Skip to main content
    • Aa
    • Aa
  • Access
  • Cited by 14
  • Cited by
    This article has been cited by the following publications. This list is generated based on data provided by CrossRef.

    Bartlett, L. A. LeFevre, A. E. Mir, F. Soofi, S. Arif, S. Mitra, D. K. Quaiyum, M. A. Shakoor, S. Islam, M. S. Connor, N. E. Winch, P. J. Reller, M. E. Shah, R. El Arifeen, S. Baqui, A. H. Bhutta, Z. A. Zaidi, A. Saha, S. and Ahmed, S. A. 2016. The development and evaluation of a community-based clinical diagnosis tool and treatment regimen for postpartum sepsis in Bangladesh and Pakistan. Reproductive Health, Vol. 13, Issue. 1,

    Duttaroy, Asim K. and Basak, Sanjay 2016. Early Nutrition and Lifestyle Factors.

    Hurt, Lisa ten Asbroek, Augustinus Amenga-Etego, Seeba Zandoh, Charles Danso, Samuel Edmond, Karen Hurt, Chris Tawiah, Charlotte Hill, Zelee Fenty, Justin Owusu-Agyei, Seth Campbell, Oona M and Kirkwood, Betty R 2013. Effect of vitamin A supplementation on cause-specific mortality in women of reproductive age in Ghana: a secondary analysis from the ObaapaVitA trial. Bulletin of the World Health Organization, Vol. 91, Issue. 1, p. 19.

    Parker, Jacqui A Barroso, Filipa Stanworth, Simon J Spiby, Helen Hopewell, Sally Doree, Carolyn J Renfrew, Mary J and Allard, Shubha 2012. Gaps in the evidence for prevention and treatment of maternal anaemia: a review of systematic reviews. BMC Pregnancy and Childbirth, Vol. 12, Issue. 1,

    Wu, Zhen-Ming Yeh, Chang-Ching Day, Deborah and Huang, S 2012. Nutrition, Lifestyle Factors, and Blood Pressure.

    Christian, Parul and West, Keith P. 2011. Nutrition: Vitamin A supplementation—maternal and neonatal survival. Nature Reviews Endocrinology, Vol. 7, Issue. 4, p. 190.

    Bawadi, Hiba A. Al-Kuran, Oqba Al-Bastoni, Lily-Ann A. Tayyem, Reema F. Jaradat, AbdalNasser Tuuri, Georgianna Al-Beitawi, Soha N. and Al-Mehaisen, Lama M. 2010. Gestational nutrition improves outcomes of vaginal deliveries in Jordan: an epidemiologic screening. Nutrition Research, Vol. 30, Issue. 2, p. 110.

    Palmer, Amanda C. and West, Keith P. 2010. A Quarter of a Century of Progress to Prevent Vitamin A Deficiency Through Supplementation. Food Reviews International, Vol. 26, Issue. 3, p. 270.

    Christian, Parul Khatry, Subarna K. LeClerq, Steven C. and Dali, Sanu Maiya 2009. Effects of prenatal micronutrient supplementation on complications of labor and delivery and puerperal morbidity in rural Nepal. International Journal of Gynecology & Obstetrics, Vol. 106, Issue. 1, p. 3.

    Hill, Zelee Kirkwood, Betty Kendall, Carl Adjei, Eunice Arthur, Paul and Agyemang, Charlotte Tawiah 2007. Factors that affect the adoption and maintenance of weekly vitamin A supplementation among women in Ghana. Public Health Nutrition, Vol. 10, Issue. 08,

    Van Den Broek, NR White, SA Flowers, C Cook, JD Letsky, EA Tanumihardjo, SA Mhango, C Molyneux, M and Neilson, JP 2006. Maternal medicine: Randomised trial of vitamin A supplementation in pregnant women in rural Malawi found to be anaemic on screening by HemoCue. BJOG: An International Journal of Obstetrics & Gynaecology, Vol. 113, Issue. 5, p. 569.

