1. 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)

2. 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

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

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

5. 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 mg/day, whereas the sufficient amount is mg 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 ( ) of dietary calcium intake of pregnant women.

6. 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

7. 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

8. 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

9. Introduction of the calcium pilot program > Site selection > Dailekh

10. 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
Explain membership and role of TAG 10

11. 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

12. 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

13. 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
Distributed training and BCC materials, calcium bottle, urine bottles and dipsticks on June 2012

14. 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

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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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 bottles of calcium
Total of 405 technical support visits were made to HF (145) and FCHVs (260)

24. 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

25. 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

26. THANK YOU