1. Mr. Dharma Raj Jaisi Focal Person District Health Office, Dailekh Overview of Calcium Pilot

2. Background of the Pilot (1)  Evidence-based, Proven Intervention 1  Utilize existing government systems and channels  Maximize Coverage and Compliance using ANC contact 1 Atallah AN, Hofmeyr GJ, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems (Cochrane Review). In: The Reproductive Health Library, Issue 9, 2006

3. Background of the Pilot (2)  67% reduction in PE/E 1  WHO recommendation for preventing PE/E (In areas where dietary calcium intake is low, calcium supplementation during pregnancy (at doses of 1.5–2.0 g elemental calcium/day) is recommended for the prevention of pre-eclampsia in all women, but especially those at high risk of developing pre-eclampsia.) - Page no. 2  MoHP interested in piloting calcium supplementation to look at Coverage and Compliance through existing govt. platform. 1 Atallah AN, Hofmeyr GJ, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems (Cochrane Review). In: The Reproductive Health Library, Issue 9, 2006

4. MMR is declining, though still high: 229/100,000 (MMS, 2008/9) SBA deliveries increasing but still low o 19% in 2006 to 36% in 2011 o 2 of 3 women deliver at home with no SBA Eclampsia is the leading cause of maternal mortality o 21% of total maternal deaths o 29.8% of hospital maternal deaths Background of the Pilot (3) – PE/E in Nepal 199820092011 MMR 539229 PPH 39%18% Eclampsia12%21% % birth with SBAs 17%19%36%

5. Background of the Pilot (4) - 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

6. Steps followed (1)  Organized TAG meetings on February, November 2012 and July 2013  Tippani approved on March 2012  Got approval from NHRC on March 2012  Developed Implementation Guideline  Got approval from Johns Hopkins University IRB on August 2012  Developed training and BCC materials  Developed tools for monitoring the pilot 6

7. Why implemented in Dailekh?  Hill district, easy scalability to Terai  Reasonably good number of expected pregnancy compared to mountain districts  Pilot initiated in collaboration with NFHP, and chosen Dailekh as one of NFHP districts  Program implementation (training, field support, BCC materials) supported by MCHIP/USAID 7

8. Calcium related BCC materials Flex at health facility Flip chart for FCHV Brochure, bag and calcium bottles for PW Taking calcium during pregnancy helps the mother and baby be healthy

9. Three prong strategy of MOHP Nepal to address PE/E

10. Steps followed (2)  Organized district Orientation and planning meeting on April 2012  Organized different level trainings at district June- July 2012  Conducted review and update for HW in Nov 2012  Strengthened HF for detection and prevention of PE/E- BP, Dipstick and MgSO4 use

11. Calcium Pilot Programme for prevention of Pre-eclapmsia/ eclampsia of pregnancy period DateProgrammeNo of pts 27 April 2012Orientation for stakeholders38 21 June 2012DTOT for district focal persons27 22-24 June 2012TOT for HF in charge79 28 June-20July 2012Training for ANMs and AHWs170 28 June-20July 2012Training for FCHVs789 27-30 Nov 2012Review meeting with ANMs119

12. Procurement cost Cost of calcium :  First procurement – Purchased 16,50,000 tablets, total cost NRs 4,22,500, cost per pregnant women -NRs 196 (from MissionPharma, India)  Second procurement – Purchased 10,00,000 tablets, total cost- 13,50,000, cost per pregnant women- NRs 405 (from Curex pharmaceuticals, Nepal) Dipstick – Procured 500 box, total cost- NRs1,62,500 Urine collection bottles – Procured 25,000 bottles, total cost- NRs 75,000 Procurement support from Jhpiego

13. Handover calcium and other materials to DHO and distributed to all HFs S. No. List of materialsQuantity 1Calcium Tablet26,50,000 2Calcium bag11,500 3Brochure14,500 4Flex70 5FCHV flip chart (set)2,200 6Dipstick500 bottle 7Urine bottle25,000 8Calcium register150 set 9HF level reporting form100 set 10VHW/MCHW level rep form150 set 11FCHV form1000 set

