September 2025 — Anaemia continues to pose a major threat to maternal and newborn health in Ethiopia, contributing to low birth weight, preterm delivery, and preventable deaths. While iron and folic acid supplements (IFAS) have long been the standard of care, recent global evidence shows that Multiple Micronutrient Supplementation (MMS) offers broader benefits by addressing multiple nutritional deficiencies simultaneously.

The Ministry of Health (MoH), in collaboration with UNICEF, is now introducing MMS nationwide. But successful uptake depends not only on supply, but also on behavioural and social factors—including awareness, trust in healthcare providers, and support from family and community networks.

To support this transition, the Busara Center for Behavioral Economics conducted a rigorous evaluation of behavioural interventions designed to enhance MMS adherence, ANC attendance, and dietary practices among pregnant women.

The Interventions

The study focused on three behavioural tools, designed through human-centered design workshops with pregnant women, health workers, husbands, and mothers-in-law:

1. Healthcare Worker Empathy Training

   • What it was: A one-day, in-person training for health professionals and health extension workers using role-plays, case studies, and practical modules.

   • Behavioural rationale: Empathetic communication builds trust and reduces psychological barriers like stigma or fear of judgment. Evidence from behavioural science shows that patients’ perceptions of respect and care strongly influence motivation to adhere to treatment and return for follow-up. By addressing implicit bias and strengthening relationships, this training aimed to shift provider–patient dynamics from directive to collaborative.

2. Supermom’s Journey Comic Booklet and Video

   •  What it was: Illustrated stories—available in multiple languages and audio-visual formats—comparing the experiences of women who adhere to MMS and those who do not.

   • Behavioural rationale: Stories activate narrative persuasion, making information more relatable and memorable than abstract health advice. By showing role models and consequences, the comic leveraged social learning theory and normative influence—helping women see adherence as both beneficial and socially valued. Tailoring formats for low-literacy audiences also reduced cognitive barriers, ensuring equitable access.

3. Journey to Motherhood Game Board

   • What it was: An interactive, pictorial game played by women and their families to learn about nutrition, anaemia, and ANC.

   • Behavioural rationale: Gamification introduces fun and engagement, which improves cognitive salience (remembering and recalling information). By involving husbands and mothers-in-law, the game also targeted injunctive norms (what important others expect) and collective efficacy, recognizing that maternal nutrition decisions are often made within households rather than by women alone.

These interventions were tested through a cluster-randomized controlled trial (cRCT) across 29 health centers in six woredas, with a total of 588 women included in the endline sample. The trial was complemented by in-depth qualitative interviews with 28 women and 15 healthcare workers.

Key Findings

The study produced mixed results:

• Quantitative results: No statistically significant improvements were observed in MMS adherence, ANC attendance, or dietary diversity.

• Qualitative findings: Both pregnant women and healthcare workers reported positive experiences:

  • Mothers stated that the comic book and game improved their knowledge and encouraged regular MMS intake.

  • Health workers emphasized that empathy training enhanced their ability to engage effectively with women and improved follow-up on MMS use.

  • Importantly, perceived empathy from healthcare providers was strongly associated with increased ANC attendance and adherence to MMS.

These findings suggest that while interventions did not independently produce measurable changes at scale, they positively influenced perceptions, understanding, and practices among both service users and providers.

Barriers Identified

The evaluation also revealed practical challenges:

• Literacy barriers limited the effectiveness of text-based materials.

• Cultural beliefs—such as reliance on local alcohol (Tella) for perceived nutritional value—interfered with pill adherence.

• Time constraints and forgetfulness reduced engagement with intervention tools.

• Facility access limitations hindered the impact of health worker training.

What This Means for Maternal Health

To maximize impact, the study recommends:

• Integration of tools into routine ANC sessions and women’s groups.

• Expansion of empathy training for frontline health workers, with refresher courses to sustain skills.

• Adaptation of materials into culturally relevant, visual, and audio formats to address literacy gaps.

• Bundling interventions with complementary approaches such as home visits, counselling, and community mobilization to create enabling environments.

• Family and community engagement, particularly with husbands, mothers-in-law, and local leaders, to reinforce maternal health behaviours through supportive norms.

By integrating behavioural science into the design of maternal health interventions, Ethiopia is demonstrating how to move beyond information provision toward behaviourally effective solutions:

• Training that builds provider empathy to foster motivation and trust.

• Storytelling that leverages social norms and role modeling.

• Interactive games that enhance salience, recall, and household support.

These approaches show that improving maternal nutrition requires addressing not just what women know, but also how they feel, what they perceive as possible, and the social environments in which decisions are made.

Conclusion

The Ethiopia MMS study highlights how behavioural science, applied through human-centered design, can help close the gap between availability of services and actual uptake. By aligning interventions with human motivation, social dynamics, and decision-making processes, Ethiopia is paving the way toward better maternal nutrition, healthier pregnancies, and stronger newborn survival outcomes. 

The findings reinforce a key lesson from behavioural science: changing health behaviours requires more than information—it requires trust, social support, habit-building, and culturally resonant approaches. By embedding these principles into policy and practice, Ethiopia can accelerate progress in maternal and child health.