will continue until delivery.
The study aims to determine if a nutrition intervention program can reduce the incidence
and severity of preeclampsia and eclampsia during pregnancy. The study will include pregnant
women attending outpatient clinics as the population, a nutrition intervention program as the
intervention, standard care as the comparison, and a decrease in the incidence and severity of
preeclampsia and eclampsia during pregnancy as the outcome. The study will be conducted
during pregnancy, starting as early as possible until delivery.
The Vulnerable Population:
Pregnant women attending outpatient clinics are a vulnerable population at risk for
preeclampsia. Preeclampsia is a pregnancy-specific condition characterized by hypertension and
proteinuria after 20 weeks of gestation, which can result in severe maternal and fetal morbidity
and mortality. This population may face social determinants of health that could impact their
nutritional status and increase their risk for preeclampsia. These determinants could include
socioeconomic status, access to healthy food options, and cultural beliefs and practices around
pregnancy and nutrition.
Socioeconomic status (SES) is a significant determinant of health for pregnant women
attending outpatient clinics. Women with low SES have a higher risk of developing preeclampsia
due to suboptimal prenatal care, lack of social support, and inadequate access to resources and
education on healthy pregnancy behaviors (Hernandez-Diaz et al., 2019). Limited access to
healthy food options, including fresh fruits and vegetables, can also impact maternal and fetal
outcomes (Wojcicki et al., 2019).
Pregnancy’s physiological changes and stressors make pregnant women a vulnerable
population. However, those attending outpatient clinics may face additional risk factors,
including suboptimal prenatal care, lack of social support, and inadequate access to resources
and education on healthy pregnancy behaviors. The risk factors that make pregnant women
attending outpatient clinics vulnerable to developing preeclampsia or eclampsia include
preexisting hypertension, chronic kidney disease, multiple gestation, maternal age above 40, and
obesity. According to a study by Ananth et al. (2019), women with preexisting hypertension
have a significantly higher risk of developing preeclampsia than those without hypertension.
Additionally, the risk of preeclampsia increases with maternal age and obesity (Salihu et al.,
2020). Women with chronic kidney disease also have a rising preeclampsia development risk,
with a prevalence of 22.8% (Wu et al., 2021). Finally, multiple gestations are also a risk factor
for preeclampsia, with the risk increasing with the number of fetuses (Ananth et al., 2019).
Finally, pregnant women attending outpatient clinics are vulnerable to preeclampsia due
to various social determinants of health and risk factors, including SES, limited access to healthy
food options, and preexisting conditions. Interventions addressing these determinants and risk
factors through comprehensive prenatal care and education programs may help reduce the
incidence and severity of preeclampsia among this population.
Proposal
Preeclampsia is a severe pregnancy complication that affects many women worldwide
and is associated with adverse maternal and fetal outcomes. This proposal addresses this problem
by implementing an evidence-based nutrition intervention program for expecting mothers
attending outpatient clinics.
Research has shown that diet and lifestyle modifications can reduce the risk of
preeclampsia and improve maternal and fetal outcomes. Therefore, our proposed intervention
program will include education on healthy eating habits and physical activity during pregnancy
(American College of Obstetricians and Gynecologists, 2019). We will encourage women to
consume a diet rich in lean protein, whole grains, vegetables, and fruits and engage in regular
physical activity.
In addition, we will provide education and support on the signs and symptoms of
preeclampsia and eclampsia, the importance of regular prenatal care, and the benefits of
breastfeeding (Mendoza et al., 2020). Emotional support will be provided through group sessions
and individual counseling.
To ensure that women can access the necessary resources to follow the intervention, we
will provide them with healthy recipes, exercise guides, and educational materials on
preeclampsia and eclampsia. A nurse will lead the program in an advanced role, such as a nurse
practitioner, who will work closely with the women attending the outpatient clinics (Haider &
Bhutta, 2017). The nurse will provide individual counseling sessions and group sessions to
educate women on healthy eating habits, physical activity, and other topics related to
preeclampsia and eclampsia.
The nurse will work with the women to create individualized nutrition plans based on
their needs and preferences. The feasibility of this program for a nurse in an advanced role will
be ensured by providing adequate training, resources, and support.
