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

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.