This ‘Call to Action’ reflects the collective expertise, experiences, and recommendations of delegates from across Africa, developed during the 2nd Africa Maternal Nutrition and MMS Technical Meeting, held in Nairobi, Kenya, in October 2024. Grounded in evidence-based discussions and enriched by diverse regional perspectives, it charts a shared path for accelerating the adoption and scale-up of maternal nutrition interventions, notably MMS as a part of essential antenatal care services to improve maternal and child health outcomes in Africa.

Adverse birth outcomes particularly preterm births and congenital anomalies are the leading causes of infant mortality globally, and the burden is highest in developing countries. We set out to determine the frequency of adverse birth outcomes and the risk factors associated with such outcomes in a cohort of pregnant women in Kenya. From October 2017 to July 2019, pregnant women < 28 weeks gestation were enrolled and followed up until delivery in three hospitals in coastal Kenya. Newborns were examined at delivery. Among women with birth outcome data, we assessed the frequency of congenital anomalies defined as gastroschisis, umbilical hernia, limb abnormalities and Trisomy 21, and adverse birth outcomes, defined as either stillbirth, miscarriage, preterm birth, small for gestational age, or microcephaly. We used log-binomial regression to identify maternal characteristics associated with the presence of at least one adverse outcome. Among the 2312 women enrolled, 1916 (82.9%) had birth outcome data. Overall, 402/1916 (20.9%; 95% confidence interval (CI): 19.1–22.8) pregnancies had adverse birth outcomes. Specifically, 66/1916 (3.4%; 95% CI: 2.7–4.4) were stillbirths, 34/1916 (1.8%; 95% CI: 1.2–2.4) were miscarriages and 23/1816 (1.2%; 95% CI: 0.8–1.9) had congenital anomalies. Among the participants with anthropometric measurements data, 142/1200 (11.8%; 95% CI: 10.1 − 13.8) were small for gestational age and among the participants with ultrasound records, 143/1711 (8.4%; 95% CI: 7.1–9.8) were preterm. Febrile illnesses in current pregnancy (adjusted risk ratio (aRR): 1.7; 95% CI: 1.1–2.8), a history of poor birth outcomes in prior pregnancy (aRR: 1.8; 95% CI: 1.3–2.4) and high blood pressure in pregnancy (aRR: 3.9, 95% CI: (1.7–9.2) were independently associated with adverse birth outcomes in a model that included age, education, human immunodeficiency virus status and high blood pressure at enrolment. We found similar rates of overall adverse birth outcomes, congenital anomalies, and small for gestational age but higher rates of stillbirths and lower rates of prematurity compared to the rates that have been reported in the sub-Saharan Africa region. However, the rates of adverse birth outcomes in this study were comparable to other studies conducted in Kenya. Febrile illnesses during the current pregnancy, previous history of poor birth outcomes and high blood pressure in pregnancy are predictive of an increased risk of adverse birth outcomes.

There is growing evidence that the provision of nutritious supplemental foods to undernourished pregnant women can improve maternal and infant outcomes. However, comparing and synthesizing the evidence base is complicated by differences in interventions and products and the use of ambiguous terminology. We aimed to define 2 common types of nutritious supplemental foods used in pregnancy, balanced energy-protein (BEP) supplements and lipid-based nutrient supplements (LNS), and to review the evidence supporting each via a narrative review of systematic reviews and meta-analyses (SRMAs). Information about the nutritional composition of the food supplements and their effects on maternal and infant outcomes was abstracted. Five SRMAs (n ¼ 20 trials) evaluated the effect of BEP compared with no BEP/ control (comparison group commonly received iron and folic acid [IFA]). BEP foods/products ranged in calories (118–1017 kcals), protein (3–50 g), fat (6–57 g), and micronutrient content. Overall, maternal BEP improved birth weight and reduced the risk of stillbirth and small for gestational age when compared with no BEP/control in pregnancy. Three SRMAs (n ¼ 5 trials) evaluated the effect of LNS compared with IFA or multiple micronutrients (MMNs). The LNS interventions comprised small- and large-quantity LNS that ranged in calories (118–746 kcals), protein (3–21 g), fat (10–53 g), and micronutrient content. LNS compared with IFA increased pregnancy duration, birth weight, and birth length and reduced the risk of small for gestational age and infant stunting; however, no beneficial effect of LNS was identified when compared with MMN. Despite heterogeneity in the nutritional composition of BEP supplements, the evidence suggests that in nutritionally at-risk populations, these products may improve birth outcomes in pregnant women. The evidence is limited but promising when LNS is compared with IFA in improving maternal and infant outcomes. Overall, BEP, compared with MMN or LNS, are key areas that have not been studied and deserve attention.

