Temporal Trends and Geographic Variation in Multiple Micronutrient Supplementation Implementation Performance in Ethiopia: A Routine Monitoring Data Analysis, 2023–2026
Abstract:
Maternal micronutrient deficiencies remain an important public health challenge in Ethiopia and contribute to adverse maternal and newborn outcomes. Ethiopia introduced Multiple Micronutrient Supplementation (MMS) through routine antenatal care services and progressively expanded implementation from 21 pilot woredas in 2023–2024 to 80 woredas nationwide by 2026. However, evidence on implementation performance during national scale-up remains limited. This study assessed temporal trends and geographic variation in MMS implementation performance using routine program monitoring data collected between January 2023 and June 2026. A longitudinal secondary analysis was conducted using woreda-month observations from the national MMS monitoring database. MMS achievement was defined as the percentage of pregnant women newly supplemented with MMS relative to the monthly target. Descriptive and non-parametric statistical analyses were applied. The final analytical dataset included 2,268 unique woreda-month observations of which 1,724 (76.0%) had available MMS achievement data. Mean MMS achievement was 100.2% (SD 56.3), while the median was 94.6% (IQR 70.5–120.4). Median achievement declined from 98.8% during 2023–2024 to 93.2% in 2025 and 89.9% in 2026. Existing woredas achieved higher median performance than Expansion woredas (96.4% vs. 85.3%; p<0.001). Significant regional variation was observed, with median achievement ranging from 64.1% in Somali to 102.0% in Oromia and Dire Dawa. Reporting completeness declined substantially during scale-up. MMS implementation remained broadly aligned with program targets but varied across regions and implementation settings, highlighting the need for strong implementation support, monitoring systems, and data-quality assurance during national expansion.References:
[1]. World Health Organization. WHO
recommendations on antenatal care for a positive pregnancy experience:
nutritional interventions update, multiple micronutrient supplements during
pregnancy. Geneva: World Health Organization; 2020.
[2]. Keats EC, Haider BA, Tam E, Bhutta ZA.
Multiple-micronutrient supplementation for women during pregnancy. Cochrane
Database Syst Rev. 2019;3:CD004905.
[3]. Haider BA, Yakoob MY, Bhutta ZA. Effect of
multiple micronutrient supplementation during pregnancy on maternal and birth
outcomes. BMC Public Health. 2011;11(Suppl 3):S19.
[4]. Smith ER, Shankar AH, Wu LSF, Aboud S,
Adu-Afarwuah S, Agustina R, et al. Modifiers of the effect of maternal multiple
micronutrient supplementation on stillbirth, birth outcomes, and infant
mortality: an individual patient data meta-analysis from 17 randomized trials
in low-income and middle-income countries. Lancet Glob Health.
2017;5(11):e1090-e1100.
[5]. Kawai K, Spiegelman D, Shankar AH, Fawzi
WW. Maternal multiple micronutrient supplementation and pregnancy outcomes in
developing countries: meta-analysis and meta-regression. Bull World Health
Organ. 2011;89(6):402-411.
[6]. World Health Organization. WHO
recommendation on multiple micronutrient supplementation during pregnancy.
Geneva: World Health Organization; 2021.
[7]. Federal Democratic Republic of Ethiopia,
Ministry of Health. National Nutrition Program II (2016-2020). Addis Ababa:
Ministry of Health; 2016.
[8]. Federal Democratic Republic of Ethiopia.
National Food and Nutrition Strategy (2021-2030). Addis Ababa: Government of
Ethiopia; 2021.
[9]. UNICEF Ethiopia. Multiple Micronutrient
Supplements boost the health of pregnant women and their babies. Addis Ababa:
UNICEF Ethiopia; 2023.
[10]. Marchant T, Alemayehu S, Asfaw E, Daba AK,
Defar A, Opondo C, et al. Effect of prenatal multiple micronutrient
supplementation on birth weight in Ethiopia: protocol for a pragmatic
cluster-randomized trial. BMJ Open. 2022;12:e063757.
[11]. UNICEF. Maternal Nutrition Programming
Guidance. New York: United Nations Children's Fund; 2022.
[12]. Tesfa AB, Defar A, Taye G, Daba AK,
Alemayehu S, Tessema M, et al. Piloting multiple micronutrient supplementation
within the routine antenatal care system in Ethiopia: insights from
stakeholders. Matern Child Nutr. 2025;21:e70003.
[13]. United Nations University, UNICEF, World
Health Organization. Composition of a multiple micronutrient supplement to be
used in pilot programs among pregnant women in developing countries (UNIMMAP).
New York: United Nations University Press; 1999.
[14]. Bhutta ZA, Das JK, Rizvi A, Gaffey MF,
Walker N, Horton S, et al. Evidence-based interventions for improvement of
maternal and child nutrition: what can be done and at what cost? Lancet.
2013;382(9890):452-477.
[15]. Black RE, Victora CG, Walker SP, Bhutta ZA,
Christian P, de Onis M, et al. Maternal and child undernutrition and overweight
in low-income and middle-income countries. Lancet. 2013;382(9890):427-451.
[16]. Ethiopian Public Health Institute (EPHI),
ICF. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and
Rockville, Maryland, USA: EPHI and ICF; 2017.
[17]. Ethiopian Public Health Institute (EPHI),
Federal Ministry of Health (FMoH), ICF. Ethiopia Mini Demographic and Health
Survey 2019: Key Indicators. Addis Ababa, Ethiopia, and Rockville, Maryland,
USA: EPHI, FMoH, and ICF; 2021.
[18]. Peters DH, Adam T, Alonge O, Agyepong IA,
Tran N. Implementation research: what it is and how to do it. BMJ.
2013;347:f6753.
[19]. Proctor EK, Landsverk J, Aarons G, Chambers
D, Glisson C, Mittman B. Implementation research in mental health services: an
emerging science with conceptual, methodological, and training challenges. Adm
Policy Ment Health. 2009;36(1):24-34.
[20]. World Health Organization. Data quality
review: a toolkit for facility data quality assessment. Geneva: WHO; 2017.
[21]. Aqil A, Lippeveld T, Hozumi D. PRISM
framework: a paradigm shift for designing, strengthening and evaluating routine
health information systems. Health Policy Plan. 2009;24(3):217-228.
