What is taking us so long? Structural Inequities in the rollout of Maternal Multiple Micronutrient Supplements (MMS)

By guest contributors Dr Javeria Bilal Qamar; Dr Aduragbemi Banke-Thomas; Dr Fyezah Jehan

Quietly prescribed, universally accepted, and utterly uncontroversial, prenatal vitamins are a given in the Global North. Their Global South ‘version’, multiple micronutrient supplements (MMS), although proven to improve pregnancy outcomes, remains far away from the standard in much of the world.

This is not a supply chain problem. It’s a power problem. It reflects the structural inequities at the heart of global health. Decades of rigorous data showing its cost-effectiveness compared to current standard treatment, and even growing policy support has been unable to overcome the inertia created by fragmented guidance, donor hesitancy, and an unequal standard of proof demanded of interventions in the Global South.

The MMS rollout has dragged on for years. And while it stalls, global health actors continue to deny care to the world’s most vulnerable mothers and babies. (Figure 1).

Image by Maaz J of Deconstruction Station

Early evidence supporting MMS emerged in the 2000s soon after its development in 1999 (Figure 1) with studies demonstrating its superiority over the more routinely recommended iron and folic acid (IFA) supplementation, in reducing low birthweight, small-for-gestational-age (SGA) births, and stillbirths. By 2019, 68 countries had added MMS to their National Essential Medicines Lists. Yet implementation did not follow. Donors failed to align. Global health actors kept demanding more evidence.

In 2020, the WHO updated its guidance, recommending MMS only “in the context of rigorous research” largely due to trial heterogeneity as well as iron dosing concerns – MMS contains 30 mg instead of the 40-60 mg present in IFA. However, the phrasing reinforced a cycle we know too well, no policy without more proof. No rollout without more research! This posture, cautious on paper and paralysing in practice delayed rollout once again. Meanwhile, the exact same supplement, branded as prenatal vitamins, was being handed out daily in the Global North, no questions asked. No debates. No delays.

By 2021, MMS made it to the WHO’s Model List of Essential Medicines. Systematic reviews published in 2023 and 2025 resolved earlier doubts about its benefits and comparisons of 30 mg vs 60 mg iron formulations, dispelling fears of inferior hematologic outcomes. A meta-analysis of over 42,000 pregnancies confirmed it: MMS significantly reduced both preterm and SGA births. The science was clear. The policy inertia? That came from somewhere else.

Why is it taking so long?

Why is it taking so long? The answer lies not in the strength of the data, but in how global health systems value, and often devalue, that evidence depending on where it comes from and whom it serves. Global agencies, technical groups, and donors turned MMS into a subject of endless debate.

To be clear, not all countries were prepared or inclined to roll out MMS at scale early on. Many health systems in the Global South operate under tight financial, regulatory, and political constraints. Public health decisions are often dependant on external funding, international technical validation, and alignment with donor priorities. However, even when national policymakers are convinced by the evidence, they sometimes face institutional inertia, procurement barriers, or fear of acting without full endorsement of the global community. In some cases, stepping forward without global backing is seen as taking a political and technical risk, a move that feels like stepping out without a safety net.

Even where the will to act existed, countries were held back, not by lack of evidence but by a global system that could not keep up with the urgency of local needs and, sometimes, the momentum of national leadership. This inertia was a product of enforced caution which not only delayed access to a safe, low-cost, and evidence-based intervention, but it also sidelined early movers and reinforced a troubling dynamic- that maternal health interventions in the Global South must meet higher thresholds of evidence, consensus, and reassurance before being trusted or implemented. But some countries did not wait for permission.

Success stories

Despite the structural constraints and cautious global guidance, some countries refused to wait, and charted their own course, driven by local evidence, national priorities, and the urgency of improving maternal and newborn outcomes.

In Nepal, the Ministry of Health and Population supported by its long-standing public nutrition programs, evaluated piloted MMS distribution through antenatal care platforms as early as 2018. Building on formative research and early implementation trials, Nepal moved ahead with integrating MMS into national policy dialogues, even when international consensus remained lukewarm.

Bangladesh leveraged its history of community-based delivery systems and strong research institutions to test MMS at scale, working with partners like icddr, b and BRAC. Local manufacturing capacity also gave it a practical advantage, reducing costs and allowing for more agile distribution planning.

The government of Indonesia launched a major rollout of MMS through its Posyandu community health posts, backed by a multi-stakeholder partnership that included academic institutions, local NGOs, and donor support. Implementation research was built into the rollout and not as a gatekeeper, but as a tool for learning and scale-up.

Burkina Faso demonstrated how MMS could be embedded into broader nutrition and reproductive health strategies with champions within the Ministry of Health who helped drive policy changes and secure procurement channels with donor support, even amid competing priorities.

And in Pakistan, the momentum has steadily grown since 2022. The Ministry of National Health Services, with technical support from UNICEF, Gates Foundation, Nutrition International, Kirk Humanitarian and the Junaid Family Foundation, began piloting MMS in selected provinces and districts.

In October 2023, Pakistan formally added MMS to its Essential Medicines List and committed to reaching 50% of pregnant women by 2027. Pakistan is investing in assessing feasibility, acceptability, and adherence, laying the groundwork for national expansion. Efforts are now underway to enable local manufacturing, improving both affordability and supply chain resilience.

These are not case studies. They are proof that when local leadership is trusted, it leads, and it delivers. They are evidence of countries stepping up, navigating resource constraints, and reclaiming agency in maternal health decision-making. They remind us of that countries in the Global South are not waiting to be led; they are already leading.

So, what needs to change?

First, global health needs to stop hiding behind process and start responding to evidence. We need timely, coherent guidance that moves policy and not just papers, especially when the same intervention is already standard practice in high-income countries. The double standard of one set of rules for the Global North and another for everyone else must end.

Second, implementation research should serve as a tool for learning, not as a barricade to delay access. Demanding “rigorous evidence” only when the beneficiaries are poor women and babies in the Global South is not science, it is structural bias.

Third, national governments must be equipped to act on their own terms, not those set by global consensus or donor calendars. That means investing in domestic financing, regulatory independence, and local manufacturing. Recent U.S. aid cuts have only underscored the fragility of relying on external funding. As long as maternal nutrition depends on the next donor meeting, it remains vulnerable to decisions made continents away from the women who need it.

Looking ahead, we need to stop pretending this is about inclusion or capacity building. The real issue is colonialism, dressed up in donor strategies, technical jargon, and slow-moving consensus processes. If the global community is truly committed to saving lives of mothers and babies, then the Global North must step aside. Whether it is about decision-making, funding, or data; control of all of these must shift, now, to the people who live this crisis every day.

We’ve had the science. We’ve had the evidence. What we lacked, till now, is the trust, the urgency, and the willingness to let countries lead.

The question is no longer ‘Should MMS be implemented?’ It is, ‘Why the hell are we still waiting?’

So no, we don’t need to wait. Those who hold the power need to step aside, step back, and support countries in stepping up now. Only then will global health start to live up to its name, not just in principle but also in practice.

About the authors

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.