Country Examples on Gaps and Facilitating Factors for Calcium Supplementation (use of the scale-up map tool)

Dr. Ferdousi Begum Associate Professor , OBGYN, DMC Obstetrical & Gynecological Society of Bangladesh

Contents
Evidences Bangladesh Cochrane Database WHO Recommendations Retail Costs for Selected Calcium Supplements Calcium: Food Sources of Bioavailability Govt. of Bangladesh Operation Plan on National Nutrition Services Pathway to Implement Calcium Supplementation At Scale

 Overall rickets prevalence among children-4% Rickets in Chakaria (Coxs Bazar, Bangladesh) is of the Ca-deficiency type
Gerald F. Biol Trace Elem Res (2008) 121:193204

Dietary calcium intake in premenopausal Bangladeshi women: Do socio-economic or physiological factors play a role?
Dhaka city area and the Betagair Union, Nandail, Mymensingh 47% of subjects of High SE Gr failed to meet even the lowest level (400 500mg=day) of WHO recommended dietary allowances (RDA) of calcium for adult women. No subject in low SE Gr was found to meet the RDA level. Moreover, 63% of the women in group L had calcium intake lower than 200mg=day. These figures could be more critical in both groups if we consider the recent USA-RDAs of calcium for adult women (1000mg=day). The difference of socio-economic status on calcium density of the diet is significant(P<0.001) .
MZ Islam et al. European Journal of Clinical Nutrition (2003) 57, 674680

Distribution of the subjects by socioeconomic groups and monthly family income

The mean daily intake of calcium in sub-groups of the two groups MZ Islam et al

Total mean daily calcium intake in low SE in Bangladeshi women MZ Islam et al

In Low Income Group

Cereal products -32% of the total calcium intake Fish was the second major source Milk and other basic food form less than 1- 18% of the total calcium intake Egg - 1% of total intake of calcium

Total mean daily calcium intake in high SE in Bangladeshi women MZ Islam et al

In High Income Group Fish - 42% (main source) Milk -19% of the total daily calcium intake (second highest source)

The mean calcium density (mg Ca=1000 kcal) in the subgroups of the two groups

Clinical and radiographic improvement of rickets in Bangladeshi children as a result of nutritional advice
Five-component nutritional advice: (i) The routine addition of 1 g limestone/kg rice, (ii) Consuming small fish (including bones) instead of large ones, (iii) Daily consumption of 5 g ground sesame seeds, (iv) 100 g leafy vegetables and, if possible, (v) 100 ml of milk. CONCLUSIONS -in mild calcium-deficiency active rickets, nutritional advice may be a cost-effective treatment and possibly a valuable long-term solution to the problem.
Arnaud J, Ann Trop Paediatr. 2007 Sep;27(3):185-91.

Apparent Efficacy of Food-Based Calcium Supplementation in Preventing Rickets in Bangladesh Gerald F. Biol Trace Elem Res (2008) 121:193204 1-to 5-year-old children who did not present with rickets but ranked in the upper decile of plasma alkaline phosphatase (AP) activity. 158 children were randomized to a milkpowder-based dietary supplement given daily, 6 days/week, and providing either 50, 250, or 500 mg Ca, or 500 mg Ca plus multivitamins, iron, and zinc.

Calcium And Zinc Deficiency In Preeclamptic Women

Selina Akhtar, Shelina Begum, Sultana Ferdousi J Bangladesh Soc Physiol. 2011, December; 6(2): 94-99

Calcium And Zinc Deficiency In Preeclamptic Women

Selina Akhtar, Shelina Begum, Sultana Ferdousi J Bangladesh Soc Physiol. 2011, December; 6(2): 94-99

Calcium And Zinc Deficiency In Preeclamptic Women

Selina Akhtar, Shelina Begum, Sultana Ferdousi J Bangladesh Soc Physiol. 2011, December; 6(2): 94-99

Mean serum calcium and zinc levels were significantly (p<0.001) lower in study group than those of control group. Again, serum calcium and zinc showed significant negative correlation with SBP and DBP in preeclamptic women. Therefore, early detection and supplementation to treat this deficiency may reduce the incidence of preeclampsia.

Serum calcium in normal pregnant women

Akhter K, Rahman MS, Ahmed S, Ahmed A, Alam SM
Mymensingh Med J. 2003 Jan;12(1):55-7.

Serum calcium levels were determined in 30 normal non-gravid women and 30 women with normal pregnancies during third trimester with age range of 17-35 years. The mean serum calcium levels were found to be significantly lower in normal pregnant woman in third trimester than that of normal non-pregnant controls.

