Several studies have shown that Nigeria has the second worst maternal and child morbidity and mortality rates, globally; and 20 per cent of maternal deaths and 50 per cent of child deaths under age five are caused by malnutrition including iron deficiency anaemia. To address the situation, medical experts have called for among other things adoption of Multiple Micronutrients Supplementation (MMS) as a safe and cost effective way to meet micronutrient requirement of pregnancy and contribute to achieving Sustainable Development Goal two (SDG2) to end hunger and malnutrition by 2030. CHUKWUMA MUANYA writes.....CONTINUE READING THE ARTICLE FROM THE SOURCE
A recent report by the World Health Organisation (WHO) ranks Nigeria as the country with the second highest number of maternal, neonatal and child deaths worldwide. The report shows Nigeria trailing India as the two leading nations where mothers and their babies are most likely to die.
Also, recent figures from the Federal Ministry of Health and Social Welfare (FMoHSW) indicate that one in five maternal deaths and nearly half of all child deaths under age five are caused by malnutrition and Nigeria is one of the countries accounting for over 85 per cent of the burden of stunting, still births and neonatal deaths.
According to a new study published on August 29, 2024 by researchers at Harvard T.H. Chan School of Public Health, University of California Santa Barbara (UCSB), United States, and the Global Alliance for Improved Nutrition (GAIN), more than half of the global population consumes inadequate levels of several micronutrients essential to health, including calcium, iron, and vitamins C and E. It is the first study to provide global estimates of inadequate consumption of 15 micronutrients critical to human health.
The study was published in The Lancet Global Health on August 29. Micronutrient deficiencies are one of the most common forms of malnutrition globally, and each deficiency carries its own health consequences, from adverse pregnancy outcomes, to blindness, to increased susceptibility to infectious diseases.
However, according to recent studies, supplementing the diet of pregnant women and women of reproductive age with Multiple Micronutrients Supplementation (MMS) resulted to 40 per cent reduction in stunting for children under five; 50 per cent reduction of anaemia in women of reproductive age and 30 per cent reduction in low birth weight
Health officials say this makes MMS more critical than before in addressing micronutrient deficiencies during pregnancy as women and girls disproportionally bear the burden of compounding crises from climate change to conflict.
They say this and evidence from other studies necessitate the need for adoption of MMS as a safe and cost effective way to meet micronutrient requirement of pregnancy and contribute to achieving Sustainable Development Goals (SDGs) and other Global Nutrition Targets.
The stakeholders urge women of reproductive age especially pregnant women to avail themselves with free MMS. MMS is offered free of charge at Ante Natal Clinics (ANC) in public primary health care (PHC) centres and General Hospitals in Lagos State.
The SDG2 is to “End hunger, achieve food security and improved nutrition and promote sustainable agriculture” by 2030. In 2015, the world agreed to eliminate all forms of malnutrition by 2030. To accelerate progress toward this goal, the United Nations have adopted the first ever UN Decade of Action on Nutrition, from 2016-2025. In the years running up to 2016, several nutrition targets were agreed upon. To date, these targets remain unmet. Severe weather and other climate change-related events exacerbate the situation, increasing the number of people at risk of malnutrition by millions.
Anaemia is a condition in which the number of red blood cells or the haemoglobin concentration within them is lower than normal. It mainly affects women and children. It occurs when there isn’t enough haemoglobin in the body to carry oxygen to the organs and tissues. In severe cases, anaemia can cause poor cognitive and motor development in children. It can also cause problems for pregnant women and their babies.
Anaemia can be caused by poor nutrition, infections, chronic diseases, heavy menstruation, pregnancy issues and family history. It is often caused by a lack of iron in the blood.
Anaemia causes symptoms such as fatigue, reduced physical work capacity, and shortness of breath. Anaemia is an indicator of poor nutrition and other health problems.
According to the WHO, anaemia is major public health concern, mainly affecting young children, pregnant and postpartum women, and menstruating adolescent girls and women.
Low- and lower-middle income countries bear the greatest burden of anaemia, particularly affecting populations living in rural settings, in poorer households and who have received no formal education.
Globally, it is estimated that 40 per cent of all children aged six to 59 months, 37 per cent of pregnant women and 30 per cent of women 15–49 years of age are affected by anaemia.
Anaemia caused 50 million years of healthy life lost due to disability in 2019. The largest causes were dietary iron deficiency, thalassaemia and sickle cell trait, and malaria.
A clinical dietician and State Coordinator Alive & Thrive initiative/FHI 360, Olawumi Ajayi, and State Nutrition Officer Lagos State Ministry of Health, Mrs. Taiwo Fadiro, said a recent study conducted by the Multiple Micronutrient Supplementation in Pregnancy Technical Advisory Group (MMS TAG) found that taking MMS, also known as prenatal vitamins in some regions of the world, during pregnancy is better than only taking iron-folic acid (IFA) supplements. They said these findings provide strong support for the use of MMS during pregnancy to reduce the risk of adverse birth outcomes.
Ajayi and Fadiro during a recent orientation for State nutrition stakeholders and workshop on Media Roundtable/Media Visibility Advocacy Group, organised recently in Lagos by Alive & Thrive/FHI 360 with support from Bill and Melinda Gates Foundation, said micronutrient deficiencies are a common problem among women of reproductive age, affecting two-thirds of women worldwide. They said pregnant women in Nigeria and other Low and Middle Income Countries (LMICs) are particularly vulnerable due to nutrient-poor diets and increased nutritional requirements. The nutrition experts said anaemia during pregnancy, for example, increases the risk of poor outcomes for both the mother and baby, including a higher risk of maternal and perinatal death, premature birth, and low birth weight.
Indeed, in a move to improve pregnancy outcomes in Lagos State, FHI 360/Alive & Thrive, a non-governmental organisation (NGO), in collaboration with the LSMoH, on Wednesday, sensitised the state’s media stakeholders to the importance of MMS for pregnant women. The Alive & Thrive initiative, managed by FHI 360, is funded by the Bill & Melinda Gates Foundation.
The experts stressed the need for the media to advocate for maternal nutrition and MMS supplementation. They identified many challenges to MMS uptake in Nigeria. These include: low awareness of MMS- which may affect demand; higher costs of MMS compared with IFAS which may affect supply; supply chain issues; experience with previous IFAS intake, especially on adherence; and poor health seeking behaviour including low ANC attendance.
Indeed, pregnancy is an exciting time for many women, but it is also a time of increased nutritional needs as the body works to support the growing fetus. Unfortunately, many women in LMICs struggle to meet these needs, leading to micronutrient deficiencies that can have serious consequences for both mother and baby.
To address this problem, Ajayi said many LMICs including Nigeria have added IFA to their nutrition programmes. However, IFA alone may not be enough to meet all the nutritional needs of pregnant women, as deficiencies in other micronutrients like vitamin A and zinc are also common and can affect fetal growth and development. “This is where MMS come in—they contain more vitamins and minerals than IFA alone and have been shown to significantly improve maternal health and reduce the risk of adverse birth outcomes. These supplements, such as the United Nations International Multiple Micronutrient Antenatal Preparation (UNIMMAP) formulation, include 13 vitamins and minerals in addition to IFA,” she said.
Ajayi said more than 20 years of research have provided clear evidence that MMS is efficacious, safe, cost-effective, and affordable. Ajayi said the objectives of Alive & Thrive (A&T) project are: to improve State and Local Government Area (LGA) Nutrition stakeholders MMS programming/planning knowledge and skills respectively; help state and LGA nutrition stakeholders appreciate A&T’s MMS mandates and support as well as securing nutrition stakeholder buy-in; integrate A&T’s MMS support into State MMS implementation plan for the second half of 2024; and understand State/LGA/PHC/community specific capacity building/training methodology (health care providers and community resource persons levels).
She said Alive & Thrive’s approach to MMS implementation in Nigeria is working with partners and enablers like United Nations Children Fund (UNICEF) on supporting inclusion of MMS in the National Essential Medicine List; conducting Landscape Analysis of MMS in 18 States of Nigeria including Bauchi and Lagos; advocating for implementation of the revised Micro Nutrient and Deficiency Control Guidelines at states level, which provides the policy environment for MMS by integrating it into already existing programmes; advocating to government to provide funding for procurement and distribution of MMS in health facilities to promote access and use; pushing the agenda at every opportunity/talk about it/offer this presentation on MMS/ get state and LGA structures conscious of MMS; pushing for financial resources to build capacity of frontline health workers; supporting the inclusion of appropriate indicators of MMS into existing data tools in Nigeria; and partnering with other nutrition partners and NGOs leveraging on community structures to reach more pregnant women effectively and efficiently with MMS.
“Antenatal MMS for pregnant women has been proven to improve maternal nutrition status and, in comparison with IFAS, further reduce the risk of adverse birth outcomes such as preterm birth, stillbirth, low birth weight, and small-for-gestational-age birth. Providing MMS to women during pregnancy can prevent long-lasting human capital losses in educational years and lifetime income.
“Scaling up programmes that deliver MMS to vulnerable mothers is now an urgent priority. This requires efficient supply chain systems and building awareness of its health benefits among mothers, communities, and maternal healthcare providers.
“Pregnancy increases the daily requirement of several vitamins and minerals to meet the nutritional needs of the developing fetus and other metabolic functions. Antenatal MMS is designed to address these heightened demands, which are often not met through diet alone. It is particularly useful for pregnant women in resource-poor settings where micronutrient intake is typically low due to poor dietary diversity, limited access to nutritious food, gender inequity, and prevalent social norms.
“MMS is delivered in the form of a tablet, capsule, powder, or liquid that provides a combination of vitamins and minerals in the right amounts. It is often accompanied by nutrition education and counseling to help ensure daily consumption.
“The UNIMMAP MMS is an internationally accepted and standardised formulation that contains 15 essential vitamins and minerals, including iron and folic acid in recommended doses. In 2021, UNIMMAP MMS was included in the World Health Organisation’s Model List of Essential Medicines based on evidence that it is effective and safe,” she said.
According to Ajayi, “In Nigeria, the current protocol is to place a pregnant woman on IFAS instead of MMS (recently MMS TAG encouraged anaemic woman to continue the use of MMS in addition to elemental iron). Both cannot and should not be used together. The 30mg of iron in MMS is as effective as the 60mg in IFAS because of the presence of other nutrients that enhance the absorption of Iron.”
On dosage and duration, Ajayi said pregnant woman should begin taking one whole MMS tablet per day, every day, throughout her entire pregnancy. “As soon as the woman knows she is pregnant, she should visit ANC where, as part of routine ANC services, she will get MMS tablets. She should begin taking one whole MMS tablet as early in pregnancy as possible, every day, throughout her entire pregnancy. If she has leftover MMS tablets, she can continue to consume the remainder on a daily basis after delivery. MMS tablet should be swallowed with clean water. MMS should not be chewed nor crushed,” she said.
The dietician said MMS can be taken with meal, but should not be taken with tea, coffee, nor with calcium or calcium rich foods (like milk) given their effect on decreasing the absorption of iron in the body.
Ajayi further explained: “If a pregnant woman forgot, missed of stopped taking MMS for a while, she should simply continue to take one table daily. It is important that the woman take one daily MMS tablet throughout the pregnancy (from the day the woman notice’s she is pregnant till delivery). She could set an alarm or reminder to take MMS daily and keep the container in a location where it is seen every day (and out of reach of children and away from direct sunlight). Taking MMS at the same time each day is a good strategy. The pregnant woman can seek the help of her husband or other family member to remind her daily about her dose of MMS and to obtain adequate supplies by contacting health workers and attending ANC.”
She said taking MMS as prescribed will help the pregnant woman to feel less tired and more energetic, and support a healthy pregnancy and optimal growth of the feotus. Ajayi said when MMS is taken as directed, MMS tablets are not expected to cause serious side effects. “However, some women experience upset stomach, constipation, headaches, or an unusual or unpleasant taste in their mouth after taking the tablet. These side effects are often temporary and will go away as the body adjusts to the MMS and this will improve in a few days. I advise the pregnant woman to consume extra water and fruits and vegetables to soften stools; consume the tablet at night after the evening meal to prevent nausea and dizziness,” she said.
