WHO Guidelines on Calcium Supplementation for Prevention of Preeclampsia: Adoption, Feasibility and Acceptability in Rural Kenya

To design optimal programs to deliver WHO guidelines on calcium (Ca) supplementation for prevention of preeclampsia, we must understand factors that influence its implementation. Yet, this has not been reported in any setting. With a mixed methods approach, we studied factors affecting feasibility of the guidelines among 38 pregnant women in 6 Kenyan community groups. We randomly assigned the participants to 3 different regimens. The regimens, based on trade‐off between bioavailability and feasibility, were a) Complex: 4 pill‐taking events, 1.5g elemental Ca (3×500mg) plus IFA taken separately, as per WHO guidelines. b) Simpler: 3 pill‐taking events, 1.5g elemental Ca (3×500mg) and IFA taken with last Ca dose and c) Low: 2 pill‐taking events, 1.0g elemental Ca (2×500mg) and IFA taken with last Ca dose. Combining Ca and IFA, given the lack of evidence of significant clinical effects of interaction, was considered reasonable to reduce regimen complexity and potentially improve feasibility. In addition, participants selected either ‘hard’ or ‘chewable’ Ca products with different organoleptic properties. They were provided with supplements, counseled on the guidelines, and interviewed 4 times over 6 weeks to assess barriers and motivators over time. We tracked supplement consumption with pill bottle electronic monitors. Interview transcripts were thematically analyzed based on grounded theory. Among the 38 participants, 18% were < 20 y of age, 18% were primigravid, and 61% had not attended ante‐natal care visits in this pregnancy. Six women were delivered and 4 women relocated before final interview. At visit 1, all participants were willing to try the recommendations. At subsequent visits, 3 women declined to continue, because of advice from relatives and perceived risk of side effects. Mean supplemental calcium consumption was 724mg/day. With the ‘chewable’ product type, average Ca consumed daily was higher compared to the ‘hard’ product type. Participants preferred the ‘sugary taste’ of the chewable type and reported that ability to consume it without water was desirable. Difficulties with the complex regimen included afternoon doses when women were likely to forget or be away from home, and having to wait a couple hours after supper for last dose. The low regimen was feasible because it eliminated both of these. The simple regimen eliminated the wait after supper, increasing feasibility, and retained the afternoon dose. Women assigned to this regimen consumed more supplemental calcium (887mg/day), compared to those assigned to the complex regimen (688mg/day) and the low regimen (681 mg/day). Daily tracking of consumption with a calendar, keeping supplements in conspicuous locations and requesting support from relatives were identified as strategies for improving feasibility. We conclude that Kenyan women are likely to adopt Ca supplementation in pregnancy, with appropriate programmatic adaptations. Careful attention is needed to adapt the WHO guideline in terms of product attributes, regimen complexity and strategies for helping women remember to consume their supplements. Support or Funding Information Funding for this research was provided by The Micronutrient Initiative

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