1
|
Escobar MF, Benitez-Díaz N, Blanco-Londoño I, Cerón-Garcés C, Peña-Zárate EE, Guevara-Calderón LA, Libreros-Peña L, Galindo JS. Synthesis of evidence for managing hypertensive disorders of pregnancy in low middle-income countries: a scoping review. BMC Pregnancy Childbirth 2024; 24:622. [PMID: 39354425 PMCID: PMC11443752 DOI: 10.1186/s12884-024-06796-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 08/29/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Hypertensive disorders of pregnancy (HDPs) remain one of the leading causes of maternal mortality globally, especially in Low- and middle-income countries (LMICs). To reduce the burden of associated morbidity and mortality, standardized prompt recognition, evaluation, and treatment have been proposed. Health disparities, barriers to access to healthcare, and shortage of resources influence these conditions. We aimed to synthesize the literature evidence for the management of HDPs in LMICs. METHODS A scoping review was conducted in five databases (PubMed, Web of Science, Epistemonikos, Clinical Key and, Scielo) using MeSh terms, keywords, and Boolean connectors. We summarized the included studies according to the following categories: study design, objectives, settings, participant characteristics, eligibility criteria, interventions, assessed outcomes, and general findings. RESULTS Six hundred fifty-one articles were retrieved from the literature search in five databases. Following the selection process, 65 articles met the predefined eligibility criteria. After performing a full-text analysis, 27 articles were included. Three themes were identified from the articles reviewed: prevention of HDPs, management of HDPs (antihypertensive and non-hypertensive management) and pregnancy monitoring and follow-up. The topics were approached from the perspective of LMICs. CONCLUSIONS LMICs face substantial limitations and obstacles in the comprehensive management of HDPs. While management recommendations in most LMICs align with international guidelines, several factors, including limited access to crucial medications, unavailability of diagnostic tests, deficiencies in high-quality healthcare infrastructure, restrictions on continuing professional development, a shortage of trained personnel, community perceptions of preeclampsia, and outdated local clinical practice guidelines, impede the comprehensive management of patients. The development and implementation of protocols, standardized guides and intervention packages are a priority.
Collapse
Affiliation(s)
- María Fernanda Escobar
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia.
- Facultad de Ciencias de La Salud, Universidad Icesi, Calle 18 No. 122 -135, Cali, Colombia.
| | - Nicole Benitez-Díaz
- Facultad de Ciencias de La Salud, Universidad Icesi, Calle 18 No. 122 -135, Cali, Colombia
| | | | - Catalina Cerón-Garcés
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
| | - Evelyn E Peña-Zárate
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
| | - Lizbeth A Guevara-Calderón
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
| | - Laura Libreros-Peña
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
| | - Juan Sebastián Galindo
- Facultad de Ciencias de La Salud, Universidad Icesi, Calle 18 No. 122 -135, Cali, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra 98 No. 18 - 49, 760032, Cali, Colombia
| |
Collapse
|
2
|
Matenga TFL, Agarwal H, Adeniran OP, Lam-McCarthy M, Johnson EA, Nyambe J, Chabaputa R, Chanda S, Habinda DM, Mulenga L, Sakanya S, Kasaro MP, Maman S, Chi BH, Martin SL. Engaging Family Members to Support Exclusive Breastfeeding, Responsive care, and Antiretroviral Therapy Adherence Among Families with Children who are HIV-Exposed and Uninfected. AIDS Behav 2024:10.1007/s10461-024-04467-z. [PMID: 39249627 DOI: 10.1007/s10461-024-04467-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2024] [Indexed: 09/10/2024]
Abstract
Children who are HIV-exposed and uninfected (CHEU) are at increased risk for poor growth, health, and development compared to children who are HIV-unexposed and uninfected. To support families with CHEU, we assessed the acceptability of engaging family members to support women living with HIV (WLWH) with exclusive breastfeeding (EBF) and antiretroviral therapy (ART) adherence and to engage in responsive infant caregiving. We conducted trials of improved practices, a consultative research approach, that follows participants over time as they try recommended behaviors. We enrolled postpartum women in Lusaka, Zambia, who identified home supporters. At visit 1, WLWH were interviewed about current practices. At visit 2, WLWH and home supporters received tailored EBF, responsive care, and ART adherence counseling. At visit 3, WLWH and home supporters were interviewed about their experiences trying recommended practices for 2-3 weeks. Interview transcripts were analyzed thematically. Participants included 23 WLWH, 15 male partners, and 8 female family members. WLWH reported several barriers to EBF. The most common were fear of HIV transmission via breastfeeding-despite high ART adherence-and insufficient breastmilk. After counseling, WLWH reported less fear of HIV transmission and improved breastfeeding practices. Home supporters reported providing WLWH increased support for EBF and ART adherence and practicing responsive caregiving. Both male and female home supporters appreciated being included in counseling and more involved in caregiving, and WLWH valued the increased support. Families with CHEU need focused support. Tailored counseling and family support for WLWH show promise for improving EBF, responsive caregiving, and ART adherence.
