1 2 Facilitate dialogue amp create consensus View these slides as a resource for anyone wanting to communicate the evidence and benefits of MMS for pregnant women and their babies Our goal is to equip the presenter of these slides with key messages that can be delivered to decision makers or t ID: 934817
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Slide1
Advancing Multiple Micronutrient Supplementation
1
Slide22
Facilitate dialogue & create consensusView these slides as a resource for anyone wanting to communicate the evidence and benefits of MMS for pregnant women and their babies. Our goal is to equip the presenter of these slides with key messages that can be delivered to decision makers or to those considering piloting, scaling, and implementation of MMS.
Customize dialogue
Speaker notes are provided with each slide, but they are not intended to be read word-for-word. Tailor and add your own speaking notes to make this relevant for your audience.
ADAPT to Your Audience
Content in red font should be tailored, then updated to black font. Slides labeled ‘National impact and investment case’ should be tailored with data and statistics from your country and made relevant for your audience. Slides or entire sections can be removed or re-ordered. Additional resources can be found at the end of the presentation.
How to use this slide deck
We’d like to hear from you! Contact
HMHBConsortium@micronutrientforum.org if you have questions or would like additional support.
Slide33
Advocates & Public Health ProfessionalsSuggested sections include A-E
National health officials & NGOS
Suggested sections include A-E
Research & Academia
Suggested sections include B-D
Audiences for this slide deck
Local providers & DistributorsSuggested sections include B
This presentation provides an overview of maternal nutrition and the evidence on multiple micronutrient supplements (MMS), providing key messages and slides that can be tailored with country-specific data to support the introduction, piloting, and scaling of MMS. You may wish to include (or omit) specific sections of the presentation. Suggested sections for each audience are included here. See the section descriptions on Slide 5.
Slide4Meeting Objectives
Optional slide to add meeting agenda and/or objectives
4
TEMPLATE to be adapted. Remove this box once updated.
Slide5Slides 19 - 24
Slides 25 - 37
Slides 38 - 45
Slides 46 - 61
B. Global scope of maternal malnutrition
C. Evidence on multiple micronutrient supplements
D. National impact and investment case
E. Introducing and scaling MMS
Sections
5
A. Pregnancy and nutrition
Slides 6 - 18
Slide6Pregnancy and nutrition
Slide7Good nutrition is important – especially during pregnancy
Pregnancy increases a woman’s energy,
protein
, and
micronutrient
needs.Average increase of 300 calories per day due to the rapid growth and development that occurs.
7
Source:
Kominiarek
et al. 2017.
Nutrition recommendations in pregnancy and lactation
. Med Clin North Am.
Slide8Micronutrients are critical for mothers
8
Source: Bourassa et al. 2019.
Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries
. Annals of the New York Academy of Sciences.
Pregnant women in low- and middle-income countries (LMICs) are at increased risk of being deficient in multiple, critically important, micronutrients:
Vitamins: A, C, D, E, B1 (thiamine), B2 (riboflavin), B3 (niacin), B6, B12, folic acid
Minerals: iron, zinc, iodine, copper, and selenium
Slide9Micronutrients are critical for their babies
Inadequate nutrition can lead to critical health risks to the infant, such as: low birth weightpre-term delivery being born small for gestational age
Poor nutrition can also lead to serious maternal health outcomes and even to the death of the mother or her baby.
9
Source:
Kominiarek
et al. 2017.
Nutrition recommendations in pregnancy and lactation
. Med Clin North Am
Slide10Poor maternal nutrition has dire consequences for women and children
Malnourished women with severe anemia are 2x as likely to die during or shortly after childbirth.
10
Sources:
Smith et al, 2017.
Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries. Lancet Global Health. Osendarp et al. 2021. The COVID-19 crisis will exacerbate maternal and child undernutrition and child mortality in low- and middle-income countries
. Nat Food.
Micronutrient deficiencies can have lifelong impacts on a child’s physical, mental, and emotional development.