    West Jr, K.P. 2004. Vitamin A deficiency as a preventable cause of maternal mortality in undernourished societies: plausibility and next steps. International Journal of Gynecology & Obstetrics, Vol. 85, p. S24.

    Binstock, T. 2001. An immune hypothesis of sexual orientation. Medical Hypotheses, Vol. 57, Issue. 5, p. 583.

    Tomkins, Andrew 2001. Nutrition and maternal morbidity and mortality. British Journal of Nutrition, Vol. 85, Issue. S2, p. S93.


Vitamin A and causes of maternal mortality: association and biological plausibility

  • Hala Faisel (a1) and Rüdiger Pittrof (a2)
  • DOI:
  • Published online: 01 January 2007

To review the association between major causes of maternal mortality and vitamin A, trying to determine if these associations are causal in nature, and to highlight possible biological pathways that may explain vitamin A effects.


Literature review, observational studies and clinical trials. The strength of association was determined by applying Bradford Hill criteria of causality.


In a vitamin A deficient population, vitamin A is essential for adequate treatment of anaemia. While vitamin A does not seem to be capable of preventing uterine atony, obstetric or surgical trauma, which are important causes of haemorrhage, it might be capable of preventing or decreasing coagulopathy. Possible effects on the placenta as regards implantation, site and size are not clear. As regards pregnancy-related infections, vitamin A supplementation can improve wound healing by decreasing fibrosis and increasing transforming growth factor-β (TFG-β). It can increase resistance to infection by increasing mucosal integrity, increasing surface immunoglobulin A (sIgA) and enhancing adequate neutrophil function. If infection occurs, vitamin A can act as an immune enhancer, increasing the adequacy of natural killer (NK) cells and increasing antibody production. β-carotene in its provitamin form can act as an antioxidant by decreasing endothelial cell damage (the pathognomonic feature of pre-eclampsia) and promote the vasodilator effect of nitric oxide that might bring about a better outcome of toxaemia in pregnancy. It is unlikely that vitamin A or β-carotene has an effect on obstructed labour.


Plausible biomedical pathways can only be constructed for obstetric haemorrhage, anaemia in pregnancy, hypertension in pregnancy and pregnancy-related infections. A 40% reduction in the maternal mortality ratio, as observed in Nepal, is unlikely to be solely explained through the aforementioned pathways.

    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Vitamin A and causes of maternal mortality: association and biological plausibility
      Your Kindle email address
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about sending content to Dropbox.

      Vitamin A and causes of maternal mortality: association and biological plausibility
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about sending content to Google Drive.

      Vitamin A and causes of maternal mortality: association and biological plausibility
      Available formats
Corresponding author
*Corresponding author: Email
Linked references
Hide All

This list contains references from the content that can be linked to their source. For a full set of references and notes please see the PDF or HTML where available.

4CJ. Bates . Vitamin A. Lancet 1995; 345: 31–5.

5M. Moden Vitamin A in embryonic development. Nutr. Rev. 1990; 52: S3–12.

6S Smeland , T Bjerknes , L. Malaba Tissue distribution of the receptor for plasma retinol-binding protein. Biochem. J. 1995; 305(2): 419–24.

7R Dimenstein , NM Trugo , CM Donangelo , LC Trugo , AS Anastacio . Effect of subadequate maternal vitamin-A status on placental transfer of retinol and beta-carotene to the human fetus. Biol. Neonate. 1996; 69(4): 230–4.

9C Calzada , KR Bruckdorfer , CA Rice Evans . The influence of antioxidant nutrients on platelet function in healthy volunteers. Atherosclerosis. 1997; 128(1): 97105.

11G Bekyarova , T Yankova , B. Galunska Increased antioxidant capacity, suppression of free radical damage and erythrocyte aggregatability after combined application of alpha-tocopherol and FC-43 perfluorocarbon emulsion in early postburn period in rats. Artif. Cells Blood Substit. Immobil. Biotechnol. 1996; 24(6): 629–41.

