Anemia among women of reproductive age, particularly during pregnancy, is widespread, but there are remedies such as iron and folic acid (IFA) supplements that can increase iron intake. This study documents the barriers faced by pregnant women (PW) in adhering to daily IFA supplementation as recommended by the World Health Organization. We designed interventions for large-scale antenatal care programs to improve adherence in Bangladesh, Burkina Faso, Ethiopia, and India. 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. We improved women’s knowledge, beliefs, self-efficacy, and perception of social norms 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. Read More >>