Factors Associated with Multiple Micronutrient Supplementation Achievement During National Scale-Up in Ethiopia: A Longitudinal Analysis of Routine Monitoring Data

Maternal micronutrient deficiencies remain a major 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 nationwide.However, evidence regarding factors associated with implementation performance during large-scale program expansion remains limited.This study examined implementation and health-system factors associated with MMS achievement during national scale-up in Ethiopia.A longitudinal secondary analysis was conducted using routine MMS monitoring data collected between January 2023 and August 2026.The unit of analysis was the woreda-month observation.MMS achievement, defined as the percentage of pregnant women newly supplemented with MMS relative to the reported monthly target, was the primary outcome.Mixed-effects regression models with random intercepts for woredas were used to assess associations between MMS achievement and implementation factors.The analytical dataset included 2,268 implementation observations from 75 woredas across 13 regions, 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).In adjusted analyses, community dialogue was associated with a 17.99-percentage-point higher MMS achievement (95% CI: 3.11-32.86;p = 0.018), and commodity availability was associated with a 23.50-percentage-point higher MMS achievement (95% CI: 14.08-32.92;p < 0.001).Health-worker training, supportive supervision, implementation status, reporting period, and regional comparisons were not independently associated with achievement after adjustment.Substantial between-woreda variation remained (ICC = 0.358).Commodity availability and community engagement were the strongest factors associated with higher MMS achievement.Strengthening supply-chain reliability, community engagement, and routine monitoring systems may improve MMS implementation performance during national scale-up in Ethiopia.