1. Preventing Pre-Eclampsia: Supplementing Calcium In Nepal Harshad Sanghvi, Vice President Innovations & Medical Director, Jhpiego/Baltimore Kusum Thapa, Regional Technical advisor, Jhpiego/Nepal 1 Guidance on Implementing effective programs to prevent Preeclampsia, 14 April 2013, Johannesburg, SA

2. 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 Nepal: Background 199820092011 MMR 539247 PPH 37%19% Eclampsia14%21% % birth with SBAs 17%19%36%

3. 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 MgSO 4 before referral/transfer  Limited access to emergency obstetric & newborn care (EmONC) services

4. 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

5. 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.

6. Coat of calcium tablets 1g per day /150 days 6 Estimated shipping and customs costs: 25% included Calcium Sprinkles: $ 1.88 PPW

7. Key Inputs: Gaining Confidence  Acceptability and compliance of calcium supplementation (Tablets and sprinkles consumer preference study  Calcium introduction study ( ongoing) 7 Dailekh Photo credit: Dipendra Rai, MCHIP/Nepal

8. 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) CALCIUM DISTRIBUTION Titihiriya VDC Udarapur VDC Tablet Powder Tablet Preference: Tablet/Powder Preference: Powder/Tablet 30 days

9. Calcium Preference study Compliance among women who accepted calcium Calcium tablets (148) Calcium Sprinkles (110) Took all 30 days74%72% Missed 5 days or less8% Missed More than 5 days16% Not taken/not received1%4% 9

10. 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%) 10

11. 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 11

12. 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 12

13. Acceptability  Willingness to continue calcium supplementation beyond 2 months: 92%  Willingness to recommend to others : 95%  Preference for pills: 78%, For Sprinkles: 18% 13

14. 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 14

15. 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 nation- wide scale up  GON’s 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.

16. 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

17. Role OF FCHV Role of FCHV Promotion of ANC Counseling on Calcium Follow Up for Compliance Appropriate Referral Recording and Reporting 17 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. 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

19. 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) 19

20. Technical support visits maintain implementation quality: HF and FCHV  Multipurpose visits  Data  Monitoring  Education  Problem solving  Linkage to central decision makers  Motivation 20 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

21. Timing to receive calcium

22. Number of pregnant women received one, two and three bottles of calcium Problem: Many women attend ANC late. Starting calcium later in pregnancy will not impact PE rates FCHV distribution more likely to achieve timely initiation

23. Final Thought: Unprecedented Commitment Coverage at Scale Quality at Scale Impact at Scale 23