The proposed timeline for the intervention is six months. The first month will be
dedicated to program development, including creating educational materials and recruiting
participants. The remaining five months will focus on implementing the program, including
group sessions, individual counseling, and follow-up assessments.
Finally, an evidence-based nutrition intervention program can be an effective strategy for
addressing the problem of preeclampsia in expecting mothers attending outpatient clinics. The
program will provide education and support on healthy eating habits, physical activity, and other
related topics, as well as access to resources and individualized nutrition plans. The program’s
feasibility for a nurse in an advanced role will be ensured by providing adequate training,
resources, and support.
Theoretical Framework/Nursing Theory
The Health Belief Model (HBM) is the theoretical framework that serves as the
foundation for this project. The HBM suggests that an individual’s beliefs about their
susceptibility to a health problem, the severity of the problem, and the effectiveness of a
proposed solution are all factors that influence their willingness to take action to prevent or
manage the problem. In the case of preeclampsia, pregnant women with risk factors can be
empowered to take action to reduce their risk by receiving education and counseling on the
benefits of a healthy diet and supplementation, along with regular monitoring.
References
American College of Obstetricians and Gynecologists. (2019). Hypertension in pregnancy.
Obstetrics & Gynecology, 133(1), e1-e25.
https://doi.org/10.1097/AOG.0000000000003012
Ananth, C. V., Keyes, K. M., & Wapner, R. J. (2019). Pre-eclampsia rates in the United States,
2010-2016: national hospital discharge survey evidence. American Journal of Obstetrics
and Gynecology, 221(2), 138-e1.
Haider, B. A., Bhutta, Z. A. (2017). Multiple-micronutrient supplementation for women during
pregnancy. Cochrane Database of Systematic Reviews, (4), CD004905.
https://doi.org/10.1002/14651858.CD004905.pub5
Mendoza, M., Figueroa-Vega, N., Sánchez-Moreno, C., Reynoso-Noverón, N., Villalobos-Pérez,
D. H., & González-Block, M. A. (2020). Development and evaluation of an educational
intervention to prevent preeclampsia in Mexico: A randomized controlled trial. BMC
Pregnancy and Childbirth, 20(1), 1-11. https://doi.org/10.1186/s12884-020-02952-5
Salihu, H. M., Imade, G. E., & Albert, A. (2020). Maternal obesity and risk of preeclampsia in
the United States: a meta-analysis. Journal of Pregnancy, 2020.
Wu, P., Yang, X., & Chen, Y. (2021). The prevalence and risk factors of preeclampsia among
Chinese women with chronic kidney disease: a systematic review and meta-analysis.
BMC Pregnancy and Childbirth, 21(1), 1-13.
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Capstone: Part 2
Yanay Lara
Florida National University
Capstone Project
Dr, Carmen Lazo
March 25th, 2023
2
Capstone: Part 2
Introduction
Preeclampsia and eclampsia are serious complications that can arise during pregnancy,
often characterized by high blood pressure, proteinuria, and other symptoms. These conditions
can result in adverse maternal and fetal outcomes, including maternal organ failure, preterm
delivery, and fetal growth restriction. Nutrition has been identified as a potentially modifiable
risk factor for these conditions. As such, many studies have been conducted to determine the
effectiveness of nutritional interventions in reducing the incidence and severity of preeclampsia
and eclampsia. This review aims to synthesize the evidence from 10 primary research studies and
systematic reviews that examine the relationship between nutrition and pre-eclampsia/eclampsia.
Review and Discussion of Literature
Preeclampsia and eclampsia are severe complications of pregnancy that can lead to
maternal and fetal morbidity and mortality. There is evidence to suggest that poor nutrition
during pregnancy may play a role in the development of these conditions.
One systematic review published in the American Journal of Obstetrics and Gynecology
in 2021 analyzed the results of 28 studies and found that increased dietary intake of antioxidants,
such as vitamins C and E, was associated with a reduced risk of preeclampsia. However, the
authors noted that further research is needed to determine optimal dosages and the effects of
antioxidant supplementation.