Due to COVID-19, rates of malnutrition in mothers and young children are predicted to rise sharply over the next 3 years.
Slide11Consequences across a woman’s life course
S
hort stature
Impaired
cognitive development
Anemia & other micronutrient deficiencies Fatigue & impaired well-beingImpaired productivity
& school performance11
Adolescence
INADEQUATE FOOD, HEALTH,
AND CARE
Slide12Consequences across a woman’s life course
S
hort stature
Impaired
cognitive development
Anemia
&
other micronutrient deficiencies
Fatigue & impaired well-beingImpaired productivity
& school performance
12Low pre-pregnancy BMILower income
Adolescence
Pre-conception
INADEQUATE FOOD, HEALTH
,
AND CARE
Slide13Consequences across a woman’s life course
S
hort stature
Impaired
cognitive development
Anemia
&
other micronutrient deficiencies
Fatigue & impaired well-being
Impaired productivity
& school performance
13
Low pre-pregnancy BMI
Lower income
Obstructed/prolonged labour
Eclampsia
&
p
re-eclampsia
Maternal mortality
Adolescence
Pre-conception
Pregnancy
INADEQUATE FOOD, HEALTH
,
AND CARE
Slide14Consequences across a woman’s life course
14
Adolescence
Pre-conception
Pregnancy
INADEQUATE FOOD, HEALTH
,
AND CARE
Post-natal
S
hort stature
Impaired
cognitive development
Anemia
&
other micronutrient deficiencies
Fatigue & impaired well-being
Impaired productivity
& school performance
Low pre-pregnancy BMI
Lower income
Obstructed/prolonged labour
Eclampsia
&
p
re-eclampsia
Maternal mortality
Consequences for infants and children:
Low birthweight, small-for-gestational age
Pre-term birth, stillbirth
Spina bifida, congenital defects
Child mortality and morbidity
Poor post
-
natal p
h
ysical and cognitive growth and development
Slide15Consequences across a woman’s life course
Short statureImpaired cognitive developmentAnemia & other micronutrient deficiencies
Fatigue & impaired well-being
Impaired productivity
& school performance
15
Low pre-pregnancy BMILower incomeObstructed/prolonged labourEclampsia & pre-eclampsia
Maternal mortality
Adolescence
Pre-conception
Pregnancy
Post-natal
INADEQUATE FOOD, HEALTH
,
AND CARE
Consequences for infants and children:
Low birthweight, small-for-gestational age
Pre-term birth, stillbirth
Spina bifida, congenital defects
Child mortality and morbidity
Poor post
-
natal p
h
ysical and cognitive growth and development
Sources: Gernand et al. 2016.
Micronutrient deficiencies in pregnancy worldwide: Health effects and prevention
. Nature Publishing Group.
Aviram et al. 2011.
Maternal obesity: implications for pregnancy outcome and long-term risks-a link to maternal nutrition
. Int J Gynaecol Obstet.
Slide16Gender inequality in women’s nutrition
Poor servicesWomen often lack available, accessible, and affordable health services and interventions to properly care for their health.
16
Source: Brinda et al. 2015.
Association between gender inequality index and child mortality rates: a cross-national study of 138 countries
. BMC Public Health.
Low decision-making power
Polices, guidelines, and programs regarding women’s nutrition programs are low priority and lack funding.
Poor quality diets
Women eat last and least in terms of nutritious foods, good quality food is unaffordable to them.
Slide17Women’s Voices:
Agurash from Ethiopia
“I am the wife of a farmer, so I do not rest.
We work bent all day on the farm and walk long distances.
I worry about a few things about my pregnancy now. The first is my health. And second is fulfilling everything that is needed for the baby.
When food is served, I am happy if my family eats before me. If I am hungry, I keep it to myself, because I run the house.After others, the woman can eat the leftovers. If there are no leftovers, she can survive that too.”
17
Agurash, in her third trimester of pregnancy
Slide18Women’s Voices:
Shakuntala from India
“You could say health workers like me are ‘walking hospitals.’
