Background:

Multiple micronutrient supplementation (MMS) has been proven to be more effective than iron and folic acid supplementation (IFA) supplementation by reducing various adverse health outcomes such as preterm birth and stillbirths.  Afghanistan faces a significant burden of maternal micronutrient deficiencies, particularly during pregnancy, and ranks among the highest globally in neonatal mortality, with 35 deaths per 1,000 live births. Afghanistan has made MMS a national priority, implementing it in 17 provinces to date, with plans to expand to the remaining 17 provinces through support from the Ministry of Public Health, UNICEF Afghanistan, and a recent donation from Kirk Humanitarian. Afghanistan is at a pivotal stage where it is equipped to scale up its MMS efforts, however, there is limited research conducted evaluating previous MMS and IFA interventions to guide the upcoming scale-up efforts.

Methods:

Afghanistan is primed to conduct implementation research (IR) on MMS that would support its improved delivery, reach, and uptake and, ultimately, positively impact health and nutrition outcomes among Afghan women and children. This report outlines a multi-year, mixed methods implementation plan for the scale-up of MMS composed of three phases. Phase 1 (Formative Research) focuses on a thorough landscape analysis, building partnerships, and designing an MMS modality trial. Phase 2 (Adherence Testing and Testing Modalities) will deploy a cluster randomized trial of MMS delivery modalities, qualitative studies with health workers and pregnant women to explore uptake and adherence, and a cost-effectiveness analysis to evaluate the efficiency and value of community-based distribution approaches. Finally, Phase 3 (Dissemination and Scaling) is for data synthesis, analysis, and internal dissemination of top-priority recommendations for MMS scale-up.  

Discussion:

The methods outlined in this paper are designed to be adaptable and applicable to other complex settings like Afghanistan, where political instability, conflict history, and health system limitations pose unique challenges to implementing maternal health interventions at scale.