Maternal nutrition has often been a neglected area and the global burden of maternal undernutrition in low-and middle-income countries remains staggeringly high. An estimated 450 million women have short stature, 240 million are underweight with a body mass index below 18.5, and 496 million are anaemic.
In addition to the deleterious effects on her own health, poor maternal nutrition also increases a mother’s chance of giving birth to a baby with low birthweight (LBW), small-for-gestational age, or preterm. If we fail to address maternal nutrition, the intergenerational cycle of malnutrition and its devastating consequences will persist.
Yet there is clear evidence that deficiencies in other micronutrients remain alarmingly high. For example, on average, 63% of women of reproductive age in LMICs are vitamin-D-deficient, 41% are zinc-deficient, and 40% are iodine-deficient.
After 20 years of successful research, there is a product that has proven far superior to IFA for improving birth outcomes. Multiple micronutrient supplements contain a combination of 15 vitamins and minerals – including iron and folic acid – which all play a critical role in the growth and development of the baby. As of today, only around 3% of pregnant women in LMICs have access to MMS in a handful of countries.
Rochona, a Bangladeshi woman, is a 28-year-old mother of two. She started taking MMS when she was three months pregnant with her son. Rochona says she was glad to continue investing the 180 taka – around $2 – per month per box once she noticed the changes in herself. She claims that she felt less tired, did not have any issues with her appetite, and there was not a single day during her pregnancy where she fell ill, unlike her first pregnancy with her daughter, when she did not take MMS. Her son, Ali Hamza, was born at a healthy weight.
How many more years of research are needed for a policy change?
Every year, around 20 million babies, or approximately 15%, are born LBW. There is great potential to reduce this high burden of LBW, if LMICs transition from provision of IFA to MMS for pregnant women.
Since 1968, the World Health Organization has recommended IFA as the standard of care for pregnant women, with consistent data showing low levels of compliance.
For the first time, in July of this year, WHO updated its guidelines to recommend MMS in the context of “rigorous research.” While this is a positive step in the right direction, the recommendation has raised the concern of the ethical imperatives of delaying life-saving MMS implementation versus the need for investing in years and years of research.
Given that the science for MMS is so clear and compelling, and its safety established, one wonders how many more years of research are needed to trigger policy change. As it is almost impossible for pregnant women to meet their high micronutrient needs with diet alone, in high-income countries it is normal for women to take MMS during pregnancy. In today’s world – where we can have at least one COVID-19 vaccine developed and ready for uptake within a year – it should be possible to recommend MMS as part of comprehensive maternal nutrition.
As former World Bank President Jim Yong Kim said: “The world has invested too much in what to deliver and too little in how to deliver it, with the result that ‘it’ often fails to reach and benefit people.”
A change in WHO guidelines to a universal recommendation for MMS in LMICs could help accelerate the switch and create momentum.
One of the potential barriers for not definitively recommending MMS over IFA is cost.
Bundling 15 micronutrients will inherently come at a higher cost than a product that only contains two micronutrients. However, cost-benefit analyses have shown that the long-term economic benefits of transitioning from IFA to MMS far outweigh the initial cost.
There are already agencies, such as Kirk Humanitarian, that have been able to demonstrate cost parity of MMS with IFA at scale. Importantly, as more countries make the switch from IFA to MMS and volumes increase, cost will gradually come down at near parity with IFA.
Using evidence to champion change at scale
The updated WHO guidelines create an opportunity for champion countries with a high burden of LBW and maternal anaemia to step forward and make the policy decision for themselves to switch from IFA to MMS. Several early-adopter countries are already doing it.
Bangladesh has the highest prevalence of LBW in the world. As the forerunner, its government, led by the National Nutrition Services/Institute of Public Health Nutrition of the Ministry of Health and Family Welfare, has led and initiated discussions on MMS with key partners, including academia and the private sector.
The Children’s Investment Fund Foundation, the Global Alliance for Improved Nutrition, Social Marketing Company, and Sight and Life are working together with partners to set up a sustainable business model for MMS through pharmacy networks in Bangladesh. The aim of the investment is to make MMS affordable, available, and desirable to every pregnant woman in the country by 2025.
This is not the first time that Bangladesh is championing a low-cost public health solution. Bangladesh pioneered oral rehydration salts and zinc and subsequently has among the world’s highest coverage of both ORS and zinc. This has contributed to a large reduction in childhood diarrhoea deaths over the past several decades.This success reflects a range of factors, including strong political leadership and commitment by government, a thriving marketplace, domestic production, and large-scale concerted awareness raising.
To help guide countries make the switch, Sight and Life has published a report on MMS, which compiles the latest evidence, case studies from nine countries, and practical resources for scale-up.
It is not often that the global nutrition community has a product that holds such great potential for breaking the intergenerational cycle of malnutrition. We cannot afford to wait, when the global burden of maternal undernutrition remains so high and millions of babies continue to be born LBW.
It’s time that an MMS policy recommendation is made for all pregnant women in LMICs. MMS policy change is a matter of taking science to scale; it’s a matter of equity; and it’s an opportunity to place maternal nutrition at the centre of antenatal care. Let’s not fail our mothers.
(Dr. Sufia Askari is the director of child health and development at the Children’s Investment Fund Foundation. Sarah Gibson is a program officer on the child health and development team at the Children’s Investment Fund Foundation. Dr. Rudaba Khondker is the country director of the Global Alliance of Improved Nutrition in Bangladesh).