12S Horie , K Kizaki , H Ishii , M. Kazama Retinoic acid stimulates expression of thrombomodulin, a cell surface anticoagulant glycoprotein, on human endothelial cells. Differences between up-regulation of thrombomodulin by retinoic acid and cyclic AMP. Biochem. J. 1992; 281(1): 149–54.

14TA Sanders , M Vickers , AP Haines . Effect on blood lipids and haemostasis of a supplement of cod-liver oil, rich in eicosapentaenoic and docosahexaenoic acids, in healthy young men. Clin. Sci. 1981; 61(3): 317–24.

15EA Thompson , L Nelles , D. Collen Effect of retinoic acid on the synthesis of tissue-type plasminogen activator and plasminogen activator inhibitor-1 in human endothelial cells. Eur. J. Biochem. 1991; 201(3): 627–32.

17WJ McGanity , RO Cannon , EB Bridgforth , The Vanderbilt cooperative study of maternal and infant nutrition. IV. Relationship of obstetric performance to nutrition. Am. J. Obstet. Gynecol. 1945; 67: 501–27.

18C Edmond , SV Clemmesen . On parental vitamin A treatment of dysaptation (nyctalo-hemeralopia) in some pregnant women. Acta Med. Scand. 1936; 89: 6992.

19MS Mikhail , PR Palan , J Basu , A Anyaegbunam , SL Romney . Decreased beta-carotene levels in exfoliated vaginal epithelial cells in women with vaginal candidiasis. Am. J. Reprod. Immunol. 1994; 32(3): 221–5.

20P Christian , KP West , SK Khatry , Night blindness of pregnancy in rural Nepal – nutritional and health risks. Int. J. Epidemiol. 1998; 27(2): 231–7.

21RD Semba . Vitamin A, immunity, and infection. Clin. Infect. Dis. 1994; 19(3): 489–99.

26G Szabo , M Puppolo , B Verma , D. Catalano Regulatory potential of ethanol and retinoic acid on human monocyte functions. Alcohol. Clin. Exp. Res. 1994; 18(3): 548–54.

28RD Semba . The role of vitamin A and related retinoids in immune function. Nutr. Rev. 1998; 56(1 part 2): S38–48.

31J Buck , G Ritter , L Dannecker , Retinol is essential for growth of activated human B cells. J. Exp. Med. 1990; 171(5): 1613–24.

33M Ballow , W Wang , S. Xiang Modulation of B-cell immunoglobulin synthesis by retinoic acid. Clin. Immunol. Immunopathol. 1996; 80(3/2): S73–81.

34A Garbe , J Buck , U. Hammerling Retinoids are important cofactors in T cell activation. J. Exp. Med. 1992; 176(1): 109–17.

39MS Mikhail , A Anyaegbunam , D Garfinkel , Preeclampsia and antioxidant nutrients: decreased plasma levels of reduced ascorbic acid, alpha-tocopherol, and beta-carotene in women with preeclampsia. Am. J. Obstet. Gynecol. 1994; 171(1): 150–7.

40SA Ziari , VL Mireles , CG Cantu , Serum vitamin A, vitamin E, and beta-carotene levels in preeclamptic women in northern Nigeria. Am. J. Perinatol. 1996; 13(5): 287–91.

41T Koskinen , P Valtonen , I Lehtovaara , R. Tuimal Amniotic fluid retinol concentration in late pregnancy. Biol. Neonate. 1986; 49: 81–4.

42JW Studd , RW Shaw , DE Bailey . Maternal and fetal serum protein concentration in normal pregnancy and pregnancy complicated by proteinuric pre-eclampsia. Am. J. Obstet. Gynecol. 1972; 114(5): 582–8.

44D Wickens , MH Wilkins , J Lunec , G Ball , TL Dormandy . Free radical oxidation. peroxidation products in plasma in normal and abnormal pregnancy. Ann. Clin. Biochem. 1981; 18(3): 158–62.

45M Shaarawy , A Aref , ME Salem , M. Sheiba Radical-scavenging antioxidants in pre-eclampsia and eclampsia. Int. J. Gynaecol. Obstet. 1998; 60(2): 123–8.