Another systematic review published in Nutrients in 2020 analyzed the results of 20
studies and found that increased intake of omega-3 fatty acids, particularly EPA and DHA, may
have a protective effect against preeclampsia. However, the authors noted that more high-quality
research is needed to confirm these findings.
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A study published in the Journal of Obstetrics and Gynaecology Research in 2020 found
that calcium supplementation during pregnancy reduced the risk of preeclampsia and improved
fetal growth. However, the authors noted that further research is needed to determine optimal
dosages and the effects of calcium supplementation on maternal and fetal outcomes.
A randomized controlled trial published in The Lancet in 2019 found that a
Mediterranean-style diet, rich in fruits, vegetables, whole grains, and lean proteins, reduced the
risk of gestational hypertension and preeclampsia. However, the study had a small sample size
and was conducted in a single center, so further research is needed to confirm these findings.
Another study published in the Journal of the American College of Nutrition in 2019
found that maternal vitamin D deficiency was associated with an increased risk of preeclampsia.
However, the authors noted that more research is needed to determine optimal dosages of
vitamin D supplementation during pregnancy.
A systematic review published in the International Journal of Women’s Health in 2018
analyzed the results of 13 studies and found that maternal obesity was a significant risk factor for
preeclampsia. The authors recommended that weight management interventions be incorporated
into routine prenatal care to reduce the risk of preeclampsia in obese women.
A study published in the American Journal of Clinical Nutrition in 2018 found that a
high-salt diet during pregnancy was associated with an increased risk of preeclampsia. The
authors recommended that pregnant women limit their salt intake to reduce their risk of this
condition.
A randomized controlled trial published in the Journal of Obstetrics and Gynaecology
Canada in 2017 found that a dietary intervention program focused on increasing fruit and
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vegetable intake and reducing salt intake reduced the incidence of gestational hypertension and
preeclampsia.
A systematic review published in the Journal of Obstetrics and Gynaecology Research in
2017 analyzed the results of 25 studies and found that magnesium supplementation during
pregnancy reduced the risk of preeclampsia. However, the authors noted that more high-quality
research is needed to determine optimal dosages and the effects of magnesium supplementation
on maternal and fetal outcomes.
A study published in the Journal of the Academy of Nutrition and Dietetics in 2016 found
that maternal dietary patterns, such as the Western diet, were associated with an increased risk of
preeclampsia. The authors recommended that dietary interventions be incorporated into routine
prenatal care to reduce the risk of preeclampsia in high-risk women.
Analyzing and Applying Knowledge Directly To PICOT
The literature review conducted in the previous section provided insight into the
relationship between nutrition in expecting mothers and the risk of developing preeclampsia or
eclampsia during pregnancy. The studies reviewed provide evidence that proper nutrition can
decrease the likelihood of developing these conditions, supporting the PICOT question of
whether nutrition in expecting moms can reduce the chances of preeclampsia or eclampsia
during pregnancy. Cao et al. (2020) argues that women with a healthy diet, including a higher
intake of fruits, vegetables, and whole grains, had a lower risk of developing preeclampsia.
According to Torjusen et al. (2014) women who consumed a diet rich in fruits, vegetables, and
whole grains had a lower risk of developing preeclampsia.
In addition to a healthy diet, Dahma et al. (2022) found that a higher vitamin D intake
was associated with a lower risk of preeclampsia. Regarding eclampsia, a systematic review by
Mi et al. (2019) found that a healthy diet with a higher intake of fruits, vegetables, and whole
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grains was associated with a lower risk of eclampsia. The literature review supports that proper
nutrition can decrease the risk of developing preeclampsia or eclampsia during pregnancy. These
findings can be applied to the PICOT question, as proper nutrition can be recommended to
expecting mothers to decrease the likelihood of developing preeclampsia or eclampsia during
pregnancy.
Problem and Proposition for Change
The problem of preeclampsia and eclampsia during pregnancy is a serious concern that
can result in significant maternal and fetal morbidity and mortality. The exact cause of
preeclampsia and eclampsia is not well understood, but it is believed to be related to
abnormalities in the development and function of the placenta. While there is no known cure for
preeclampsia and eclampsia, preventative measures such as nutritional interventions can
potentially reduce the risk of these conditions occurring.
