The Micronutrient Initiative-Cornell University Calcium (MICa) project: Implementation research on prenatal micronutrient supplementation to prevent preeclampsia and anemia
Reviews of clinical evidence demonstrate that calcium supplementation during pregnancy can prevent preeclampsia, a major cause of maternal mortality globally. In 2013, the World Health Organization (WHO) issued guidelines recommending prenatal calcium supplementation in populations where dietary calcium intake is low, but there is limited experience with delivering this intervention.
We conducted a multi-phase implementation research project in Kenya and Ethiopia, called the Micronutrient Initiative-Cornell University Calcium (MICa) project, to understand the factors that influence the design, implementation, and utilization of calcium supplementation. The results can inform recommendations for national policies and implementation of this evidence-based intervention to improve the health and well-being of women and children.
Formative research: Exploring experiences with prenatal supplementation
We conducted formative research in Ethiopia and Kenya to understand women’s and health workers’ experiences with and perspectives on prenatal micronutrient supplements, anemia, and preeclampsia.
Household trials: Assessing adherence to supplements
In both countries, we conducted Trials of Improved Practices (TIPs) to assess the acceptability of calcium supplementation. We conducted a series of home visits during which participants were counseled on calcium and IFA supplementation, assigned one of three calcium and IFA regimens, and allowed to choose either chewable or hard calcium supplements. We documented barriers and facilitators to calcium and IFA adherence and supplement and regimen preferences. In addition, participants were encouraged to ask someone to be their “adherence partner” – a person who would remind and encourage them to take their supplements.
Pilot testing: A cluster-randomized trial to integrate calcium into antenatal care
In Kenya, we pilot-tested a model for delivering calcium supplementation through antenatal care as part of a cluster randomized trial of two (higher and lower) dosing regimens to assess feasibility and factors that influence adherence. For this trial, we trained ANC providers and community health workers and developed job aids and behavior change materials for calcium and IFA supplementation and adherence partners.
Click here for our training materials: A Trainer’s Guide for Healthcare Providers and Community Health Workers.
Click here for our job aids and materials: Calcium and Iron-Folic Acid Supplementation Behavior Change Materials.
The primary outcome for the trial was comparing supplement consumption between women assigned the higher-dose and lower-dose calcium regimens. Secondary outcomes included examining relationships between adherence and social support, and assessing the acceptability and feasibility of adherence partners.
Research Team: This research was led by principal investigators Katherine L. Dickin and Rebecca J. Stoltzfus. Cornell team members included Gretel Pelto, Jean-Pierre Habicht, Sera Young, Lanre Omotayo, Stephanie Martin, Gina Chapleau, Stephanie Ortolano, and Gretchen Seim. Data collection in Ethiopia was led by research supervisor Zewdie Birhanu and research assistants Yohannes Kebede, Mamusha Aman, Garumma Feyissa, Keneni Gutema, Abebe Mamo, Yohannes Mulugeta, and Gemeda Zeleke. Biniyam Tesfaye of the Ethiopian Public Health Institute provided implementation support. Data collection in Kenya was led by research supervisor Lanre Omotayo and research assistants Rose Chesoli, Erina Oundo, Hillary Opoma, and Felix Makasanda. Erick Mwanga of the Ministry of Health provided implementation support. A subset of interviews was conducted by Salome Wawire, Violet Wawire, and Hedwig Ombunda. Officers from Nutrition International (formally Micronutrient Initiative) provided logistical support including Jacqueline Kung’u, Crispin Ndedda, Henock Gezahegn, and Girma Mamo Bogale.
Funding: This research was funded by Global Affairs Canada through a grant given to the Micronutrient Initiative, and the Sackler Institute for Nutrition Science at the New York Academy of Sciences.
Resources and Learnings: Click on the active links below to learn more about calcium supplementation and the MICa project.