Calcium supplementation during pregnancy to prevent pre-eclampsia and its complications

A Cochrane systematic review of 13 RCTs, involving a total of 15,730 women, investigated the effects of routine (daily) supplementation with at least 1 g of calcium when used for preventing pre-eclampsia and related problems.
Hofmeyr GJ, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews, 2010, (8):CD001059

Calcium supplementation during pregnancy to prevent pre-eclampsia and its complications

As many as 96.2% of the women recruited were at a low risk of developing pre-eclampsia and over 70% had low baseline dietary calcium intake (less than 900 mg per day). All the trials in the review compared calcium supplementation with placebo or with no treatment. Supplemental calcium dose used ranged between 1.5 g and 2.0 g per day in all trials.
Hofmeyr GJ, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews, 2010, (8):CD001059

Calcium supplementation during pregnancy to prevent pre-eclampsia and its complications

For all women, irrespective of the baseline risk of developing pre-eclampsia and calcium intake status, calcium supplementation more than halved the risk of pre-eclampsia when compared with placebo (13 trials, 15 730 women; RR 0.45, 95% CI 0.310.65).
Hofmeyr GJ, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews, 2010, (8):CD001059

Calcium supplementation during pregnancy to prevent pre-eclampsia and its complications

This risk reduction was 41% for women at low risk of developing pre-eclampsia
(eight trials, 15,143 women; RR 0.59, 95% CI 0.410.83)

whereas the largest risk reduction (78%) was recorded among those at high risk of hypertensive disorders.
(five trials, 587 women; RR 0.22, 95% CI 0.120.42)
Hofmeyr GJ, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews, 2010, (8):CD001059

Calcium supplementation during pregnancy to prevent pre-eclampsia and its complications

In women or populations with low calcium intake, there was a modest reduction in risk for the composite outcome of maternal death or WHO recommendations for serious morbidity among women who received calcium compared with placebo (four trials, 9732 women, RR 0.80, 95% CI 0.650.97).
Hofmeyr GJ, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews, 2010, (8):CD001059

Calcium supplementation during pregnancy to prevent pre-eclampsia and its complications

Overall, a statistically significant increase in the risk ratio for HELLP syndrome was observed among women who received calcium supplementation compared with placebo (two trials, 12 901 women; RR 2.67, 95% CI 1.056.82).
Hofmeyr GJ, et al. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews, 2010, (8):CD001059

Calcium supplementation during pregnancy to prevent pre-eclampsia and its complications

There were no statistically significant differences between the two groups for other critical (and proxy) outcomes addressed by the review:

Eclampsia
(three trials, 13 425 women; RR 0.73, 95% CI 0.411.27);

Maternal death (one trial, 8312 women; RR 0.17, 95% CI 0.021.39); Maternal intensive care unit admission
(one trial, 8312 women; RR 0.84, 95% CI 0.661.07);

Stillbirth or death before discharge from hospital

(11 trials, 15 665 women, RR 0.90,95% CI 0.741.09); and

Admission to neonatal intensive care unit

(four trials, 13 406 women, RR 1.05, 95% CI 0.941.18) Hofmeyr GJ, et al. Cochrane Database of Systematic Reviews, 2010, (8):CD001059

Calcium supplementation during pregnancy to prevent pre-eclampsia and its complications

Recommendation In areas where dietary calcium intake is low, calcium supplementation during pregnancy (at doses of 1.52.0 g elemental calcium/day) is recommended for the prevention of Preeclampsia in all women, but especially in those at high risk of developing pre-eclampsia.
(Moderate-quality evidence. Strong recommendation.)
Hofmeyr GJ, et al. Cochrane Database of Systematic Reviews, 2010, (8):CD001059

Interventions that are recommended for prevention of pre-eclampsia and eclampsia

Recommendation Quality of evidence Strength of Recommendation

In areas where dietary calcium intake is low, calcium supplementation during pregnancy (at doses of 1.5 2.0 g elemental calcium/day) is recommended for the prevention of pre-eclampsia in all women, but especially those at high risk of developing pre-eclampsia.

Moderate

Strong

WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia, WQ 215, World Health Organization 2011.

Interventions that are recommended for prevention of pre-eclampsia and eclampsia

Recommendation Quality of evidence Strength of Recommendation

Low-dose acetylsalicylic acid (aspirin, 75 mg) is recommended for the prevention of preeclampsia in women at high risk of developing the condition.

Moderate

Strong

WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia, WQ 215, World Health Organization 2011.

Interventions that are recommended for prevention of pre-eclampsia and eclampsia

Recommendation Quality of evidence Strength of Recommendation

Low-dose acetylsalicylic Low acid (aspirin, 75 mg) for the prevention of preeclampsia and its related complications should be initiated before 20 weeks of pregnancy.

