This document aims to provide guidance to country-level decision-makers who are interested in introducing MMS for pregnant women in ANC programs. The guidance provided in this document is contextualized to the 2020 update to the WHO antenatal recommendations for a positive pregnancy experience, nutritional interventions update: Multiple micronutrient supplements for pregnancy.
Dietary counseling for healthy eating and appropriate weight gain
Counseling about healthy eating and keeping physically active during pregnancy is recommended for pregnant women to stay healthy and prevent excessive weight gain during pregnancy. Specifically, in undernourished populations, nutrition education on increasing daily energy and protein intake is recommended for pregnant women to reduce the risk of low birth-weight newborns.
Effective, at-scale social and behavior change communication (SBCC) campaigns – grounded in the local context – can be used at the population, facility, and individual level to strengthen nutrition counseling and improve the uptake of and compliance with all maternal nutrition interventions.
The UNICEF technical programme brief on Counselling to improve maternal nutrition aims to improve the coverage and quality of nutrition counseling before and during pregnancy and while breastfeeding.
Create an enabling environment to support implementation research.
To ensure the long-term success of efforts to incorporate MMS into healthcare systems, creating an enabling environment is an essential first step during which national stakeholders (e.g., champions, influencers, and decision-makers) are identified and engaged to
i) raise awareness about MMS and advocate for its use;
ii) facilitate an understanding of the evidence as it relates to the benefits of MMS over IFA, and a consensus around the evidence and about what issues may need further examination (e.g., issues related to supply and demand) in a national program to ensure sustainability and impact; and
iii) develop a consensus on the need, feasibility, and plan to introduce MMS.
Analyze key determinants of anemia.
Given the variable etiologies of anemia, countries should analyze data on the magnitude and distribution of anemia and its determinants (e.g. iron and other micronutrient deficiencies, malaria or soil-transmitted helminthic (STH) infections). Where malaria and STH infections are endemic and anemia is a severe public health problem (≥40% among pregnant women), measures to prevent, diagnose and treat these infections should be implemented concomitantly with MMS as per the WHO and/or national ANC guidelines.
Introduce MMS as part of comprehensive ANC
The updated WHO guideline offers an opportunity for countries to introduce MMS as part of a strategy to improve the access to and quality of nutrition services in ANC. The WHO guideline recommends that women have eight ANC contacts, including those through the community, potentially offering additional opportunities to deliver MMS. Countries should undertake an analysis of ANC barriers based on which effective strategies can be identified to improve ANC services and MMS coverage/adherence, thereby forming the basis of implementation research. In some countries, there may be opportunities to test the use of MMS as part of social protection schemes and market-based approaches.
Ensure uninterrupted quality MMS supplies
Ensuring an uninterrupted and quality supply of MMS is necessary for women to harness its benefits. Countries should undertake a supply chain analysis to identify and remove impediments to MMS access at health facilities especially where IFA stockouts are routinely reported. Some countries may be interested in establishing local manufacturing capacities for MMS for which an analysis of local production capacities and regulatory aspects of MMS is important. Where local production is not feasible, understanding the regulatory landscape can help to identify barriers and solutions to facilitate MMS importation.
Strengthen health worker capacities to effectively deliver, counsel, and support women to receive and consume MMS.
Investing in the training of the health workers is essential for a smooth transition from IFA to MMS. Improving the quality of nutrition counseling and communications is also key to ensuring effective distribution and adherence to MMS. This includes training health workers and community workers on the benefits of MMS, managing side effects, and strategies on how to remember to take MMS daily throughout pregnancy, along with counseling on nutritious diets.
Counsel women and adolescent girls, and key influencers on the importance of MMS and nutritious diets in pregnancy.
Ensuring pregnant women and adolescent girls have an enabling environment that supports MMS use is critical. This requires attention to social behavior change communications, which are tailored to the specific needs of pregnant women and adolescent girls and key influencers (e.g. 6 husbands, mothers-in-law, grandmothers, and community members) on the importance of nutritious diets, including the routine use of MMS. Formative research can be instrumental in identifying social and cultural barriers, social norms, and key influencers to target and overcome issues of MMS and can be used to promote acceptance and adherence that may affect MMS uptake.
Identify and treat anemic pregnant women and adolescent girls.
A critical component of ANC is routine screening and treatment of anemic women. The WHO guideline recommends routinely testing women for anemia at ANC contact 1 (12 weeks), 3 (26 weeks), and 6 (36 weeks), and treating women with low hemoglobin as per the WHO and/or national protocols.
Integrate MMS coverage into routine monitoring systems
Many administrative reporting systems such as health management information systems (HMIS) collect information on the provision of iron-containing supplements to pregnant women during ANC contacts. Increasingly this information is integrated into District Health Information Systems. In countries introducing MMS, it is imperative that MMS monitoring is integrated into the HMIS. Furthermore, there may be opportunities to introduce MMS monitoring into health facility assessments and household surveys (e.g. Demographic Health Surveys).
The recent inclusion of a great step forward in encouraging governments and development agencies to step up and explore the feasibility and efficiency of introducing MMS through antenatal care (ANC) services, but more must be done.