Pregnant women in the village cannot even afford two proper meals per day.
After everyone is done, she only has the leftovers. That is the main reason for malnourishment in pregnant women.
When these women give birth, their babies are malnourished too.”
18
Shakuntala, health worker (on left) weighs a pregnant woman.
Slide19Global scope of maternal malnutrition
Slide20Globally, many women lack access to
nutritious diets…20
Sources:
WHO Global Health Observatory Indicators website
Dalmiya et al, 2022.
UNICEF Programming Guidance. Prevention of malnutrition in women before and during pregnancy and while breastfeeding. United Nations Children’s Fund.
Bourassa et al. 2019. Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries. Annals of the New York Academy of Sciences.
170 million women – 1 in 10 – of reproductive age are underweight.
In South/Southeast Asia, stunting (short stature) affects 35% of women.
570 million women – 1 in 3 – of reproductive age are anemic.
Slide21…and lack access to quality health
& nutrition servicesOnly 59% of pregnant women attend 4 antenatal care (ANC) visits. Since 2016, WHO recommends
8 ANC contacts, which further increases the gap
.
21
Sources: Dalmiya et al, 2022.
UNICEF Programming Guidance. Prevention of malnutrition in women before and during pregnancy and while breastfeeding. United Nations Children’s Fund.Osendarp et al. 2021.
The COVID-19 crisis will exacerbate maternal and child undernutrition and child mortality in low- and middle-income countries. Nat Food.
Only 38% of women receive 90+ iron folic acid (IFA) tablets during their pregnancy.
Each year,
20 million babies suffer from low birthweight (LBW), an early marker of poor maternal and fetal nutrition.
Due to COVID-19,
access to quality diets and services is decreasing leading to “worst case scenarios”
.
Slide22Poor maternal nutrition has dire consequences for communities and the world
The economic consequences of poor nutrition can affect an individual for 30+ years and their families for generations.
22
Source: Halim et al, 2015.
The economic consequences of selected maternal and child nutrition interventions in low- and middle- income countries: A systematic review of recent literature, 2000–2013.
BMC Women’s Health.
Good nutrition is linked to improved school performance and increased productivity. This leads to long-term economic benefits on individual, national, and global scales.
Investing in nutrition could reach USD $5.7 trillion a year in economic gains to society by 2030.
Slide23Improving maternal malnutrition is possible when we invest in women and deliver a package of evidence-based maternal nutrition interventions.
Slide24Multiple micronutrient supplements (MMS),
commonly referred to as prenatal multivitamins, are one of the most impactful nutrition interventions that significantly improves maternal health and birth outcomes.
Slide25Evidence on multiple micronutrient supplements (MMS)
Slide26MMS contains 15 micronutrients, including iron and folic acid (IFA).
Research supports switching from IFA to MMS, especially for women with poor diets.
Before 2020, global policy guidance recommended use of IFA.
26
Source:
HMHB Consortium website
MMS has significant benefits compared to IFA
Slide27*United Nations International Multiple Micronutrient Antenatal Preparation Multiple Micronutrient Supplementation (UNIMMAP MMS)
Note: for brevity, the term MMS will be used moving forward
What is
multiple
micronutrient supplementation?
UNIMMAP MMS* contains 15 essential vitamins and minerals for pregnant and nursing women and meets micronutrient requirements that poor diets cannot meet.
UNIMMAP MMS composition*
V
itamin A800 µg
Vitamin D200 IU
Vitamin E
10 mg
V
i
tamin C
70 mg
Thiamin
1.4 mg
Riboflavin
1.4 mg
Niacin
18 mg
V
i
tamin B6
1.9 mg
Folic Acid
400 µg
Vitamin B12
2.6 µg
Copper
2 mg
Iodine
150 µg
Iron
30 mg
Selenium
65 µg
Zinc
15 mg
27
Slide28How does MMS compare to IFA?
Iron and Folic Acid contains just 2 essential vitamins and minerals.
