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•Antenatal MMS is a cost-effective intervention to be integrated in antenatal care•Global advocacy opportunities and costed roadmaps are key to scaling MMS•Implementation science guides effective context-specific MMS implementation•Government ownership and advocacy are vital for MMS success and sustainability•Strengthening supply chains ensures MMS aligns with national strategies and demand Maternal undernutrition in Africa remains a public health challenge, contributing to negative pregnancy outcomes, neonatal mortality, and perpetuating intergenerational cycles of poor health. Antenatal multiple micronutrient supplementation (MMS), a cost-effective intervention recognized for its potential to improve maternal and neonatal health, reduces risks of low birth weight, preterm birth, small for gestational age, and stillbirth while offering a $37 return for every $1 invested. Despite its benefits, MMS adoption across African countries remains suboptimal. This position paper synthesizes the outcomes of the 2nd Africa Maternal Nutrition and MMS Technical Meeting: A Path Toward Introduction and Scale-up of MMS in Africa, held in Nairobi, Kenya, in October 2024. The 3-d meeting convened government representatives from 17 African member states, donors, and experts to align on a shared vision for MMS introduction and scale-up in Africa. Participants emphasized MMS integration into antenatal care as a cornerstone of maternal nutrition strategies and identified actionable recommendations to overcome policy, supply chain, financing, and implementation barriers. Key messages include the urgency of scaling MMS, the role of implementation science in tailoring programs to local contexts, and the necessity of regional collaboration to share lessons and facilitate progress. It outlines a pathway for integrating MMS into antenatal care services, ensuring a quality supply, securing financial commitments, strengthening delivery, and engaging communities. The accompanying “Call to Action” provides a detailed roadmap to guide stakeholders in scaling up MMS as an urgent priority to enhance maternal and neonatal health, advance gender equality, and fulfill Africa’s global health commitments.

Background Multiple Micronutrient Supplementation (MMS) is recommended globally to improve maternal nutrition and pregnancy outcomes. As Indonesia transitions from iron-folic acid to MMS, understanding the perspectives of pregnant women is critical for effective implementation. However, evidence on pregnant women’s perceptions and acceptance of MMS remains limited. This study aims to assess the levels and determinants of knowledge, attitude, and acceptance (KAA) of MMS among pregnant women in Indonesia. Methods A nationwide cross-sectional study was conducted using a validated online survey. Participants were recruited via digital outreach and midwife networks. Descriptive statistics and multivariable logistic regression were used to assess KAA levels and predictors, reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results Most participants had a positive attitude (90.1%), 62.7% had good knowledge, and 66.5% reported high acceptance. Poor knowledge was less likely among women aged 25–34 (aOR: 0.27; CI: 0.08–0.89), those with junior high (aOR: 0.46; CI: 0.25–0.85), senior high (aOR: 0.28; CI: 0.16–0.49), or higher education (aOR: 0.32; CI: 0.18–0.57), incomes of 1–3 million (aOR: CI: 0.64; 0.42–0.98), 3–5 million (aOR: 0.56; CI: 0.34–0.87), or > 5 million (aOR: 0.52; CI: 0.33–0.83), and those in the first (aOR: 0.22; CI: 0.14–0.35) or second trimester (aOR: 0.30; CI: 0.20–0.45). Negative attitude was less likely with income of 3–5 million (aOR: 0.46; CI: 0.46–0.89), first (aOR: 0.09; CI: 0.02–0.39) or second trimester (aOR: 0.04; CI: 0.01–0.30), and good knowledge (aOR: 0.52; CI: 0.33–0.82), but more likely among employed women (aOR: 1.60; CI: 1.02–2.49). Low acceptance was more likely in the second trimester (aOR: 2.13; CI: 1.34–3.37), but less likely with good knowledge (aOR: 0.25; CI: 0.18–0.34). Conclusion While attitudes toward MMS were largely positive, gaps in knowledge and acceptance persist. Improving knowledge was consistently associated with better attitude and higher acceptance. Strengthening early antenatal education is essential to improving informed acceptance and effective integration of MMS into maternal care in Indonesia.

