DISCUSSION
diarrhoea, nausea, vomiting, quantity‐LNS
In Ghana and Malawi, we found that after excluding the first trimester due to the small number of women enrolled in that period, maternal morbidity symptoms were most common in the second trimester of pregnancy and prevalence declined significantly through 3–6 months of lactation. In Ghana, the three intervention groups did not differ significantly in the morbidity outcomes measured, except for the period prevalence of vomiting in the third trimester of pregnancy (greater in the MMN group than the LNS group) and 0–3 months lactation (greater in the MMN group than the IFA group) and mean percentage of days with nausea in the third trimester of pregnancy and during 0–3 months of lactation (greater in the MMN and LNS groups than in the IFA group). Likewise, in Malawi, the three intervention groups differed significantly only in the period prevalence of severe diarrhoea during 3–6 months of lactation (greater in the LNS group than the MMN group). In both countries, the differences between groups in these three outcomes were small and possibly due to chance. Overall, we did not find consistent evidence that SQ‐LNS or MMN increased or decreased maternal morbidity during pregnancy or lactation, compared to IFA.The strengths of our study included the random allocation of participants to intervention groups and the frequent home visits by study staff to collect the morbidity data. There are potential limitations. First, the self‐reported morbidity data could not be clinically verified and may also be compromised by recall bias. Second, the period prevalence of morbidity outcomes during the second trimester of pregnancy may be underestimates because many women in both countries were enrolled later in that trimester rather than earlier, and thus some morbidity symptoms during that period may have been missed. In Malawi, the biweekly data collection focused on the ‘past 7 days’, which reduced the risk of recall bias (relative to a 14‐day recall period) but meant that we missed collecting morbidity data for approximately one‐half of the days during the follow‐up period. Third, we tested multiple hypotheses involving 11 or 10 morbidity symptoms in either country and therefore, at least some of the observed differences may be due to chance (Li et al., Despite these limitations, self‐reported data may reflect community experiences not often captured in clinic or hospital settings (Kim et al., We reported previously that the intervention groups in Ghana (Adu‐Afarwuah et al., Morbidity data from other trials evaluating small quantity‐ or medium quantity‐LNS (Dewey et al., In Ghana, the observed group differences in the mean percentage of days of monitoring when women had nausea during the third trimester of pregnancy and 0–3 months postpartum may potentially be related to the perceived metallic ‘taste’ or ‘aftertaste’ of LNS when consumed without being mixed with food (Klevor et al., We conclude that Ghanaian and Malawian women receiving IFA, MMN or SQ‐LNS supplements during pregnancy and lactation generally do not appear to differ in morbidity symptoms. Additional studies to examine the impact of SQ‐LNS consumption on maternal morbidity would be useful.