Weak

WHO recommendations for Prevention and treatment of pre-eclampsia and eclampsia, WQ 215, World Health Organization 2011.

Retail Costs for Selected Calcium Supplements and UNICEF Drug List Costs for Iron-Folic Acid Supps
Calcium Calcium carbonate pill citrate pill (1.5-2.0 g/d) (1.5-2.0 g/d) Calcium chewable pill-antacids

Iron-folic-acid pill (60 mg of ferrous fumarate)*

Cost of supplement /day /woman ($US) Cost of supplements/ Pregnancy($US) (from 20 wk GA)

0.0960.15

0.2640.375

0.0210.041

5.34/1,000 or 0.00534/ea

13.4421.00

36.9652.50

2.94-5.74 $0.48/ woman

*In cases of severe anemia, the woman may require 120 mg of ferrous fumarate.

Retail Costs for Selected Calcium Supplements and UNICEF Drug List Costs for Iron-Folic Acid supps
Calcium carbonate pill (1.5-2.0 g/d) Calcium citrate pill (1.5-2.0 g/d) Calcium chewable pill-antacids Iron-folic-acid pill (60 mg of ferrous fumarate)*

Cost per pregnancy for shipping to country (US$)

0.375 (by sea/land) 4.12 (by air)

0.375 (by sea/land) 4.12 (by air)

0.375 (by sea/land) 4.12 (by air)

0.015 (by sea/land) 0.165 (by air)

Retail Costs for Selected Calcium Supplements and UNICEF Drug List Costs for Iron-Folic Acid supps
Calcium carbonate pill (1.5-2.0 g/d) Calcium citrate pill (1.5-2.0 g/d) Calcium chewable pill-antacids Iron-folic-acid pill (60 mg of ferrous fumarate)*

Cost per pregnancy for supplement and shipping (US$)

13.8221.38 (by sea/land) 17.5625.12 (by air)

36.8852.88 (by sea/land) 41.0856.62 (by air)

3.34-6.12 (by sea/land) 7.06-9.86 (by air)

0.50 (by sea/land) 0.64 (by air)

Retail Costs for Selected Calcium Supplements and UNICEF Drug List Costs for Iron-Folic Acid supps
Calcium carbonate pill (1.5-2.0 g/d) Calcium citrate pill (1.5-2.0 g/d) Calcium chewable pill-antacids Iron-folic-acid pill (60 mg of ferrous fumarate)*

1.50 1.50 Other program cost per pregnancy (US$) 15.3238.38Total costs per 22.88 (by 54.38 sea/land) pregnancy 19.06(US$) 26.62 (by air)

1.50

1.50

4.84-7.62 2.00
(by land/sea) (by sea/land)

8.5611.36
(by air)

2.14 (by air)

Calcium: Food Sources of Bioavailability

Food Serving size (g) Calcium content (mg) Fractio Estimated Serving nal absorbable needed absorp calcium/ to equal tion serving 1 c. of % (mg) milk

250 ml milk or 1 c. yogurt or 1.5 oz cheese Beans, dried Kale Spinach Tofu, calcium set

260

300

32

96

177 65 90 126

50 47 122 258

16 59 5 31

8 28 6 80

12 4 16 1

Adapted from Weaver, CM, et al., AJCN 70:543S-8S., 1999 (as shown in Shils, et al., Modern Nutrition in Health and Disease, 2006.)

Government of Peoples Republic of Bangladesh

Operation Plan for National Nutrition Services July 2011 - June 2016
Health, Population and Nutrition Sector Development Program (HPNSDP)

Directorate General of Health Services Ministry on Health and Family Welfare July 2011

8.2 Major Components of OP and their PM / DPM

PM-DGHS(DD-IPHN) PM-DGFP (DD-DGFP on deputation) PM--Multisectoral
e) Other Micronutrient Problems of Public Health Importance (ZINC, vit D, Calcium etc.)

10. (A) Priority Interventions and Activities of the National Nutrition Services
10.A.3 Micronutrient Supplementation a) Vitamin A supplementation b) Iron folate supplementation c) Iron supplementation and deworming of adolescent girls d) Zinc supplementation during treatment of diarrhoea

e) Vitamin D, Calcium supplementation

e) Vitamin D, Calcium Supplementation Very recently disability among children due to deficiency of calcium and/or vitamin D is also found in some pocket areas of Bangladesh which are suspected as Rickets cases. Special programs for Calcium and Vitamin D supplementation for specific cases will be undertaken.

e) Vitamin D, Calcium Supplementation

Calcium deficiency is a common problem among elderly or post menopausal women which leads to osteoporosis and osteoarthritis diseases. Calcium is also essential for pregnant women for the growing fetus. Thus promotional program will be designed to advocate for consumption of calcium rich food and calcium supplementation during pregnancy and after 40 years of age.