Background Micronutrient deficiencies among pregnant women contribute to adverse maternal and neonatal outcomes. Multiple micronutrient supplementation (MMS) has proven its superiority when compared to the standard iron and folic acid (IFA) supplementation for maternal and infant morbidity and mortality. The Government of Nepal is exploring the scale-up of MMS, but first requires evidence such as on its adherence and acceptability. The objective of this study, thus, is to generate this needed evidence. Methods The Non-inferiority Assessment of Maternal Adherence to Supplements, a Trial on the Effects of Multiple Micronutrient Supplementation (NAMASTE-MMS) in Nepal study is a three-arm, parallel, non-inferiority cluster-randomized controlled trial (c-RCT) assessing how well pregnant women adhere to and accept different types of supplements: MMS in blister packs or bottles versus IFA in blister packs. In one of Nepal’s seven provinces, Lumbini, the longitudinal NAMASTE-MMS study is being implemented across 120 health facilities (clusters), enrolling 2640 pregnant women into one of three arms: IFA-blister, MMS-blister, or MMS-bottle. The primary outcome is adherence to 180 supplements during pregnancy, measured by tablet counts with a non-inferiority margin of 13%. Secondary outcomes include comparisons of adherence between the two MMS arms and utilization of Antenatal Care (ANC), both potentially impacted by type of packaging. Exploratory outcomes include comparisons of adherence as well as the degree of acceptability to supplementation during early and mid pregnancy and post-partum. Discussion Evidence generated from this study and three related mixed-methods implementation research studies will help the government in its potential scale-up of MMS supplementation during pregnancy and lactation. Trial registration NCT06327646 (ClinicalTrials.gov, March 18, 2024 registered).

IntroductionOptimising the micronutrient status of women before and during reproduction confers benefits to them and their offspring. Antenatal multiple micronutrient supplements (MMS), given as a daily tablet with nutrients at ~1 recommended dietary allowance (RDA) or adequate intake (AI) reduces adverse birth outcomes. However, at this dosage, MMS may not fully address micronutrient deficiencies in settings with chronically inadequate diets and infection. A bioefficacy study to determine amounts required to attain nutrient adequacy among women of reproductive age (WRA) and pregnant women (PW) aims to address this gap.Methods and analysisTwo, four-arm, dose-response trials (n=240 participants/trial) with a double-blind, individually randomised, controlled design are underway in 18–35 year-old WRA and PW in rural northern Bangladesh. The trials will test dose response to four levels of 19 micronutrients from 1 RDA/AI up to ~75% of the tolerable upper intake level (UL), where applicable. These levels of micronutrients are delivered in the form of a reconstituted (in water) powdered drink, daily, including a placebo drink in the control arm, plus a fortified, balanced energy and protein (BEP) food product containing each micronutrient at ~1 RDA per serving. The supplement duration is 3 months in WRA and~6 months (until birth) in PW, who are enrolled at 12–16 weeks of pregnancy; women are randomised to one of the four arms at enrolment. Supplement consumption is directly observed by study staff and weekly side effects and adverse events are monitored. Blood and urine are collected at baseline, a midpoint, and at/near the end of supplementation, with a birth visit and postpartum biospecimen collection (post supplementation) for PW. Outcomes are biomarkers of nutrient status. Pharmacokinetic modelling will estimate micronutrient intakes at which sufficiency for each nutrient without excess is achieved. Enrolment was initiated on 22 October 2023.Ethics and disseminationThe study was approved by the Institutional Review Board of Johns Hopkins Bloomberg School of Public Health and the research and ethical review committees of icddr,b, Bangladesh. A data safety and monitoring board is in place for the study. Findings will be disseminated in peer-reviewed papers and in-country meetings.Trial registration numberNCT06081114Cite Now

