Effective Programming: Calcium Supplementation and Preeclampsia/eclampsia

Presented by: Emily Gold 14 April, 2013

Objectives of this presentation

Highlight gaps in our knowledge needed for the translation of the evidence into program design and initiate a discussion on appropriate ways to move programs forward while awaiting this additional evidence Reflect on lessons from IFA programming that can be applied to Calcium supplementation programs Share preliminary findings from research underway in collaboration with Cornell University

Current research (including randomized control trials) do not provide critical information for the design of programs
What is appropriate delivery strategy for calcium?

Will calcium supplementation inhibit absorption of

iron?

How can IFA programs and Ca. supplementation

programs co-exist/ be integrated?

How do we ensure high compliance?

The impact in a program does not depend only on the biological potential but also the potential of the program to deliver the intervention
Timely care-seeking during pregnancy Care provider knows to give Ca, provides education to use Culture, traditions, availability of services Quality of services and counselling
ABSORPTION AND BIOLOGICAL PATHWAYS

Calcium supplement available Calcium supplement received

Reduced preeclampsia

Side effects managed Calcium supplement consumed regularly Barriers managed (e.g. Memory, acceptance, taste, etc)

Inadequate calcium intake

Procurement and distribution

Impact of interventions dependant on multiple factors

Impact Nutritional Need + Coverage + Utilization
NEED

Utilization Uptake + Knowing benefits & how to use + External motivation

Coverage Provision + Uptake by those in need

External Factors Socio-cultural Technical Economic Political

Uptake Awareness Attitude Accessibility

Provision Quantity Quality Timeliness

Contextually relevant package of interventions

Some of the challenges that we have seen for IFA programs are likely to be similar for Calcium supplementation programs
Demand side: Contact with women may begin only late in pregnancy Irregular and infrequent contact may limit effective coverage, opportunities for encouragement to comply Care providers may not be effective to council compliance Possible issues with uptake and compliance Lack of information on managing side effects Supply side: Budget allocation donor dependency Poorly functioning supply chains

Some of the challenges that we have seen for IFA programs are likely to be similar for Calcium supplementation programs
Demand side: Contact with women may begin only late in pregnancy Irregular contact Although may limit well effective coverage, recognized, many of these issues opportunities forhave encouragement to complyaddressed for IFA not been adequately programs. Now we should: Possible issues with uptake and compliance
Avoid Ca programs likely to suffer from similar Supply side: supply and demand-side problems Budget allocation donor dependency Take advantage to renew efforts to strengthen Poorly functioning IFA supply andchains Ca programs simultaneously Be aware of additional challenges related to compliance and interactions

Some lessons learnt and common sense responses to these challenges

Intense and effective training will be required for health care providers Motivation to accept and implement programs effectively, including supply management and MIs Maternal and Neonatal Health and Nutrition Programwith pregnant women communication Alternative delivery strategies should be examined Effective behaviour change communication Requires an understanding of the barriers and factors that would facility uptake and adherence
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MIs Calcium project (Ethiopia and Kenya) to be implemented in 2 phases to address specific challenges for program design. In Phase 1:
Challenge 1: Low uptake of IFA, low ANC and late /infrequent contact with health care system Potential for greater risk with additional supplement (larger, additional tablet, side effects etc.) Aiming to identify optimal delivery platform

Challenge 2: Poor compliance with IFA supplementation Potential for greater risks with addition of calcium Collecting and assimilate information on the perspectives of health care providers and beneficiaries to inform BCI Designing models for delivery and promotion of Ca and IFA supplements in pregnancy.
, 2006.

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Some results from Phase 1:

FAQs Calcium Supplementation include: Dosage- better bioavailability when taken in smaller (< 500 mg) divided doses Formulation-benefits of both Ca. Carbonate and Ca. Citrate Malate. Time of dosing can affect absorption depending on formulation Malaria- at this time there are no data or evidence to suggest that calcium interacts with typical anti-malarial drugs FAQs IFA lessons for Calcium include: Successful strategies for improving ANC Successful strategies for improving supplies of supplements Successful strategies for improving adherence Alternate ways of reaching women with micronutrients Discussion paper on implications of new Ca recommendation for biomedical practices

Next steps in Phase 1:

Trial of Improved Practice (TIPs) methodology used to test delivery, acceptance and compliance with several dosages and regiments of Calcium and IFA supplements in Kenya and Ethiopia Test of 2 delivery systems Explore innovative packaging ideas to limit cost & complexity &permit procurement Explore potential to reduce calcium dosage without compromising impact

Phase 2 will include pilot testing the new delivery model in both countries
Objective 1: Test models developed in Phase 1 by implementing Ca and IFA supplementation within the health system Objective 2: Evaluate the implementation process and effectiveness of the model strategies. Objective 3: Refine models and make recommendations for improving implementation and effectiveness. Objective 4: Disseminate results to provide policy makers, program developers and health care providers

, 2006.

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Some countries may wish to move programs forward before results from these studies are available a few suggestions in doing so:
Programs in all countries should invest in the formative research and information collection that will ensure appropriate program design in their context: Innovative alternatives for delivery (particularly if IFA programs have not been successful)
Eg. Using community level health agents

Identification and resolution of forecasting and supply chain issues for IFA and Calcium Effective training for health care providers and relevant and effective communication to promote update and utilization
Requires understanding of the barriers that they perceive both for providers and pregnant women and those who may influence their decision related to ANC and supplement use