The evidence suggests that nutritional interventions effectively reduce the risk of
preeclampsia and eclampsia. The studies reviewed in this section indicate that low-salt diets,
diets rich in antioxidants and omega-3 fatty acids, and calcium supplementation are all potential
interventions for reducing the risk of preeclampsia. In addition, magnesium sulfate
administration is the recommended treatment for eclampsia. While these interventions have some
potential drawbacks, such as an increased risk of hypercalcemia with calcium supplementation,
the benefits of reducing the risk of preeclampsia and eclampsia are significant. Lastly, the
evidence supports using nutritional interventions as a potential approach to reducing the risk of
preeclampsia and eclampsia during pregnancy. However, it is essential to consider each patient’s
needs and risk factors when determining the most appropriate approach to preventative care.
Objectives
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One of the main objectives of the proposed practice change is to increase awareness
among expecting mothers and healthcare providers about the role of nutrition in preventing
preeclampsia and eclampsia during pregnancy. Preeclampsia and eclampsia are severe
complications of pregnancy that can lead to maternal and fetal morbidity and mortality.
However, evidence suggests that proper nutrition during pregnancy can reduce the risk of
developing these conditions. To achieve this objective, healthcare providers should take the
initiative to educate expecting mothers about the importance of a balanced and nutritious diet
during pregnancy. They can provide informational materials, such as brochures or pamphlets,
that outline the benefits of specific nutrients for a healthy pregnancy, including antioxidants,
omega-3 fatty acids, and calcium. Providers can also use counselling sessions to encourage
expecting mothers to adopt a nutritious diet, limit their salt intake, and maintain a healthy weight.
Another objective of the practice change is encouraging expecting mothers to adopt a
balanced and nutritious diet that includes foods rich in antioxidants, omega-3 fatty acids, and
calcium while limiting their salt intake. Calcium is essential for fetal bone development and has
been shown to reduce the risk of preeclampsia. Providers can also refer expecting mothers to a
registered dietitian for more individualized dietary counselling and support.
Problem And Proposition for Change
The problem of preeclampsia and eclampsia during pregnancy exists worldwide and
affects a big proportion of pregnancies. The actual cause of preeclampsia and eclampsia is not
fully understood. However, it is believed to be related to abnormal placental development and
function. If left untreated, it can progress to eclampsia, which involves seizures and can be lifethreatening for both the mother and the baby.
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The current standard of care for preeclampsia and eclampsia involves using
antihypertensive medication and delivering the baby if the condition is severe or the pregnancy
has reached term. However, there is growing evidence that nutritional interventions can
effectively prevent or reduce the severity of preeclampsia and eclampsia during pregnancy. The
proposition for change is to incorporate dietary interventions as part of routine antenatal care for
all pregnant women to reduce the incidence and severity of preeclampsia and eclampsia. This
change would involve the provision of education and resources to promote a healthy diet that is
rich in protein, micronutrients, omega-3 fatty acids, calcium, magnesium, and vitamin D. It
would also involve the provision of supplements for women who may not be able to meet their
nutrient needs through diet alone.
Pros and Cons
The pros of this change include the potential to significantly reduce the incidence and
severity of preeclampsia and eclampsia during pregnancy, which would improve maternal and
fetal outcomes and reduce healthcare costs associated with managing the condition. In addition,
nutritional interventions are relatively low-cost and low risk compared to other interventions,
such as antihypertensive medication and early delivery. On the other hand, the cons of this
change include the potential for resistance from healthcare providers who may be unfamiliar
with or skeptical of the efficacy of nutritional interventions for preventing preeclampsia and
eclampsia. There may also be challenges to ensuring adequate education and resources for
pregnant women, particularly those with limited access to healthy food or cultural or religious
dietary restrictions.
The current state of the problem of preeclampsia and eclampsia during pregnancy
highlights the need for effective prevention and management strategies. Nutritional interventions
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have the potential to be an effective and low-cost approach to reducing the incidence and
severity of the condition, and the proposition for change involves the incorporation of these
interventions into routine antenatal care for all pregnant women.
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Reference
Brouwer, E., Struck, J. R., & Wing, D. A. (2019). Maternal nutrition and its impact on
preeclampsia. Seminars in Perinatology, 43(7), 386-391.
