Multiple micronutrient supplements versus iron-folic acid supplements and maternal anemia outcomes: an iron dose analysis

Ann N Y Acad Sci. 2022 Jun;1512(1):114-125. doi: 10.1111/nyas.14756. Epub 2022 Feb 25.


Antenatal multiple micronutrient supplements (MMS) are more effective than iron and folic acid (IFA) supplements in reducing adverse pregnancy outcomes. Questions remain, however, about the ability of MMS to prevent anemia as effectively as IFA, especially at a lower dose of daily iron and in areas of high anemia prevalence. Analyzing data from 11 trials from a recent Cochrane review, we compared MMS to IFA, delivering either 30 or 60 mg of iron, in sustaining hemoglobin and preventing third trimester anemia and iron deficiency anemia (IDA), accounting for daily iron dose, total supplemental iron intake, and baseline prevalence of anemia. There were no differences between MMS and IFA in third trimester hemoglobin concentration or risks of anemia or IDA by iron dose or total supplemental iron consumed. MMS providing 30 mg of iron was comparable to IFA with 60 mg of iron: mean hemoglobin difference of -0.26 g/L (95% CI: -1.41 to 0.89), risk ratios of 0.99 (95% CI: 0.92-1.07) for anemia, and 1.31 (95% CI: 0.66-2.60) for IDA. Baseline prevalence of anemia did not explain heterogeneity in findings. Compared to IFA, MMS results in comparable hemoglobin concentration and protection against anemia during pregnancy, independently of iron dose.

Keywords: anemia; iron; iron deficiency anemia; micronutrient supplements; pregnancy.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anemia* / epidemiology
  • Anemia, Iron-Deficiency* / drug therapy
  • Anemia, Iron-Deficiency* / epidemiology
  • Anemia, Iron-Deficiency* / prevention & control
  • Dietary Supplements
  • Female
  • Folic Acid / therapeutic use
  • Hemoglobins
  • Humans
  • Iron / therapeutic use
  • Micronutrients
  • Pregnancy


  • Hemoglobins
  • Micronutrients
  • Folic Acid
  • Iron