Level 1: Likely reliable evidence

Maternal multiple micronutrient (MMN) supplementation reduces infant mortality compared with iron and folic-acid supplement alone in undernourished and/or anemic women, based on a cluster-randomized trial of 262 midwives in Indonesia (Lancet. 2008;371:215-227). Participating midwives were randomized to distribute an MMN supplement vs. an iron and folic-acid supplement as part of prenatal care; 31,290 women received supplements that were to be taken daily from enrollment to 90 days postpartum.

Comparing MMN supplementation vs. iron and folic-acid supplementation, infant mortality was 3.55% vs. 4.3% in the first 90 days postpartum (P=.01, NNT 133), 1.7% vs. 1.9% in the first seven days postpartum (not significant), 0.55% vs. 0.62% at 8-28 days postpartum (not significant), and 1.2% vs. 1.7% at 29-90 days postpartum (P=.004, NNT 200). In babies born to 9,363 undernourished mothers (mid upper-arm circumference <23.5 cm [9.25 inches]), infant mortality was 4.1% vs. 5.5% at 90 days postpartum (P=.002, NNT 72). In babies born to 8,978 mothers with anemia (hemoglobin <110 g/L), mortality was 3.1% vs. 4.9% (P<.0001, NNT 56). There were no significant differences in rates of spontaneous abortion (1.9% vs. 2.1%) or stillbirths (1.7% vs. 1.9%). MMN supplementation was associated with a trend toward decreased rate of low birth weight (≤2,500 g [5.5 lb]) in 11,101 infants weighed within one hour of birth (9% vs. 11%, P=.06).

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