Multiple micronutrient supplements in pregnancy: Implementation considerations for integration as part of quality services in routine antenatal care. Objectives, results, and conclusions of the meeting.

Abstract Health promotion, screening, diagnosis, and disease prevention are essential services of quality routine antenatal care for pregnant adult and adolescent women. Supplementation programmes in pregnancy, generally implemented in the context of antenatal care services, have had less than optimal results in many countries, generally attributed to limited access, low coverage, and reduced adherence to the recommended regimens and counselling. The World Health Organization Department of Nutrition for Health and Development, in collaboration with the United Nations Children's Fund and Nutrition International, convened the technical consultation “Multiple micronutrient supplements in pregnancy: Implementation considerations for successful incorporation into existing programmes.” The objectives of the technical consultation were to (a) examine implementation experiences of micronutrient supplementation interventions in pregnant women, lessons learnt, and best practices; (b) discuss programmatic and technical considerations of interventions on multiple micronutrient supplementation in pregnant women in low‐, middle‐, and high‐income countries; and (c) identify implementation considerations that can be useful to scaling up efforts by national policymaker and their advisors considering multiple micronutrient supplementation in pregnant women as part of existing antenatal care programmes as well as other delivery platforms. The consultation was based on presentations of background papers, case studies, and plenary discussions. Country representatives were asked to discuss the context of micronutrient supplementation for their countries and share implementation challenges they faced. This paper provides the background and rationale of the technical consultation, synopsises the presentations, and provides a summary of the main considerations and conclusions reached during plenary discussions.


| INTRODUCTION
Globally, micronutrient malnutrition in pregnant women is widespread across regions and countries. It is estimated that approximately 32 million pregnant women are anaemic worldwide and 19 million suffer from vitamin A deficiency (Ahmed, Hossain, & Sanin, 2012;Muthayya et al., 2013;World Health Organization, 2015, 2016a. Vitamin and mineral deficiencies have been associated with pregnancy complications and poor birth and infant outcomes (Gernand, Schulze, Stewart, West, & Christian, 2016). It is calculated that approximately 20 million babies are born weighing less than 2,500 g at birth (low birth weight [LBW]), about 15 million are premature, and many more are born small for their gestational age, increasing their risk of morbidity and mortality during childhood (Seshadri, 2001;World Health Organization, 2014). In spite of the evidence supporting the efficacy of these interventions, supplementation programmes in pregnancy, generally implemented in the context of antenatal care (ANC) programmes, have had less than optimal results in many countries, including low intervention coverage and adherence. Reasons, among others, include women's limited access to routine and timely ANC due to geographic distance, reduced number of facilities and other gender-related factors affecting women's access to healthcare, including their beliefs and motivation about the daily use of the supplements and their own expectations of care (Bhutta et al., 2013;Risnes et al., 2011). In other settings, low motivation, poor interpersonal skills, and training of health staff have been limiting factors. Poor quality and insufficient supply of supplements, due to inadequate programme contextualization, may also affect programmes' success (Abu-Saad & Fraser, 2010; March of Dimes, 2012).
Owing to the increased needs of various vitamins and minerals during pregnancy, WHO remarks that IFA formulations may also include other vitamins and minerals in a MMN supplement. This intervention is being implemented in a few low-, middle-, and highincome countries and has also been the practice in emergency settings. There is evidence suggesting that there may be decreased risk of LBW and small-for-gestational age in comparison with IFA supplementation alone (Haider & Bhutta, 2017;Ramakrishnan et al., 2012). However, before considering the implementation of this nutrition intervention as part of routine ANC at large scale, particularly in low-and middle-income countries, it is necessary to examine key implementation considerations for helping interested parties to successfully incorporate this intervention into existing programmes.

