A new chapter in maternal nutrition:
Nepal’s journey toward MMS

A mother's journey

When Sheela Rokaya gave birth to her first child four years ago, her circumstances were very different from what they are now. Living in India during the COVID-19 pandemic lockdown, she was isolated, fatigued, and undernourished. Her daughter, Deewansi, was born prematurely at just seven months and weighed just 1.5 kilograms. “She was too little,” Rokaya said, cupping her hands to show how small Deewansi was. “But when I took her in my hands, I was very happy.”

Now living with her in-laws in Banke district, in Nepal’s Lumbini province, Rokaya has a better support system, access to nutritious foods, and regular visits to the local health center. As a participant in the MMS research study, Rokaya also received a daily dose of MMS from 13 weeks of pregnancy until the birth of her son, Divansh, who arrived healthy in January, weighing 2.6 kilograms.

Her experience is especially representative of women living in Nepal’s border areas, such as Banke district, where cross-border movement impacts maternal health. Rokaya’s story highlights the potential benefits of MMS and why Nepal is exploring a nationwide transition to these supplements.

The barriers to good nutrition

At Chisapani health post, a small rural health center about 8 kilometers from Rokaya’s home, senior antenatal care provider Shanti Kumari Nepali is all too familiar with the signs of poor maternal nutrition. The situation has improved over the past two decades, in large part due to better nutritional counseling, but she still sees troubling cases. Of the roughly 20 pregnant women who visit the clinic each month, typically about three are underweight and have anemia, she said.

The causes range from poverty to limited awareness to certain cultural beliefs, said Kumari Nepali. In this border region, seasonal migration also has an impact. Frequent movement — especially when women return to their maternal homes across the border during pregnancy — can make it harder for health workers to maintain contact and ensure timely prenatal care. In addition, it can contribute to financial instability. “There are some families where the head of the family works in India throughout the year and comes home on festivals only. They pay their children's fees, parents' treatment, household expenses, and wife's treatment costs at that time,” she explained.

When women come to the health post for their antenatal visits — with eight recommended checkups throughout pregnancy — they receive nutritional counselling alongside routine services such as blood pressure checks, a hemoglobin test, and nutritional supplements. For those enrolled in the research study, Kumari Nepali also distributes either MMS or IFA, depending on their assigned group.

Generating evidence for policy reform

Nepal has made significant progress in addressing the burden of maternal anemia, which in the late 1990s was estimated to afflict an estimated 75% of pregnant women and is now down to 34% nationally. Yet over the past 15 years, the prevalence of babies born with low birth weight has stagnated at approximately 12%, and malnutrition among children under 5 remains high.

A growing evidence base has shown that MMS has the potential to reduce low birth weight, anemia, and adverse pregnancy outcomes. In a major endorsement, MMS was added to the World Health Organization’s list of essential medicines in 2021.

Encouraged by these findings, Nepal’s Ministry of Health and Population, with support from nutrition NGO Helen Keller Intl, has been conducting research to assess the feasibility of a national transition. “We have to look at the cost factors. We have to look at the logistics, management challenges, and most importantly, we have to look at the acceptability by our clients, that is the pregnant women,” explained Bibek Lal, director of the family welfare division at Nepal’s Ministry of Health and Population.

Closing the gaps in prenatal care

Nepal’s cadre of female community health volunteers, or FCHVs, was formed in 1988 and is a cornerstone of maternal and child health in the country. As trusted community members, FCHVs go door to door to identify pregnant women and connect them with essential health services. Their role is especially critical in remote and hard-to-reach areas, including Nepal’s hilly and mountainous regions.

Rita Bhattarai, an FCHV in Dang district in Lumbini province, looks after around 30 households. In addition to sharing vital nutrition information, volunteers like Bhattarai help build trust between the health system and local communities, often serving as the first point of contact for pregnant women. They also help to strengthen community bonds and support through regular “healthy mothers’ group” meetings — a space where women can connect, ask questions, and learn from one another.

As part of the MMS research trial, FCHVs like Bhattarai have been trained to counsel pregnant women on the benefits of the supplements and support consistent use.

Making it happen: What policy change takes

Leaders from across Nepal’s three levels of government — federal, provincial, and local — all have a role to play in making a potential nationwide scale-up of MMS a reality. A key challenge remains its higher up-front cost compared to IFA. However, the long-term benefits — measured in lives saved and disability-adjusted life years averted — make the investment worthwhile, Lal said.

“The entire health system is ready to switch from IFA to MMS, but cost remains the main barrier,” he said. He emphasized the need for additional donor support to initiate a large-scale rollout. The Eleanor Crook Foundation, or ECF, is currently exploring cofinancing opportunities with the government to help overcome this barrier, and government-led discussions on a national MMS scale-up road map are already underway. Once MMS proves acceptable, effective, and in-demand among pregnant women across the country, the goal is to secure government funding at all levels to make it a permanent national program.

Ensuring quality, safety, and sustained supply

Ensuring a steady supply of MMS poses the biggest challenge for nationwide implementation, according to Narayan Dhakal, director-general of Nepal’s Department of Drug Administration. "Once you roll out a certain product, it has to be available around the clock," he said.

MMS is currently not manufactured in Nepal and is being imported from foreign suppliers for the purposes of the research trial. Developing local manufacturing capacity would reduce procurement costs in the long run and ensure a steady supply, but it also takes considerable time. 

With ECF’s support, Nepal's Department of Drug Administration is working to include MMS and other nutrition products, such as ready-to-use therapeutic food, in the national essential medicines list, which would ensure it is treated as a priority in government procurement processes and provide sustainable funding beyond donor programs. This designation would also help to guarantee a stable market that could attract multiple manufacturers.