Iron and folic acid (IFA) supplements are currently provided to Cambodian women during pregnancy. However, recent research has found benefits of a multiple micronutrient supplement (MMS) over just IFA alone on several outcomes of perinatal and infant health. The Ministry of Health in Cambodia has proposed a transition from IFA to MMS but to effectively guide this transition requires implementation research on the acceptability and adherence to MMS (over IFA). This noninferiority trial aims to assess the adherence and acceptability of IFA (60mg elemental iron and 400μg folic acid) compared to MMS (standard UNIMMAP formulation including 15 micronutrients) during ante‑ natal care in Cambodia. A prospective cohort of 1545 pregnant women will be assigned to one of three trial arms: (1) IFA for 90days [IFA90]; (2) MMS for 180days with two distributions of 90count tablet bottles [MMS90]; or (3) MMS for 180days with one 180count tablet bottle [MMS180]. Each arm will enroll 515 women across 48 health centers (clusters) in Kampong Thom Province in Cambodia. The primary outcome is the noninferiority of adherence rates of MMS180 compared to IFA90, as assessed by tablet counts. Mixed effects logistic and linear regression models will be used to estimate the difference in the adherence rate between the two groups, with an ‘a priori’ determined noninferiority margin of 15%. Acceptability of MMS and IFA will be measured using a quantitative survey conducted with enrolled pregnant women at 30day, 90day, and 180day timepoints. Findings from this study will guide an effective and feasible MMS scaleup strategy for Cambodia. Additionally, the findings will be shared globally with other stakeholders planning to scale up MMS in other countries.

Antenatal balanced energy and protein (BEP) supplements have well-documented benefits for pregnancy outcomes. However, considerable practical gaps remain in the effective and cost-effective delivery of antenatal BEP supplements at scale in low- and middle-income countries. A randomized effectiveness study will be conducted in two sub-cities of Addis Ababa, Ethiopia, to evaluate the effectiveness, cost-effectiveness, and implementation of different targeting strategies of antenatal BEP supplements. Pregnant women aged 18 to 49, with a gestational age of 24 weeks or less, and attending antenatal visits in one of the nine study health facilities are eligible for enrollment. In six of the health facilities, participants will be randomized to one of three study arms: control (Arm 1), targeted BEP provision based on baseline nutritional status (Arm 2), and targeted BEP supplementation based on baseline nutritional status and monthly gestational weight gain (GWG) monitoring (Arm 3). In the remaining three facilities, participants will be assigned to universal BEP provision (Arm 4). Participants in Arms 2 and 3 will receive BEP supplements if they have undernutrition at enrollment, as defined by a baseline body mass index less than 18.5 kg/m2 or mid-upper arm circumference less than 23 cm. In Arm 3, in addition to targeting based on baseline undernutrition, regular weight measurements will be used to identify insufficient GWG and inform the initiation of additional BEP supplements. Participants in Arm 4 will receive BEP supplements until the end of pregnancy, regardless of baseline nutritional status or GWG. All participants will receive standard antenatal care, including iron and folic acid supplementation. A total of 5400 pregnant women will be enrolled, with 1350 participants in each arm. Participants will be followed up monthly during their visits to the antenatal facilities until delivery. Maternal and infant health status will be evaluated within 72 h after delivery and at 6 weeks postpartum. The effectiveness and cost-effectiveness of the different BEP targeting strategies in preventing adverse pregnancy outcomes will be compared across arms. Qualitative data will be analyzed to assess the feasibility, acceptability, and implementation of different supplementation strategies. Discussion This study will inform global recommendations and operational guidelines for the effective and cost-effective delivery of antenatal BEP supplements. The targeted approaches have the potential for broader scale-up in Ethiopia and other low-resource settings with a high burden of undernutrition among pregnant women.

Balanced energy and protein (BEP) dietary supplementation is an evidence-based intervention to improve the nutrition of mothers and babies, particularly in food-insecure settings where access to healthy diets and antenatal care services is limited. Adequate nutrition during pregnancy is critical to support the growing fetus, safeguard maternal health, and reduce the risk of complications such as babies born too small, or with low birthweight. Providing BEP dietary supplementation to pregnant women offers a safe and effective way to provide additional energy and nutrients to meet the increased demands of pregnancy.

The MMS in Pregnancy Technical Advisory Group (MMS TAG), hosted by the Healthy Mothers Healthy Babies (HMHB) Consortium, commissioned this document to meet stakeholder demand for more guidance on the use of implementation science (IS), including rigorous implementation research (IR) across the phases of multiple micronutrient supplementation (MMS) program introduction and scale-up.

