(P10-046-24) Systems Trial of Antenatal Multiple Micronutrient Supplements (MMS) Versus Iron-Folic Acid in a UN Health Care System Serving Palestinian Camps in Jordan

Objectives: Gestational micronutrient deficiencies are common in Palestine refugees. Multiple micronutrient supplements (MMS) can reduce adverse pregnancy outcomes. UNRWA provides antenatal care (ANC) to ~90,000 refugee women annually. Since 2020, UNWRA has conducted implementation research to align with WHO guidelines for replacing iron-folic acid (IFA) with MMS as standard of ANC. Starting in Jordan, we compared MMS vs IFA program acceptability, adherence and effectiveness in preventing anemia.

Methods: We 1^st piloted MMS in 2 large clinics to orient staff, leading to a formal systems trial, randomizing 11 more clinics (total = 13) where midwives dispensed 180-ct bottles of UNIMMAP-formulated MMS and another 12 clinics where midwives dispensed folic acid (0.4 mg) in the 1^st trimester and IFA (100 mg & 0.4 mg) thereafter, both in 10-ct blister packs. Adherence was derived by subtracting recalled days missed since last clinic visit from # of prescribed days in an interval, validated for MMS by recording bottle wt each visit. Acceptability was assessed by sampling and interviewing mothers exiting 6 large clinics in each group. Effectiveness of anemia prevention, given an UNRWA treatment threshold of Hb < 10 g/dL, was compared by abstracting Hb data in the Agency’s eHealth system. Ethical approvals were obtained from the UNRWA Research Review Board and JHU IRB.

Results: Preliminary data are reported for 6997 and 4025 women registered and followed for > 3 ANC visits thru Dec 2023 in MMS and IFA clinics, respectively. For daily prescriptions, adherence to MMS and IFA from 1^st to 4^th visits was consistently ~82% and ~69%, respectively (p < 0.01 at each visit). Among 2644 and 1313 follow up visit interviewees in MMS and IFA clinics, 73% vs 48% reported no stomach upset/constipation, 50% vs 38% were feeling more energy, and 28 % vs 46% said tablets smelled good, respectively (all p< 0.001). Among 6618 and 4166 women in MMS and IFA clinics with a 1^st trimester Hb > 10 g/dL, the RR for treating mid-pregnancy (gestation wk: 22-28) anemia (Hb < 10 g/dL) was 0.69 (95% CI: 0.56-0.85), favoring MMS.

Conclusions: In UNWRA clinics providing ANC to Palestine refugees in Jordan, MMS was more acceptable and adherent among mothers and effective in preventing anemia than IFA.

Funding Sources: Vitamin Angels Alliance, UNRWA, Johns Hopkins University, Sight and Life Foundation, Kirk Humanitarian Foundation