Background Micronutrient deficiencies among pregnant women remain highly prevalent in low and middle-income countries. Multiple micronutrient supplementation (MMS) has been proven more beneficial than standard iron-folic acid supplementation in reducing adverse pregnancy outcomes. Limited data on adherence to MMS in pregnant women in programmatic settings is available. Therefore, our study aims to assess adherence to the recommended intake of a multiple micronutrient supplement (UNIMMAP-MMS) in relation to demographic characteristics alongside a community-based MMS program. Method A prospective longitudinal study was performed in the Parepare district, South Sulawesi province, Indonesia, including 1216 participants. MMS was provided at the first antenatal care visit and women were followed up until delivery. The number of MMS tablets consumed, the start of MMS intake and information regarding possible intake determinants were recorded. Adherence was defined as ≥ 90 tablets. Binary logistic regression was used to assess associations between characteristics of women and adherence. Results Among the 655 women (53.9%) who started MMS intake in the first trimester, approximately 90% continued using MMS in the following trimesters and 75.3% consumed MMS ≥ 90 tablets. Among the 41.2% of women who started in the second trimester, 90% continued intake in the third trimester and 32.3% consumed ≥ 90 tablets. Only 4.9% started MMS in the third trimester. Overall adherence to MMS was 53.9%. Factors that impacted MMS intake were pregnancy interval ≤ 2y (AOR = 0.65, 95% CI 0.46, 0.92), start of MMS use in the second trimester and third trimester (AOR = 0.15, 95% CI 0.12, 0.20) and (AOR = 0.01, 95% CI 0.00, 0.04) respectively, being overweight (AOR = 1.44, 95% CI 1.04, 2.00) and experiencing no side effects (AOR = 3.46, 95% CI 1.82, 6.58). Conclusion Implementation of MMS via community health centers resulted in high adherence once supplementation started. As many women started MMS late, attention to antenatal visit planning earlier in pregnancy can be further improved.

Optimal maternal nutrition, including adequate intake and status of essential micronutrients, is important for the health of women and developing infants. Currently, the World Health Organization (WHO) Antenatal care recommendations for a positive pregnancy experience recommend daily iron and folic acid (IFA) supplementation as the standard of care. The use of multiple micronutrient supplements (MMS) is recommended in the context of rigorous research as more evidence was needed regarding the impact of switching from IFA supplements to MMS, including evaluation of critical clinical maternal and perinatal outcomes, acceptability, feasibility, sustainability, equity and cost‐effectiveness. WHO convened a technical consultation of key stakeholders to discuss research priorities with the objective of providing guidance and clarity to donors, implementers and researchers about this recommendation. The overarching principles of the research agenda include the use of clinical indicators and impact measures that are applicable across studies and settings and the inclusion of outcomes that are important to women. Future studies should consider using standardized protocols based on current best practices to measure critical outcomes such as gestational age (GA) and birthweight (BW) in studies. As GA and BW are influenced by multiple factors, more research is needed to understand the biological impact pathways, and how initiation and considerations for timing of MMS influence these outcomes. A set of core clinical indicators was agreed upon during the technical consultation. For implementation research, the Evidence‐to‐Decision framework was used as a resource for discussing components of implementation research. The implementation research questions, key indicators and performance measures will depend on country‐specific context and bottlenecks that require further research and improved solutions to enable the successful implementation of iron‐containing supplements. World Health Organization recommends iron and folic acid supplementation in pregnancy and has called for additional clinical and implementation research on the use of multiple micronutrient supplements. Research priorities include the use of clinical indicators applicable across studies, standardized protocols to measure critical outcomes and country‐specific implementation research questions and performance measures. Key messages WHO recommends the use of MMS within the context of rigorous research. More evidence is desired on the impact of switching from supplements containing iron and folic acid alone to MMS, including evaluation of maternal and perinatal outcomes, acceptability, feasibility, sustainability, equity and cost‐effectiveness. Future research on MMS should include clinical indicators and impact measures that are applicable across studies and settings, and incorporate outcomes important to women, using standardized protocols. Specific research questions, key indicators and performance measures of implementation research activities will depend on the country context. This research can help improve the effectiveness of supplementation programmes and strengthen antenatal care services.