Collapse
Affiliation(s)
- Tulani Francis L Matenga
- UNC Global Projects Zambia, Lusaka, Zambia
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Harsh Agarwal
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Oluwamuyiwa P Adeniran
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Melissa Lam-McCarthy
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | | | | | | | | | | | | | - Suzanne Maman
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie L Martin
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| |
Collapse
|
3
|
Cormick G, Moraa H, Zahroh RI, Allotey J, Rocha T, Peña-Rosas JP, Qureshi ZP, Hofmeyr GJ, Mistry H, Smits L, Vogel JP, Palacios A, Gwako GN, Abalos E, Larbi KK, Carroli G, Riley R, Snell KI, Thorson A, Young T, Betran AP, Thangaratinam S, Bohren MA. Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review. BMJ Open 2023; 13:e070677. [PMID: 38135336 DOI: 10.1136/bmjopen-2022-070677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVES Daily calcium supplements are recommended for pregnant women from 20 weeks' gestation to prevent pre-eclampsia in populations with low dietary calcium intake. We aimed to improve understanding of barriers and facilitators for calcium supplement intake during pregnancy to prevent pre-eclampsia. DESIGN Mixed-method systematic review, with confidence assessed using the Grading of Recommendations, Assessment, Development and Evaluations-Confidence in the Evidence from Reviews of Qualitative research approach. DATA SOURCES MEDLINE and EMBASE (via Ovid), CINAHL and Global Health (via EBSCO) and grey literature databases were searched up to 17 September 2022. ELIGIBILITY CRITERIA We included primary qualitative, quantitative and mixed-methods studies reporting implementation or use of calcium supplements during pregnancy, excluding calcium fortification and non-primary studies. No restrictions were imposed on settings, language or publication date. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias. We analysed the qualitative data using thematic synthesis, and quantitative findings were thematically mapped to qualitative findings. We then mapped the results to behavioural change frameworks to identify barriers and facilitators. RESULTS Eighteen reports from nine studies were included in this review. Women reported barriers to consuming calcium supplements included limited knowledge about calcium supplements and pre-eclampsia, fears and experiences of side effects, varying preferences for tablets, dosing, working schedules, being away from home and taking other supplements. Receiving information regarding pre-eclampsia and safety of calcium supplement use from reliable sources, alternative dosing options, supplement reminders, early antenatal care, free supplements and support from families and communities were reported as facilitators. Healthcare providers felt that consistent messaging about benefits and risks of calcium, training, and ensuring adequate staffing and calcium supply is available would be able to help them in promoting calcium. CONCLUSION Relevant stakeholders should consider the identified barriers and facilitators when formulating interventions and policies on calcium supplement use. These review findings can inform implementation to ensure effective and equitable provision and scale-up of calcium interventions. PROSPERO REGISTRATION NUMBER CRD42021239143.
Collapse
Affiliation(s)
- Gabriela Cormick
- Centro de Investigaciones en Epidemiología y Salud Pública (Consejo Nacional de Investigaciones Científicas y Técnicas- CONICET), Instituto de Efectividad Clinica y Sanitaria, Buenos Aires, Argentina
- Universidad Nacional de La Matanza, San Justo, Provincia de Buenos Aires, Argentina
| | | | - Rana Islamiah Zahroh
- Gender and Women's Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - John Allotey
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Centre (BRC), University Hospitals Birmingham, Birmingham, UK
| | - Thaís Rocha
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | | | - G Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand Faculty of Health Sciences, East London, Eastern Cape, South Africa
- University of Botswana, Gaborone, Botswana
| | - Hema Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Luc Smits
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands
| | - Joshua Peter Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Alfredo Palacios
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- Centre for Health Economics, University of York, York, UK
| | | | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina
| | | | - Guillermo Carroli
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Santa Fe, Argentina
| | - Richard Riley
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | | | - Anna Thorson
- Human Reproduction Program/World Health Organization (Geneva), Geneva, Switzerland
| | - Taryn Young
- Centre for Evidence-based Health Care, Division Epidemiology and Biostatistics, Dept. of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Ana Pilar Betran
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women's Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Centre (BRC), University Hospitals Birmingham, Birmingham, UK
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Meghan A Bohren
- Gender and Women's Health Unit, Nossal Institute for Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
4
|
Ajong AB, Kenfack B, Ali IM, Yakum MN, Ukaogo PO, Mangala FN, Aljerf L, Telefo PB. Calcium supplementation in pregnancy: An analysis of potential determinants in an under-resourced setting. PLoS One 2023; 18:e0292303. [PMID: 37796953 PMCID: PMC10553325 DOI: 10.1371/journal.pone.0292303] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 09/18/2023] [Indexed: 10/07/2023] Open
Abstract
INTRODUCTION Despite the evidence that calcium supplementation in pregnancy improves maternofoetal outcomes, many women still do not take calcium supplements during pregnancy in Cameroon. This study identifies factors that influence calcium supplementation during pregnancy in a low resource setting. METHODS We conducted a cross-sectional hospital-based study (from November 2020 to September 2021) targeting 1074 healthy women in late pregnancy at the maternities of four major health facilities in the Nkongsamba Health District, Cameroon. Data were collected using an interview-administered semi-structured questionnaire and analysed using Epi Info version 7.2.4.0, and the statistical threshold for significance set at p-value = 0.05. RESULTS The mean age of the participants was 28.20±6.08 years, with a range of 15-47 years. The proportion of women who reported taking any calcium supplements in pregnancy was 72.62 [69.85-75.22]%. Only 12% of calcium-supplemented women took calcium supplements throughout pregnancy, while a majority (50%) took calcium supplements just for 4-5 months. Women believe that taking calcium supplements is more for foetal growth and development (37.12%) and prevention of cramps (38.86%), than for the prevention of hypertensive diseases in pregnancy (2.84%). About all pregnant women (97.65%) took iron and folic acid supplements during pregnancy, and 99.24% took these supplements at least once every two days. Upon control for multiple confounders, the onset of antenatal care before 4 months of pregnancy (AOR = 2.64 [1.84-3.78], p-value = 0.000), having had more than 3 antenatal care visits (AOR = 6.01 [3.84-9.34], p-value = 0.000) and support/reminder from a partner on the necessity to take supplements in pregnancy (AOR = 2.00 [1.34-2.99], p-value = 0.001) were significantly associated with higher odds of taking any calcium supplements in pregnancy. CONCLUSION Calcium supplementation practices in pregnancy remain poor in this population and far from WHO recommendations. Early initiation of antenatal care, a high number of antenatal visits and reminders or support from the partner on supplement intake significantly increase the odds of taking any calcium supplements in pregnancy. In line with WHO recommendations, women of childbearing age should be sensitised to initiate antenatal care earlier and attain as many visits as possible. Male involvement in prenatal care might also boost the likelihood of these women taking calcium supplements.