This guidance document complements the Framework for Country MMS Scale-up (Framework) that was set forth by a collaboration of donors — Kirk Humanitarian, the Bill & Melinda Gates Foundation (BMGF), the Children’s Investment Fund Foundation (CIFF), and the Eleanor Crook Foundation (ECF) — in their May 2024 publication, Healthier Pregnancies and Brighter Futures for Mothers and Babies: A global investment roadmap for multiple micronutrient supplementation. The Framework presents a generalized approach to MMS program introduction that can be adapted and applied by national governments and their partners. Additionally, it identifies key results and high-level actions and activities at each phase of MMS program introduction and scale-up, and champions using IS across the process.

This guidance document complements the Framework by explaining the rationale for using IS, the essential components of IS, and how IS can be applied across the pillars and phases defined in the Framework.

This guidance is aimed at national-level stakeholders who want to understand more specifically how IS can support efforts to introduce and scale MMS programming. These may include national or subnational MMS TAGs or task force members, government partners, implementing partners, research and academic partners, and/or private sector partners. It may be helpful to work through this guidance as a group.

The MMS in Pregnancy Technical Advisory Group (MMS TAG), hosted by the Healthy Mothers Healthy Babies (HMHB) Consortium, commissioned this document to meet stakeholder demand for more guidance on the use of implementation science (IS), including rigorous implementation research (IR) across the phases of multiple micronutrient supplementation (MMS) program introduction and scale-up.

This guidance document complements the Framework for Country MMS Scale-up (Framework) that was set forth by a collaboration of donors — Kirk Humanitarian, the Bill & Melinda Gates Foundation (BMGF), the Children’s Investment Fund Foundation (CIFF), and the Eleanor Crook Foundation (ECF) — in their May 2024 publication, Healthier Pregnancies and Brighter Futures for Mothers and Babies: A global investment roadmap for multiple micronutrient supplementation. The Framework presents a generalized approach to MMS program introduction that can be adapted and applied by national governments and their partners. Additionally, it identifies key results and high-level actions and activities at each phase of MMS program introduction and scale-up, and champions using IS across the process.

This guidance document complements the Framework by explaining the rationale for using IS, the essential components of IS, and how IS can be applied across the pillars and phases defined in the Framework.

This guidance is aimed at national-level stakeholders who want to understand more specifically how IS can support efforts to introduce and scale MMS programming. These may include national or subnational MMS TAGs or task force members, government partners, implementing partners, research and academic partners, and/or private sector partners. It may be helpful to work through this guidance as a group.

A collaborative of private philanthropies (the Bill & Melinda Gates Foundation, Children’s Investment Fund Foundation, Eleanor Crook Foundation, and Kirk Humanitarian) released a global investment roadmap designed to catalyze and prioritize action and investment in multiple micronutrient supplements (MMS). The plan presents an opportunity to reach at least 260 million women in 45 high-burden countries with MMS by the end of 2030, an ambition that would save more than 600,000 lives, improve birth outcomes for more than 5 million babies, and prevent anemia in over 15 million pregnant women. At a cost of just over $4 per pregnancy (a total cost of $1.1 billion over seven years – $720 million from donors and the remainder coming from domestic resources), the roadmap would translate to monumental health gains while directing coordinated efforts to strengthen and improve health systems and antenatal care services in parallel.

The MMS in Pregnancy Technical Advisory Group (MMS TAG), hosted by the Healthy Mothers Healthy Babies (HMHB) Consortium, commissioned this document to meet stakeholder demand for more guidance on the use of implementation science (IS), including rigorous implementation research (IR) across the phases of multiple micronutrient supplementation (MMS) program introduction and scale-up.

This guidance document complements the Framework for Country MMS Scale-up (Framework) that was set forth by a collaboration of donors — Kirk Humanitarian, the Bill & Melinda Gates Foundation (BMGF), the Children’s Investment Fund Foundation (CIFF), and the Eleanor Crook Foundation (ECF) — in their May 2024 publication, Healthier Pregnancies and Brighter Futures for Mothers and Babies: A global investment roadmap for multiple micronutrient supplementation. The Framework presents a generalized approach to MMS program introduction that can be adapted and applied by national governments and their partners. Additionally, it identifies key results and high-level actions and activities at each phase of MMS program introduction and scale-up, and champions using IS across the process.

This guidance document complements the Framework by explaining the rationale for using IS, the essential components of IS, and how IS can be applied across the pillars and phases defined in the Framework.

This guidance is aimed at national-level stakeholders who want to understand more specifically how IS can support efforts to introduce and scale MMS programming. These may include national or subnational MMS TAGs or task force members, government partners, implementing partners, research and academic partners, and/or private sector partners. It may be helpful to work through this guidance as a group.