Background/Objectives: Zinc deficiency remains a public health concern in South Asia but is rarely studied through gestation to infancy. Methods: We identified maternal and infant factors related to plasma zinc of 3 mo old Bangladeshi infants (n = 317) in the context of a trial of a daily antenatal to 3 mo postpartum multiple micronutrient supplementation (MMS) with 15 vitamins and minerals, including 12 mg zinc, versus iron–folic acid (IFA). Factors explored included maternal age, parity, and plasma zinc in early (pre-supplementation) and late pregnancy, at 3 months postpartum, and in milk; cord blood zinc (n = 83); birth outcomes; and infant feeding and biomarkers. Consequently, infant zinc was explored with 3 mo anthropometry and growth rates. Results: Mean ± SD infant plasma zinc was 15.63 ± 6.65 µmol/L, with 10.1% deficiency (<9.9 µmol/L). In adjusted analyses, infant zinc was positively associated with maternal age [20–30 years +0.11 µmol/L (p = 0.018) and ≥30 years +0.28 µmol/L (p = 0.003) relative to <20 years], maternal early pregnancy zinc (+0.01 µmol/L per 1 µmol/L maternal zinc, p = 0.011), and infant ferritin (+0.001 µmol/L per 1 µg/L, p = 0.007); conversely, infant zinc was −0.13 µmol/L lower (p = 0.013) with maternal parity ≥2 versus 0–1 and with partial versus exclusive breastfeeding (−0.15 µmol/L, p = 0.038). Relationships with MMS, maternal later pregnancy, postpartum, milk, and cord blood zinc were absent. Length-for-age (+0.02 per µmol/L, p = 0.047) but not weight-for-length Z-scores at 3 months were associated with infant zinc. Conclusions: Thus, infant zinc was associated with pre- but not post-MMS maternal zinc, age and parity, feeding style, and infant iron status. Infant length but not weight was associated with plasma zinc.

Undernutrition and a lack of learning opportunities can jeopardize long-term growth and development among infants in low- and middle-income countries. We conducted a 6-month 2 × 2 cluster-randomized trial to assess the effects of multiple micronutrient-fortified beverages and responsive caregiving interventions among infants 6–18 months in 72 community sectors in southwest Guatemala. We administered baseline and endline assessments of childhood development (Bayley Scales of Infant and Toddler Development) and socioemotional development (Brief Infant Toddler Socio-Emotional Assessment) and measured ferritin and hemoglobin on a subsample. The trial was analyzed using linear mixed models. At the baseline, the mean age (SD) was 13.0 (4.6) months, including 49% males, 32% who were stunted, 55% who were anemic, and 58% who were iron deficient. At the endline (n = 328/386, 85% retention), there was no synergistic effect on the fortified beverage and responsive caregiving intervention. Compared to the non-fortified beverage group, socioemotional development improved in the fortified beverage group. There were no intervention effects on other measures of child development, hemoglobin, or ferritin. In a setting with high rates of anemia and iron deficiency, a multiple micronutrient-fortified beverage improved infants’ socioemotional development.

