Maternal nutrition plays a pivotal role in the health and wellbeing of both mothers and their children, breaking vicious cycles of intergenerational malnutrition and paving the way for a brighter, healthier future. As the National Coordinator for the Nutrition and National Fortification Alliance in the Ministry of National Health Services Regulations and Coordination (NHSR&C) I’ve seen firsthand the transformative power of investing in maternal health and nutrition. Well-nourished women have the potential to actively contribute to their communities, while healthy infants and children, born to well-nourished mothers, are more likely to reach their full physical and cognitive potential and positively influence social and economic development. Pakistan faces staggering rates of malnutrition, with the country bearing the second-highest burden of neonatal mortality in the world.

The implementation of the Government of Pakistan’s (GoP) five-year National Maternal Nutrition Strategy (2022-2027) demonstrates our commitment to tackling this pressing issue. This comprehensive framework includes a key recommendation to implement multiple micronutrient supplementation (MMS) as part of comprehensive antenatal care (ANC) services for pregnant women. Antenatal MMS, a daily supplement containing 15 essential micronutrients that mothers require during pregnancy, has been shown to be equally as effective as iron and folic acid (IFA) supplementation in preventing maternal anaemia and more effective in improving birth outcomes. Following recent recommendations from the World Health Organization and to provide context specific research that will help guide a pathway to scale up, the government looked to Nutrition International’s technical and operational expertise to undertake implementation research. The GoP’s ultimate goal? To replace the long-standing use of IFA supplementation, which has not achieved the desired results during the past two decades, with MMS through ANC in 67 high burden districts of the National Nutrition Program.

Cognizant of the potential pitfalls of scaling up a new intervention too quickly, our joint efforts are focussing on conducting implementation research in Swabi district, Khyber Pakhtunkhwa, to help identify challenges that may arise during the transition from IFA to MMS; and to assess the population’s perception, acceptance and compliance of MMS, evaluating its feasibility and identifying any concerns and gaps that could be addressed. Additionally, switching from IFA to MMS is a complex process that involves careful consideration of a multitude of factors in order to establish MMS as the standard of care for ANC, including training healthcare providers, implementing behaviour change interventions and establishing effective monitoring and supply chain mechanisms.

For over two decades, Nutrition International has been a key ally to the government of Pakistan in the fight against malnutrition. Initially concentrating on food fortification, their support has expanded to bolstering government initiatives focused on child survival and maternal health. The organization’s effective interventions as well as strategic support to our government over the years firmly established Nutrition International as an expert in delivering technical assistance to effectively address these vital areas.

Using a health systems approach, Nutrition International helped us conduct a cost-effectiveness analysis to determine whether antenatal MMS is a better option as an alternate to IFA in Pakistan’s unique context. Using the MMS Cost Benefit Tool, we were able to test scenarios and run custom analyses that enabled us to make a case that antenatal MMS is better value for money in Pakistan. Following this, an evidence translation workshop was convened with key stakeholders to discuss the findings of the analysis, the recent evidence on MMS, the 2020 WHO recommendation and galvanize support for implementation research on MMS. As a result, a Technical Working Group was established under the leadership of Nutrition Wing of Ministry of NHSR&C, which brought together key nutrition partners and stakeholders in Pakistan to provide guidance and supervision for the MMS implementation research project, as well as help define the research questions to be examined. There were many relevant research questions when considering the transition, however, the Technical Working Group utilized an evidence-based prioritization exercise to decide upon the following:

1. What implementation approaches could be used to enhance the delivery of ANC nutrition services and introduce antenatal MMS to replace IFA supplementation for pregnant women in Pakistan?
2. Does implementation of these enhanced approaches increase pregnant women’s adherence to MMS? If so, how?

To investigate these questions, we adopted a phased approach using mixed methods. First, MMS had to be introduced into the ANC platform in Swabi district, the project’s pilot area. This provision of bottles of MMS is available at government health facilities, through Lady Health Workers and Community Midwives.

Phase one began with a comprehensive situational analysis that delved into the landscape of existing ANC service delivery programs, platforms, stakeholders, and the availability of both IFA supplements and MMS across the country. Additionally, research was conducted to gain insight into the perspectives, beliefs of pregnant women, their families and healthcare providers. Phase two used participatory research to develop a set of enhanced implementation approaches to support healthcare providers when they deliver MMS as part of their maternal nutrition services. This set of tools and techniques focuses on strengthening nutrition counselling, supportive supervision and family engagement and are designed to help women take MMS every day of their pregnancy.

In the final phase, we are now evaluating the effectiveness of these approaches in terms of increasing adherence to MMS among pregnant women. Outcome, process and cost-effectiveness evaluations have been designed to answer this question and are currently underway. The outcomes of this phase will shape decision-making and practices relating to maternal nutrition services and MMS not only in Swabi district, but nationwide.

The transition to MMS in Pakistan presents an opportunity for us to accelerate country and global level progress towards several Sustainable Development Goals and World Health Assembly Global Nutrition Targets 2025. This implementation research is helping us better understand how to strengthen our ANC platform to better serve pregnant women and consider the myriad of factors that influence their adherence. I am confident this project will help us move towards smart, sustainable MMS scale up and ultimately improve the health and wellbeing of women and children in Pakistan for generations to come.

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