1. Dr. Yagya Bahadur Karki Population, Health and Development (PHD) Group Date: 9 th December, 2013 Hotel Himalaya, Lalitpur Evaluation of a Program to Prevent Pre-Eclampsia and Eclampsia through Calcium Supplementation for Pregnant Women in Nepal Dailekh District Dissemination meeting Key findings

2. Outline of Presentation  Research questions  Methodology  Findings  Conclusion and Recommendations

3. Research Questions  What proportion of pregnant women attend at least one antenatal care (ANC) visit?  What proportion of pregnant women agree to take calcium offered during ANC services?  What proportion of pregnant women who receive calcium during ANC take it according to the instructions?  Do women taking calcium during pregnancy take iron folate as directed?  What is the level of knowledge and experience with the calcium program?

4. Methodology  Data collection methods:  Post intervention household survey of RDW: Household screening questionnaire, quantitative structured questionnaire for RDW  Post intervention interviews with ANC Health Care Providers and FCHVs  Data analysis:  Descriptive statistics including frequencies, means, medians and cross tabulations  Weights applied to adjust for rural/urban distribution in Dailekh district (census data)

5. Methodology  Sample:  Cluster sample: 60% of VDCs selected and 62 wards chosen with probability proportional to population size method  20 recently delivered women (RDW - women who delivered in last 6 months) to be randomly chosen for interview from each ward for a total of at least 1,230  100 ANC providers and 100 FCHVs to be randomly selected from the 62 clusters

6. Methodology…. Definition of coverage and compliance  Calcium coverage:  % received calcium in total and out of those coming for ANC  Complete Course:  Quantity taken: % of RDW taking a full course (150 days)  Compliance:  Taking it as directed with respect to dosage, timing and frequency

7. Findings: Sample Size and Characteristics  Interviewed 1,240 RDW, 109 health care providers and 112 FCHVs.  Background characteristics of RDW:  Median age - 23 years, 39% had no education, 92% live in a rural area  Background characteristics of FCHVs:  Median age - 35 years, 3% had no education  Of 109 health care providers:  54 ANMs/ Sr. ANMs, 23 AHWs, 12 Sr. AHWs/ CMAs, 7 MCHWs, 5 HAs and 8 Public Health Supervisors, VHWs and Nurse

8. Findings: ANC and Delivery Coverage  95% RDW attended at least one ANC visit  71% of RDW made 4 or more antenatal care visits  urban women (90%),  rural women (69%)  95% of RDW received iron tablets  67% of RDW delivered at a health facility

9. Findings: Calcium Coverage  95% (n=1,173) of total interviewed RDW received calcium tablets, and 100% of ANC clients received calcium tablets  highest among women attending ANC (n=1,173) with highest education(98%), followed by women with some secondary education and those living in urban area (97%) while in rural areas it is 94%.  Main dispenser of calcium to mothers - Staff nurse or ANM (82%), and no one received calcium from FCHV.

10. Findings: Calcium Coverage  Bottles received:  82% received 3 bottles of calcium  14% received 2 bottles  4% received only one bottle  72% reported starting calcium from the 4 th month, 20% after the 4 th month and 8% even before the 4 th month of pregnancy.  Women receiving calcium bottles also received calcium pilot programme promotional materials such as a bag (93%) and brochure (87%)

11. Findings: Complete course of calcium among RDW who received calcium (n=1,173) Complete course criteriaCategory % meeting the criteria among RDW who received calcium Took a full course for 150 daysFull course67% Took a partial course for at least 90 daysPartial course24% Took a short course for < 90 daysShort course9%

12. Findings: Complete course of calcium by Background Characteristics of RDW Background characteristics (n=1,173) Distribution of full or partial course Full coursePartial courseShort courseTotal N Mother's age at birth** <2062.029.38.7 208 20-2969.423.37.3 792 30-4564.521.514.0 173 Residence* Rural66.424.98.7 1,076 Urban76.515.38.2 98 Education*** No education63.924.212.0 443 Some education69.524.16.4 730 Gestational age when received calcium (months)**** 3 - 5 months78.717.24.1 1,004 6 - 9 months0.065.134.9 169 Total67.324.18.6 1,173 Significant at *p≤0.10; **p≤0.05; ***p≤0.01; ****p≤0.001.

