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Preventing Pre-Eclampsia: Supplementing Calcium In Nepal

Harshad Sanghvi, Vice President Innovations & Medical Director,


Kusum Thapa, Regional Technical advisor, Jhpiego/Nepal

Guidance on Implementing effective programs to prevent Preeclampsia, 14 April 2013, Johannesburg, SA

Nepal: Background
MMR is declining, though still high:
229/100,000 (MMS, 2008/9) SBA deliveries increasing but still low 19% in 2006 to 36% in 2011 2 of 3 women deliver at home with no SBA Eclampsia is the leading cause of maternal mortality 21% of total maternal deaths 29.8% of hospital maternal deaths

1998 2009
539 37% 247 19%


Eclampsia 14%
% birth 17% with SBAs

19% 36%

Why Do Women Die from PE/E in Nepal?

Half of pregnant women complete 4 ANC visits Testing of BP and urine not always done during ANC

Proteinuria testing is not routine as urine dipstick tests are not supplied by the MOHP

Difficult and delay in reaching health facility after danger signs appear 36% of women deliver with a skilled provider (NDHS 2011)

Reluctance to treat PEE by health care providers where it occurs

Reluctance to give the loading dose of MgSO4 before referral/transfer

Limited access to emergency obstetric & newborn care (EmONC) services

Three prong strategy of MOHP Nepal to address PE/E

MOPH NESOG Partnership to improve quality of Eclampsia management using SBMR Strengthen ANC Community detection of PE

Calcium pilot ANC Community sprinkles

Key inputs: stakeholders

At least 3 years of wide discussion with stakeholders consensus on need, but concern regarding
Cost negative impact on successful iron programs Community vs ANC platform dosage, limited availability in local market, most preps are costly,

often combined with Vitamin D which reduces shelf life of combined product.

Coat of calcium tablets 1g per day /150 days

Estimated shipping and customs costs: 25% included

Calcium Sprinkles: $ 1.88 PPW

Key Inputs: Gaining Confidence

Acceptability and compliance of calcium supplementation (Tablets and sprinkles consumer preference study Calcium introduction study ( ongoing)

Dailekh Photo credit: Dipendra Rai, MCHIP/Nepal

Calcium Acceptability and Compliance Study: Study Design

Titihiriya and Udarapur VDCs of Banke District Household-level antenatal contact for health education, assessment and dispensing of calcium by FCHVs 1g/day for 90 days 97 PW participated Supplemented with two different forms of calcium:
Powder (1 packet/day) Tablet (2 tablets/day)

Titihiriya VDC

Udarapur VDC


30 days



30 days


Preference: Tablet/Powder

30 days

Preference: Powder/Tablet

Calcium Preference study Compliance among women who accepted calcium

Calcium tablets (148)

Took all 30 days Missed 5 days or less 74% 8%

Calcium Sprinkles (110)

72% 8% 16% 4%

Missed More than 5 days 16% Not taken/not received 1%

Reasons for missing calcium

Forgot to take ( majority about 60%) Away from Home, inconvenient, Experiencing symptoms Health concerns ( may affect baby) Discouraged by family member For Sprinkles: altered taste of food (18%) For Pills: too large, difficult to swallow (11%) For Pills: took only 1 tablet ( 7%)

Timing Issues
Theoretical concern: if calcium and iron taken together, iron may not be absorbed as well Suggested solution: Take at different meal times Findings: About 50% do not practice taking breakfast


Reported symptoms while on calcium

More prevalent with sprinkles ( 5% vs 20%) Belching or gas Heaviness in stomach With Pills: Lowered appetite With sprinkles: Constipation, nausea


Willingness to continue calcium supplementation beyond 2 months: 92% Willingness to recommend to others : 95% Preference for pills: 78%, For Sprinkles: 18%


Impact on Iron program

Missed taking iron some days: 21% Reason: Forgot mostly, did not attribute this to calcium 87% felt taking tablets at different times was Ok


Implementation challenges
Difficulty in finding calcium without Vitamin D Require large storage space: calcium is bulky Continuing concerns of GON regarding the sustainability to cover cost for nationwide scale up GONs decision of distributing Calcium through health facilities unlike Iron which was distributed by FCHV. Desire to meet ANC coverage targets by Offering this additional service Ongoing debate regarding dosage as WHO most recent recommendation is for 1.5-2 gm.

Role division of HW
Role of Health Worker First ANC Visit- Routine ANC care (BP& Urine Protein test), Counseling on PE/E and Calcium Distribution of Calcium- 3 bottles each with 100 tablets given to the PW and advised to take 2 tablets daily in the morning for 150 days Recording and reporting Manage referrals as appropriate use of MgSO4

A health workers screens a pregnant woman in Dailekh for high blood pressure, a symptom of pre-eclampsia, during an ANC visit. Photo credit: Jona Bhattarai, MCHIP/Nepal

Role of FCHV Promotion of ANC Counseling on Calcium Follow Up for Compliance Appropriate Referral Recording and Reporting

An FCHV at a pregnant womens group n Dailekh talking about the risks of preeclampsia/eclampsia and the use of calcium for prevention. Phot credit: Dipendra Rai, MCHIP/Nepal


Calcium related BCC materials

Brochure, bag and calcium bottles for PW
Flex at health facility

Flip chart for FCHV

Taking calcium during pregnancy helps the mother and baby be healthy

Implementation Modality
Calcium Distribution at first ANC visit by health worker All PW are eligible to receive calcium Strengthening HF for detection and prevention of PE/E- BP, Dipstick and MgSO4 use Distributed through first ANC visit, regardless of gestational age Encouraged to take Calcium: From 4 months of pregnancy 2 tablets every day For 150 days (5 months)


Technical support visits maintain implementation quality: HF and FCHV

Multipurpose visits
Data Monitoring Education Problem solving

Linkage to central

decision makers Motivation

Field officers visit pregnant woman at home to ensure she has received calcium and is not having any difficulties taking it daily. This woman is storing her calcium in the bag behind. Phot credit: Dipendra Rai, MCHIP/Nepalc


Timing to receive calcium

60 Percent of pregnant women enrolled 50





0 June 012 July 012 ANC 1 Aug 012 ANC 2 Sep 012 Oct 012 Nov 012 Dec 012 ANC 3 ANC 4 Other ANC

Number of pregnant women received one, two and three bottles of calcium
3000 2723 2500 Problem: Many women attend ANC late. Starting calcium later in pregnancy will not impact PE rates FCHV distribution more likely to achieve timely initiation 1342 1065 1000 500 0 Received one bottle Received two bottles Received three bottles

Number of pregnant women

2000 1500

Final Thought: Unprecedented Commitment

Coverage at Scale Quality at Scale Impact at Scale