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Nepal: Background
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
MMR PPH
1998 2009
539 37% 247 19%
2011
Eclampsia 14%
% birth 17% with SBAs
21%
19% 36%
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)
often combined with Vitamin D which reduces shelf life of combined product.
Titihiriya VDC
Udarapur VDC
Tablet
30 days
Powder
Powder
30 days
Tablet
Preference: Tablet/Powder
30 days
Preference: Powder/Tablet
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
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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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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 nationwide scale up GONs 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.
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
Role OF FCHV
Role of FCHV Promotion of ANC Counseling on Calcium Follow Up for Compliance Appropriate Referral Recording and Reporting
An FCHV at a pregnant womens group n Dailekh talking about the risks of preeclampsia/eclampsia and the use of calcium for prevention. Phot credit: Dipendra Rai, MCHIP/Nepal
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Taking calcium during pregnancy helps the mother and baby be healthy
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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Linkage to central
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
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0 June 012 July 012 ANC 1 Aug 012 ANC 2 Sep 012 Oct 012 Nov 012 Dec 012 ANC 3 ANC 4 Other ANC
Number of pregnant women received one, two and three bottles of calcium
3000 2723 2500 Problem: Many women attend ANC late. Starting calcium later in pregnancy will not impact PE rates FCHV distribution more likely to achieve timely initiation 1342 1065 1000 500 0 Received one bottle Received two bottles Received three bottles
2000 1500
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