Omotayo MO, Dickin KL, O’Brien KO, Neufeld LM, De Regil LM, Stoltzfus RJ. Calcium supplementation to prevent preeclampsia: Translating guidelines into practice in low-Income countries. Advances in Nutrition. 2016 March: 275-278
Omotayo MO, Dickin KL, Stoltzfus RJ. Perinatal mortality due to pre-eclampsia in Africa: A comprehensive and integrated approach is needed. Global Health: Science and Practice. 2016 June: 350-351.
Martin SL, Seim GL, Wawire S, Chapleau GM, Young SL, Dickin KL. Translating formative research findings into a behaviour change strategy to promote antenatal calcium and iron and folic acid supplementation in western Kenya. Maternal and Child Nutrition. 2016 February: Online.
Birhanu Z, Chapleau GM, Ortolano SE, Bogale GM, Martin SL, Dickin KL. Ethiopian women’s perspectives on antenatal care and iron-folic acid supplementation: Insights for translating global antenatal calcium guidelines into practice. Maternal & Child Nutrition. 2017 July: Online.
Martin SL, Birhanu Z, Omotayo MO, Kebede Y, Pelto GH, Stoltzfus RJ, Dickin KL. “I can’t answer what you’re asking me. Let me go, please.”: Cognitive interviewing to assess social support measures in Ethiopia and Kenya. Field Methods. 2017 May: 317-332.
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 Nutrition, Cambridge University Press. 2018 October: 1–11.
Trials of improved practices
Martin SL, Omotayo MO, Chapleau GM, Stoltzfus RJ, Birhanu Z, Ortolano SE, Pelto GH, Dickin KL. Adherence partners are an acceptable behaviour change strategy to support calcium and iron-folic acid supplementation among pregnant women in Ethiopia and Kenya. Maternal and Child Nutrition. 2016 April: Online.
Omotayo MO, Martin SL, Stoltzfus RJ, Ortolano SE, Mwanga EO, Dickin KL. With adaptation, the WHO guidelines on calcium supplementation for prevention of preeclampsia are adopted by pregnant women. Maternal & Child Nutrition. 2017 November: Online.
Omotayo MO, Dickin KL, Chapleau GM, Martin SL, Chang C, Mwanga EO, Kung’u JK, Stoltzfus RJ. Cluster-randomized non-inferiority trial to compare supplement consumption and adherence to different dosing regimens for antenatal calcium and iron-folic acid supplementation to prevent preeclampsia and anemia. Journal of Public Health Research. 2015; 4: 171–175.
Omotayo MO, Dickin KL, Pelletier DL, Mwanga EO, Kung ’U JK, Stoltzfus, RJ. A simplified regimen compared with WHO guidelines decreases antenatal calcium supplement intake for prevention of preeclampsia in a cluster-randomized noninferiority trial in rural Kenya. The Journal of Nutrition. 2017 September: 147.
Martin SL, Omotayo MO, Pelto GH, Chapleau GM, Stoltzfus RJ, Dickin KL. Adherence-specific social support enhances adherence to calcium supplementation regimens among pregnant women. The Journal of Nutrition. 2017 March: 688-696.
Martin SL, Wawaire V, Li T, Sklar K, Tzehaie H, Wong A, Ombunda H, Omotayo M, Chapleau G, Stoltzfus R, Dickin K. Incorporating calcium supplementation into antenatal care services is acceptable to providers, pregnant women, and families in western Kenya. The FASEB Journal. 2017 April: 786.32.
Martin SL, Wawire V, Ombunda H, Li T, Sklar K, Tzahaie 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. Current Developments in Nutrition. 2018 August: Online.
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 & Child Nutrition. 2018 March: Online
Frequently Asked Questions (FAQs)
Prevention of pre-eclampsia FAQ: Calcium supplementation in pregnancy for prevention of pre-eclampsia
Experiences with prenatal IFA supplementation FAQ: Guidance for prenatal calcium supplementation programming based on experiences with iron and folic acid (IFA) supplementation