Incorporating Calcium Supplementation into Antenatal Care Services is Acceptable to Providers, Pregnant Women, and Families in Western Kenya
Authors: Martin Stephanie , Wawire Violet , Li Terry , Sklar Kelsey , Tzehaie Hiwet , Wong Athena , Ombunda Hedwig , Omotayo Moshood , Chapleau Gina , Stoltzfus Rebecca , Dickin Katherine 
Published: November 2023

The World Health Organization recommends providing calcium supplements to pregnant women through antenatal care (ANC) along with iron‐folic acid (IFA) supplements to reduce maternal mortality. Although the efficacy of calcium supplementation to reduce the risk of preeclampsia is well established, evidence on the effective implementation of these guidelines through health systems is needed; current guidelines recommend women take 3 calcium pills plus 1 IFA pill at separate times daily. The objectives of this implementation research were to assess providers' experiences delivering calcium supplementation to pregnant women during routine ANC visits, and to explore the experience of women and their families with calcium and IFA supplements. Women were recruited from participants in a trial integrating calcium supplementation into 16 health facilities in western Kenya. For the larger trial, the study team trained ANC providers on calcium and IFA supplementation and counseling, provided behavior change materials, and ensured adequate supplement supplies at each facility. We purposively sampled participants to reflect diversity in facility level, adherence levels, and social support. Semi‐structured interviews were conducted with 7 ANC providers, 32 women, and 20 family members. Interviews were transcribed, translated, and analyzed qualitatively using principles of grounded theory. ANC providers reported feeling positively about the calcium supplements, training they received, and behavior change materials, but reported increased workloads. Women reported that providers counseled them on supplement benefits and managing side effects, introduced reminder strategies, and provided supplements and behavior change materials. Overall, women listed experienced and perceived benefits of calcium and IFA supplements as facilitators for supplement adherence, and they reported that behavior change materials for women and family members were helpful reminders. Most family members reported providing reminders and other instrumental support to help with pill taking, which women confirmed. Some women reported that co‐morbidities, concerns about being perceived as HIV infected, pill burden, unfavorable organoleptic properties, and food insecurity were barriers to adherence, which was consistent with providers' reports. Women also requested visits from community health workers to provide additional support. While integrating calcium into prenatal IFA supplementation was generally acceptable to ANC providers, pregnant women, and their families, calcium supplementation presents unique challenges that must be addressed for the successful implementation of these guidelines.Support or Funding InformationMicronutrient Initiative and the Sackler Institute for Nutrition Science at the New York Academy of Sciences funded this research