| TECHNICAL CONSULTATION
The Evidence and Programme Guidance Unit, Department of Nutrition for Health and Development, WHO, in collaboration with the United Nations Children's Fund (UNICEF) and Nutrition International, convened the technical consultation "Multiple micronutrient supplements in pregnancy: Implementation considerations for successful incorporation into existing programmes," to examine the programmatic evidence, including successful implementation experiences, best practices, and lessons learnt, in order to inform the scale up of MMN supplementation during pregnancy as part of quality existing services in routine ANC programmes in these settings. The objectives of the technical consultation were to (a) examine implementation experiences of micronutrient supplementation interventions in pregnant women, lessons learnt, and best practices; (b) discuss programmatic and technical considerations of interventions on MMN supplementation in pregnant women in high-, middle-, and low-income countries; and (c) identify the needed implementation considerations that can be useful to scaling up efforts by member states considering MMN supplementation in pregnant women as part of existing ANC programmes as well as other delivery platforms.
Prior to this technical consultation, the Evidence and Programme Guidance Unit, launched a call for authors interested in preparing review papers on diverse topics related to the implementation considerations for the successful integration of MMN supplements in pregnancy into existing programmes. The papers and case studies reviewed technical areas and evidence gaps to provide policy makers with guidance on micronutrient supplementation interventions in pregnant women. Authors were requested to gather programmatic evidence including successful implementation experiences, best practices, and lessons learnt that could provide policy makers with

Key messages
• Micronutrient malnutrition persists among childbearing aged and pregnant women worldwide.
• Successful antenatal supplementation programmes require addressing policy, operational, and financial issues in addition to selecting an appropriate nutrition commodity, which should respond to the nutrition and health burden in pregnancy and post birth.
• Micronutrient supplementation during pregnancy can benefit from setting up or strengthening monitoring and surveillance systems.
• Creating awareness and knowledge about optimal nutrition before and during pregnancy augments the potential to beneficially impact pregnancy outcomes. the best available evidence to inform policies and programmes providing MMN supplements to pregnant women.
The topics requested in the call for authors included an overview of the major policy-related considerations related to IFA and MMN supplementation, including delivery platforms; the identification of the major cost-related concerns involved in introducing MMN and in transitioning from IFA to MMN; the production and procurement processes likely to be affected by a transition from IFA to MMN; the implications for demand creation identifying the mechanisms needed to introduce MMN or shift from IFA to MMN on a programmatic/ operational level when countries decide to introduce MMN;   The comprehensive implementation plan on maternal, infant, and young child nutrition aims to alleviate the double burden of malnutrition in children, starting from the earliest stages of development (World Health Organization, 2012. Substantial benefits can be obtained by concentrating efforts from conception through the first 2 years of life, but at the same time, a life-course approach needs to be considered so that good nutritional status can be maintained. Progress can be made in the short term, and most nutrition challenges can be resolved within the current generation (Bhutta et al., 2008). The best way is to set targets at country level, assess the resources available, ensure development policies and programmes include nutrition, create links between different sectors as well as different stakeholders, and develop and implement suitable monitoring and evaluation mechanisms.

| WHO ANC guidelines
Evidence-based, effective interventions, both nutrition specific and nutrition sensitive investments at the policy, health system, and community levels are needed. Some strategies should include identifying, scale-up coverage of prevention and treatment, developing strategic interventions, monitoring, and evaluating. Beyond these, there are other collaborative approaches, such as the 10 commitments of the FAO/WHO Second International Conference on Nutrition (ICN2), Every Woman Every Child, 1,000 days, Framework for Action, and the commitment of the member states in the last World Health Assembly.

