Implementation challenges of India's national anaemia reduction program among pregnant women: insights from mixed-methods implementation research.

Introduction: Anaemia remains a pressing public health concern in low- and middle-income countries, disproportionately affecting pregnant women. In India, despite longstanding national programs like Anaemia Mukt Bharat (AMB) i.e., "Anaemia free India". Anaemia prevalence remains alarmingly high with 53% of pregnant women reported to have anemia in India. This percentage is even higher in underperforming districts such as Palwal in Haryana with 56.8% pregnant women being affected by the condition. This implementation research (IR) aimed to identify implementation and contextual barriers to this program across beneficiaries, community health providers, and the health system. Methods: A convergent parallel mixed-methods design was employed as part of Phase I of this IR nested within the Sustainable Scalable Interventions to Improve Maternal and Newborn Health in India (SIIMA) project. Quantitative data were collected from 370 pregnant women and nine public health facilities through structured assessments and programmatic records. Qualitative data were gathered through 35 in-depth interviews and 6 focus group discussions with pregnant and lactating women, and healthcare providers. The Capability Opportunity Motivation-Behaviour (COM-B) model guided qualitative thematic analysis, supplemented with inductive coding. Integration of findings occurred during the interpretation phase, with qualitative insights used to explain patterns and gaps observed in the quantitative data. Results: Only 67% of pregnant women received at least one dose of iron and folic acid (IFA), and just 48.6% had undergone haemoglobin testing. Among women for whom both Hb and IFA data were available, merely 5% received IFA dosages aligned with their anaemia severity, as recommended. Mean IFA consumption in the previous month was far below expected levels, while no participant achieved full compliance. Qualitative findings revealed that while both beneficiaries and frontline providers were aware of anaemia and its risks, adherence was undermined by cultural misconceptions, limited counselling, lack of follow-up systems, and fragmented supply chains. Providers cited knowledge adequacy but were constrained by erratic stock availability, diagnostic gaps, and lack of structured supervision. Conclusion: Despite reasonable awareness and intent, systemic and behavioural challenges impeded AMB implementation. Enhancing supply reliability, strengthening diagnostic, counselling services, and engaging families in decision-making are vital for optimizing program delivery. These findings will inform the development of tailored implementation strategies in Phase II to improve effective coverage and compliance with AMB guidelines in rural India.