The MOM-CARE Trial : Evaluating Antenatal and Postnatal MMSPlus for Improved Infant Birth and Growth Outcomes

This is a two-phase, Phase III double-blind, adaptive randomized controlled trial designed to evaluate the effects of enhanced multiple micronutrient supplementation (MMS Plus) compared to standard UNIMMAP MMS and iron/folic acid (IFA) supplementation on maternal and infant health outcomes in peri-urban Karachi, Pakistan. The trial is being conducted by The Aga Khan University and is funded by the Bill Gates Foundation.

Study Phases and Design:

Antenatal Phase:

Pregnant women between 8-14 weeks of gestation will be enrolled and randomized (1:1) into one of two arms:

MMS Plus (enhanced formulation) Standard MMS (UNIMMAP formulation)

Both groups will also receive standard antenatal care (ANC) and nutrition counseling. The primary endpoint is a composite 5-point ordinal scale of infant health at 28 days post-birth, which includes perinatal mortality and growth-for-gestational-age outcomes - Small for gestational age (SGA), Appropriate for Gestational Age (AGA) and Large for Gestational Age (LGA), along with preterm or term. The trial employs a Bayesian adaptive design, with interim analyses beginning after 500 participants have birth outcomes, and subsequent evaluations every 250 outcomes. The design allows early stopping for superiority or continuation based on posterior probabilities.

Postnatal Phase:

Women with live births will be re-randomised (1:1:1) within one week postpartum into one of three arms:

MMS Plus Standard MMS IFA (standard care)

All groups receive standard postnatal care and nutrition counselling. The primary endpoint is infant length velocity (cm/month) at 6 months among exclusively breastfed infants. Secondary outcomes include additional anthropometric measures and neurodevelopmental assessments. Adaptive analyses in this phase also begin after 500 infants have outcome data.

Interventions:

MMS Plus includes 22 micronutrients with additional components: choline (450 mg), DHA (200 mg), calcium (500 mg), and a higher dose of nicotinamide (118 mg NE).

Standard MMS follows the UNIMMAP formulation with 15 micronutrients. IFA includes 60 mg of iron and 400 mcg folic acid.

All supplements are administered daily via single-dose sachets, indistinguishable in packaging and taste to preserve blinding. Products are manufactured by Remington Pharma.

Setting and Recruitment:

The trial is implemented through the Clinical Trials Unit (CTU) of Aga Khan University. Recruitment will occur in three peri-urban catchment communities: Ali Akbar Shah Goth (AG), Bhains Colony (BH), and Qayyumabad (QB). Two sites (AG and BH) are located in District Malir and one (QB) in District East. These communities have been selected due to high burdens of maternal undernutrition and established surveillance systems through the Integrated Research Platform (IRP).

Pregnant women will be recruited during Antenatal Care (ANC) visits and confirmed eligible via ultrasound. Postnatal re-randomization occurs for women with eligible live-born infants. Follow-up includes scheduled home and clinic visits until 6 months postpartum. Participants will receive all clinical services and transportation free of charge.

Data Management and Monitoring:

Data will be collected using a digital platform developed on OpenSRP, enabling longitudinal tracking of mother-child dyads. Unique IDs link all clinical encounters and supplement adherence records. Data quality assurance includes weekly field audits, double-entry verification, and remote monitoring by the trial coordination team.

A Data Safety Monitoring Board (DSMB) will review interim results and safety data. Trial governance includes a Trial Management Group (TMG) and an independent Trial Steering Committee. All adverse events will be reported following institutional and national regulatory guidelines.

Scientific Rationale:

Despite global efforts to improve maternal and infant nutrition, Pakistan continues to report high levels of maternal anaemia, low birth weight, and childhood stunting. While MMS is being piloted for national scale-up, the evidence base for extended formulations remains limited, especially regarding postnatal supplementation. MMS Plus is hypothesised to offer superior outcomes due to its inclusion of neurodevelopmentally and metabolically relevant nutrients (choline, DHA, calcium, and high-dose nicotinamide). These additions are based on recent findings from the MUMTA trial and other global data highlighting their role in fetal brain development, infant growth, and maternal health.

This trial addresses critical knowledge gaps in the timing (antenatal vs. postnatal), formulation, and impact of micronutrient interventions, using robust adaptive methodologies to optimise power, efficiency, and ethical participant exposure.

• Gestational Weight Gain (GWG) [Time frame: At birth]
• Intrauterine Growth Restriction (IUGR) [Time frame: GA 20 and 32 weeks]
• Gestational age at birth [Time frame: Within 72 hours of birth]
• Birth Weight (gm) [Time frame: Within 72 hours of birth]
• Birth length (cm) [Time frame: within 72 hours of birth]
• Head circumference (cm) [Time frame: within 72 hours of birth]
• Infant MUAC (cm) [Time frame: within 72 hours of birth]
• Neonatal Mortality [Time frame: within the first 28 days of life]
• Infant weight velocity [Time frame: 1, 2, 4, 6, 12, 24 months of life]
• Length-for-age z-score (LAZ) [Time frame: 2, 4, 6, 12, 24 months of life]
• Weight-for-age z-score (WAZ) [Time frame: 2, 4, 6, 12, 24 months of life]
• Stunting, wasting and underweight Stunting <-2 LAZ ( Length for age Z) scores; Wasting <-2 WHZ (Weight for height Z) scores; underweight <-2WAZ (Weight for age Z) scores [Time frame: 2, 4, 6, 12, 24 months of life]