Indonesia revamps its pregnancy supplements to improve maternal health
What’s behind Indonesia’s decision to transition from offering pregnant women iron folic acid to multiple micronutrient supplementation? The country’s Director of Family Health Services Dr. Lovely Daisy and Vitamin Angels’ Quinn Harvey explain.
Written by Devex
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Last fall, Indonesia announced it was transitioning away from providing iron folic acid, or IFA, to pregnant women and instead offering the United Nations International Multiple Micronutrient Antenatal Preparation, or UNIMMAP, also referred to in this article as simply MMS. The change, supported by Vitamin Angels, UNICEF, Kirk Humanitarian, the World Bank, and many others, aims to improve maternal and newborn outcomes.
As it stands, rates of maternal malnutrition are high in Indonesia, and nearly half of all pregnant women suffer from anemia. This can lead to serious complications for both mother and baby, including preterm birth, low birth weight, stunting, and increased risk for maternal and child deaths.
Maternal mortality in Indonesia persists, with 173 women dying for every 100,000 live births — although this has improved from 299 per 100,000 in the year 2000. As part of its measures to address the issue, the Indonesian Ministry of Health has long provided IFA supplements. Yet, research shows that MMS will do even more to advance the health of pregnant women and newborns in the country.
Dr. Lovely Daisy, Indonesia’s Director of Family Health Services, explains why the Ministry of Health decided to shift its strategy towards providing pregnant women with multiple micronutrient supplements.
“MMS has been proven to contribute to better pregnancy outcomes when compared to just taking IFA alone. That’s because MMS has 15 essential vitamins and minerals instead of just IFA which has just 2 ingredients,” explained Quinn Harvey, director of program quality and impact at Vitamin Angels, a public health nonprofit working to improve nutrition and health outcomes in low-resource settings worldwide.
The challenge, however, has been in creating the enabling environment for MMS — in terms of policy, the regulatory environment, supply, and delivery — which need to be addressed simultaneously to switch the mass roll-out of one supplement to another. Over several years, Vitamin Angels and others have supported the country in making this decision and now plans to work to ensure high levels of adherence. The aim, Harvey said, is to provide 4.8 million women with MMS by 2026, reaching all the country’s 38 provinces. So far, MMS has been rolled out to 15 districts. Last year, 1.3 million bottles of MMS were shipped, and over 100,000 of those supplements have already been distributed to community health centers. Another 1.3 million bottles are slated to be shipped to Indonesia in June.
Sitting down with Devex, Harvey explained several key activities behind the transition announcement, how it might be replicated with other evidence-based nutrition interventions, and what lessons could be learned from Indonesia’s example.
This conversation has been edited for length and clarity.
What are the contributors to maternal undernutrition in Indonesia?
A number of factors contribute to maternal undernutrition. The first is not unique to Indonesia: Pregnant women in general have increased micronutrient requirements. Pregnancy is a period of rapid growth and development, and it’s often difficult to meet those nutrient requirements through diet alone.
In Indonesia — and this is also true for many other countries — adherence to prenatal supplementation, specifically IFA, has been low, reducing the effectiveness of the nutrition intervention.
Other aspects such as geography can contribute as well. For example, Indonesia is a vast country made up of thousands of islands, and that can make high-quality diets and delivery of services or interventions difficult.
Rostina prepares to meet her first child with a mix of nerves and excitement. She learned about the benefits of MMS in a class delivered by Vitamin Angels and their partners. Photo: © Vitamin Angels / Muhammad Fadli
How has Vitamin Angels been supporting the Indonesian government in better meeting the needs of pregnant women?
We first began working in Indonesia to support the introduction of MMS in 2019. It’s been a long journey and we’ve been providing technical assistance and support for MMS implementation and scale-up activities mostly through local partners and government. The turning point, and where we saw the momentum ramp up, was in 2020 when a national MMS technical advisory group, or TAG, was formed. Members of the MMS-TAG, which included maternal health experts, worked closely with the government to inform them of recommendations based on the evidence.
From there, Vitamin Angels supported several different activities related to MMS programming, collaborating with researchers who work with the Indonesian Ministry of Health and district health offices to support implementation research. These researchers are based at leading public health universities in Indonesia and the U.S., including Universitas Indonesia and the Johns Hopkins Bloomberg School of Public Health. That was again aimed at identifying strategies that would help improve MMS adoption and adherence, along with providing technical support to help build out the local and regional manufacturing capacity to produce high-quality MMS products.
The third area we supported was engaging in policy dialogue with various government agencies to ensure a positive policy and regulatory environment for MMS.
We worked with dedicated government officials, various university partners, and members of the MMS task force, while Kirk Humanitarian donated the initial supply of MMS needed to kick-start all of this. Others like UNICEF, Nutrition International, and the World Bank were also involved.
Vitamin Angels works with a lot of different countries, but why Indonesia in this specific instance?
In Indonesia, Vitamin Angels has an existing team and a strong relationship with the government and other key nutrition stakeholders in the country. It’s also a country with a strong interest in MMS — one of the largest efficacy trials examining the impact of MMS in comparison to IFA was conducted in Indonesia. When you talk about being able to have an impact, that was one country where we saw a huge opportunity.
Surianti was pregnant with her second child when she attended the prenatal classes delivered by Vitamin Angels and partners at her local health clinic. Photo: © Vitamin Angels / Muhammad Fadli
What lessons has Vitamin Angels learned about strategies to support the uptake of MMS in Indonesia that could be applied elsewhere?
The key to the successful introduction of MMS, or any intervention, is understanding the context of the country and the leadership of the government/Ministry of Health. We worked with governments, universities, and implementing organizations, but also importantly with health care providers, understanding their perspectives — as well as those of influential family members and pregnant women. Involving all those different voices was key to strengthening the overall system and affecting change.
Indonesia has been a great example because we learned early on from stakeholders that adherence to IFA was a major barrier. That pointed us in the direction of doing more in-depth, formative research with local universities to map out barriers and enablers. Then we went through a collaborative process, working with pregnant women, health care providers, and others to design different strategies to address those challenges.
Specifically in Indonesia, some of the strategies we are focusing on are health care provider communication, engaging in storytelling, and using song-based messaging. These were all strong tools that we could integrate into the program and use to inform the overall technical guidelines for implementing MMS.
Looking ahead, what is your call to action for Indonesia but also other countries that may also be experiencing the same challenges regarding maternal and newborn health?
Launching the official policy to transition from IFA to MMS was a huge step forward, but there’s still a lot of work to effectively scale up MMS across the entire country. We want to continue to create this enabling environment that supports lasting change and better nutrition for pregnant women. Applying an evidence-based, systematic, and iterative approach helps ensure all necessary elements of MMS introduction and scale-up are addressed to ensure lasting program sustainability.
Additionally, policy change is important because it fosters a positive environment for countries working to strengthen their health systems to ensure that women have access to the nutrition they need during pregnancy and beyond. Going through all of these steps to strengthen the overall system is what’s going to allow us to improve nutrition outcomes globally.
Learn more about Vitamin Angel’s work in Indonesia here.
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