Iron and Folic Acid
Folic Acid
400 µg
Iron
6
0 mg
28
Sources: Gomes et al, 2022.
Multiple micronutrient supplements vs iron-folic acid supplements and maternal anemia outcomes: an iron dose analysis.
Ann. N.Y. Acad. Sci.
Gomes et al, 2022.
Effect of multiple micronutrient supplements vs iron and folic acid supplements on neonatal mortality: a reanalysis by iron dose.
Public Health Nutr.
Slide2929
Sources: Keats et al. 2019.
Multiple-micronutrient supplementation for women during pregnancy
. Cochrane Database Syst.
Smith et al, 2017.
Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries. Lancet Global Health. Research
supports MMSMore than 15 randomly controlled trials have been analyzed. Using different criteria, two different meta-analyses both confirm MMS is effective and safe.
2017
2019
Slide30Global guidance supports MMS
in various settings 30
Sources:
Bloem et al, 2007.
Preventing and controlling micronutrient deficiencies in populations affected by an emergency
. WHO, WFP, UNICEF.
WHO. 2013. Guideline: Nutritional care and support for patients with tuberculosis. World Health Organization. WHO. July 2020. Nutritional interventions update: multiple micronutrient supplements during pregnancy. World Health Organization.
WHO. 2021. World Health Organization Model List of Essential Medicines. World Health Organization.
In emergency situations:For patients with tuberculosis:
In the context of rigorous research:In the WHO List of Essential Medicines:
Slide3131
Evidence on MMS
MMS is effective
MMS is safe
MMS is affordable & cost-effective
Slide32Source:
Smith et al, 2017. Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries. Lancet Global Health.
MMS is effective
Strong evidence shows
MMS
improves maternal nutrition and reduces the risk of adverse birth outcomes.In fact, MMS provides
even greater benefit for anemic women and underweight women compared to IFA.
32
Additionally, MMS reduces the risk of female infant mortality in the first 6 months by 15%. If the mother is anemic, the reduction in risk is 29%.
Slide33MMS is safe
While stomach problems are common for pregnant women, data shows there are
no significant difference in reported side effects
between IFA or MMS.
33
Sources: Source: Bourassa et al. 2019.
Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries. Annals of the New York Academy of Sciences.WHO antenatal care recommendations for a positive pregnancy experience. July 2020.
Nutritional interventions update: multiple micronutrient supplements during pregnancy. WHO.
No known evidence of serious adverse effects.In trials, there was no difference in adherence to IFA versus MMS.
Slide34MMS is affordable and cost-effective
Countries can calculate the value of switching from IFA to MMS using Nutrition International’s cost-benefit tool
.
34
Source:
HMHB Consortium website
MMS is a cost-effective antenatal care intervention.
MMS is affordable. Efforts are underway to improve local manufacturing capacity and increase MMS supply – which could drive the cost down even further.
Slide35Global impact
of MMSTransitioning from IFA to MMS can avert between
7 – 28 million additional infant deaths and disabilities
across 32 LMICs.
Scaling up MMS to 90% coverage is projected to contribute to huge human capital gains for all babies born per year across 132 LMIC
s:+ 5 m
illion additional school years+
18 bi
llion USD in cumulative lifetime income
35
Perumal et al. July 2021. Impact of scaling up prenatal nutrition interventions on human capital outcomes in low-and middle-income countries: a modeling analysis. American Journal of Clinical Nutrition.
Slide36Antenatal Care (ANC) Services
SupplementationMultiple micronutrient supplementsMaternal calcium supplementsBalanced-energy protein (BEP) supplements
36
Source:
The Lancet Series on Maternal and Child Undernutrition Progress
(2021)
MMS must be included in a package of antenatal maternal nutrition interventions for populations, including:
Nutrition Counseling
Healthy weight gainIncreased energy and protein intakeDiverse diet (including fortified foods)
Slide37MMS implementation across the world
37
Source: https://hmhbconsortium.org/world-map/
Information on MMS available - no active implementation
Exploration phase to build an MMS enabling environment
Initial implementation supported by implementation research
Scale-up MMS delivery at the national or sub-national level
Slide38National impact and investment case for
<insert country>
Slide39Maternal malnutrition is high in
<country name>qq% of women are underweight
xx
% of pregnant women suffer from anemia
yy
% of women have short statureMaternal mortality rate is zz%Add in other data points on micronutrient deficiencies in your country, if available.
