Factors affecting the implementation of calcium supplementation strategies during pregnancy to prevent pre-eclampsia: a mixed-methods systematic review.

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.

Association between obstetric and medical risk factors and stillbirths in a low-income urban setting.

OBJECTIVE: To evaluate the association between obstetric and medical risk factors and stillbirths in a Kenyan set-up. METHODS: A case-control study was conducted in four hospitals between August 2018 and April 2019. Two hundred and fourteen women with stillbirths and 428 with live births at more than >28 weeks of gestation were enrolled. Data collection was via interviews and abstraction from medical records. Outcome variables were stillbirth and live birth; exposure variables were sociodemographic characteristics, and medical and obstetric factors. The two-sample t test and χ2 test were used to compare continuous and categorical variables respectively. The association between the exposure and outcome variable was done using logistic regression. A P value less than 0.05 was considered statistically significant. RESULTS: Stillbirth was associated with pre-eclampsia without severe features (odds ratio [OR] 9.1, 95% confidence interval [CI] 2.6-32.5), pre-eclampsia with severe features (OR 7.4, 95% CI 2.4-22.8); eclampsia (OR 9.2, 95% CI 2.6-32.5), placenta previa (OR 8.6 95% CI 2.8-25.9), placental abruption (OR 6.9 95% CI 2.2-21.3), preterm delivery(OR 9.5, 95% CI 5.7-16), and gestational diabetes mellitus, (OR 11.5, 95% CI 2.5-52.6). Stillbirth was not associated with multiparity, anemia, and HIV. CONCLUSION: Proper antepartum care and surveillance to identify and manage medical and obstetric conditions with the potential to cause stillbirth are recommended.

Association between utilization and quality of antenatal care with stillbirths in four tertiary hospitals in a low-income urban setting.

INTRODUCTION: About 2.6 million stillbirths per year occur globally with 98% occurring in low- and middle-income countries including Kenya, where an estimated 35 000 stillbirths occur annually. Most studies have focused on the direct causes of stillbirth. The aim of this study was to determine the association between antenatal care utilization and quality with stillbirth in a Kenyan set up. This information is key when planning strategies to reduce the stillbirth burden. MATERIAL AND METHODS: This was a case-control study in four urban tertiary hospitals carried out between August 2018 and April 2019. A total of 214 women with stillbirths (cases) and 428 with livebirths (controls) between 28 and 42 weeks were enrolled. Information was obtained through interviews and data abstracted from medical records. Antenatal care utilization was assessed by the proportions of women not attending antenatal care; booking first antenatal care visit in first trimester and not making the requisite four antenatal care visits. Quality of antenatal care was assessed using individual surrogate indicators (antenatal profile testing, weight/blood pressure/urinalysis testing in each antenatal visit, utilization of early obstetric ultrasound, completeness of antenatal records) and a codified indicator made up of seven parameters (attending antenatal care, booking first antenatal care in the first trimester, making four or more antenatal visits, having all antenatal profile tests, having a complete antenatal record, having blood pressure and weight measured at all visits). The association between antenatal care utilization and quality with stillbirth was assessed using univariate and multivariate analysis using logistic regression. Statistical significance was defined as a two-tailed P value ≤ .05. RESULTS: Women with stillbirth were likely to have a parity ≥4 (19.6% vs 12.6%, P = .02), have an obstetric complication (36% vs 8.6%, P = .001) and have a medical disorder (5.6% vs 1.6%, P = .01). The odds of a stillbirth were four times higher among those who did not attend antenatal care ( odds ratio [OR] 4.1, 95% confidence interval [CI] 1.6-10, P < .003). Compared with four antenatal care visits, those who had one or two visits had higher odds of a stillbirth: OR 2.96 (95% CI 1.4-6.1), P = .003, and OR 2.9 (95% CI 1.7-5), P = .003, respectively. As per the individual surrogate indicators, the likelihood of a stillbirth was lower in women who received good quality antenatal care: Hemoglobin testing (OR 0.6, 95% CI 0.4-0.8, P = .03), blood group test (OR 0.4, 95% CI 0.2-0.6, P < .001), HIV test (OR 0.3, 95% CI 0.2-0.5, P = .001), venereal disease research laboratory test (OR 0.2, 95% CI 0.1-0.4, P = .001), weight measurement (OR 0.7, 95% CI 0.5-1.0, P = .047). As per the composite indicator, the quality of antenatal care was poor across the board and there was no association between this surrogate indicator and stillbirth. CONCLUSIONS: Lack of antenatal care, attending fewer than four antenatal visits and poor quality antenatal care as measured by surrogate indicators were significantly associated with stillbirth. In addition, women with low education level, obstetric complications, multiparity and medical complications had a significantly higher likelihood of stillbirth. Improving the utilization of four or more antenatal visits and the quality of antenatal care can reduce the risk of stillbirth.