Collapse
Affiliation(s)
- Atem Bethel Ajong
- Department of Mother and Child care, Kekem District Hospital, Kekem, West Region, Cameroon
- Department of Biochemistry, University of Dschang, Dschang, West Region, Cameroon
| | - Bruno Kenfack
- Department of Obstetrics / Gynaecology and Maternal Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, West Region, Cameroon
| | - Innocent Mbulli Ali
- Department of Biochemistry, University of Dschang, Dschang, West Region, Cameroon
| | - Martin Ndinakie Yakum
- Department of Epidemiology and Biostatistics, School of Medical and Health Sciences, Kesmonds International University, Bamenda, Cameroon
| | | | - Fulbert Nkwele Mangala
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
- Maternity unit, Nkongsamba Regional Hospital, Nkongsamba, Littoral Region, Cameroon
| | - Loai Aljerf
- Faculty of Dentistry, Damascus University, Damascus, Syria
| | - Phelix Bruno Telefo
- Department of Biochemistry, University of Dschang, Dschang, West Region, Cameroon
| |
Collapse
|
5
|
Willemse JP, Smits LJ, Braat MM, Meertens LJ, van Montfort P, van Dongen MC, Ellerbrock J, van Dooren IM, Duvekot EJ, Zwaan IM, Spaanderman ME, Scheepers HC. Counseling pregnant women on calcium: effects on calcium intake. J Perinat Med 2023; 51:346-355. [PMID: 35998889 PMCID: PMC10010736 DOI: 10.1515/jpm-2021-0376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 07/29/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the effect of incorporating calcium advice into early pregnancy counseling on calcium intake during pregnancy in the Netherlands. METHODS A multicenter prospective before-after cohort study was conducted introducing risk-based care including calculating individual pre-eclampsia risk. Part of the intervention was to incorporate calcium advice into routine counseling. We calculated individual daily calcium intake and adequacy of calcium intake (≥1,000 mg/day) at 16, 24 and 34 weeks of pregnancy. We performed a multiple logistic regression adjusting for covariates to identify any differences in the risk of inadequate calcium intake between RC and CAC. RESULTS In regular care (RC, 2013-2015, n=2,477) 60% had inadequate calcium intake, compared to 49% during calcium advice care (CAC, 2017-2018, n=774) (aOR 0.75, 95% CI 0.64-0.88). Specific calcium supplements were used by 2% and 29% in RC and CAC, respectively (OR 25.1, 95% CI 17.8-36.0). Determinants of an inadequate calcium intake were lower age (aOR per additional year 0.96, 95% CI: 0.94-0.98), nulliparity (aOR 1.22, 95% CI: 1.03-1.45) and non-Caucasian origin (aOR 1.83, 95% CI 1.09-3.09). In CAC, risk of inadequate intake decreased with increasing predicted pre-eclampsia risk, which was a trend reversal compared to RC. CONCLUSIONS Incorporating calcium advice into early pregnancy counseling was shown to lead to a decrease in the risk of inadequate calcium intake during pregnancy, but still inadequate intake in half of the women suggesting the need for further study on improving implementation. Awareness of individual increased PE risk had positive effect on calcium intake.
Collapse
Affiliation(s)
- Jessica P.M.M. Willemse
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | - Luc J.M. Smits
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | | | - Linda J.E. Meertens
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | - Pim van Montfort
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | - Martien C. van Dongen
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht UniversityMaastricht, The Netherlands
| | - Jonas Ellerbrock
- Department of Obstetrics & Gynaecology, Zuyderland Medical CentreHeerlen, The Netherlands
| | - Ivo M.A. van Dooren
- Department of Obstetrics and Gynaecology, Sint Jans Gasthuis WeertWeert, The Netherlands
| | - Ella. J. Duvekot
- Department of Obstetrics and Gynaecology, VieCuri Medical CentreVenlo, The Netherlands
| | - Iris M. Zwaan
- Department of Obstetrics and Gynaecology, Laurentius Medical CentreRoermond, The Netherlands
| | - Marc E.A. Spaanderman
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hubertina C.J. Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Grow, school for oncology and developmental biology, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
6
|
Ngwira MM, Gadama LA, Shanmugalingam R, Makris A, Hennessy A. Health Care Workers and Key Policy Informant’s Knowledge of the use of Calcium and Low Dose Aspirin for Prevention of Preeclampsia in Malawian Women. Pregnancy Hypertens 2022; 30:221-225. [DOI: 10.1016/j.preghy.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/27/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022]
|
7
|
Menezes R, Lelijveld N, Wrottesley SV, Brennan E, Mates E, James PT. Integrating Women and Girls' Nutrition Services into Health Systems in Low- and Middle-Income Countries: A Systematic Review. Nutrients 2022; 14:4488. [PMID: 36364750 PMCID: PMC9657561 DOI: 10.3390/nu14214488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 08/16/2023] Open
Abstract
Women's nutrition has been highlighted as a global priority to ensure the health and well-being of both them and future generations. This systematic review summarises the available literature on the integration of nutrition services for girls and women of reproductive age (GWRA) into existing public health systems across low- and middle-income countries, as well as any barriers to integration. We searched PubMed and Cochrane Database of Systematic Reviews for articles published since 2011 according to eligibility criteria. A total of 69 articles were included. Evidence suggested that several services for GWRA are well integrated into public health systems, including antenatal care services, nutrition education and counselling, and micronutrient supplementation programmes. However, there was limited evidence on the integration of family planning, adolescent health, and reproductive health services. Barriers to integration fell into five main themes: lack of training and capacity building, poor multisectoral linkages and coordination, weak advocacy, lack of M&E systems, and inequity. We identified a lack of evidence and services for non-pregnant GWRA and for women postpartum. Addressing barriers to integration and gaps in nutrition services for GWRA would increase service coverage and contribute to improving health outcomes for GWRA and future generations.
Collapse
|
8
|
Njiru H, Njogu E, Gitahi MW, Kabiru E. Effectiveness of public health education on the uptake of iron and folic acid supplements among pregnant women: a stepped wedge cluster randomised trial. BMJ Open 2022; 12:e063615. [PMID: 36691203 PMCID: PMC9462084 DOI: 10.1136/bmjopen-2022-063615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/22/2022] [Indexed: 01/26/2023] Open
Abstract
INTRODUCTION Iron deficiency is the most prevalent micronutrient deficiency in pregnancy globally responsible for nearly 120 000 maternal deaths per year and a fifth of maternal mortality. Over 46% of pregnant women in Africa and 62% of pregnant women in Kenya are anaemic. Anaemia has severe economic and health consequences. Daily iron and folic acid supplementation (IFAS) is an efficacious strategy recommended in pregnancy to reduce the risk of anaemia and improve maternal and neonatal survival. However, most pregnant women do not consume IFAS as recommended. Limited knowledge on IFAS, its benefits and its connection with anaemia, and mitigation of its side effects lead to poor consumption. The main objective of this trial is to determine the effectiveness of public health education on uptake of antenatal IFAS. METHODS AND ANALYSIS A stepped wedge cluster randomised trial with antenatal clinics as units of randomisation. Twelve clusters will be randomised to receive the intervention and levels of IFAS uptake compared with preintervention period. The 9-month trial will enrol 1205 pregnant women. The primary outcome will be the proportion of pregnant women effectively taking up IFAS measured through self-reports, residual pill count and inspection of pill reminder cards. Routine clinical data on haemoglobin counts and fetal growth monitoring will also be used. Descriptive and bivariate analysis will be conducted in Stata using Pearson's χ2 test for association, and multivariate logistic regression to identify determinants of uptake. The potential public health benefits will be estimated using the number needed to treat and the preventable fraction. ETHICS AND DISSEMINATION Ethical approval was granted by Kenyatta University Ethics Review Committee (PKU/2443/11575). The research permit is obtained from Kenya National Commission for Science, Technology and Innovation (NACOSTI/P/22/16168). Findings will be disseminated through peer-reviewed publications and public health conferences. TRIAL REGISTRATION NUMBER PACTR202202775997127.