39
List source here
COUNTRY TEMPLATE to be adapted. Remove this box once updated.
Insert a country-specific image
Slide40Maternal malnutrition in
<country name> is impacted by:
Optional slide to add related country or region-specific topics, such as
:
Data on COVID-19’s impact on food shortages
High rates of HIV, TB, etc. that may lead to higher rates of malnutritionSeverity of anemia or high obesity rates
40
List source here
COUNTRY TEMPLATE to be adapted. Remove this box once updated.
Slide4141
Maternal malnutrition in <country name> leads to high levels of adverse birth outcomes
xx
% of babies are born with low birth- weight
yy
% of babies are born small-for-gestational-age
zz% of babies are born too early (pre-term)xx% of children under age 5 are stunted Neonatal mortality rate is yy%
List source here
COUNTRY TEMPLATE to be adapted. Remove this box once updated.
Slide42Coverage of maternal nutrition interventions is low
xx% of women receive at least 90 tablets of IFA during pregnancyyy
% of women attend at least 1 ANC session and
zz
% have 4 ANC contacts
(or % of attendance for 8 ANC contacts, if known)Antenatal interventions don’t reach pregnant women in <insert names of underserved regions>
42
List source here
COUNTRY TEMPLATE to be adapted. Remove this box once updated.
Insert a country-specific image
Slide43Investing in MMS can generate
<x currency>in <country name>
Scaling up MMS to 90% coverage
in
<country>
is projected to add:+ X million additional
school years+ <x currency> in cumulative lifetime income for all babies born per year
43
<Find detailed information for selected countries in the supplemental file here.>
COUNTRY TEMPLATE to be adapted. Remove this box once updated.
Slide44Is MMS a better value than IFA?
Use Nutritional International's
MMS Cost-Benefit Tool
to generate results for your
country. Insert data on the next slide, and then delete this slide before presenting.
44
Slide45MMS is a very cost-effective antenatal care intervention in
<country name>Value of DALYs* averted: $
X
Additional investment over 10 years: $
X
Benefit Cost Ratio: XAdditional cost per DALY averted: $XVery Cost-effective according to WHO guidelines
DALYs = Disability-adjusted life years45
List source here
COUNTRY TEMPLATE to be adapted. Remove this box once updated.
Slide46Introducing and scaling MMS
Slide47MMS implementation generally follows
a three-phased approach
47
HMHB Consortium website
Slide48Exploration
Build an enabling environment for MMS through landscape analysis.Conduct landscape analysis Undertake exploratory initiatives Assess the regulatory landscape
48
Slide49Exploration (continued)
Build an enabling environment for MMS through advocacy activities:
49
Gather data to demonstrate need for use of MMS.
Convene stakeholders and facilitate an understanding of the evidence.
Build consensus on the need for transition from IFA to MMS.
Advocate for inclusion of MMS into a national essential medicine list.
