What will it take to close the prenatal vitamin gap?

Access to maternal nutrition – or lack thereof – closely tracks global economic disparities: while mothers in high-income countries routinely take prenatal vitamins, those in low and lower-middle-income countries like Nigeria often lack this basic care. Micronutrient deficiencies affect approximately two-thirds of women of reproductive age worldwide, with pregnant women especially vulnerable in settings where access to diverse, nutrient-rich diets is limited. This inequity contributes to approximately 295,000 preventable maternal deaths and millions of preventable infant deaths annually.

Anemia during pregnancy, often caused by iron, folate, and/or vitamin B12 deficiencies, results in low red blood cell levels, compromising oxygen delivery to both the mother and the developing baby. Globally, 37% of pregnant women suffer from anemia, increasing the risk of maternal mortality as well as low birth weight and lifelong health complications for babies. Prenatal vitamins (more formally referred to as multiple micronutrient supplements, or MMS) effectively address micronutrient deficiencies, yet getting them to the women who need them most remains a significant barrier.

In September 2024, Evidence Action launched a pilot program across 90 Nigerian healthcare facilities to help prevent nutrient deficiencies including anemia and improve health outcomes for mothers and babies. Through our Accelerator, this is our first practical application to understand delivery challenges for MMS – a single daily tablet containing 15 essential vitamins and minerals designed specifically for pregnant women. MMS costs approximately $2.13 per woman for the full WHO-recommended 180-day course. Given its low cost and high efficacy, researchers have identified the intervention as a 'global best investment,’ yielding an estimated $37 economic return for every $1 invested.

The critical nutrients many mothers never get

A mother's nutritional status directly determines her health during pregnancy while profoundly influencing her child's development. Half of all childhood stunting originates during the critical 500 days between conception and 6 months of age, yet women's nutrition during this period remains neglected. No region is on track to meet the 2030 global targets to halve anemia or reduce low birthweight by 30%.

Maternal nutrition and gender equality are inextricably linked, with malnutrition undermining women's health, economic potential, and autonomy. This creates a cycle of disempowerment that spans generations. Studies show that MMS – which include vitamins A, B, C, D, E, and B12, as well as iron, zinc, iodine, and folic acid – can significantly improve maternal and child health outcomes. Compared to iron and folic acid supplementation, which has long been a recommended prenatal intervention to prevent anemia and support fetal development, MMS has been shown to reduce low birth weight by 12% and small-for-gestational-age births by 8% when compared with iron and folic acid supplementation.

The situation is particularly acute in countries with high maternal mortality rates and widespread food insecurity like Nigeria, which accounted for nearly 20% of all global maternal deaths in 2019. Additionally, maternal nutrition challenges may be increasingly complicated by climate change impacts. A recent assessment warns that 33 million Nigerians, including millions of children and pregnant or breastfeeding women, will face acute food insecurity in 2025 due to economic hardship, climate change, and conflict. With this convergence of challenges threatening to further compromise maternal and child health outcomes, micronutrient supplementation becomes critical as a safety net ensuring pregnant women receive essential nutrients regardless of environmental conditions.

Introducing MMS presents an opportunity to evaluate access to prenatal supplements by assessing existing health facilities, supply chains, and data systems to identify any weaknesses that prevent women from using supplements and taking the full course – what we call adherence.

Designing a radically practical approach informed by research

Our approach is not just about knowing what works – it’s about making it work within real-world constraints, at a scale that reaches every mother who needs it.

To ensure our pilot would be both contextually relevant and scalable, we conducted formative research on the obstacles and supporting factors that influence pregnant women's use of and adherence to iron and folic acid supplementation, the current standard of care for pregnant women in Nigeria. Our pilot leverages existing infrastructure for delivering iron and folic acid supplementation – encouragingly found to already be distributed in 95% of health facilities we assessed – to effectively deliver MMS.