Collapse
Affiliation(s)
- Haron Njiru
- Department of Community Health and Epidemiology, Kenyatta University, Nairobi, Kenya
| | - Eunice Njogu
- Department of Food, Nutrition and Dietetics, Kenyatta University, Nairobi, Kenya
| | - Mary W Gitahi
- Department of Community Health and Epidemiology, Kenyatta University, Nairobi, Kenya
| | - Ephantus Kabiru
- Department of Community Health and Epidemiology, Kenyatta University, Nairobi, Kenya
| |
Collapse
|
9
|
Gomes F, Ashorn P, Askari S, Belizan JM, Boy E, Cormick G, Dickin KL, Driller‐Colangelo AR, Fawzi W, Hofmeyr GJ, Humphrey J, Khadilkar A, Mandlik R, Neufeld LM, Palacios C, Roth DE, Shlisky J, Sudfeld CR, Weaver C, Bourassa MW. Calcium supplementation for the prevention of hypertensive disorders of pregnancy: current evidence and programmatic considerations. Ann N Y Acad Sci 2022; 1510:52-67. [PMID: 35000200 PMCID: PMC9306576 DOI: 10.1111/nyas.14733] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/27/2021] [Accepted: 11/14/2021] [Indexed: 12/13/2022]
Abstract
Most low- and middle-income countries present suboptimal intakes of calcium during pregnancy and high rates of mortality due to maternal hypertensive disorders. Calcium supplementation during pregnancy is known to reduce the risk of these disorders and associated complications, including preeclampsia, maternal morbidity, and preterm birth, and is, therefore, a recommended intervention for pregnant women in populations with low dietary calcium intake (e.g., where ≥25% of individuals in the population have intakes less than 800 mg calcium/day). However, this intervention is not widely implemented in part due to cost and logistical issues related to the large dose and burdensome dosing schedule (three to four 500-mg doses/day). WHO recommends 1.5-2 g/day but limited evidence suggests that less than 1 g/day may be sufficient and ongoing trials with low-dose calcium supplementation (500 mg/day) may point a path toward simplifying supplementation regimens. Calcium carbonate is likely to be the most cost-effective choice, and it is not necessary to counsel women to take calcium supplements separately from iron-containing supplements. In populations at highest risk for preeclampsia, a combination of calcium supplementation and food-based approaches, such as food fortification with calcium, may be required to improve calcium intakes before pregnancy and in early gestation.
Collapse
Affiliation(s)
- Filomena Gomes
- Nutrition Science ProgramNew York Academy of SciencesNew York CityNew York
- NOVA Medical SchoolUniversidade NOVA de LisboaLisboaPortugal
| | - Per Ashorn
- Faculty of Medicine and Health TechnologyTampere University and Tampere University HospitalTampereFinland
| | | | - Jose M. Belizan
- Institute for Clinical Effectiveness and Health Policy/CONICETBuenos AiresArgentina
| | - Erick Boy
- International Food Policy Research InstituteWashingtonDistrict of Columbia
| | - Gabriela Cormick
- Institute for Clinical Effectiveness and Health Policy/CONICETBuenos AiresArgentina
| | | | | | - Wafaie Fawzi
- Harvard T.H. Chan School of Public HealthBostonMassachusetts
| | - G. Justus Hofmeyr
- University of BotswanaGaboroneBotswana
- University of the Witwatersrand and Walter Sisulu UniversityMthathaSouth Africa
| | - Jean Humphrey
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMaryland
| | | | - Rubina Mandlik
- Hirabai Cowasji Jehangir Medical Research InstitutePuneIndia
| | | | | | - Daniel E. Roth
- The Hospital for Sick Children and University of TorontoTorontoOntarioCanada
| | - Julie Shlisky
- Nutrition Science ProgramNew York Academy of SciencesNew York CityNew York
| | | | | | - Megan W. Bourassa
- Nutrition Science ProgramNew York Academy of SciencesNew York CityNew York
| |
Collapse
|
10
|
Kachwaha S, Nguyen PH, Tran LM, Avula R, Young MF, Ghosh S, Forissier T, Escobar-Alegria J, Sharma PK, Frongillo EA, Menon P. Specificity Matters: Unpacking Impact Pathways of Individual Interventions within Bundled Packages Helps Interpret the Limited Impacts of a Maternal Nutrition Intervention in India. J Nutr 2021; 152:612-629. [PMID: 34792151 PMCID: PMC8826931 DOI: 10.1093/jn/nxab390] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/17/2021] [Accepted: 11/11/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND To address gaps in coverage and quality of nutrition services, Alive & Thrive (A&T) strengthened the delivery of maternal nutrition interventions through government antenatal care (ANC) services in Uttar Pradesh, India. The impact evaluation of the A&T interventions compared intensive ANC (I-ANC) with standard ANC (S-ANC) areas and found modest impacts on micronutrient supplementation, dietary diversity, and weight-gain monitoring. OBJECTIVES This study examined intervention-specific program impact pathways (PIPs) and identified reasons for limited impacts of the A&T maternal nutrition intervention package. METHODS We used mixed methods: frontline worker (FLW) surveys (n = ∼500), counseling observations (n = 407), and qualitative in-depth interviews with FLWs, supervisors, and block-level staff (n = 59). We assessed 7 PIP domains: training and materials, knowledge, supportive supervision, supply chains, data use, service delivery, and counseling. RESULTS Exposure to training improved in both I-ANC and S-ANC areas with more job aids used in I-ANC compared with S-ANC (90% compared with 70%), but gaps remained for training content and refresher trainings. FLWs' knowledge improvement was higher in I-ANC than S-ANC (22-36 percentage points), but knowledge of micronutrient supplement benefits and recommended foods was insufficient (<50%). Most FLWs received supervision (>90%), but supportive supervision was limited by staff vacancies and competing work priorities. Supplies of iron-folic acid and calcium supplements were low in both areas (30-50% stock-outs). Use of monitoring data during review meetings was higher in I-ANC than S-ANC (52% compared with 36%) but was constrained by time, understanding, and data quality. Service provision improved in both I-ANC and S-ANC areas, but counseling on supplement benefits and weight-gain monitoring was low (30-40%). CONCLUSIONS Systems-strengthening efforts improved maternal nutrition interventions in ANC, but gaps remained. Taking an intervention-specific perspective to the PIP analysis in this package of services was critical to understand how common and specific barriers influenced overall program impact.
