Pre-Eclampsia/ Eclampsia Interventions and their Cost Effectiveness Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting,

Pre-Eclampsia/ Eclampsia Interventions and their Cost Effectiveness

Interventions for Impact in Essential Obstetric and Newborn CareAfrica Regional Meeting, 21–25 February 2011

Steve Hodgins MCHIP/ JSI (presenting),Amada Pomeroy MCHIP/ JSI,Hiwot Belay MCHIP/ JSI,Marge Koblinsky MCHIP/ JSI


Planning and Prioritizing

•In making decisions about supporting new initiatives, we select among options based on relative:

1. disease burden, 2. effectiveness of the proposed intervention(s), 3. feasibility and cost.

•PE/E accounts for ~19% of maternal deaths in Africa•MgSO4 for treatment and calcium and ASA for prevention are known to be effective•For all 3 of these, the first two conditions are met•What about feasibility and cost?


Feasibility

•Feasibility – could we do this effectively in our setting?•Challenges for service providers, for the system•Cost – scalability, sustainability

•Available service delivery platforms: ANC, HF deliveries, community-based distribution

•MgSO4 issues•Antenatal ASA and calcium issues


Interventions considered in our modeling

•For pre-eclampsia/ eclampsia:•Prevention

•antenatal calcium from 20 weeks•aspirin from 15 weeks

•Treatment: MgSO4 loading dose

•For comparison, we include:•Antenatal iron-folate from 20 weeks•Routine oxytocin during the 3rd stage, to prevent post-partum hemorrhage


Intervention Efficacy

•We don’t have as much evidence as we would like: difficulties for preventive intervention effects on maternal mortality.•Studies with huge samples are required to show mortality effects with adequate statistical power.•For established interventions, often it is considered unethical to do a RCT, as they would entail withholding such interventions.•In some cases, we have only proxy endpoints, e.g. serious morbidity, from which we infer comparable mortality effects, e.g. severe PE or severe PPH.


Maternal – all cause

Maternal – PE/E

Maternal – PPH

Neonatal – all cause

Neonatal – prematurity

Calcium .20 .24

Aspirin .17 .14

MgSO4 .41

Oxytocin .27

Iron-folate

.25 .22

Mortality Reduction Efficacy


Effectiveness

•As a common yardstick comparing preventive & treatment interventions, we are using averted maternal and neonatal deaths per 100,000 pregnancies/ deliveries reached

•Depending on evidence available, we use efficacy in reducing cause-specific mortality or overall maternal or neonatal mortality


Measuring Effectiveness

•To model mortality reduction efficacy for calcium we multiply

MMR x %PE/E x documented efficacy.

•So, in a country with an MMR of 500, the number of averted deaths/ 100,000 reached =

500 x 19% x .20 = 19 deaths


Measuring Effectiveness

•In the following 2 tables, we assume:•MMR = 500•NNMR = 30•PPH % of MMR = 34%*•PE/E % of MMR = 19%*•Prematurity % of NNMR = 29%*

* from Countdown Coverage 2010 report


Maternal Neonatal

Calcium 19 190

Aspirin 16 380

MgSO4 40

Oxytocin 47

Iron-folate 130 590

Averted deaths/ 100,000 reached


Costs

•Full costs vs. marginal costs; costs for whom•Up-front costs: training, infrastructure, equipment•Recurrent costs

•Commodity-related: procurement, storage, transport, wastage•Supervision, maintenance and repair, some ongoing training

•For interventions considered in this exercise, relatively modest up-front and non-commodity costs.


Costs in this Modeling Exercise

•For simplicity in comparing across interventions, cost assessment for this presentation has been restricted to commodity-related, reckoned /100,000 reached•Quantification:

•Universal preventive vs. case-management for complications•Volume/ quantity required per patient/ beneficiary

•Unit costs – costs per pill/ vial; from MSH price guidehttp://erc.msh.org/mainpage.cfm?file=1.0.htm&module=Dmp&language=English


Measuring Costs

Unit cost ($s)

Volume/ beneficiary

Volume/ 100,000 reached

Cost/ 100,000 reached

Calcium .0053-.065/ tablet

250 25 million $130,000 -$1,600,000

Aspirin .0015-.0052/ tablet

160 16 million $24,000 -$83,000

MgSO4.93-2.09/ 20cc vial

2 2000 $1,900 -$4,200

Oxytocin .059-.227/ 10iu vial

1 100,000 $5,900 -$22,700

Iron-folate

.0013-.0048/ tablet

180 18 million $23,000 -$86,000


Conclusions & Next Steps

•In deciding on new initiatives, consider: disease burden, effectiveness of interventions, feasibility, cost

•We are finalizing a more complete analysis which we expect to make available shortly; this is intended as an aid to decision makers, particularly in ministries of health and among partner agencies


For further information, you can contact me at:

[email protected]

wwww.mchip.net

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Pre-Eclampsia/ Eclampsia Interventions and their Cost Effectiveness Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting,