Temporal Trends and Geographic Variation in Multiple Micronutrient Supplementation Implementation Performance in Ethiopia: A Routine Monitoring Data Analysis, 2023–2026

Maternal micronutrient deficiencies remain an important public health challenge in Ethiopia and contribute to adverse maternal and newborn outcomes.Ethiopia introduced Multiple Micronutrient Supplementation (MMS) through routine antenatal care services and progressively expanded implementation from 21 pilot woredas in 2023-2024 to 80 woredas nationwide by 2026.However, evidence on implementation performance during national scale-up remains limited.This study assessed temporal trends and geographic variation in MMS implementation performance using routine program monitoring data collected between January 2023 and June 2026.A longitudinal secondary analysis was conducted using woreda-month observations from the national MMS monitoring database.MMS achievement was defined as the percentage of pregnant women newly supplemented with MMS relative to the monthly target.Descriptive and non-parametric statistical analyses were applied.The final analytical dataset included 2,268 unique woreda-month observations of which 1,724 (76.0%) had available MMS achievement data.Mean MMS achievement was 100.2% (SD 56.3), while the median was 94.6% (IQR 70.5-120.4).Median achievement declined from 98.8% during 2023-2024 to 93.2% in 2025 and 89.9% in 2026.Existing woredas achieved higher median performance than Expansion woredas (96.4% vs. 85.3%;p<0.001).Significant regional variation was observed, with median achievement ranging from 64.1% in Somali to 102.0% in Oromia and Dire Dawa.Reporting completeness declined substantially during scale-up.MMS implementation remained broadly aligned with program targets but varied across regions and implementation settings, highlighting the need for strong implementation support, monitoring systems, and data-quality assurance during national expansion.