46AK Poranen , U Ekblad , P Uotila , M. Ahotupa Lipid peroxidation and antioxidants in normal and pre-eclamptic pregnancies. Placenta 1996; 17(7): 401–5.

47Y Wang , SW Walsh . Antioxidant activities and mRNA expression of superoxide dismutase, catalase, and glutathione peroxidase in normal and preeclamptic placentas. J. Soc. Gynecol. Investig. 1996; 3(4): 179–84.

49JT Uotila , RJ Tuimala , TM Aarnio , KA Pyykko , MO Ahotupa . Findings on lipid peroxidation and antioxidant function in hypertensive complications of pregnancy. Br. J. Obstet. Gynaecol. 1993; 100(3): 270–6.

51SM Cueto , AD Romney , Y Wang , SW Walsh . Beta-carotene attenuates peroxide-induced vasoconstriction in the human placenta. J. Soc. Gynecol. Investig. 1997; 4(2): 6471.

53JF Keaney Jr, JM Gaziano , A Xu , Dietary antioxidants preserve endothelium-dependent vessel relaxation in cholesterol-fed rabbits. Proc. Natl. Acad. Sci. USA 1993; 90(24): 11880–4.

54PD Reaven , E Ferguson , M Navab , FL Powell . Susceptibility of human LDL to oxidative modification. Effects of variations in beta-carotene concentration and oxygen tension. Arterioscler. Thromb. 1994; 14(7): 1162–9.

55DM Gilligan , MN Sack , V Guetta , Effect of antioxidant vitamins on low density lipoprotein oxidation and impaired endothelium-dependent vasodilatation in patients with hypercholesterolemia. J. Am. Coll. Cardiol. 1994; 24(7): 1611–17.

56LC Chappell , PT Seed , AL Briley , Effect of antioxidants on the occurrence of pre-eclampsia in women at increased risk: a randomised trial. Lancet 1999; 354: 810–16.

57A Many , CA Hubel , JM Roberts . Hyperuricemia and xanthine oxidase in preeclampsia, revisited. Am. J. Obstet. Gynecol. 1996; 174(1): 288–91.

58RB Brandt , DG Mueller , JR Schroeder , Serum vitamin A in premature and term neonates. J. Pediatr. 1978; 92(1): 101–4.

59JP Shenai , F Chytil , A Jhaveri , MT Stahlman . Plasma vitamin A and retinol-binding protein in premature and term neonates. J. Pediatr. 1981; 99(2): 302–5.

60J Navarro , MB Causse , N Desquilbet , F Herve , D. Lallemand The vitamin status of low birth weight infants and their mothers. J. Pediatr. Gastroenterol. Nutr. 1984; 3(5): 744–8.

62MB Yassai , F. Malek Newborns vitamin A in relation to sex and birth weight. J. Trop. Pediatr. 1989; 35(5): 247–9.

63K Ghebremeskel , L Burns , TJ Burden , Vitamin A and related essential nutrients in cord blood: relationships with anthropometric measurements at birth. Early Hum. Dev. 1994; 39(3): 177–88.

64PJ Dison , G Lockitch , AC Halstead , Influence of maternal factors on cord and neonatal plasma micronutrient levels. Am. J. Perinatol. 1993; 10(1): 30–5.

69D Suharno , CE West , Muhilal, Supplementation with vitamin A and iron for nutritional anaemia in pregnant women in West Java, Indonesia. Lancet 1993; 342: 1225–8.

70KH Wagner . Die experimentelle Avitaminose A beim Menschen. Hoppe Seyler. Z. Physiol. Chem. 1940; 264: 135. (Cited in eds Hodges RE, Sauberlich HE, Canham JE et al. Hematopiotic studies in vitamin A deficiency. Am. J. Clin. Nutr. 1978; 31: 876–85.)

Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Public Health Nutrition
  • ISSN: 1368-9800
  • EISSN: 1475-2727
  • URL: /core/journals/public-health-nutrition
Please enter your name
Please enter a valid email address
Who would you like to send this to? *