14. Implementation Modality (1) Calcium Distribution at first ANC visit by health worker  Health workers trained on calcium  Flex put up in Clinic  Calcium distributed with a bag and brochure Strengthening HF for detection and prevention of PE/E- BP, Dipstick and MgSO4 use 14

15. Implementation Modality (2)  All PWs are eligible to receive calcium  Distributed through first ANC visit, regardless of gestational age  Initiated 1gm daily supplementation of calcium to all pregnant women coming for ANC in whole of Dailekh district Calcium should be taken:  From 4 months of pregnancy  2 tablets every day, in the morning  For 150 days (5 months)

16. Implementation Modality (3) - Role of Health Worker  First ANC Visit: Routine ANC care (BP& Urine Protein test), Counseling on PE/E and Calcium  Distribution of Calcium based on month of gestation  3 bottles: 4-5 months  2 bottles: 6-7 months  1 bottle: 8-9 months  Recording and reporting  Manage referrals as appropriate – use of MgSO 4 16 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

17. Implementation Modality (4) - Role of FCHV 17  FCHVs oriented on calcium  Calcium flipchart page added to the BPP 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 pre- eclampsia/eclampsia and the use of calcium for prevention. Phot credit: Dipendra Rai, MCHIP/Nepal

18. Implementation Modality (5) - Technical support visits (TSV) TSVs made to HF & FCHV to maintain implementation quality 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

19. Implementation Modality (6) - Data Collection Tools and Process DATA SOURCES Calcium register – kept at the facility to record calcium distribution FCHV Register – record per pregnant women maintained by FCHV VHW/MCHW level reporting forms – compiles FCHV closed forms HF level reporting forms – compiles VHW/MCHW level reporting forms Technical support visit (TSV) – HF and FCHV 19

20. Accomplishments (1) Calcium Pilot started from June 2013 End line survey conducted on August 2013 Dissemination meeting will be held on December 2013

21. Calcium supplementation started from July 2012 and will end on July 2013 Estimated to cover 7400 pregnant women in a year Covered 9246 pregnant women by the mid of Aug 2013 (figure 1) Distributed 23211 bottles of calcium by the mid of Aug 2013 Total of 367 technical support visits were made to HF (133) and FCHVs (234) Accomplishments (2) - Details on calcium distribution and monitoring

22. Accomplishments (3) – Secondary data

23. Accomplishments (4) – Secondary data

24. Accomplishments (5) – Secondary data

25. Accomplishments (6) – Secondary data

26. Accomplishments (7) – Secondary data

27. PEE prevalence before and after the pilot (Based on hospital records) FY Mild PE Severe PE Eclampsia Total PE/E cases 2069/70 (Before the pilot) 15 14 2068/69 (During the pilot) 312 6

28. Details of 6 PE/E cases: calcium intake and outcome Type of case Helath Facility Calcium intakeManagementOutcome EclampsiaDistrict hospital No ANC checkup hence not received calcium Managed with MgSo4, referred to Surkhet Mother and baby okay EclampsiaDistrict hospital Did not receive calcium as program has not initiated, Delivered at Toli SHP and referred to district hospital, managed with Mgso4 Mother and baby okay Sever PELakuri SHPJust received calcium while diagnosed (28 tabs taken) Referred to hospital by giving MgSo4, DH referred to Surkhet, client returned home, Still birth, mother okay Severe PELakuri SHPTook whole course of calcium Delivered at homeMother and baby okay Mild PESattala HPReceived calcium but did not take it as suggested Delivered at Bardiya hospitalMother and baby okay Mild PESattala HPReceived calcium but did not take it as suggested Referred to Surkhet but delivered at home Mother and baby okay

29. Challenges and way forward Shortfall of calcium during the pilot, hence needed second procurement in between with reasonable high cost  Could not get similar calcium bottles in second purchase Training and implementation started in rainy season hence logistic difficulty in materials/calcium transportation to health facilities No unanticipated problems happened during the pilot Needs planning among GON/DHO and partners to continue calcium supplementation