Key NNS Activities with responsibilities at different levels of services in the health sector program
Activity Responsibility/service delivery and supervision/monitoring District level (DH/MCWC) Delivery and supervision: CS/DDFP TS & Logistics; LD-NNS Upazila health Complex Delivery and supervision: UHFPO/UFPO TS & Logistics: LD-NNS Union health facility Delivery and supervision: UHFPO/UFPO T S & Logistics: LD-NNS
Community clinics/community

Iron-Folic Acid Supplementation for pregnant and lactating women, and adolescent girls

Delivery and supervision: LD-CC TS & Logistics: LD-NNS

Other Micronutrients supplementatio n of public health importance (Zn, Ca etc. )

Delivery and supervision: CS/DDFP TS & Logistics; LD-NNS

Delivery and supervision: UHFPO/UFPO TS & Logistics: LD-NNS

Delivery and supervision: UHFPO/UFPO TS & Logistics: LD-NNS

Delivery and supervision: LD-CC TS & Logistics: LD-NNS

Same service delivery, supervision, technical support and logistic channels for IFA and Calcium

14. Location-wise break up of the components (Taka in lakh)

Name components Natio Esti Name nal mat of ed Division cost All components Natio 2980 7 Div. nal 1 Other All Micronutrient problems of Public Health (Zinc, vitamin importance $US. 240964) (Zinc, vitamin D, calcium etc.) Esti mat ed cost 1509 Nam e of Distr ict 64 Dist. All Esti mate d cost 1379 6 Name of Upazi lla 482 Upazi lla All Esti mate d cost 1039 03.38 2000 (20
Crore)

D, calcium etc.

(1.36 % of the total cost)

Action Plan for Mainstreaming Nutrition services

Sl Activity Service delivery Existing Proposed Responsibility Current Proposed

Child Nutrition ABCN, 6 Iron supplementation ICDP (micronutrient powder) 8 Other Nil Micronutrients (Vit D, Calcium etc.) Maternal and Newborn Nutrition Iron-folic acid ANC, supplementation PNC, for pregnant and ABCN lactating women

Communi DGHS, ty-IMCI, DGFP CC Communi DGHS, ty & FDGFP IMCI, CC

ANC, PNC, CC DGHS, DGFP, NNP

DGHS, DGFP

DGHS, DGFP

Pathway to Implement Calcium Supplementation At Scale

Global Action National Strategic Choices Program Implementation
Program design Early Introduction Mature Implementation

Sustainability / Institutionalization

Global Actions
Global advocacy and partnerships: Global action to support work to reduce PE/E

Global Actions
Global clinical and program approaches: Efficacy for calcium supplementation to prevent PE/E

Demonstrated and WHO recommendations issued

Global Actions
Global programmatic guidelines for calcium supplementation developed and issued: Effective interventions for calcium supplementation demonstrated Some recommendations made This meeting can add to the guideline / recommendation

Global Actions
Global source of calcium supplements: UNICEF does not have a low cost calcium supplement for pregnant women on its drug list Need for exploration of development partners, funding

National Strategic Choices

National Strategic Choices

Maternal calcium supplementation policy: National policy/strategy sets reducing PE/E as a priority and recommends calcium during pregnancy National guideline for prevention & treatment of PE/E recommends calcium during pregnancy May need to generate evidence at local level

National Strategic Choices

Health system governance: Proactive financing of maternal health including calcium supplementation to prevent PE/E Some allocation in the OP of HPNSDP, 2011 to 2016

National Strategic Choices

Service delivery capacity at sites: Presence of reliable infrastructure, personnel, and systems to deliver PE/E interventions including calcium supplementation Some infrastructure, personnel System of ANC & IFA can be used to deliver calcium supplementation for PE/E intervention

Program Implementation Program design Early Introduction Mature implementation

Program Design
Formative research: Demand and supply-side barriers to calcium supplementation determined (womens perceptions of PE/E as a problem and taking calcium to prevent it; supply and logistic gaps)
May need operations research Ma Moni Project may generate some evidences

Program Design
Drug supply procurement: Systems in place to ensure adequate forecasting and delivery of calcium supplies to health facilities and pregnant women
General system can be used Needs National planning and finance

Program Design
SBCC: SBCC strategy developed including counseling messages and materials to ensure compliance, social mobilization campaigns, and use of media to raise awareness
Some messages have been generated in MaMoni project area Needs further action & support

