Maternal undernutrition in Africa remains a public health challenge, contributing to negative pregnancy outcomes, neonatal mortality, and perpetuating intergenerational cycles of poor health. Antenatal multiple micronutrient supplementation (MMS), a cost-effective intervention recognized for its potential to improve maternal and neonatal health, reduces risks of low birth weight, preterm birth, small for gestational age, and stillbirth while offering a $37 return for every $1 invested. Despite its benefits, MMS adoption across African countries remains suboptimal. This position paper synthesizes the outcomes of the 2nd Africa Maternal Nutrition and MMS Technical Meeting: A Path Toward Introduction and Scale-up of MMS in Africa, held in Nairobi, Kenya, in October 2024. The 3-d meeting convened government representatives from 17 African member states, donors, and experts to align on a shared vision for MMS introduction and scale-up in Africa. Participants emphasized MMS integration into antenatal care as a cornerstone of maternal nutrition strategies and identified actionable recommendations to overcome policy, supply chain, financing, and implementation barriers. Key messages include the urgency of scaling MMS, the role of implementation science in tailoring programs to local contexts, and the necessity of regional collaboration to share lessons and facilitate progress. It outlines a pathway for integrating MMS into antenatal care services, ensuring a quality supply, securing financial commitments, strengthening delivery, and engaging communities. The accompanying "Call to Action" provides a detailed roadmap to guide stakeholders in scaling up MMS as an urgent priority to enhance maternal and neonatal health, advance gender equality, and fulfill Africa's global health commitments.

In settings where more than 20% of women of reproductive age are classified as underweight, the World Health Organization recommends balanced energy and protein (BEP) supplementation during pregnancy to reduce adverse birth outcomes. However, guidance on contextually acceptable and feasible supplement delivery platforms remains limited, posing critical challenges for implementation. We synthesized literature on acceptable and feasible delivery platforms for BEP supplementation (direct evidence), as well as iron and folic acid (IFA) or multiple micronutrient supplements (MMS; indirect evidence) to pregnant and breastfeeding women (PBW) to broaden the search scope. A systematic search was conducted across five databases and grey literature to identify studies that addressed the acceptability and feasibility of BEP supplement delivery platforms in low- and middle-income countries (LMICs), at facility and community levels. We identified 48 studies conducted in LMICs: 22 specifically evaluated BEP supplement delivery, while 26 evaluated IFA or MMS. In the direct evidence, home delivery (11/22) was the most frequently mentioned delivery platforms of BEP supplements followed by community-level feeding centers (provided cooked meals or take-home rations) anchored by frontline community health workers (8/22 studies) and antenatal care (ANC) at health facilities (6/22; some studies assessed multiple delivery platforms). Only four studies assessed preferred BEP delivery platforms, and PBW favored home over facility-based delivery. Authors attributed this preference to the comprehensive nutrition education and behavior change communication (BCC) provided during home delivery. Indirect evidence showed that enhancing delivery of IFA or MMS at health facilities (not specific) through strategies such as BCC and home visits may improve supplement compliance. Overall, limited evidence exists regarding market-based approaches for delivering any of these interventions. Based on existing evidence, scale-up delivery of BEP supplementation through ANC at health centers, enhanced by community health workers may be feasible in reaching PBW, especially when combined with BCC.

The World Health Organization recommends the use of balanced energy protein (BEP) supplements during pregnancy in settings with a ≥ 20% prevalence of underweight women of reproductive age to reduce the risk of adverse health outcomes. Several countries are implementing BEP supplementation in varied formats. However, the implementation and monitoring of outcomes remain poor across countries. This qualitative study explores the experiences, opportunities, and challenges related to implementing national and sub-national BEP supplementation programs in nine countries (12 countries originally invited) to inform best practices. Methods: Semi-structured interviews were conducted with 15 personnel involved in its implementation in Haiti, India, Malawi, Mexico, Nigeria, Pakistan, Rwanda, Senegal, and Sri Lanka between October 2024 and March 2025. The interviewees in each country were predominantly implementation experts but also government officials involved in the provision of BEP supplementation. The transcripts were analyzed thematically, focusing on acceptability, adoption, appropriateness, cost, feasibility, and sustainability of outcomes. Results: In non-humanitarian settings (five countries), BEP supplementation was commonly integrated into the governmental health system or social protection programs. However, humanitarian contexts (four countries) often relied on partner-led (e.g., UN organizations) implementation. Clear operational protocols, including behavioral change communication strategies, facilitated the implementation. Community-based organization partnerships strengthened adherence; however, implementation costs, stock shortages, and geographic inequities in coverage varied and were limiting factors in scale-up, primarily in humanitarian contexts. Conclusion: In sum, two distinct implementation pathways emerged: government-led models characterized by policy integration, national ownership, and more stable systems, and humanitarian or donor-led models shaped by crisis response, external dependency, and non-committal challenges. Successful implementation of BEP supplements depends on the presence of effective policies, context-adapted design, integration into health systems, consistent funding, and effective monitoring. There is a need for implementation research to generate evidence on best practices when implementing BEP supplementation programs.