September 2025 — Anemia 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

   • One-day, in-person training for health professionals and health extension workers.

   • Focused on empathetic communication, addressing implicit bias, and building stronger patient-provider relationships.

   • Delivered through role-plays, case studies, and practical modules.

2. Supermom’s Journey Comic Booklet and Video

   • Illustrated stories comparing the experiences of women who use MMS and those who do not.

   • Designed for easy comprehension, including versions in local languages and an audio-visual format for low-literacy audiences.

   • Emphasized the benefits of regular ANC attendance and nutritional practices.

3. Journey to Motherhood Game Board

   • An interactive educational tool where women and their families could learn about nutrition, anemia, and ANC through games.

   • Combined pictorial and written instructions to accommodate varying literacy levels.

   • Aimed to make maternal health education engaging and memorable.

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.

Recommendations

Based on the findings, the report outlines several strategies to strengthen impact:

1. Integration into Routine Care

   • Embed comics, games, and counseling into ANC sessions and pregnant women’s group meetings.

   • Ensure consistent exposure rather than one-off delivery.

2. Expand Empathy Training

   • Scale training to all frontline maternal health providers.

   • Make it mandatory for new staff and refresh periodically.

   • Link empathy training with supervision and accountability systems.

3. Adapt to Literacy and Culture

   • Use culturally relevant visuals, simplified text, and audio formats.

   • Address misconceptions about alcohol and supplements through community campaigns.

4. Bundle with Complementary Measures

   • Combine behavioral tools with nutritional counseling, home visits, and community awareness activities.

   • Engage husbands, mothers-in-law, and local leaders to reinforce messages.

5. Strengthen Delivery Mechanisms

   • Incorporate reminder systems, such as phone messages or community health worker visits.

   • Improve facility readiness to ensure consistent and quality service delivery.

Conclusion

This evaluation demonstrates that behavioral interventions alone may not be sufficient to drive large-scale change in maternal health outcomes. However, when combined with empathetic healthcare, culturally tailored materials, and community support, they can play a vital role in strengthening Ethiopia’s transition to MMS and improving maternal and child health.