Collapse
Affiliation(s)
- Shivani Kachwaha
- International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | | | | - Rasmi Avula
- International Food Policy Research Institute (IFPRI), Washington, DC, USA
| | | | | | | | | | | | | | - Purnima Menon
- International Food Policy Research Institute (IFPRI), Washington, DC, USA
| |
Collapse
|
11
|
Rakanita Y, Syamsunarno MRAA, Sinuraya RK, Suradji EW, Abdulah R, Suwantika AA. Cost-Effectiveness of Ferrous Fumarate-Folic Acid and Ferrous Gluconate-Multivitamins in a High Prevalence Area of Iron Deficiency Anemia in Indonesia. Ther Clin Risk Manag 2021; 17:1075-1081. [PMID: 34629872 PMCID: PMC8493107 DOI: 10.2147/tcrm.s328226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Up to now, the combinations of ferrous fumarate-folic acid (FF-FA) and ferrous gluconate-multivitamins (FG-MV) have been implemented by the local government in the province of Papua. Nevertheless, there is no a specific economic evaluation that has been applied to investigate the cost-effectiveness of FF-FA and FG-MV. OBJECTIVE This study aimed to investigate the cost-effectiveness of FF-FA and FG-MV to be implemented in Teluk Bintuni, as one of the districts with the highest prevalence of iron deficiency anemia in Papua by taking the healthcare perspective into account. METHODS A prospective observational study was applied by considering two groups of women (15-49 years old) with iron deficiency anemia who received FF-FA and FG-MV from September to November 2018. Applying a purposive sampling method, respondents were selected from 875 targeted women in six sub-districts, who met inclusion criteria. To estimate the total cost, we applied a healthcare perspective that considered direct medical cost only (eg, the procurement cost of iron tablets, cost of Hb test, and cost of healthcare visit). To estimate the effectiveness of intervention, we applied two major parameters, such as Hb level and utility score in quality-adjusted life year (QALY). The cost-effectiveness values were evaluated by using the criteria on the cost-effectiveness of healthcare intervention according to the threshold of gross domestic product (GDP) per capita (cost per QALY gained). RESULTS From 875 targeted women in six sub-districts who met inclusion criteria, we found approximately 222 women with moderate-severe iron deficiency anemia and 110 women with complete data in the group of FF-FA (n=69) and FG-MV (n-41). The results showed that there were significant differences (p-value <0.05) on the number of respondents, age, oral iron cost, total healthcare cost and utility score in both intervention groups. Comparing the use of FG-MV with FF-FA, we estimated the incremental cost-effectiveness ratios (ICERs) would be $255.77 per controlled patient, $142.09 per patient with Hb increment >2.00 g/dL, $79.93 per patient with Hb increment >1.00 g/dL, and $11.59 per QALY gained. CONCLUSION The ICER was estimated to be $11.59 per QALY gained, which was highly cost-effective, according to GDP-based cost-effectiveness threshold. In addition, the utility score of women with iron deficiency anemia was considered to be the most influential factor impacting the cost-effectiveness value.
Collapse
Affiliation(s)
- Yasinta Rakanita
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- College of Pharmaceutical Sciences Pelita Mas, Palu, Indonesia
| | | | - Rano K Sinuraya
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Eka W Suradji
- Department of Public Health, Faculty of Medicine, Krida Wacana University, Jakarta, Indonesia
- UKRIDA Hospital, Jakarta, Indonesia
| | - Rizky Abdulah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Auliya A Suwantika
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- Center for Health Technology Assessment, Universitas Padjadjaran, Bandung, Indonesia
| |
Collapse
|
12
|
Abioye AI, Okuneye TA, Odesanya AMO, Adisa O, Abioye AI, Soipe AI, Ismail KA, Yang JF, Fasehun LK, Omotayo MO. Calcium Intake and Iron Status in Human Studies: A Systematic Review and Dose-Response Meta-Analysis of Randomized Trials and Crossover Studies. J Nutr 2021; 151:1084-1101. [PMID: 33758936 DOI: 10.1093/jn/nxaa437] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/20/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The interaction between dietary (and supplementary) divalent ions has been a long-standing issue in human nutrition research. Developing an optimal calcium and iron supplementation recommendation requires detailed knowledge of the potential trade-offs between: 1) the clinical effects of concurrent intake on iron absorption and hematological indices; and 2) the potentially negative effects of separated ingestion on adherence to iron and/or calcium supplements. Human clinical studies have examined the effects of calcium intake on iron status, but there are no meta-analyses or recent reviews summarizing the findings. OBJECTIVES To synthesize peer-reviewed, human, randomized, and cross-over studies on effects of calcium consumption on iron indices without age, gender, or any other restrictions. METHODS Weighted mean differences for total, heme, and nonheme iron absorption (%) and serum ferritin (μg/L) were obtained from pooled analysis of the highest daily calcium intake compared to the lowest daily calcium intake. RESULTS The negative effect of calcium intake was statistically significant in short-term iron absorption studies, but the effect magnitude was low [weighted mean difference (WMD) = -5.57%; 95% CI: -7.09 to -4.04]. The effect of calcium on the iron status was mixed. The inverse dose-response association of calcium intake with the serum ferritin concentration was significant (P value = 0.0004). There was, however, no reduction in the hemoglobin concentration (WMD = 1.22g/L; 95% CI: 0.37-2.07). CONCLUSIONS The existing body of studies is insufficient to make recommendations with high confidence due to heterogeneity in designs, limitations of ferritin as an iron biomarker, and a lack of intake studies in pregnant women. Prescribing separation of prenatal calcium and iron supplements in free-living individuals is unlikely to affect the anemia burden. There is a need for effectiveness trials comparing the effects of prescribing separated intake to concurrent intake, with functional endpoints as primary outcomes and adherence to each supplement as intermediate outcomes.