13. Findings: Calcium Compliance Among RDW Who Received Calcium (n=1,173)  Irrespective of the number of days women took calcium, 99% reported taking two tablets after the morning meal  10% of RDW receiving calcium discontinued  Leftover calcium tablet:  55% returned to FCHVs  30% kept with them  12% threw them away  3% returned to health facility

14. Findings: Knowledge among RDW who Received Calcium (n=1,173) Knowledge about calcium and iron among recently delivered women who received calcium (n=1,173) Knowledge test itemCorrect answer% Number of times a day calcium should be takenOne time97.9 Number of calcium tablets should be taken each dayTwo tablets99.6 Time calcium tablets should be taken each day In the morning after a meal99.6 Number of iron tablets should be taken each dayOne tablet99.1 Time iron tablets should be taken each day In the evening after a meal98.7

15. Findings: Knowledge among RDW Who Received Calcium (n=1,173) 95% received iron tablets

16. Findings: Opinions and Attitudes Toward Calcium Among RDW (n=1,173)  84% of mothers who took calcium liked the taste.  Only 1% mother reported difficulty in storing calcium tablet bottles in their homes.  The majority (98%) of the mothers would like to take calcium tablets if they become pregnant again.  Would recommend other people (87%) and pregnant women (98%) to take calcium tablets.

17. Knowledge about calcium among ANC providers (n=109) Knowledge test itemCorrect answer% Can iron and calcium be taken together No97 Number of calcium tablets that should be taken each day Two tablets99 Time calcium tablets should be taken each day In the morning after a meal 99 Month calcium should be startedFourth month99 Time iron tablets should be taken each day In the evening after a meal 99 Findings: Knowledge of Calcium among ANC providers

18. Findings: Knowledge and Experience of ANC Health Workers (n=109)  All health workers from hospital, PHCs and HPs said that calcium prevents PE/E while the corresponding figure for SHPs was 94%.  Why to use calcium:  93% - to save life of mother and child,  84% - to control high blood pressure in pregnancy and  82% - to prevent unconsciousness as part of Eclampsia  Every health worker interviewed said he/she examined for swelling/oedema and counselled on dangers signs.  99% health workers said that they distributed calcium tablets and conducted BP examination, and 98% reported testing urine.

19. Findings: Health Facilities Health facility observation (n=41)  Except in one facility, all other observed facilities were found managing the storeroom according to FEFO.  Behaviour change communication materials on calcium were found in waiting room and examination room of all observed PHCC and HP and in >90% of SHPs observed Quote from a health worker: “Pre-eclampsia / eclampsia has been controlled and because of calcium programme ANC check up has become regular among pregnant women in health facilities".

20. Knowledge about calcium among FCHVs (n=112) Knowledge test itemCorrect answer% Can iron and calcium be taken together No100 Number of calcium tablets that should be taken each day Two tablets100 Time calcium tablets should be taken each day In the morning after a meal 100 Month calcium should be startedFourth month97 Time iron tablets should be taken each day In the evening after a meal 100 Findings: Knowledge of Calcium among FCHVs

21. Findings: Knowledge and experience with calcium programme among FCHVs  99% FCHV interviewed know that calcium prevents PE/E, improves mother's as well as child's health  All FCHVs discussed about calcium with pregnant women in home visits and also discussed about taking iron and calcium at different times of day  90% FCHVs referred pregnant women for ANC services in the last month  66% FCHVs referred pregnant women to HF for delivery services and 39% had referred women with danger signs of pregnancy, delivery and postpartum to health facility in the last month

22. Findings: Knowledge and experience with calcium programme among FCHVs  Over 90% interviewed FCHVs organized monthly meetings in their respective HF last month where they also discussed about calcium  55% of interviewed FCHVs said they advised women to break tablet into 2 pieces if it was difficult to swallow  FCHVs shown their interest to distribute calcium tablets in the future.  A few FCHVs put some conditions before accepting to get involved in calcium distribution in future such as training, incentives and so on.

23. Findings: PE/E Screening/Detection among RDW attending ANC BP measuredUrine tested At first ANC visit - among all women attending ANC (n=1,173) 98%97% At every ANC visit – among women ever tested 88%70%

24. Conclusions  Calcium distribution through ANC produced very high coverage of calcium (95% of all women surveyed received calcium).  Completion rate was high - 67% of women who received calcium taking the full course (150 days) and compliance was high – 99% of women who received calcium reported taking it as instructed.  RDW, FCHVs and ANC health care providers achieved high levels of knowledge about calcium through this program approach.

25. Conclusions…  Calcium consumption did not appear to reduce iron consumption, and the majority of women reported taking iron and calcium at different time as advised.  Calcium distribution is acceptable to ANC providers and feasible to incorporate into their current responsibilities.  FCHVs are willing to incorporate calcium counseling into their work.

26. Recommendations  The MOHP should consider scaling up the current model of calcium distribution to other districts in Nepal.  If calcium supplementation is scaled up to additional districts, the MOHP can consider integrating training of health care workers and FCHVs into regular district review meetings or other ongoing meetings  Calcium procurement and distribution to health facilities could be incorporated into the government’s logistics management system.