To Fadiro: “We are here to further promote the use of MMS supplement for women of reproductive age and especially pregnant women just to curtail anaemia in pregnancy. The Federal Government is just introducing it but I can assure you that the state started like three years back. The state has been collaborating with vitamin angel, which is one of our donor partners to get MMS, which we have been allocating to in public facilities primary healthcare centres and general hospitals for the past three years and it is just for us to reduce anaemia in pregnant women.”
One whether the women are accepting MMS three years down the line, Fadiro said: “Definitely, they are there to replace the normal iron and folate supplementation. For instance, when the state first started, we did not have much but the little we had, we started with women in the first two to three trimesters. So, we gave to them and it was widely acceptable. You know it has 180 tablets in a container and it will cover you for that period.”
On what measures have been put in place to ensure that these women are not asked to pay for the MMS, she said: “No, they are not asked to ay kobo. When we talk about public facility, especially PHC and secondary facility, general hospitals, the state has monitors, we go on a lot of supportive supervision. When you give things like this, you monitor it. So, people from the state, people from PHC Board go on monitoring. It is not something that should be sold and now with collaboration with UNICEF and other implementing partners, there is this committee we are working on now, it is called Catch Force on nutrition commodities where people on the hierarchy will be there. There will be task force on this that will check the people it is being sullied to, it will check the people that giving it out, it will check everybody to ensure that these commodities are used directly as requested, they are not diverted, they are not used for other purposes than what is being accepted for. So, in the task force committee you have the permanent secretary ministry of health being part of it, you have the director family health and nutrition and you have other partners being part of it until it gets to the grassroot.”
On the burden of iron deficiency in Lagos State, Fadiro said: “It is an issue nationwide not only in Lagos State. For instance, looking at the economic situation and how it affects everyone around the world, but the people that are most vulnerable are children and women, and they are the ones carrying these babies. So, we now decided to start from this people that will deliver these children. If a woman is not anaemic, she will not give birth to a child that is not fit enough as expected. So that is why women are being targeted. It is not only in Lagos but a federal level and worldwide.”
Commenting on MMS, Minister of Health and Social Welfare, Prof. Muammad Ali Pate, said there need to create awareness on the health benefits of MMS among mothers, communities, and maternal healthcare providers as a means of addressing maternal malnutrition especially during pregnancy.
Pate called on the media to partner with the ministry in enlightening the public particularly pre – and antenatal women on the efficacy of the MMS even as the Ministry has launched its rollout.
The minister said this will enable the initiative scale nationally in tandem with FMOHSW goal to deliver equitable, efficient and improved quality health outcomes for all Nigerians irrespective of geographical location or status.
The Minister, while noting that maternal malnutrition is not only a public health issue but also an issue of inequity and development, stated that prioritising the implementation of MMS programmes will go a long way in ensuring that mothers receive the essential nutrients they need for a healthy pregnancy.
In 2020, the World Health Organisation (WHO) updated its recommendations for pregnant women and adolescent girls to improve the quality of their routine health care during pregnancy to include MMS. But the WHO’s recommendation on MMS was conditional, calling for further research to fully understand its effects on things like premature birth and low birth weight.
The Federal Ministry of Health and Social Welfare based on the 2020 WHO recommendation on antenatal care for a positive pregnancy experience adopted the use of MMS during pregnancy. MMS has been included in the “National Guidelines for the Prevention and Control of Micronutrients Deficiencies Control in Nigeria”.
Meanwhile, a study, published in the Maternal & Child Nutrition journal, analysed data from 16 studies to determine whether the effects of MMS or IFA were different for three birth outcomes of interest (on low birth weight, being born too small or too early) depending on how pregnancy length was determined. The findings showed that MMS improved birth outcomes compared to IFA, regardless of the method used to determine pregnancy length (example, based on ultrasound, date of last menstrual period, or other method). MMS showed even more pronounced benefits when ultrasound was used, which is considered the gold standard for dating pregnancy. This study complements previous findings that demonstrated MMS were just as good as IFA for preventing anemia during pregnancy, even when the MMS contained less iron than IFA.
