Evaluation of a Program to Prevent Pre-Eclampsia and Eclampsia through Calcium Supplementation for Pregnant Women in Nepal - Dailekh District Dissemination meeting Introduction of the pilot program (9th December 2013, hotel Himalaya) Dr. Kiran Regmi Director, Family Health Division Post doctorate (Harvard), Ph D (New England University, Australia), MD (India), MPH (UK), MA (Nepal)

Introduction of the calcium pilot program > Rationale > Maternal health key indicators Value Maternal mortality rate 229/100,000 live births * Antenatal care, at least one visit 84.8% ** Antenatal care, at least one visit from skilled provider (doctor, nurse, or ANM) 58% ** Antenatal care, four or more visits 50.1% ** Median months pregnant at first ANC 3.7 ** Institutional deliveries 35% ** Data Sources: *Nepal Maternal Mortality and Morbidity Study 2009, **NDHS 2011

Introduction of the calcium pilot program > Rationale > Causes of maternal death Source: Nepal Maternal Mortality and morbidity Study, Family Health Division, 2009

Introduction of the calcium pilot program > Rationale > Decadal change in causes of maternal death (1998 and 2008/9)

Introduction of the calcium pilot program > Rationale > Women die from Pre-Eclampsia and Eclampsia in Nepal ANC coverage and health facility delivery is still low Dietary calcium intake for pregnant women in Asia is between 200-500mg/day, whereas the sufficient amount is 1000-1300mg for non lactating women of reproductive age * Testing of BP and urine not always done during ANC Difficult to reach health facility in time after danger signs appear Reluctance to treat PE/E by health care providers: Concern over the management of severe PE cases Reluctance to give the loading dose of MgSO4 before referral/transfer Limited access to emergency obstetric & newborn care (EmONC) services * WHO systematic review (1991-2004) of dietary calcium intake of pregnant women.

Evidence-based, proven intervention1 Introduction of the calcium pilot program > Characteristics of the pilot Evidence-based, proven intervention1 Utilize existing government systems and channels Maximize coverage using ANC contact Unique site selection that was the hilly Dailekh district 6

Introduction of the calcium pilot program > Site selection > Rationale behind choosing Dailekh A hilly district was chosen because this is the most common type of district – out of 75, 39 are hill districts in Nepal It has a greater population than mountain districts It has more difficult access to ANC compared to Terai districts, hence its findings could be easily scaled up to terai districts   7

Introduction of the calcium pilot program > Site selection > Dailekh Tanahu Surkhet Arg Pyut Dang Banke Kapilv Bardiya Rolpa Salyan Palpa Nawalparasi Rupa Chitwan Myagdi Gulm Bagl Sya Pa Kaski Humla Dadeldhura Kailali Kanchanpur Achham Doti Darchula Baitadi Bajura Bajhang Dolpa Rukum Jajarkot Dailekh Manang Mustang Kalikot Jumla Mugu Par s a Uday Mah o t r i Dh n u h Siraha Raut Bara Sa l Sindhuli Saptari Morang Sunsari Jhapa Dhan Khota ng B j p Ilam Tehr Panc SinPal Makwanpur L Kavre K Dhad Gorkha Lamjung Nuwa Rasuwa Rame Okhaldhunga Sankhuwa Solukhum Dolk Taplejung Index Program district

Introduction of the calcium pilot program > Site selection > Dailekh

Introduction of the calcium pilot program > Implementation > Process > Approval Organized first TAG meeting on February 2012 to work on approval Approval from the Government (Tippani) received on March 2012 Approval from NHRC on March 2012 Approval from JHU IRB on August 2012 Explain membership and role of TAG 10

Introduction of the calcium pilot program > Implementation > Process > Materials development Developed tools for monitoring the pilot Calcium page added to the existing BPP flipchart – job aid Developed training and BCC materials