Early Introduction
Training and education: Pre-service and in-service training conducted on calcium supplementation To some extent Supervision and on the job training in place No

Early Introduction
Quality of care : Quality of care introduced at community and facility levels
Needs to be included in pre service and in-service training curriculum of all categories of HSP

Early Introduction
Community engagement: Community driven support for prevention of PE/E and Calcium supplementation community /facility linkages in place
Ma Moni project may explore & highlight the possible way May need operations research

Early Introduction
Monitoring and evaluation: Routine monitoring in place: National coverage surveys conducted 35 years
Needs strengthening

Early Introduction
Programmatic growth: Adding districts, partners, and financing
After operations research can be scaled up HPNSDP plans to cover all MC, DH/MCWC, UHC

Mature Implementation
Capacity development: Providers have complete knowledge and counseling skills on calcium supplementation
Incomplete knowledge and counseling skills

Mature Implementation
Quality of Care: Providers are self-assessing and supervisors provide supportive supervision Self assessment should be in built in the system General chain of supervision may be used Periodical especial study or survey may be conducted

Mature Implementation
Drug and supply availability: Calcium for all pregnant women available in community/facility
Long way to go

Mature Implementation
Clinical coverage: High coverage and uptake of calcium supplementation
Low Coverage

All doctors prescribe Tab. Calcium 0.5 - 1 g /day

Received antenatal care from a doctor, 43%, BDHS 2011

Sustainability/ Institutionalization

Monitoring & Evaluation

Input & Output Data (Program Learning) Indicators in HMIS
Routine Monitoring

Prevalence Data

Outcome Data

 Approaches fully adapted/implementation at scale Approaches introduced/implementation started but not at scale Approaches not yet introduced/adapted

PATHWAY TO IMPLEMENTATION OF CALCIUM SUPPLEMENTATION AT SCALE

Global Actions
National Strategic Choices Program Implementation Program design Early Introduction
Training and education: Pre-service & in-service training conducted on calcium supplementation; supervision and on-thejob training in place Standardization: Quality of care improved at community and facility levels. Community engagement: Community-driven support for prevention of PE/E & communityfacility linkages for calcium supplementation in place Monitoring & evaluation: Routine monitoring of both distribution and compliance in place; national surveys Programmatic growth: Adding districts, partners, financing coverage (average) of CA supplementation
0% 25% 50% 75% 100%

Mature Implementation
Capacity development: Providers have complete knowledge and counseling skills on calcium supplementation Quality of care: Providers are selfassessing & supervisors provide supportive supervision

Sustainability / Institutionalization

Global advocacy and partnerships: Global action to support work to reduce PE/E

Global clinical and program approaches: Efficacy for calcium supplementation to prevent PE/E demonstrated and WHO recommendation issued

Maternal calcium supplementation policy: National policy/strategy sets reducing PE/E as priority and recommends calcium supplementation for all pregnant women Health system governance: Proactive financing of maternal health including calcium supplementation to prevent PE/E Service delivery capacity at sites: Presence of reliable infrastructure, personnel, and systems to deliver calcium supplementation

Formative research: Demand & supply-side barriers to calcium supplementation determined (womens perceptions of PE/E as a problem & taking calcium to prevent it; supply & logistics gaps) Drug supply procurement: Systems in place to ensure adequate forecasting & delivery of calcium supplies to health facilities & pregnant women SBCC: SBCC strategy developed including counseling messages & materials to ensure compliance, social mobilization campaigns, and use of media to raise awareness

Global programmatic guidelines for calcium supplementation developed and issued: Cost-effective, feasible and consumer-acceptable interventions for calcium supplementation demonstrated

Drug & equipment availability: Calcium for all pregnant women available in community/facility
Clinical coverage: High coverage & uptake of calcium

REDUCTION OF PE/E AND IMPROVED MATERNAL & BIRTH OUTCOMES

Global source of calcium supplements: UNICEF has available for programs sufficient supplies of lowcost calcium supplements for pregnant women

M&E

Prevalence Data

Outcome Data

Input & Output Data (Program Learning)

Indicators in HMIS

Routine monitoring

INTRODUCING INNOVATION

MOVING TOWARDS SUSTAINABLE IMPACT AT SCALE

Coverage of CA Supplementation
coverage (average) of CA supplementation schematic

The color filled in here is illustrative and needs to be adjusted based on country experience. Guidelines for filling in this box should be based on the following indicator: % of pregnant women receiving 1500 mg of calcium per day (or whatever the country recommendation is) from 20 weeks of gestation