Anemia remains a critical maternal nutrition issue in low- and middle-income countries. Literature search, formative research and baseline surveys, informed the design of interventions to improve adherence to iron and folic acid supplementation in Bangladesh, Burkina Faso, Ethiopia and India.

The Alive & Thrive interventions addressed underlying barriers at the individual, community, and health system levels. Interventions were further adapted for integration into existing large-scale antenatal care programs through continuous monitoring. The barriers included poor supplies, lack of counseling during antenatal visits, and insufficient community and family support for PW.

We strengthened service delivery protocols and the capacity of community workers to engage families. We trained health workers, improved supervision and counseling quality, strengthened supply systems for IFA tablets, and facilitated family support for PW.

Women’s knowledge, beliefs, self-efficacy, and perception of social norms were improved through interventions tailored for each country setting.

Considering the high burden of anemia in low- and middle-income countries among women especially during pregnancy and health consequences for mothers and newborns of low iron intake, decision makers and implementers need to pay greater attention to understanding local barriers to adherence and designing interventions that can improve adherence.

Social and behavioral science theories and health systems strengthening frameworks provide a strong technical basis for designing effective interventions to improve IFA adherence.