Acceptability, Adherence, and Provision Through Antenatal Care: Evidence on Multiple Micronutrient Supplementation in Pakistan and Nigeria.

Background/Objectives: Globally, momentum is building around antenatal multiple micronutrient supplementation (MMS), with evidence that it is as effective as iron-folic acid supplementation in preventing maternal anemia and more effective in improving birth outcomes. In line with the World Health Organization 2020 recommendation and as part of a broader implementation research project, this study examines MMS acceptability, pregnant women (PW)'s adherence practices and experiences, and facilitators and barriers to acceptability, adherence, and provision of MMS within public ANC services in Pakistan and Nigeria. Methods: Following introduction of MMS by the Government of Pakistan in April 2022 (Swabi District) and the Government of Nigeria in December 2023 (Bauchi State), mixed-methods research was conducted using cross-sectional surveys (one in each country), focus group discussions (6 in Pakistan, 9 in Nigeria), and in-depth interviews (7 in Pakistan, 10 in Nigeria) with PW, family members, and facility- and community-based healthcare providers (HCPs). Results: Findings in both settings showed that MMS is widely accepted, and almost all women (>97%) started consuming the MMS they received. Adherence levels, assessed using both pill-count and self-reported measures, exceeded 70%. In both countries, perceived benefits were identified as a key enabler to MMS acceptability and adherence among PW, whereas perceived negative effects acted as a barrier. Facilitators of MMS provision included trusting relationships between PW and HCPs, while delayed antenatal care (ANC) initiation, anemia screening, and limited agency of PW were identified as barriers. Conclusions: This study provides findings to inform MMS scale-up across public ANC platforms in two low- and middle-income countries and contributes to global evidence on context-specific considerations for MMS implementation.