Collapse
Affiliation(s)
| | - Taofik A Okuneye
- Department of Family Medicine, General Hospital, Odan, Lagos, Nigeria
| | | | | | | | - Ayorinde I Soipe
- Department of Emergency Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Kamal A Ismail
- Department of Hematology, Lagos State University College of Medicine, Lagos, Nigeria
| | - JaeWon F Yang
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | | | - Moshood O Omotayo
- Centre for Global Health and Division of Pediatric Global Health, Massachusetts General Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
13
|
Tumilowicz A, Pelto GH. Interventions to improve dietary intake behaviors among children and adolescents. GLOBAL FOOD SECURITY 2020. [DOI: 10.1016/j.gfs.2020.100413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
14
|
Spatio-temporal trends in anaemia among pregnant women, adolescents and preschool children in sub-Saharan Africa. Public Health Nutr 2020; 24:3648-3661. [PMID: 33190664 DOI: 10.1017/s1368980020004620] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE We investigated the spatiotemporal trends in the burden of maternal, adolescent and child anaemia in sub-Saharan Africa (SSA) and evaluated some individual and household predictors of anaemia. DESIGN Average Hb concentrations and anaemia prevalence were estimated, plotted over time and mapped by country and sub-region. Multilevel linear regression models were used to evaluate individual and household predictors of Hb concentration. PARTICIPANTS Data from Demographic and Health Surveys (DHS) spanning 2000-2018 were merged into data sets for 37 623 pregnant women, 89 815 older adolescent girls and 401 438 preschool children. SETTING The merged DHS represent nationally representative samples from thirty-three countries. RESULTS Prevalence of anaemia remains high in SSA, affecting 60, 36 and 44 % of children, adolescents and pregnant women, respectively. Anaemia prevalence among children did not materially improve from 2000 to 2018. Anaemia prevalence among older adolescent girls and pregnant women did not also improve, but this masks a period of improvement followed by depreciation in population anaemia status. Pregnant adolescents had 12·5 g/l (95 % CI: 11·3, 13·6) lower Hb concentration compared with non-pregnant adolescents and 1·7 g/l (95 % CI: 0·7, 2·6) lower Hb concentration compared with pregnant women > 40 years, respectively. Stunting and wasting were associated with 1·3-3·3 g/l lower Hb concentration among children. Other significant predictors of Hb concentration were educational attainment, wealth quintiles, source of drinking water, number of children < 5 years in the household and possession of bed-nets. CONCLUSION Anaemia in SSA has not improved remarkably since year 2000 and remains excessive among children.
Collapse
|
15
|
Klemm GC, Birhanu Z, Ortolano SE, Kebede Y, Martin SL, Mamo G, Dickin KL. Integrating Calcium Into Antenatal Iron-Folic Acid Supplementation in Ethiopia: Women's Experiences, Perceptions of Acceptability, and Strategies to Support Calcium Supplement Adherence. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:413-430. [PMID: 33008855 PMCID: PMC7541115 DOI: 10.9745/ghsp-d-20-00008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/16/2020] [Indexed: 01/10/2023]
Abstract
Recommendations for antenatal calcium supplementation to prevent preeclampsia could substantially reduce maternal mortality, but adherence to multiple daily doses may constrain effectiveness. World Health Organization guidelines recommend 3 daily calcium supplements (1.5-2 g/d), taken separately from 1 iron-folic acid (IFA) supplement; however, limited data suggest lower calcium doses may also be effective. We conducted mixed-methods household trials to identify strategies for supporting adherence and integrating calcium into antenatal IFA supplementation programming in Ethiopia. Participants were randomly assigned to 3 regimens varying in dose and timing and were later given a choice of regimens. Semistructured interviews conducted over 6 weeks explored acceptability, barriers, and facilitators and offered opportunities to choose calcium pill type. Interviews were transcribed, translated, and analyzed thematically. Calcium adherence was measured using medication event monitoring. All participants (N=48) agreed to try supplementation. Adherence barriers included forgetting to take pills when busy or travelling and perceived side effects. Midday doses were the most challenging because of farming, market, and social events; women avoided taking supplements in public due to fear of being perceived as HIV positive. Social support from families, visual reminders, and anticipated benefits motivated adherence. More participants (75%) selected chewable versus conventional supplements due to organoleptic properties, but this preference declined over time. Adherence rates did not substantially differ across regimens with 2 (81.1%), 3 (83.4%), or 4 (77.1%) pill-taking events. Women indicated that the 2-event regimen was more acceptable than 3- and 4-event regimens, but this acceptability was not associated with higher adherence. Consequently, mean daily calcium consumption (811.3 mg) was lower than for 3-event (1,251.1 mg) and 4-event (1,156.4 mg) regimens. Integrating calcium into antenatal IFA supplementation is acceptable to Ethiopian women, with a 3-event regimen yielding the highest consumption rates. Despite women experiencing challenges with midday dosing and stigma, using simple home-based strategies and being counseled on the purpose of supplementation were more effective than reducing dosage for mitigating barriers and improving adherence.