Our assessment determined key access barriers and adherence challenges:

• Inconsistent protocols and training: Only 40% of facilities have received training on iron and folic acid supplementation, with significant variation in testing and treatment protocols for maternal anemia. Anemia testing is needed to identify women who need extra iron in addition to MMS, but was found to occur  in just 54% of prenatal visits, leaving many cases undiagnosed.
• Stock management challenges: Inconsistencies in products and inventory management practices across facilities disrupt supply.
• Low attendance: Nearly half of pregnant women make only 2-3 of the recommended 8 antenatal care visits during pregnancy, often starting after 20 weeks. This irregular attendance reduces the likelihood of consistent supplement use, limiting its impact..
• Financial barriers: 70% of facilities charge fees for prenatal services, creating significant obstacles to care, especially for those most likely to need it.

The model of requiring monthly prenatal care visits has posed challenges for decades, given the low number of visits most pregnant women can make. Instead of requiring behavioral shifts from pregnant women, our pilot design adapts to their realities with distribution methods that prioritize affordability and feasibility.

• Full supply upfront: We provide all 180 MMS tablets at the first visit, recognizing that many women will not return monthly.
• Streamlined protocols: We provide clear guidance for healthcare workers on using MMS to prevent maternal anemia, in addition to screening and treating maternal anemia with extra iron.
• Tailored adherence tools: We selected four key interventions to test whether they help women remember to take their supplements daily: counseling flip charts, phone alarm reminders, SMS messages, and paper calendars, based on focus groups with pregnant women and healthcare workers.

Our research revealed that most pregnant women, both in urban and rural areas, had access to mobile phones and were comfortable receiving SMS reminders about their supplements, particularly in the morning hours. Paper calendars were also a popular choice among both healthcare workers and pregnant women, especially in rural settings. Additionally, phone alarm reminders were identified as a low-cost and user-friendly option for promoting adherence. Counseling flip charts were also well-received by healthcare workers, who felt they aided in explaining the benefits of supplements clearly and engagingly.

Several interventions were ruled out due to low preference and feasibility concerns. These included home or group visits by model mothers, group visits by community health workers or traditional birth attendants, WhatsApp groups, and interactive SMS.

Beyond supplements: strengthening maternal health systems

In addition to piloting delivery, we are using this initiative to tackle systemic barriers identified in our research, collaborate with the government to align Nigeria’s national guidelines with global best practices for MMS distribution and anemia care, train healthcare workers, and support adherence. By embedding our pilot within the existing healthcare infrastructure and collaborating with local stakeholders, we aim to design a sustainable program that leads to increased MMS use, improved adherence, and ultimately, a decrease in maternal anemia and adverse birth outcomes.

To effectively implement this pilot and prepare for potential scale-up, we are:

• Training healthcare workers on MMS initiation, side effects, counseling, and reporting
• Reinforcing anemia screening protocols at 1st, 26-week, and 36-week visits per updated WHO guidelines
• Establishing standardized treatment protocols for mild, moderate, and severe anemia
• Introducing MMS as a single tablet to simplify the prevention regimen (versus separate iron and folic acid tablets)
• Improving stock management practices through better tracking and monitoring
• Exploring technical solutions like obtaining hemoglobinometers for improved anemia screening and triaging

We are also conducting A/B testing to determine which program elements deliver the most value for their cost. This includes evaluating whether paper calendars – favored by women but pricier than other tools – improve adherence enough to justify their cost compared to other modalities, reflecting our commitment to creating interventions that balance impact with affordability.

Applying what works, where it’s needed most

By rigorously identifying the most impactful and cost-effective program components that can be easily delivered, we are developing a model that governments can adopt and sustain nationwide. Our research across healthcare settings confirms what matters most isn't just what we provide, but how we provide it. By centering perspectives of local women and healthcare workers, interventions can gain traction because they're designed with real lives and constraints in mind. Recognizing that addressing maternal nutrition requires collaborative action, we are committed to working with governments, healthcare providers, and communities to ensure every woman has access to essential nutrients during pregnancy.

The benefits can cascade through generations. This care doesn't have to be complicated or expensive – it just has to reach the women who need it. Our pilot takes a new approach that is grounded in the realities of women's lives and designed to achieve lasting change. The results will provide insights into program management, stock management, counseling practices, anemia screening, and adherence, informing a blueprint for wider scale-up.

Next, we are exploring pathways to scale in Tanzania, Liberia, and Cameroon – countries where mothers face equally urgent nutritional challenges. It's time to scale what works, where it's needed most – because no mother should die, and no baby should suffer from a preventable vitamin deficiency.