Mali national policy recommends that women take iron and folic acid supplements (IFA) from the time of the first antenatal care (ANC) visit, throughout pregnancy and during the first 3 months after delivery. In 2020, the World Health Organization (WHO) updated their ANC guidelines to recommend the United Nations International Multiple Micronutrient Antenatal Preparation (UNIMMAP) formulation of multiple micronutrient supplements (MMS) in the context of rigorous research, including implementation research. In Bamako, Mali, a codesign process was used to tailor antenatal care MMS packaging and counselling materials aimed at optimizing delivery and uptake of and adherence to MMS. This paper presents the codesign process along with the results of a post‐intervention qualitative assessment to evaluate the behaviour change intervention. At the conclusion of the intervention, we conducted semistructured qualitative interviews with 24 women who had received the intervention and six pharmacy managers from the six health centres participating in the study. We conducted two focus groups with midwives who had delivered the intervention and two group discussions with family members of women who had received the intervention. Respondent perspectives reveal an easy experience transitioning from previously used IFA. Women and providers concur that the intervention counselling materials and visual aids were instrumental in influencing the perceived benefit and uptake of MMS. Family members play an influential role in pregnant women's decision‐making regarding MMS uptake. MMS and the associated implementation strategies developed through the codesign process were found to be a highly acceptable intervention. Pregnant women, midwives and others participated in a codesign process to develop implementation strategies to support the delivery of a multiple micronutrient supplementation (MMS) intervention. Both the MMS and the accompanying strategies were found to be highly acceptable to pregnant women and midwives in Bamako Mali. Key messages United Nations International Multiple Micronutrient Antenatal Preparation (UNIMMAP) multiple micronutrient supplementation (MMS) and the associated implementation strategies developed through the codesign process were found to be highly acceptable interventions. Any national transition from iron and folic acid supplements to MMS will need to include planning and budgeting for necessary resources, training on antenatal care MMS counselling and ongoing supportive supervision to antenatal care providers. Additional implementation strategies might focus on community‐based behaviour change strategies that support the uptake of and adherence to MMS as well as supply chain mechanisms to support a reliable and sustainable stock of UNIMMAP MMS.

Antenatal multiple micronutrient supplementation (MMS) is an intervention that can help reach three of the six global nutrition targets, either directly or indirectly: a reduction in low birth weight, stunting, and anaemia in women of reproductive age. To support global guideline development and national decision‐making on investments into maternal nutrition, Nutrition International developed a modelling tool called the MMS cost–benefit tool to help users understand whether antenatal MMS is better value for money than iron and folic acid supplementation (IFAS) during pregnancy. The MMS cost–benefit tool can generate estimates on the potential health impact, budget impact, economic value, cost‐effectiveness and benefit–cost ratio of investing in MMS compared to IFAS in LMICs. In the 33 countries with data included in the tool, the MMS cost–benefit tool shows that transitioning is expected to generate substantial health benefits in terms of morbidity and mortality averted and can be very cost‐effective in multiple scenarios for these countries. The cost per DALY averted averages at US $ 23.61 and benefit–cost ratio ranges from US$41–US $ 1304: $ 1.0, which suggest MMS is good value for money compared with IFAS. With its user‐friendly design, open access availability, and online data‐driven analytics, the MMS cost–benefit tool can be a powerful resource for governments and nutrition partners seeking timely and evidence‐based analyses to inform policy‐decision and investments towards the scale‐up of MMS for pregnant women globally. With recent evidence and updated World Health Organization's guidance encouraging low‐ and middle‐income countries (LMICs) to consider multiple micronutrient supplementation (MMS) for pregnant women, national governments are looking for additional analysis on the cost and cost–benefit of this nutrition intervention. Nutrition International's MMS cost–benefit tool is an evidence‐based, open‐access, and dynamic tool designed for governments and their partners to inform policy decisions and investments into MMS as part of maternal nutrition programming. The MMS cost–benefit tool uses a rigorous methodology to estimate the potential health impact, budget impact, economic value, cost‐effectiveness, and benefit‐cost ratio of investing in MMS compared to IFAS for 33 LMICS and has the capability to conduct custom analysis. The MMS cost–benefit tool's analysis demonstrates that investing in MMS compared to IFAS for antenatal care programming is consistently cost‐effective in LMICs and the long‐term economic value of health benefits generated by MMS far outweighs the costs.