Collapse
Affiliation(s)
- Gina C Klemm
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Zewdie Birhanu
- Faculty of Public Health, Department of Health, Behavior and Society, Jimma University, Jimma, Ethiopia
| | - Stephanie E Ortolano
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Yohannes Kebede
- Faculty of Public Health, Department of Health, Behavior and Society, Jimma University, Jimma, Ethiopia
| | - Stephanie L Martin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - Girma Mamo
- Ethiopia-Canada Cooperation Office, Nutrition International, Addis Ababa, Ethiopia
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA.
| |
Collapse
|
16
|
Kamau MW. Time for change is now: Experiences of participants in a community-based approach for iron and folic acid supplementation in a rural county in Kenya, a qualitative study. PLoS One 2020; 15:e0227332. [PMID: 31945073 PMCID: PMC6964883 DOI: 10.1371/journal.pone.0227332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/18/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Iron and Folic Acid Supplementation (IFAS) is recommended by World Health Organization as part of antenatal care to prevent anaemia in pregnancy. In 2010, Kenya adopted this recommendation and the current policy is to provide one combined IFAS tablet for daily use throughout pregnancy, free of charge, in all public health facilities. However, adherence remains low over the years though anaemia in pregnancy remains high. Integration of IFAS into community-based interventions has been recommended because of its excellent outcome. Using Community Health Volunteers (CHVs) to distribute IFAS has not been implemented in Kenya before. METHODS Following an intervention study implementing a community-based approach for IFAS in five public health facilities in Lari Sub-County, 19 interviews were conducted among CHVs, nurses and pregnant women participating to describe their experiences. Thematic analysis of data was done using NVivo and findings described, with use of quotes. FINDINGS The nurses, CHVs and pregnant women were all positive and supportive of community-based approach for IFAS. They reported increased access and utilization of both IFAS and antenatal services leading to perceived reduction in anaemia and better pregnancy outcomes. Counselling provided by CHVs improved IFAS knowledge among pregnant women and consequent adherence. The increased IFAS utilization led to main challenge experienced being IFAS stock-outs. All participants recommended complementing antenatal IFAS distribution approach with community-based approach for IFAS. CONCLUSION Using CHVs to implement a community-based approach for IFAS was successful and increased supplement awareness and utilization. However, the role of CHVs in IFAS programme implementation is not clearly defined in current policy and their potential in IFAS education and distribution is not fully utilized. All participants endorsed integration of community-based approach for IFAS into the antenatal approach to enhance IFAS coverage and adherence among pregnant women for better pregnancy outcomes.
Collapse
Affiliation(s)
- Mary Wanjira Kamau
- School of Nursing Sciences, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| |
Collapse
|
17
|
Omotayo MO, Dickin KL, Pelletier DL, Martin SL, Kung'u JK, Stoltzfus RJ. Feasibility of integrating calcium and iron-folate supplementation to prevent preeclampsia and anemia in pregnancy in primary healthcare facilities in Kenya. MATERNAL AND CHILD NUTRITION 2019; 14 Suppl 1. [PMID: 29493897 DOI: 10.1111/mcn.12437] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/08/2016] [Accepted: 01/09/2017] [Indexed: 01/30/2023]
Abstract
Calcium (Ca) supplementation to prevent preeclampsia can save maternal and newborn lives, but there are no program models for integration into existing antenatal care platforms. We used a program impact pathway model to guide the design of integrated Ca and iron-folate (IFA) supplementation in Kenya. We provided healthcare providers with job aids (posters and counseling cards), trained them on counseling techniques and supplementation guidelines, and developed behavior change materials for pregnant women (pill-taking calendars). We allocated health facilities to prescribe either 1.0 or 1.5 g/day Ca, with standard IFA. We collected implementation data from 16 facilities and 990 women. We also explored effects of supplementation on percentage of the population meeting recommended daily allowance. Supplements and job aids were available during 90% of facility spot-check episodes; calendar availability was lower (78%). Over 98% of clients received Ca and IFA supplements, but only 76% received enough Ca supplements to last between antenatal care visits. Among clients that still had pills by return date, adherence was 77% and 83% for the IFA and Ca regimen, respectively. When 1.5 g/day of Ca supplements were prescribed, over 75% of participants met recommended daily allowance. Only 54% met the recommended daily allowance when 1.0 g was prescribed. This study illustrates a systematic approach for integrating Ca supplementation into primary healthcare and demonstrates that such integration is feasible when contextual bottlenecks are addressed. Policy makers and program planners should pay attention to supply chain, healthcare worker dispensing behavior, and appropriateness of regimen for their settings.
Collapse
Affiliation(s)
- Moshood O Omotayo
- Program in International Nutrition, Cornell University, Ithaca, New York, USA
| | - Katherine L Dickin
- Program in International Nutrition, Cornell University, Ithaca, New York, USA
| | - David L Pelletier
- Program in International Nutrition, Cornell University, Ithaca, New York, USA
| | - Stephanie L Martin
- Program in International Nutrition, Cornell University, Ithaca, New York, USA
| | | | - Rebecca J Stoltzfus
- Program in International Nutrition, Cornell University, Ithaca, New York, USA
| |
Collapse
|
18
|
Martin SL, Wawire V, Ombunda H, Li T, Sklar K, Tzehaie H, Wong A, Pelto GH, Omotayo MO, Chapleau GM, Stoltzfus RJ, Dickin KL. Integrating Calcium Supplementation into Facility-Based Antenatal Care Services in Western Kenya: A Qualitative Process Evaluation to Identify Implementation Barriers and Facilitators. Curr Dev Nutr 2018; 2:nzy068. [PMID: 30402593 PMCID: PMC6215767 DOI: 10.1093/cdn/nzy068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/11/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In countries with low calcium intake, the WHO recommends integrating calcium supplementation into antenatal care (ANC) to reduce the risk of preeclampsia, a leading cause of maternal mortality. Current WHO guidelines recommend women take 3-4 calcium supplements plus 1 iron-folic acid supplement at separate times daily. There is limited evidence about implementing these guidelines through routine ANC. Through the Micronutrient Initiative-Cornell University Calcium (MICa) trial, we examined the effect of regimen on supplement consumption among ANC clients in western Kenya. A nested process evaluation examined factors that influence calcium supplementation delivery and uptake. OBJECTIVES This process evaluation assessed ANC providers', pregnant women's, and family members' experiences with calcium supplementation, and investigated the feasibility and acceptability of engaging family members to support adherence. METHODS We conducted semistructured interviews with 7 ANC providers, 32 pregnant women, and 20 adherence partners (family members who provide reminders and support), and 200 observations of ANC consultations. Interviews were transcribed, translated, and analyzed thematically. Observational data were summarized. RESULTS ANC providers reported positive feelings about calcium supplementation, the training received, and counseling materials, but reported increased workloads. Women reported that providers counseled them on supplement benefits and managing side effects, offered reminder strategies, and provided supplements and behavior change materials. Women explained that reminder materials and adherence partners improved adherence. Most adherence partners reported providing reminders and other instrumental support to help with pill taking, which women confirmed and appreciated. Some women reported that comorbidities, concerns about being perceived as HIV positive, pill burden, unfavorable organoleptic properties, and lack of food were adherence barriers. CONCLUSIONS Although integrating calcium into antenatal iron-folic acid supplementation was generally acceptable to ANC providers, pregnant women, and their families, calcium supplementation presents unique challenges that must be considered to successfully implement these guidelines.This trial was registered at clinicaltrials.gov as NCT02238704.