| Overview of major policy-related considerations on IFA and MMN supplementation, including delivery platforms
The objective was to review existing policies (action plans, strategies, There were also some policies for adolescent girls and women in reproductive age. Twelve countries referred that supplementation helped prevent LBW (Pakistan, Yemen, India, Haiti, Bangladesh, Ethiopia, Mali, Nepal, Sri Lanka, Mozambique, Namibia, Nigeria).
Conclusions from this review indicated that 19 out of 20 countries had policies for IFA and that although four countries considered MMN an alternative to IFA, there was limited information on dose or supplement composition. The results also showed that ANC was the main delivery platform, and although community-based approaches existed, they were poorly implemented. The information on other delivery platforms, for example, child health checks or malaria prevention programmes, was limited.
3.6 | Micronutrient supplementation among pregnant women: A review of the evidence from largescale prenatal micronutrient programmes on factors contributing to success or failure in coverage, compliance, and impact This commissioned review aimed at gathering and review available experiences from large-scale prenatal micronutrient supplementation interventions in order to highlight factors, determinants, and conditions contributing to success or failure of interventions. Authors extracted information on implementation, coverage, compliance ,and impact from reports of large scale interventions in Central America, Southeast Asia, South Asia, and Sub-Saharan Africa. Findings suggested that to successfully implement supplementation interventions and achieve sustainable, permanent solutions efforts must focus on factors and processes related to quality, cost-effectiveness, coverage, utilisation, demand, outcomes, impacts, and sustainability of programmes including strategic analysis, management, collaborations to pilot a project, careful monitoring, mid-course corrections, supervision, and logistical support to gradually scaling it up (Berti, Gaffey, Bhutta, & Cetin, 2018).

| Planning tools for implementing evidenceinformed nutrition policies and programmes: GINA and the OneHealth Tool
The global database on the implementation of nutrition actions (GINA) is a database that contains more than 3,500 national nutrition-related policies and actions. It provides a repository of policy commitments made in relation to nutrition and lessons learnt from country implementations (http://www.who.int/nutrition/gina/en/). Research on health inequities is scarce, and systematic reviews do not report on health inequities very often, and although there are tools and methods to fill this gap, evidence-informed policy making will benefit from more research on inequities and from systematic reviews reporting the effects of inequities in outcomes. There are some proposed tools and methods to report health inequities in Barriers to timely access to IFA supplements were closely related to those for seeking ANC in the first trimester. Few women knew the importance of or saw value in seeking ANC during the first trimester.
Women in Ethiopia and Senegal expressed concern with revealing the pregnancy so early, because this could put the fetus at risk (Siekmans et al., 2018). Relational barriers to early ANC attendance were also related to social implications of revealing a pregnancy and the support of their husband and/or mother-in-law. Authors concluded that improved ANC access and quality is needed to facilitate MMN supplementation. Community-based delivery and counselling; behaviour change interventions to target women all ages, men, and health care providers; renewed investment; and efforts in prenatal supplementation are needed (Siekmans et al., 2018).
3.10 | SORT IT: The potential of operational research for nutrition programmes SORT IT is a tool for operational research with advocacy power, which aims to help countries to conduct operational research in accordance with their own priorities, to develop adequate and sustainable operational research capacity in public health programmes, and to create an organizational culture of policy and practice that is informed by operational research and leads to improved programme performance.

| A market-based approach to MMN interventions in Myanmar and Somaliland
Population Services International social marketing approach consisted in identifying health care market sectors; consumer segmentation; conduct formative research; and market strategy of products, pricing, placement, and promotion. At the moment of the technical consultation, they were finalizing training materials and launching social marketing campaigns and product procurement (Population Services International, 2015a, 2015b).
The presentation was a description of the programme characteristics and the ongoing development within the national policy in Somaliland and Myanmar contexts, together with the social marketing campaign, which included consumer profile generated from consumer insight and brand positioning statements of how MMN will be described and intended to be perceived by consumers.
3.14 | Situation analysis of production and procurement of MMN supplements in 12 low-, middle-, and high-income countries This paper presented a situation analysis of the market, manufacturing, and policy factors that were driving the production of MMN in 12 low-, middle-, and high-income countries. Key informants completed a self-administered structured questionnaire, which examined the local context of products available in the market and their cost, 3.17 | UNICEF supply division support programmes in quality assurance, logistics, and medicines and nutrients UNICEF supplies products to many countries worldwide and is committed to ensure the quality of the products it supplies. The UNICEF Quality Assurance system is based on standard operating procedures, international standards for quality assurance (including WHO good

| Countries' presentations
Each country participating in the meeting had the opportunity to present their scenario related to micronutrient deficiencies and what do they need in order to work together with the support of all the entities participating in this technical meeting.

