Is it time to replace iron folate supplements in pregnancy with multiple micronutrients?

Anaemia is one of the most resilient global public health problems and affects a staggering 1.62 billion of the world's population, largely concentrated in Asia and Africa. Anaemia contributes to almost 120 000 maternal deaths globally and indirectly to almost a fifth (18%) of the burden of maternal mortality. Given the widespread prevalence of micronutrient deficiencies in developing countries, supplementation with multiple micronutrients rather than iron folate alone, could be of potential benefit to the mother and the fetus. This review evaluates the evidence of the impact of multiple micronutrient supplements during pregnancy, in comparison with standard iron folate supplements, on maternal anaemia. A systematic review of randomised controlled trials was conducted using search engines like PubMed, the Cochrane Library and World Health Organization Regional Databases. Primary outcomes were 'maternal anaemia' and 'haemoglobin level'. We included seven studies for detailed data abstraction. There was no differential benefit of multiple micronutrients as compared with iron folate on maternal anaemia in the third trimester (relative risk = 1.03 [95% confidence interval 0.94, 1.12]). Results were similar for haemoglobin levels. In summary, multiple micronutrients have a similar effect on maternal anaemia compared with iron folate supplementation. These findings have to be interpreted in the context of other benefits of multiple micronutrient supplementation such as promoting better fetal growth and the possible increased risk of neonatal and perinatal mortality that are best resolved through large-scale effectiveness trials.