Collapse
Affiliation(s)
- Stephanie L Martin
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Violet Wawire
- Department of Education Foundation, Kenyatta University, Nairobi, Kenya
| | - Hedwig Ombunda
- Faculty of Education and Arts, KCA University, Nairobi, Kenya
| | - Terry Li
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Kelsey Sklar
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Hiwet Tzehaie
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Athena Wong
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Gretel H Pelto
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Moshood O Omotayo
- Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY
| | - Gina M Chapleau
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Rebecca J Stoltzfus
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Katherine L Dickin
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY
| |
Collapse
|
19
|
Tesfaye B, Sinclair K, Wuehler SE, Moges T, De-Regil LM, Dickin KL. Applying international guidelines for calcium supplementation to prevent pre-eclampsia: simulation of recommended dosages suggests risk of excess intake in Ethiopia. Public Health Nutr 2018; 22:1-11. [PMID: 30319089 PMCID: PMC10260678 DOI: 10.1017/s1368980018002562] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 08/21/2018] [Accepted: 09/03/2018] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To simulate impact of Ca supplementation on estimated total Ca intakes among women in a population with low dietary Ca intakes, using WHO recommendations: 1·5-2·0 g elemental Ca/d during pregnancy to prevent pre-eclampsia. DESIGN Single cross-sectional 24 h dietary recall data were adjusted using IMAPP software to simulate proportions of women who would meet or exceed the Estimated Average Requirement (EAR) and Tolerable Upper Intake Level (UL) assuming full or partial adherence to WHO guidelines. SETTING Nationally and regionally representative data, Ethiopia's 'lean' season 2011. SUBJECTS Women 15-45 years (n 7908, of whom 492 pregnant). RESULTS National mean usual Ca intake was 501 (sd 244) mg/d. Approximately 89, 91 and 96 % of all women, pregnant women and 15-18 years, respectively, had dietary Ca intakes below the EAR. Simulating 100 % adherence to 1·0, 1·5 and 2·0 g/d estimated nearly all women (>99 %) would meet the EAR, regardless of dosage. Nationally, supplementation with 1·5 and 2·0 g/d would result in intake exceeding the UL in 3·7 and 43·2 % of women, respectively, while at 1·0 g/d those exceeding the UL would be <1 % (0·74 %) except in one region (4·95 %). CONCLUSIONS Most Ethiopian women consume insufficient Ca, increasing risk of pre-eclampsia. Providing Ca supplements of 1·5-2·0 g/d could result in high proportions of women exceeding the UL, while universal consumption of 1·0 g/d would meet requirements with minimal risk of excess. Appropriately tested screening tools could identify and reduce risk to high Ca consumers. Research on minimum effective Ca supplementation to prevent pre-eclampsia is also needed to determine whether lower doses could be recommended.
Collapse
Affiliation(s)
- Biniyam Tesfaye
- Ethiopia Public Health Institute, Food Science and Nutrition Research Directorate, Addis Ababa, Ethiopia
| | - Kate Sinclair
- Micronutrient Initiative Contractor, Montreal, Quebec, Canada
| | - Sara E Wuehler
- Nutrition International (formerly the Micronutrient Initiative), Global Technical Services, 180 Elgin Street, Suite1000, Ottawa, Ontario, Canada, K2P 2K3
| | - Tibebu Moges
- Ethiopia Public Health Institute, Food Science and Nutrition Research Directorate, Addis Ababa, Ethiopia
| | - Luz Maria De-Regil
- Nutrition International (formerly the Micronutrient Initiative), Global Technical Services, 180 Elgin Street, Suite1000, Ottawa, Ontario, Canada, K2P 2K3
| | - Katherine L Dickin
- Cornell University, Division of Nutritional Sciences, Ithaca, New York, NY, USA
| |
Collapse
|
20
|
Omotayo MO, Martin SL, Stoltzfus RJ, Ortolano SE, Mwanga E, Dickin KL. With adaptation, the WHO guidelines on calcium supplementation for prevention of pre-eclampsia are adopted by pregnant women. MATERNAL & CHILD NUTRITION 2018; 14:e12521. [PMID: 29193667 PMCID: PMC6865867 DOI: 10.1111/mcn.12521] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 08/14/2017] [Accepted: 08/24/2017] [Indexed: 01/08/2023]
Abstract
The World Health Organization (WHO) recommends calcium supplementation for prevention of pre-eclampsia, but factors affecting adoption and acceptability of the recommendations among pregnant women have not been examined. We explored adoption of the WHO guidelines in Kenya, using the trials of improved practices. We recruited 38 pregnant women and assigned participants to three regimens representing potential trade-offs among daily dose, bioavailability, and acceptability. Participants were provided with supplements, requested to select preferred product type, counselled on how to take them, and interviewed 4 times over 6 weeks to assess their experiences. We tracked bottle opening with electronic monitors, as proxy for supplement consumption. We analysed interview transcripts thematically. All participants were willing to try the supplements. Average daily consumption ranged from 77 to 1,577 mg/d. Most participants (74%) chose the chewable product. Participants preferred its "sweet taste" and liked the ability to consume it without water. Women in the 2-dose regimen were least likely to switch; however, women assigned to the 3-dose regimen, or who switched to the 3-dose regimen, consumed the most calcium per day. Difficulties with the 4-dose regimen included afternoon doses when women were likely to forget and having to wait hours after supper for last dose. Use of an illustrated calendar, keeping supplements in conspicuous locations and requesting support from relatives were strategies that supported adherence. Pregnant women are likely to adopt Ca supplementation, with appropriate programmatic adaptations. Careful attention to product attributes, regimen complexity, and strategies for reassuring and reminding women are needed to adapt the WHO guidelines.
Collapse
Affiliation(s)
- Moshood O. Omotayo
- Program in International NutritionCornell UniversityIthacaNew YorkUSA
- Department of Epidemiology and Environmental HealthUniversity at BuffaloBuffaloNew YorkUSA
| | | | | | | | - Erick Mwanga
- Malava Sub‐County Health Management TeamKakamegaKenya
| | | |
Collapse
|