Download - 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)
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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
2723
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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