Evaluation of antenatal multiple micronutrient versus iron and folic acid supplementation in UNRWA health clinics serving Palestine refugees in Jordan: A systems trial.

Authors

Masako Horino, Luai Al-Khatib, Rami Habash, Tamara Al-Rahahleh, Saifuddin Ahmed, Klaus Kraemer, Kristen M Hurley, Akihiro Seita, Keith P West

Published in

The American journal of clinical nutrition. Pages 101587. Oct 14, 2026. Epub Oct 14, 2026.

Abstract

Multiple micronutrient deficiencies coexist among pregnant Palestine refugees. WHO recommends preventive multiple micronutrient supplementation (MMS) guided by research.
We compared implementation outcomes of antenatal MMS and folic acid/iron-folic acid (FA/IFA) regimens during a 10-month systems trial in Jordan.
Thirteen clinics prescribed a 15-nutrient MMS at registration in 180-count bottles. Twelve clinics prescribed FA (0.4 mg) daily during first trimester visits and IFA (100 mg iron+0.35 mg FA) 2, 3 or 7 times/week thereafter (preexisting standard-of-care) in blister packs. Gravidae were monitored through 7 follow-up visits. Initial prescriptions and recipient histories of supplements "running out" represented coverage. At follow-up visits, midwives assessed adherence based on days missed and inquired about seven side effects. Maternal supplement acceptability and vitamin purchases were probed during anonymous exit interviews. Anemia, routinely assessed at registration and 22-35 weeks' gestation, and hemoglobin testing costs were investigated. Relative risks (95% CIs) were adjusted for design effect (aRR). The study was approved as public health practice by two ethics boards.
From March-December 2023, 9,754 and 5,574 pregnant women registered in MMS and FA/IFA-assigned clinics, ∼70% in 1^st trimester. Prescription coverage was 96% and 79%/86%, respectively. Across intervals, 2-8% of MMS compared to 19-31% of FA/IFA-clinic registrants ran out of supplements (p<0.0001). Adherence ≥90% and <70% was observed in 80-86% and 5-6% among MMS compared to 75-83% and 9-17% among of IFA recipients (p<0.04). Fewer MMS (8-13%) than IFA (19-28%) recipients reported constipation (p<0.001). More MMS recipients noted an unpleasant taste, but recipients found MMS more acceptable, and less frequently purchased vitamins compared to IFA recipients (p<0.001). Compared to FA/IFA, prophylactic MMS reduced risk of mid-pregnancy anemia (aRR=0.66 (0.46, 0.95), improved treatment when added to IFA, and decreased elective hemoglobin testing, saving costs.
MMS outperformed IFA on adherence, acceptability, side effects, mid-pregnancy anemia prevention, and use of system resources.
N/A.

PMID:
42874928
Bibliographic data and abstract were imported from PubMed on 15 Oct 2026.

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