Slide50Phase 2: Initial Implementation
Design and test implementation strategy through implementation research and advancing procurement relationships. Conduct implementation research Create & execute implementation plan
Explore MMS supply or procurement plans
50
Slide51Phase 3: Scale Up
Robust planning and integration to expand coverage and use to sub-national or national level.Capacity-building Monitoring and evaluation (M&E)Social and Behavior Change Communications (SBCC) planning
Financing, sourcing, and procurement
51
Slide52Case Study:
Indonesia
Slide53SUMMIT study assessed the effects of MMS compared with IFA:
Early infant mortality of babies whose mothers are undernourished was reduced by 25% with MMS
Even greater results for babies of anemic women:
reduction of infant mortality by 38%, risk of LBW decreased by 33% with MMS
Case Study: Research Trials in Indonesia
Slide54Phase 1: Build an enabling environment for MMS through advocacy and landscape analysis
Stakeholder engagements in Indonesia gained consensus on the need for an MMS implementation strategy
Landscape assessments included stakeholder identification, interviews, and consultations
MMS information disseminated via publications across multiple channels, including academic journals and national reports
Indonesian MMS Taskforce formed to support MMS policy adoption
Case Study: Exploration in Indonesia
Asian Congress of Nutrition and technical consultants meet to raise awareness of MMS evidence and policy:
Slide55Phase 2: Design and test implementation strategy through implementation research and advancing procurement relationships
In coordination with the Indonesian Ministry of Health,
Johns Hopkins University and 3 Indonesian universities:
Conducted formative research
Designed and implemented implementation strategy
Identified and engaged with potential local MMS manufacturers
Monitored and evaluated implementation strategy
Case Study: Initial Implementation in Indonesia
Slide56Phase 3: Robust planning and integration to expand use to sub-national or national level
Implementation programs in 22 districts have been established to replace IFA with MMS.
Testing mHealth platform to provide data in real-time to guide strategy and improve health outcomes.
Support national efforts to introduce and provide large-scale distribution of UNIMMAP MMS across the country.
Case Study: Scale-up in Indonesia
Slide57Next Steps
Optional slide to add next step or key takeaways
57
TEMPLATE to be adapted. Remove this box once updated.
Slide58Keep In Touch
Optional slide to add website URL, social handles, and/or email address.
58
TEMPLATE to be adapted. Remove this box once updated.
Slide59Key publications
Bloem et al, 2007.
Preventing and controlling micronutrient deficiencies in populations affected by an emergency
. WHO, WFP, UNICEF.
Smith et al, 2017.
Modifiers of the effect of maternal multiple micronutrient supplementation on stillbirth, birth outcomes, and infant mortality: a meta-analysis of individual patient data from 17 randomised trials in low-income and middle-income countries.
Lancet Global Health. Prado et al, 2017. Maternal multiple micronutrient supplementation and other biomedical and socio environmental influences on children’s cognition at age 9-12 years in Indonesia: follow up of the SUMMIT randomised trial.
WHO antenatal care recommendations for a positive pregnancy experience. July 2020. Nutritional interventions update: multiple micronutrient supplements during pregnancy. World Health Organization.
Perumal et al. July 2021. Impact of scaling up prenatal nutrition interventions on human capital outcomes in low-and middle-income countries: a modeling analysis. American Journal of Clinical Nutrition. May 2020. Use of MMS for maternal nutrition and birth outcomes during COVID-19. MMS TAG.
Dalmiya et al. January 2022. Maternal Nutrition: Prevention of malnutrition in women before and during pregnancy and while breastfeeding. UNICEF. Gomes et al, 2022. Multiple micronutrient supplements vs iron-folic acid supplements and maternal anemia outcomes: an iron dose analysis.
Ann. N.Y. Acad. Sci.Gomes et al, 2022. Effect of multiple micronutrient supplements vs iron and folic acid supplements on neonatal mortality: a reanalysis by iron dose. Public Health Nutr.
59
Slide60Healthy Mothers Healthy Babies resources
HMHB Knowledge HubHMHB Knowledge Bytes
HMHB MMS Interactive World Map
HMHB FAQ and Advocacy Brief on the Inclusion of MMS on the Essential Medicine List
HMHB Launch Video
HMHB Commitment-making Guide for Nutrition for Growth
Watch the HMHB Powering Women, Promising Futures Nutrition for Growth side eventMaternal Nutrition in Focus: HMHB at FIGO 2021 World Conference
60
Join us! Visit
www.hmhbconsortium.org to become a member.
Slide61Join the Consortium at
HMHBconsortium.orgContact usHMHB@micronutrientforum.org
Follow us
@hmhbconsortium