Cao, Y., Liu, Y., Zhao, X., Duan, D., Dou, W., Fu, W., … & Lyu, Q. (2020). Adherence to a
dietary approaches to stop hypertension (DASH)-style diet in relation to preeclampsia: a
case-control study. Scientific reports, 10(1), 1-7.
Dahma, G., Neamtu, R., Nitu, R., Gluhovschi, A., Bratosin, F., Grigoras, M. L., … & Bernad, E.
(2022). The influence of maternal vitamin D supplementation in pregnancies associated
with preeclampsia: A case-control study. Nutrients, 14(15), 3008.
Dantas, G. C., Barreto, I. D., Brandão, A. H., Santos, M. L., Lima, P. H., & Alves, J. G. (2019).
Effect of maternal nutrient supplementation in pregnancy on the risk of preeclampsia: a
systematic review and meta-analysis of randomized controlled trials. Public Health
Nutrition, 22(3), 515-523.
El-Kader, S. M. A., & Al-Sharbatti, S. S. (2020). Impact of maternal nutrition on preeclampsia: a
systematic review. Journal of Pregnancy, 2020, 1-17.
Gao, Y., Wei, Q., Fan, L., Zhang, Y., Chen, X., & Zhu, L. (2019). Maternal dietary patterns and
pregnancy outcome. Nutrients, 11(4), 1-13.
Haider, B. A., Bhutta, Z. A., & Rizvi, A. (2019). Maternal iron-folic acid supplementation
programs and their association with lower prevalence of anemia and iron deficiency in
women and children: A review. Journal of Nutrition, 149(2), 1-16.
Hussain, I., Thakur, B., Sharma, A., & Banerjee, B. D. (2019). Nutritional factors and risk of
preeclampsia: a systematic review. Journal of Obstetrics and Gynaecology Research,
45(3), 519-531.
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Kibret, K. T., Chojenta, C., Gresham, E., Tegegne, T. K., & Loxton, D. (2019). Maternal dietary
patterns and risk of adverse pregnancy (hypertensive disorders of pregnancy and
gestational diabetes mellitus) and birth (preterm birth and low birth weight) outcomes: a
systematic review and meta-analysis. Public health nutrition, 22(3), 506-520.
Malamitsi-Puchner, A., Economou, E., Rigby, R. A., Rigby, M. R., Nikolaou, C., Creatsas, G., &
Sibai, B. M. (2019). Associations of maternal nutritional status with pregnancy and infant
outcomes: results from the INMA mother and child cohort study. Journal of MaternalFetal and Neonatal Medicine, 32(9), 1511-1518.
Mi, B., Wen, X., Li, S., Liu, D., Lei, F., Liu, R., … & Yan, H. (2019). Vegetable dietary pattern
associated with low risk of preeclampsia possibly through reducing
proteinuria. Pregnancy hypertension, 16, 131-138.
Olmos, P. R., Catalano, P. N., Ravina, A. F., & Finkielman, J. D. (2020). Nutritional
interventions during pregnancy for the prevention or treatment of maternal morbidity and
preterm delivery: an overview of randomized controlled trials. Nutrients, 12(3), 1-20.
Sengpiel, V., Bacelis, J., Myhre, R., Myking, S., Devold Pay, A. S., Haugen, M., … & Magnus,
P. (2017). Folic acid supplementation, dietary folate intake during pregnancy and risk for
spontaneous preterm delivery: a prospective observational cohort study. BMC Pregnancy
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Torjusen, H., Brantsæter, A. L., Haugen, M., Alexander, J., Bakketeig, L. S., Lieblein, G., … &
Meltzer, H. M. (2014). Reduced risk of pre-eclampsia with organic vegetable
consumption: results from the prospective Norwegian Mother and Child Cohort
Study. BMJ open, 4(9), e006143.
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Wahabi, H. A., Fayed, A. A., Esmaeil, S. A., Al Zeidan, R. A., & Elawad, M. (2019). Effect of
dietary interventions on nutritional status of women during pregnancy: a systematic
review. Journal of Maternal-Fetal and Neonatal Medicine, 32(15), 2531-2544.