Introduction of the calcium pilot program > Implementation > Process > Ca related BCC material Flex at health facility Brochure, bag and calcium bottles for PW Flip chart for FCHV

Introduction of the calcium pilot program > Implementation > Process > Capacity building Organized district orientation and planning meeting on April 2012 Trained district supervisors, ANC health workers (268), FCHVs (810) Conducted review and update for ANC health workers in Nov 2012 Strengthened HF to detect, manage PE/E- BP, Dipstick , MgSO4 use Jhpiego purchased 2.65 million calcium tablets 16,50,000 tablets manufactured by Mission Pharma on June 2012 and 10,00,000 tablets on March 2013 Distributed training and BCC materials, calcium bottle, urine bottles and dipsticks on June 2012

Introduction of the calcium pilot program > Implementation > Modalities > Distribution Distribution eligibility was set as for all pregnant women coming for their first ANC visit at 4th month gestational age or on wards were eligible to receive calcium Distribution amount of calcium was based on month of gestation: 4 or 5 month received 3 bottles 6 or 7 month received 2 bottles 8 or 9 months received 1 bottle

Introduction of the calcium pilot program > Implementation > Modalities > Distribution > No of women

Introduction of the calcium pilot program > Implementation > Modalities > Distribution > Gestation

Introduction of the calcium pilot program > Implementation > Modalities > Distribution > Prescription One gram daily supplementation (2 tablets containing 500 mg each of elemental calcium) provided at once To be taken everyday for 150 days, optimally to be started at 4 months of pregnancy To be taken in the morning after meal and iron to be taken in the evening 17

Introduction of the calcium pilot program > Implementation > Modalities > Distribution > Roles Roles of FCHV Promotion of ANC Counseling on calcium Follow-up for compliance Appropriate Referral Recording and reporting 18

Role of ANC health workers Introduction of the calcium pilot program > Implementation > Modalities > Distribution > Roles Role of ANC health workers Counsel pregnant women on calcium PE/E screening (BP and urine test) Distribute calcium Recording and reporting Manage referrals as appropriate-use of MgSo4

Roles of DHO and MCHIP staff Introduction of the calcium pilot program > Implementation > Modalities > Distribution > Roles Roles of DHO and MCHIP staff Made technical support visits to Health Facility & FCHV as needed for Monitoring Education Problem solving Linkage to central decision makers Motivation Data collection 20

Introduction of the calcium pilot program > Evaluation methods Data collection methods included Post-intervention household interviews with recently delivered women to measure ANC coverage, calcium coverage, and compliance with the recommended calcium supplementation regimen Interviews with ANC health workers and FCHVs Evaluation conducted by independent research agency – Population, Health and Development (PHD) Group

Introduction of the calcium pilot program > Routine data collection tools and process Data sources Description Remarks Calcium register Kept at the facility to record calcium distribution New FCHV Register Record per pregnant women maintained by FCHV Adapted VHW level reporting forms Compiles FCHV closed forms Health facility level reporting forms Compiles VHW level reporting forms Technical support visit form for health facility Technical Support Visit form for FCHV 22

Introduction of the calcium pilot program > Status of calcium distribution and monitoring Calcium supplementation started from June 2012 to mid August 2013 Estimated to cover 7400 pregnant women in a year Covered 9246 pregnant women by mid of August 2013 Distributed 23210 bottles of calcium Total of 405 technical support visits were made to HF (145) and FCHVs (260)

Introduction of the calcium pilot program > Challenges Unexpected shortfall of calcium due to the higher than expected ANC attendance Training and implementation started in rainy season hence had some logistic difficulty in materials/calcium transportation to health facilities Discontinuing calcium supplementation after the pilot completion in Dailekh was another challenge, CARE is supporting GON to supply calcium for 3 months

Introduction of the calcium pilot program > Scale up plan Plan to scale it up first in 2 terai districts with High number of expected pregnancy High PE/E case load Availability of partner organization to support scale up With baseline and end-line data collection

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