Antenatal MMS in Pakistan and Nigeria: Initiation and Adherence

Key Takeaways:

• Researchers report very high initiation after receipt of MMS in both Swabi and Bauchi, alongside moderate-to-high adherence patterns that varied by measurement approach and threshold.
• Across qualitative data, perceived benefits, trust in providers, and reminder strategies were described as facilitators, while perceived negative effects, forgetting, and household decision dynamics were commonly described barriers.

Rollout timing differed by setting, with the Government of Pakistan introducing MMS in Swabi in April 2022 and the Government of Nigeria introducing MMS in selected areas of Bauchi State in December 2023. Study teams then fielded cross-sectional surveys alongside focus group discussions and in-depth interviews. Survey respondents included pregnant women and women up to three months postpartum; in Pakistan, husbands and mothers-in-law (or other influential female family members) were also surveyed, and healthcare providers were surveyed as well.

Adherence assessment combined objective tablet counts for pregnant women at the time of survey with recall-based self-report for pregnant and postpartum respondents, calculating the percent of expected tablets consumed over the relevant exposure period.

In the surveys, almost all women who received MMS reported starting to consume it (97.4% in Pakistan and 99.9% in Nigeria). Average adherence based on pill count adherence was 73.6% in both countries; the proportions meeting prespecified thresholds were 60.4% (Pakistan) and 55.1% (Nigeria) for at least 75% of expected tablets and 48.6% and 40.1% for at least 90%. Using self-report among all surveyed women (pregnant and postpartum), daily adherence was 76.9% in Pakistan and 72.5% in Nigeria; 66.3% and 55.4% reported consuming at least 75% of expected tablets, and 57.3% and 41.4% reported consuming at least 90%. The authors also report a self-report sensitivity analysis restricted to pregnant women (71.0% in Pakistan and 73.2% in Nigeria).

Qualitative themes linked acceptability and adherence to perceived benefits, including symptom relief and expectations of healthier pregnancies, as well as trust in patient-provider relationships and clear explanations from providers. Participants described reminder approaches—such as keeping the bottle in a visible location or tying intake to a regular time or place—as habit-forming strategies that supported consistent use alongside the adherence levels reported in the surveys.

Barriers described across interviews and discussions included perceived negative effects (including fears of side effects or unwanted pregnancy outcomes) and forgetting, particularly when routines were disrupted; temporary stopping and resumption were commonly reported in both settings. Household decision-making featured prominently; respondents described husbands’ influence on ANC attendance and supplement use in both countries, and in Pakistan, mothers-in-law were described as additional influential figures, with women’s agency sometimes portrayed as constrained in ways that affected follow-up and continued access.

Provision through routine ANC used the same delivery platforms previously used for iron-folic acid, with Swabi including community-based distribution through Lady Health Workers in addition to facility-based ANC, while Bauchi provision was described within public ANC services. Accessibility of ANC-based distribution, including proximity to home in Pakistan, was viewed as an enabler, whereas provider workload and limited time for counseling were constraints on the quality and consistency of provision. Across both settings, participants and providers described anemia screening and management as a point of friction: limited diagnostic capacity and contemporaneous anemia protocols were reported as intersecting with decisions about preventive MMS versus therapeutic iron for anemic women, sometimes delaying provision or creating uncertainty.