According to the WHO, common and non-specific symptoms of anaemia include: tiredness, dizziness or feeling light-headed, cold hands and feet, headache, shortness of breath, especially upon exertion.
Severe anaemia can cause more serious symptoms including: pale mucous membranes (in the mouth, nose etc.), pale skin and under the fingernails, rapid breathing and heart rate, dizziness when standing up and bruising more easily.
Anaemia may be caused by several factors: nutrient deficiencies, inadequate diet (or the inadequate absorption of nutrients), infections, inflammation, chronic diseases, gynaecological and obstetric conditions, and inherited red blood cell disorders.
Iron deficiency, primarily due to inadequate dietary iron intake, is considered the most common nutritional deficiency leading to anaemia. Deficiencies in vitamin A, folate, vitamin B12 and riboflavin can also result in anaemia due to their specific roles in the synthesis of haemoglobin and/or erythrocyte production. Additional mechanisms include nutrient losses (example blood loss from parasitic infections, haemorrhage associated with childbirth, or menstrual loss), impaired absorption, low iron stores at birth, and nutrient interactions affecting iron bioavailability.
Infections can be another important cause of anaemia, depending on the local burden of infectious diseases, such as malaria, tuberculosis, Human Immunodeficiency Virus (HIV and parasitic infections. Infections can impair nutrient absorption and metabolism (example malaria, ascariasis) or can cause nutrient loss (example schistosomiasis, hookworm infection). Many different chronic conditions can cause inflammation and lead to anaemia of inflammation or anaemia of chronic disease. HIV infection causes anaemia through a wide range of mechanisms including ineffective production or excessive destruction of red blood cells, blood loss, and side effects of the drug treatment.
Consistent heavy menstrual losses, maternal blood volume expansion during pregnancy, and blood loss during and after childbirth, particularly in cases of postpartum haemorrhage, commonly lead to anaemia.
Additionally, in some regions, inherited red blood cell disorders are a common cause of anaemia. These include conditions such as α- and β-thalassemia due to abnormalities of haemoglobin synthesis, sickle cell disorders due to changes in the haemoglobin structure, other haemoglobinopathies due to haemoglobin gene variants, abnormalities of red cell enzymes, or abnormalities of the red blood cell membrane.
Changes in diet can help reduce anaemia in some cases, including: eating foods that are rich in iron, folate, vitamin B12, vitamin A, and other nutrients, eating a healthy diet with a variety of foods, taking supplements if a qualified health-care provider recommends them.
Other health conditions can cause anaemia. Actions include: prevent and treat malaria, prevent and treat schistosomiasis and other infections caused by soil-transmitted helminths (parasitic worms), get vaccinated and practice good hygiene to prevent infections, manage chronic diseases like obesity and digestive problems, wait at least 24 months between pregnancies and use birth control to prevent unintended pregnancies, prevent and treat heavy menstrual bleeding and haemorrhage before or after birth, delay umbilical cord clamping after childbirth (not earlier than one minute), and treat inherited red blood cell disorders like sickle-cell disease and thalassemia.
There are several ways to help prevent and manage anaemia in daily life, including eating a healthy and diverse diet and speaking to a health-care provider early if you have symptoms of anaemia.
To keep a healthy and diverse diet: eat iron-rich foods, including lean red meats, fish and poultry, legumes (example lentils and beans), fortified cereals and dark green leafy vegetables; eat foods rich in vitamin C (such as fruits and vegetables) which help the body absorb iron; and avoid foods that slow down iron absorption when consuming iron-rich foods, such as bran in cereals (whole wheat flour, oats), tea, coffee, cocoa and calcium. If you take calcium and iron supplements, take them at different times during the day.
Ajayi said lots of the micronutrients in vegetables are lost due to our cultural practices like washing vegetables after cutting and using hot water to wash as well as cooking vegetables for long hours.
“People with heavy menstrual bleeding should see their doctor for treatment. Doctors may recommend iron supplements or hormonal contraceptives. Some infections can cause anaemia. Wash your hands with soap and water and use clean toilets to reduce the risk of infection.
“Malaria can also cause anaemia. People living in places where malaria is common should follow prevention advice from local health authorities. Seek prompt treatment if you suspect you have malaria,” she said.
