Multiple-micronutrient supplementation: Evidence from large-scale prenatal programmes on coverage, compliance and impact

Abstract

Micronutrient deficiencies during pregnancy pose important challenges for public-health, given the potential adverse outcomes not only during pregnancy but across the life-course. Provision of iron-folic acid (IFA) supplements is the strategy most commonly practiced and recommended globally. How to successfully implement IFA and multiple micronutrient supplementation interventions among pregnant women and to achieve sustainable/permanent solutions to prenatal micronutrient deficiencies remain unresolved issues in many countries. This paper aims to analyse available experiences of prenatal IFA and multiple micronutrient interventions to distil learning for their effective planning and large-scale implementation. Relevant articles and programme-documentation were comprehensively identified from electronic databases, websites of major-agencies and through hand-searching of relevant documents. Retrieved documents were screened and potentially relevant reports were critically examined by the authors with the aim of identifying a set of case studies reflecting regional variation, a mix of implementation successes and failures, and a mix of programmes and large-scale experimental studies. Information on implementation, coverage, compliance, and impact was extracted from reports of large-scale interventions in Central America, Southeast Asia, South Asia, and Sub-Saharan Africa. The WHO/CDC Logic-Model for Micronutrient Interventions in Public Health was used as an organizing framework for analysing and presenting the evidence. Our findings suggest that to successfully implement supplementation interventions and achieve sustainable-permanent solutions efforts must focus on factors and processes related to quality, cost-effectiveness, coverage, utilization, demand, outcomes, impacts, and sustainability of programmes including strategic analysis, management, collaborations to pilot a project, and careful monitoring, midcourse corrections, supervision and logistical-support to gradually scaling it up.

Keywords: WHO/CDC logic-model; communication; community; large-scale implementation; micronutrients; pregnancy.

Figure 1

Outline of the methodological phases from screening titles/abstracts to selecting the final set of case studies. IFA = Iron‐Folic acid; MMN = Multiple Micronutrient

Figure 2

Conceptual framework of the WHO/CDC Logic‐Model for Micronutrient Interventions in Public Health highlighting indicators tied to expected intervention processes, as adapted from De‐Regil et al. (2014). The model is organised according to four main categories or components: Inputs: Resources invested in the intervention, including personnel, partnerships, politics and governance with different agendas, direct and indirect support from organizations, communities, and private sector, infrastructures, money, materials, and nutrition know‐out. Activities: Actions, events and processes of programme implementation such as developing protocols, passing legislation and regulation, designing production and supply delivery systems, engaging stakeholders, providing training, setting quality control systems, planning dissemination, education, counselling and advocacy communication strategies. Outputs: Direct effects or results of programme activities, such as procurement of annual supplies and availability of the supply in the country; staff trained and motivated to deliver and counsel participants on the intervention; availability of the intervention in communities or markets; and access and coverage to the intervention. Outcomes: Benefits or changes among target populations during or after the intervention in terms of the impact on both the micronutrient deficiency‐related issues (i.e., intake, nutritional status, morbidity and mortality, health functions), and the long‐term viability components (i.e., behaviours, knowledge, motivation, decision making, skills, individual/systemic/strategic/operational capacity etc.)