(P27-040-25) Antenatal Multiple Micronutrient Versus Iron-Folic Acid Supplement Delivery in the UNRWA Health Care System: An Implementation Trial in Jordan

Objectives: Micronutrient deficiencies exist among pregnant Palestine refugees in the Middle East. Antenatal multiple micronutrient supplements (MMS) can improve birth outcomes. UNRWA (United Nations Relief and Works Agency for Palestine Refugees in the Near East) has conducted research in 25 clinics in Jordan to guide replacing a standard-of-care folic acid (FA) and iron-folic acid (IFA) regimen with UN/WHO-approved 15-nutrient (UNIMMAP)-formulated MMS.

Methods: After 3 yrs of preparations, with a 6-mo MMS pilot phase in 2 clinics, an implementation trial was conducted from Mar-Dec 2023 to compare MMS vs FA/IFA on coverage, adherence, side effects, acceptability, routine mid-pregnancy Hb, and costs. Eleven more clinics were assigned to provide MMS in 180-ct bottles to registering pregnant women (total=13 clinics) and 12 continued prescribing FA (0.4 mg) in the 1^st trimester (TM) and IFA (100 mg & 0.35 mg) in 2^nd-3^rd TMs, in blister packs. Deidentified data were abstracted from eHealth system or collected anonymously at exit interviews. UNRWA Research Review Board and Johns Hopkins IRB provided ethical approvals.

Results: 9754 and 5574 women registered in MMS and FA/IFA clinics. Initial achieved coverage was 94% for MMS vs 70%/81% for FA/IFA. Excellent (≥90%) and poor ( < 70%) adherence to prescribed tablet use was 84-86% vs 74-83%, and 5-6% vs 10-17%, in MMS and IFA clinics, respectively (p < 0.04). Across visits, 12-20% fewer MMS recipients reported side effects, including 33-67% fewer with constipation. Side effects reduced adherence in both groups. Among exit interviewees at MMS and IFA clinics, 73%, 52%, 65%, 3% and 3-6% vs 47%, 41%, 59%, 27% and 14-30%, respectively, reported no stomach upset, improved appetite, feeling healthier, running out of supplements and buying “vitamins” in the market, (p < 0.0001). Among 4212 and 2349 non-anemic/mildly anemic 1^st-2^nd TM registrants (Hb>10 g/L) in MMS vs IFA clinics, mid-pregnancy RR (95% CI) of mod/severe anemia (Hb < 10 g/dL) was 0.66 (0.49-0.90). Fewer follow-up Hb tests were ordered in MMS vs IFA clinics, which can save $1,368/10,000 registered pregnancies for UNRWA in Jordan.

Conclusions: MMS clinics achieved better coverage, adherence with fewer side effects, acceptability, anemia prevention, and reduced Hb test costs and vitamin purchases by recipients. 

Funding Sources: Vitamin Angels Alliance, UNRWA, Govt of Japan