A large clinical trial conducted across 48 health centres has shown that adherence to MMS is not only comparable but superior to IFA, with fewer reported side effects and overwhelming user acceptance.
The study was conducted by researchers based in Cambodia, Canada, the US and India, with the findings clearly supporting the Cambodian Ministry of Health’s plans to transition to MMS to improve maternal and child health outcomes.
Background: Why MMS and why now?
Currently, Cambodia’s health guidelines recommend a 90-day course of IFA during pregnancy. However, global research shows that MMS — which includes iron, folic acid, and 13 other essential vitamins and minerals — offers better outcomes for both mother and child.
A 2019 review found that MMS reduced the risk of low birth weight by 12% and small-for-gestational-age births by 8% compared to IFA.
Despite this, adoption in Cambodia has lagged due to limited local data on adherence and acceptability.
To close this gap, researchers conducted a non-inferiority trial involving 1,546 pregnant women in Kampong Thom province.
The goal was to determine if MMS could match or exceed the adherence rates seen with IFA, and whether women found the new supplement acceptable.
Study design: Testing adherence and packaging options
Participants were divided into three groups — one received IFA for 90 days (the current standard), another MMS for 180 days in a single 180-tablet bottle (MMS-180), and the last MMS for 180 days in two 90-tablet bottles (MMS-90).
Researchers measured how faithfully participants followed the supplementation regimens and assessed acceptability across six categories: taste, packaging, ease of use, perceived effectiveness, cost, and self-confidence in taking the supplements.
MMS outperforms IFA across the board
The study found that adherence rates were highest among the MMS groups at 95%, compared to 91% for the IFA group — a statistically significant difference.
Importantly, providing the full 180-day supply at once or splitting it into two deliveries made no difference in adherence or in attendance at antenatal care (ANC) visits.
Women attended an average of five ANC visits regardless of how the supplements were packaged.
Taste and smell not deterrents
Researchers found that women overwhelmingly accepted MMS. In fact, 92% of MMS users liked the supplements’ taste, smell and size, compared to 87% of IFA users. The MMS packaging was also rated higher (94%) than IFA (79%).
Even though some women disliked the taste or smell, this didn’t affect their willingness to continue supplementation.
Over 95% of women in all groups believed the supplements were good for their health and their babies’ health.
Fewer side effects and significant benefits
One of the key reasons for higher MMS adherence was fewer reported side effects.
At the 30-day mark, 48% of IFA users reported side effects like nausea, constipation, and fatigue.
In contrast, only 23% of MMS-180 users and 36% of MMS-90 users experienced such issues.
At 90 days, the side effects dropped further. Only 9% of MMS-180 users and 14% of MMS-90 users reported adverse effects, compared to 27% of those on IFA.
This was likely because MMS contains a lower iron dose (30 mg compared to 60 mg in IFA) which reduces gastrointestinal side effects.
By the end of the study, 99% of women taking MMS reported positive health experiences.
Common benefits included higher energy levels (87%), improved sleep (87%), and a general sense of happiness and well-being (85%).
Policy implications: A clear path forward for Cambodia
Cambodia’s Ministry of Health has already expressed strong interest in transitioning to MMS.
This new trial provides the critical local data needed to support that policy change, which also requires supply chain assessments and the most effective delivery strategies for MMS being determined.
Factors such as packaging preferences, cost considerations, and accessibility will play a major role.
Globally, other countries are watching Cambodia’s progress closely. This trial sets an example for how to generate the right evidence before making national policy changes.
Cambodia could see significant maternal health improvements
With this strong evidence in hand, Cambodia is poised to improve maternal and child health outcomes by adopting MMS as the standard of care.
The trial’s results demonstrate that women not only adhere to MMS better but also experience fewer side effects and significant perceived health benefits.
This shift marks an important step forward for Cambodia’s healthcare system and presents valuable lessons for other countries considering similar policies.
For the nutrition and supplementation industry, it signals growing demand for innovative, effective prenatal products that meet both scientific standards and local preferences.
The researchers concluded: “Our findings suggest that the high adherence rates and acceptability of MMS support the transition from IFA to MMS in Cambodia.
“Next steps should include an MMS supply chain assessment and development of optimal delivery strategies for timely distribution.
“Our study results provide important considerations and lessons learned for stakeholders in Cambodia and other countries considering a transition from IFA to MMS.”
Source: The American Journal of Clinical Nutrition
“Assessing the adherence and acceptability to iron and folic acid compared with multiple micronutrient supplements during pregnancy: a cluster-randomized noninferiority trial in Cambodia”
https://doi.org/10.1016/j.ajcnut.2025.04.033
Authors: Cassandra Sauer, et al.
