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ATC codes: A11AA01
Indication
Maternal care for other specified conditions predominantly related to pregnancy ICD11 code: JA65.Y
Medicine type
Chemical agent
List type
Core
Additional notes
For use in specific contexts. Refer to current WHO recommendations.
Formulations
Tablet containing: Vit A: 800 mcg retinol activity equivalent Vit C: 70 mg Vit D: 5 mcg (200 IU) Vit E: 10 mg alpha tocopherol equivalent Vit B1: 1.4 mg Vit B2: 1.4 mg Vit B3: 18 mg niacin equivalent Vit B6: 1.9 mg Folic acid: 400 mcg Vit B12: 2.6 mcg Iron: 30 mg Iodine: 150 mcg Zinc: 15 mg Selenium: 65 mcg Copper: 2 mg
EML status history
First added in 2021
Sex
All
Age
Adolescents and adults
Therapeutic alternatives
The recommendation is for this specific medicine
Patent information
Patents have expired in most jurisdictions
Expert Committee recommendation
The Expert Committee noted the high prevalence of nutritional deficiencies in low- and middle-income countries where many women enter pregnancy already malnourished. Deficiencies of multiple essential vitamins and minerals result in potentially severe health consequences for pregnant women and their infants, including increased maternal and perinatal mortality. The Committee noted that evidence from over 20 randomized trials conducted across multiple countries, often at low risk of bias, demonstrates that daily supplementation with multiple micronutrient supplements in pregnancy compared with supplementation with iron and folic acid alone improves pregnancy outcomes. While the evidence does not show benefits in terms of neonatal and maternal mortality, it does show a relevant reduction in the risk of small for gestational age births, low birth weight and preterm and very preterm births. Data on mortality are affected by the high heterogeneity among studies. The evidence also shows that multiple micronutrient supplements are safe and cost-effective compared with iron and folic acid supplements, particularly where the prevalence of undernourished women is high. The Committee noted recommendations about use of multiple micronutrient supplements in pregnant women included in WHO guidelines, and joint WHO, UNICEF and World Food Programme guidelines. All recommendations agree on the direction of the recommendation (i.e. recommending multiple micronutrient supplements in certain situations), despite differences in terms of the strength and scope of the recommendations at the population level (e.g. restriction to emergency settings, use in women with tuberculosis or use in the context of research). The Committee agreed that more research is needed on the effects of switching from daily iron and folic acid supplements containing a 60 mg dose of elemental iron to daily multiple micronutrient supplements containing a lower dose (30 mg) of elemental iron in populations with a high prevalence of iron deficiency anaemia, but also recognized that there is no evidence of harm in this group. The Committee considered, however, that listing multiple micronutrient supplements as an essential medicine would not prevent answering this important question and similar questions (e.g. the potential interactions between different micronutrients) and may facilitate research. The Committee also expressed reservations about the probability that new trials will be started and completed in the short term to further explore the benefits and harms of multiple micronutrient supplements or their acceptability compared with tablets with a smaller number of micronutrients. Implementation research on the adoption of multiple micronutrient supplements will be informative, but it is unlikely that this evidence will change the cumulative evidence reached so far, with a benefit-to-harm ratio clearly in favour of multiple micronutrient supplements. The Committee therefore recommended listing multiple micronutrient supplements on the core list of the EML for the use as an antenatal supplement in pregnant women. The Committee considered that further evidence on the adequacy of the daily elemental iron dose in multiple micronutrient supplements is desirable.