| Tanzania
Recognised the need to create awareness to improve the demand from consumers, to create capital investment, and to improve nutrition technology to limit dependence on imported supplements.
They identified the need to improve human resources and strengthen regulatory frameworks.

| Nigeria
Prevalence of anaemia in children and women is around 50%.

| Uganda
The attendance to ANC is high; however, there is low adherence to supplementation programmes. There are also food fortification programmes in place (flour, oil, and salt). There is awareness about MMN; they have created a working group for anaemia, and comprehensive micronutrient deficiency guidelines are being finalised. There is intersectoral action with other interventions that affect health in general, such as mosquito nets, deworming, and supplementation.
The needs highlighted for Uganda were to improve communication about the importance and need for supplementation programmes and more research.

| Madagascar
In Madagascar, 47% of children under five suffer from malnutrition, and anaemia is the leading cause of maternal mortality. IFA coverage is 8% because 60% of people live far from a health facility. There is a need to strengthen the number and preparation of community workers to reach people who can't access or afford the supplements to be included in programmes.

| Panama
Prevalence of anaemia of 23% and ANC coverage of 96%. Ongoing programmes to deliver two tablets as ANC one combined folic acid and iron and other MMN locally produced. Population is concentrated in one city, many indigenous groups with strong cultural differences; this would be the strongest challenge.

| Indonesia
Population of 48 million, free ANC, 29% of compliance, with a long history of the IFA fortification programme. The main challenge in Indonesia is acceptability, because there is a gap between provision and consumption. They have tried MMN to see if it is more efficient than IFA in spite of the cost, but they face the same problems. MMN preparation) is already tested and may be adopted widely.

| CLOSING REMARKS
• Encouraging countries to consider the feasibility and convenience of including MMN supplements in their Essential Medicines List.
• Addressing trade and procurement barriers that may be impeding policy uptake.
• Strengthening and improving quality assurance and control mechanisms.
It was concluded there was a need for stronger programmatic emphasis on the following areas: • Equity: Improving the equitable access to nutrition interventions at the different stages of programme design, implementation, and evaluation is key to achieve successful programme outcomes.
• Behaviour communication interventions: Effective behaviour communication interventions are needed in order to strengthen ANC demand and quality and also to engage family or actors to support improved adherence (e.g., addressing men).
• Monitoring and cost/effectiveness evaluation. Micronutrient supplementation during pregnancy can benefit from setting up or strengthening monitoring and surveillance systems and to assess costs at the different stages of the supply chain (e.g., production, distribution, stock, and delivery to users). Assessing achievements and highlighting important learnings are key for effective planning and large scale implementation of interventions at public health level.
• Continuum of care. Women frequently reach pregnancy with micronutrient deficiencies. Implementing cost-effective interventions before pregnancy (e.g., women health and social empowerment, nutrition sensitive interventions, and nutrition specific interventions aimed at women) is a good strategy to improve maternal health and nutrition.
• Prioritise action plans according to the context. Countries can decide if they keep and strengthen their current IFA supplementation programmes or decide to transition to a MMN supplementation programme.
Finally, participants acknowledged that partnerships and good governance are key factors to making ANC programmes effective, coordinated, and successful. Intersectoral actions must be integrated with maternal child health interventions. Hence, it is essential to engage key stakeholders to gain political commitment and financial support.

CONFLICTS OF INTEREST
The authors declare that they have no conflicts of interest.

CONTRIBUTIONS
DE attended the technical meeting and presented a preliminary report of the meeting. MNGC wrote the first draft of the manuscript, attended the technical consultancy meeting, and finalised the manuscript. LMDR participate in the meeting preparation and review the manuscript. All authors approved the final version for publication.