Low-dose calcium supplementation during pregnancy in low and middle-income countries: A cost-effectiveness analysis

Happiness P Saronga; Pratibha Dwarkanath; Hening Cui; Alfa Muhihi; Anura V Kurpad; V Sri Poornima; Mary M Sando; R Poornima; Cara Yelverton; Honorati M Masanja; Christopher R Sudfeld; Andrea B Pembe; Wafaie W Fawzi; Nicolas A Menzies

doi:10.1371/journal.pgph.0004002

Low-dose calcium supplementation during pregnancy in low and middle-income countries: A cost-effectiveness analysis

PLOS Glob Public Health. 2025 Sep 2;5(9):e0004002. doi: 10.1371/journal.pgph.0004002. eCollection 2025.

Authors

Affiliations

¹ Department of Behavioral Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
² St. John's Research Institute, Bangalore, India.
³ Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.
⁴ Africa Academy for Public Health, Dar es Salaam, Tanzania.
⁵ St. John's Medical College, Bangalore, India.
⁶ Ifakara Health Institute, Dar es Salaam, Tanzania.
⁷ Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America.

Abstract

Calcium supplementation during pregnancy can reduce the risk of preeclampsia and preterm birth. Few countries have implemented WHO-recommended high-dose calcium supplementation (1500-2000mg/day), due to adherence and cost concerns. However, low-dose calcium supplementation (one 500mg tablet daily) has recently been shown to be similarly efficacious as high-dose supplementation. We assessed the cost-effectiveness of low-dose calcium supplementation during pregnancy, in low- and middle-income countries (LMICs) with low dietary calcium intake. To do so, we conducted a mathematical modelling analysis in which we estimated the lifetime health outcomes (cases, deaths, and DALYs averted) and costs of low-dose calcium supplementation provided through routine antenatal care to women giving birth in 2024, as compared to no supplementation. We assessed costs (2022 USD) from a health system perspective, including cost-savings from averted care for preeclampsia and preterm birth. This analysis showed that low-dose calcium supplementation could prevent 1.3 (95% uncertainty interval: 0.2, 2.6) million preterm births (a 10% (2, 18) reduction), 1.8 (1.0, 2.8) million preeclampsia cases (a 23% (14, 32) reduction), as well as 5.9 (1.3, 12.9) million disability-adjusted life years (DALYs). Intervention costs would be $267 (220, 318) million and produce cost-savings of $56 (26, 86) million, with incremental costs per DALY averted of $90 (38, 389) across all countries, and a return on investment of 19.1 (3.8, 39.5). The intervention was cost-effective in 119 of 129 countries modeled when compared to setting-specific cost-effectiveness thresholds. While there was substantial uncertainty in several inputs, cost-effectiveness conclusions were robust to parameter uncertainty and alternative analytic assumptions. Based on these results, low-dose calcium supplementation provided during pregnancy is cost-effective for prevention of preeclampsia and preterm birth in most LMICs.

Copyright: © 2025 Saronga et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.