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The Pakistan government provides pregnant women with daily iron and folic acid (IFA) supplements to prevent maternal anaemia, a proven and effective mitigation strategy. But they are now exploring introducing a different supplement – antenatal multiple micronutrient supplementation (MMS) – which has been found to be just as effective at preventing maternal anaemia, while being more effective in improving birth outcomes. Introducing a new commodity into a health system is not simply a switchover; it’s also an opportunity to assess and address existing challenges that are holding back progress on maternal nutrition. This is where implementation research comes in.

We visited a basic health unit in Swabi, Khyber Pakhtunkhwa to hear directly from women and the people who are supporting them. Below, meet a pregnant woman as she goes to her antenatal care appointment, hear from staff who are providing care, and gain insight into this implementation research and why it’s important.

A woman stands outside wearing a niqab that is green and red. She is holding a maternal nutrition pamphlet that has illustration on when and how to consume multiple micronutrient supplements.

When Sonia Hamid arrives at the basic health unit in Swabi, she readily greets the other women in the waiting area. She first visited the health unit when she was three months pregnant, prompted by the Lady Health Worker in her community. “When the Lady Health Worker came to our house and suggested I visit the health unit and told me that they are providing MMS tablets free of cost, I came here and received these tablets. I have finished one bottle and I’m feeling much better.”

Sonia received nutrition counselling, which included instructions for healthy eating and how and when to take the MMS tablets. With MMS, she receives 15 micronutrients in one tablet to help support her pregnancy, which are difficult to obtain through food alone. This is Sonia’s second pregnancy. During her first pregnancy, she didn’t take iron supplements regularly. When asked if she’s noticed any difference between these pregnancies, Sonia shared: “During my first pregnancy I felt exhausted and I wasn’t able to do my daily household chores properly, but after using MMS tablets I do all the daily household chores on my own. I’m able to take care of my child and I don’t feel as tired as I used to feel during my first pregnancy.”

A woman looks at the camera wearing a white and red niqab and holding a young child in her arms, who is warmly wrapped in a blanket.<br />

Naeema Bibi is the Lady Health Worker who visited Sonia at home, which is one of 200 homes under her charge. She was trained as part of the implementation research to learn how to counsel pregnant women at home about MMS and encourage them to come to their local health centres for routine antenatal care check-ups. Naeema also has first-hand experience. “I’m a Lady Health Worker but I’m also a mother. I’ve used these MMS tablets as well. Unlike my other pregnancies, this time after using these tablets, I didn’t have blood deficiency and gave birth to a healthy baby.”

A woman sits behind a desk wearing a mask and looking directly to the camera. She is holding a pen and has information on maternal nutrition on her desk.

Dr. Qurat-Ul-Ain is a Women Medical Officer who oversees the outpatient department at the health facility. She trained Lady Health Workers, such as Naeema, after she completed the master trainers course facilitated by Nutrition International. “I make sure to teach them about this [MMS] in our monthly meetings, which are held when Lady Health Workers and Lady Health Supervisors visit on a monthly basis. When they educate the community about its benefits and they elaborate on it, the community takes a lot of interest in it.”

She maintains the MMS tablet record along with providing antenatal care counselling. She’s also responsible for managing the demand and supply of all medicines, but shares that having access to MMS is only one piece of the puzzle. “If you have to introduce any new project in your society or in the community, then counselling is a major component. We are very grateful to Nutrition International for giving us training last year as a district master trainer on MMS tablets. I give the same training and teach the same knowledge, methodologies and techniques to my Lady Health Workers, Lady Health Visitors and Lady Health Supervisors.”

Two women sit beside each one. The woman on the left is wearing a green and red niqab and listening intently to the woman on the right who is wearing a white and red niqab. She is speaking and gesturing to a pamphlet on maternal nutrition.

Farah Naz is a Lady Health Visitor who provides care to 20 to 25 antenatal patients on any given day at the health unit. Where Lady Health Workers visit women at home, Lady Health Visitors attend to clients at the unit itself.

“Before this, we were used to giving IFA tablets to patients. After doing specialized training on MMS and nutrition, we do counselling with pregnant women and give them MMS. The message we want to give to the community about MMS is that MMS is very important as it decreases the chances of anaemia, low birthweight and premature births. So, the use of MMS is very much important for women.”

A man lifts a package of supplementation bottles onto a shelf.

Imtiaz Ahmad is the Chief Medical Technician. He manages the stock of MMS at the health facility level, in addition to other medicines, and assists Dr. Qurat-Ul-Ain with monthly reporting to the District Health Information System (DHIS). He also provides counselling to other male staff and male community members on the purposes of antenatal supplements.

During the period of implementation research in the district of Swabi, any time a pregnant woman goes for antenatal care at any public health facility or within the community, that woman will be assessed and provided a bottle of MMS along with a standard package of materials. Nutrition International monitors the implementation, linking this data to the DHIS while informing the implementation research.

Four woman stand beside each other outside a health centre looking at the camera.

Huma Habib (far right) is a consultant working with Nutrition International on the implementation research. She provides technical and operational advisory support to the project. Being from the area, she has first-hand insight into its potential. “Where we’re standing at the moment, this is my village. So it’s really good to see this kind of work being done in my district. One thing I find really interesting about this project is that we’re not only targeting pregnant women. We’re actually targeting all stakeholders, right from the healthcare providers to the pregnant women themselves and all the key influencers in their household, such as their husbands, mothers-in-law, or community leaders.”

She’s standing beside Dr. Qurat-Ul-Ain, the Women Medical Officer (centre right), Farah Naz, the Lady Health Visitor (centre left) and Lubna Pervez, the District Coordinator for Maternal and Newborn Health and Nutrition with the Shifa Foundation and Nutrition International. There are many stakeholders across the local, provincial and national levels to undertake the implementation research, which requires deep collaboration. This basic health unit is one example of the implementation in action.

“I believe strongly that if we are to tackle any public health problem of significance, we need to have multifaceted strategies and I think that’s exactly what we’ve been doing in this project,” shared Huma.

Pakistan is committed to putting women at the centre of their care and finding context specific solutions to improve maternal nutrition. “It is very important that we focus on maternal health and nutrition,” shared Dr. Khawaja Masuood Ahmed, the National Coordinator for the Nutrition and National Fortification Alliance in the Ministry of National Health Services Regulations and Coordination in Pakistan. “The WHO recommends that before launching MMS we must conduct implementation research from which you come to know about the issues you can face in its utilization, acceptability, compliance and sustainability, and how you can address them.”

Learn more about our MMS implementation research in Pakistan, utilize our MMS Cost Benefit Tool, or read the MMS Policy Brief: Pakistan.