FIGO’s Updated Guidance on Anemia in Pregnancy Endorses MMS

17 October 2025 – The International Federation of Gynecology and Obstetrics (FIGO) Childbirth and Postpartum Hemorrhage (PPH) Committee has released new Good Practice Recommendations on Anemia in Pregnancy (2025), with a strong endorsement of multiple micronutrient supplementation (MMS) as a key strategy to prevent and manage anemia and improve pregnancy outcomes. The guidance emphasizes that MMS, containing iron and folic acid, should be considered over iron and folic acid supplements alone for pregnant women in low- and middle-income countries (LMICs) and in populations with a high prevalence of nutritional deficiencies among women of reproductive age. The guidance also addresses complementary interventions, such as malaria and anti-helminthic prophylaxis, hemoglobinopathy screening, parenteral iron therapy, and transfusion protocols for women with severe anemia.

FIGO recommendations for MMS in pregnancy:

1. Multiple micronutrient supplements (containing iron and folic acid) should be considered over iron and folic acid supplements alone for pregnant women in low- and middle-income countries (LMICs) and in populations with a high prevalence of nutritional deficiencies among women of reproductive age (strong, high).
2. Multiple micronutrient supplements used in pregnancy should contain the following 15 micronutrients at doses that meet the recommended dietary allowances for these micronutrients: folic acid, iron, copper, iodine, selenium, vitamin A, vitamin B1, vitamin B2, vitamin B3, vitamin B6, vitamin B12, vitamin C, vitamin D, vitamin E, and zinc (strong, high).
3. Multiple micronutrient supplements should be administered once daily throughout pregnancy (strong, high). For the prevention of fetal neural tube defects, they should be started at least 2–3 months before pregnancy (strong, high).
4. Intermittent/weekly administration of multiple micronutrient supplements in pregnancy is not recommended (conditional, low).
5. For women at low risk for fetal neural tube defects, multiple micronutrient supplements containing 400 μg of folic acid should be started 2–3 months before pregnancy, given once daily, and continued until 12 weeks of pregnancy (strong, high). This dose should be continued beyond 12 weeks and throughout pregnancy (strong, high).
6. For women at high risk of fetal neural tube defects, multiple micronutrient supplements containing 5 mg of folic acid should be started 2–3 months before pregnancy, given once daily, and continued until 12 weeks of pregnancy, and thereafter changed to multiple micronutrient supplements containing 400 μg of folic acid, which should be continued once daily throughout pregnancy (strong, high). Women with a BMI of 30 or above and on antifolate drugs, should maintain a high daily dose of 5 mg of folic acid throughout pregnancy (conditional, low). In the absence of a multiple micronutrient supplement containing 5 mg of folic acid, additional tablet(s) of folic acid should be taken in addition to the multiple micronutrient supplement to achieve a daily dose of 5 mg of folic acid (conditional, low).
7. It is not recommended for pregnant women to use multiple micronutrient supplements containing more than 30 mg of iron, owing to side effects (conditional, low). In situations where higher doses of 60–120 mg of iron are required, rather than use multiple micronutrient supplements containing such a high dose of iron, additional iron tablets should be administered in order to achieve the desired daily iron dose (conditional, low).

By formalizing these evidence-based recommendations, FIGO reinforces the growing consensus that MMS provides a more comprehensive and effective approach to improving maternal nutrition and pregnancy outcomes, particularly in LMICs where multiple nutrient deficiencies are common.