Sanghvi_Preventing Pre-Eclampsia

7/30/2019 Sanghvi_Preventing Pre-Eclampsia

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Preventing Pre-Eclampsia: Supplementing Calcium

In Nepal

Harshad Sanghvi, Vice President Innovations & Medical Director,Jhpiego/Baltimore

Kusum Thapa, Regional Technical advisor, Jhpiego/Nepal

1Guidance on Implementing effective programs to prevent Preeclampsia, 14 April 2013, Johannesburg, SA


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MMR is declining, though still high:229/100,000 (MMS, 2008/9)

SBA deliveries increasing but stilllow

19% in 2006 to 36% in 2011

2 of 3 women deliver at homewith no SBA

Eclampsia is the leading cause of

maternal mortality

21% of total maternal

deaths

29.8% of hospital maternal

deaths

Nepal: Background

1998 2009 2011

MMR 539 247

PPH 37% 19%

Eclampsia 14% 21%

% birth

with SBAs

17% 19% 36%


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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


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Three prong strategy of MOHP Nepalto address PE/E

MOPH NESOGPartnership to

improve quality of

Eclampsia

management using

SBMR

Strengthen ANC

Community

detection of PE

Calcium pilot ANC

Community sprinkles


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Key inputs: stakeholders

At least 3 years of wide discussion with stakeholders consensuson 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.


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Coat of calcium tablets1g per day /150 days

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Estimated shipping and customs costs: 25% included

Calcium Sprinkles: $ 1.88 PPW


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Key Inputs: Gaining Confidence

Acceptability and

compliance of

calcium

supplementation(Tablets and

sprinkles consumer

preference study

Calcium introduction

study ( ongoing)

7

DailekhPhoto credit: Dipendra Rai, MCHIP/Nepal


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Calcium Acceptability andCompliance Study: Study Design

Titihiriya and Udarapur VDCsof Banke District

Household-level antenatalcontact for health education,assessment and dispensing ofcalcium 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

Powder

Tablet

Preference:Tablet/Powder

Preference:Powder/Tablet

30 days

30 days

30 days


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Calcium Preference studyCompliance among women who accepted calcium

Calcium tablets(148)

Calcium Sprinkles(110)

Took all 30 days 74% 72%

Missed 5 days or less 8% 8%

Missed More than 5 days 16% 16%

Not taken/not received 1% 4%

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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%)

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Timing Issues

Theoretical concern: if calcium and iron taken

together, iron may not be absorbed as well

Suggested solution: Take at different meal

timesFindings:

About 50% do not practice taking breakfast

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Reported symptoms while oncalcium

More prevalent with sprinkles ( 5% vs 20%)

Belching or gas

Heaviness in stomach

With Pills: Lowered appetite

With sprinkles: Constipation, nausea

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Acceptability

Willingness to continue calcium

supplementation beyond 2 months: 92%

Willingness to recommend to others : 95%

Preference for pills: 78%, For Sprinkles: 18%

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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 wasOk

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Implementation challenges

Difficulty in finding calcium withoutVitamin D

Require large storage space: calcium isbulky

Continuing concerns of GON regarding

the sustainability to cover cost for nation-wide scale up

GONs decision of distributing Calciumthrough health facilities unlike Iron whichwas distributed by FCHV.

Desire to meet ANC coverage targetsby Offering this additional service

Ongoing debate regarding dosage asWHO most recent recommendation is for1.5-2 gm.


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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 anANC visit.Photo credit: Jona Bhattarai, MCHIP/Nepal


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Role OF FCHV

Role of FCHV

Promotion of ANC

Counseling on Calcium

Follow Up for Compliance

Appropriate Referral Recording and Reporting

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An FCHV at a pregnant womens group n

Dailekh talking about the risks of pre-eclampsia/eclampsia and the use of calciumfor prevention.Phot credit: Dipendra Rai, MCHIP/Nepal


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Calcium related BCC materials

Flex at health facility

Flip chart for FCHV

Brochure, bag andcalcium bottles for PW

Taking calcium during pregnancy

helps the mother and baby be healthy


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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)

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Technical support visits maintainimplementation quality: HF and FCHV

Multipurpose visits

Data

Monitoring

Education

Problem solving

Linkage to central

decision makers Motivation

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Field officers visit pregnant woman at home toensure she has received calcium and is not havingany difficulties taking it daily. This woman isstoring her calcium in the bag behind.Phot credit: Dipendra Rai, MCHIP/Nepalc


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Timing to receive calcium

0

10

20

30

40

50

60

June 012 July 012 Aug 012 Sep 012 Oct 012 Nov 012 Dec 012

Percentofpregnantwomenenrolled

ANC 1 ANC 2 ANC 3 ANC 4 Other ANC


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Number of pregnant women received one, two and threebottles of calcium

1065

1342

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0

500

1000

1500

2000

2500

3000

Received one bottle Received two bottles Received three bottles

Num

berofpregnan

twomen

Problem: Many women attend ANC late.

Starting calcium later in pregnancy will not

impact PE rates

FCHV distribution more likely to achieve timely

initiation


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Final Thought: UnprecedentedCommitment

Coverage at Scale

Quality at Scale

Impact at Scale

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