Potential Cost-Effectiveness of Prenatal Distribution of Misoprostol for Prevention of Postpartum Hemorrhage in Uganda

In settings where home birth rates are high, prenatal distribution of misoprostol has been advocated as a strategy to increase access to uterotonics during the third stage of labor to prevent postpartum hemorrhage (PPH). Our objective was to project the potential cost-effectiveness of this strategy in Uganda from both governmental (the relevant payer) and modified societal perspectives.

To compare prenatal misoprostol distribution to status quo (no misoprostol distribution), we developed a decision analytic model that tracked the delivery pathways of a cohort of pregnant women from the prenatal period, labor to delivery without complications or delivery with PPH, and successful treatment or death. Delivery pathway parameters were derived from the Uganda Demographic and Health Survey. Incidence of PPH, treatment efficacy, adverse event and case fatality rates, access to misoprostol, and health resource use and cost data were obtained from published literature and supplemented with expert opinion where necessary. We computed the expected incidence of PPH, mortality, disability adjusted life years (DALYs), costs and incremental cost effectiveness ratios (ICERs). We conducted univariate and probabilistic sensitivity analyses to examine robustness of our results. In the base-case analysis, misoprostol distribution lowered the expected incidence of PPH by 1.0% (95% credibility interval (CrI): 0.55%, 1.95%), mortality by 0.08% (95% CrI: 0.04%, 0.13%) and DALYs by 0.02 (95% CrI: 0.01, 0.03). Mean costs were higher with prenatal misoprostol distribution from governmental by US$3.3 (95% CrI: 2.1, 4.2) and modified societal (by US$1.3; 95% CrI: -1.6, 2.8) perspectives. ICERs were US$191 (95% CrI: 82, 443) per DALY averted from a governmental perspective, and US$73 (95% CI: -86, 256) per DALY averted from a modified societal perspective.

Prenatal distribution of misoprostol is potentially cost-effective in Uganda and should be considered for national-level scale up for prevention of PPH.

Below:  Tornado diagram of univariate sensitivity analysis. The diagram shows the impact of the 10 most influential parameters on the incremental cost per DALY averted from a governmental perspective

Below:  Tornado diagram of univariate sensitivity analysis. The diagram shows the impact of the 10 most influential parameters on the incremental cost per DALY averted from a modified societal perspective

Below:  Incremental cost-effectiveness scatter plot showing the distribution of 10,000 incremental cost and DALY averted pairs.  The green cloud shows the analysis from the governmental perspective and the purple cloud shows the analysis from the modified societal perspective. The dashed red line represents the lower threshold of willingness to pay per DALY averted (one times the GDP of Uganda) and the solid red line represents the higher threshold of willingness to pay per DALY averted (three times the GDP of Uganda).

Full article at:  http://goo.gl/01QuAt

By: 

Solomon J. Lubinga, Joseph B. Babigumira

Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, Washington, United States of America

Solomon J. Lubinga, Joseph B. Babigumira

Global Medicines Program, Department of Global Health, University of Washington, Seattle, Washington, United States of America

Esther C. Atukunda

Department of Pharmacology, Mbarara University of Science and Technology, Mbarara, Uganda

George Wasswa-Ssalongo

Department of Obstetrics and Gynecology, Mbarara Regional Referral Hospital, Mbarara, Uganda

 

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Factors Associated with Postpartum Hemorrhage Maternal Death in Referral Hospitals in Senegal and Mali: A Cross-Sectional Epidemiological Survey

Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Sub-Saharan-Africa (SSA). Although clinical guidelines treating PPH are available, their implementation remains a great challenge in resource poor settings. A better understanding of the factors associated with PPH maternal mortality is critical for preventing risk of hospital-based maternal death. The purpose of this study was thus to assess which factors contribute to maternal death occurring during PPH. The factors were as follows: women’s characteristics, aspects of pregnancy and delivery; components of PPH management; and organizational characteristics of the referral hospitals in Senegal and Mali.

A cross-sectional survey nested in a cluster randomized trial (QUARITE trial) was carried out in 46 referral hospitals during the pre-intervention period from October 2007 to September 2008 in Senegal and Mali. Individual and hospital characteristics data were collected through standardized questionnaires. A multivariable logistic mixed model was used to identify the factors that were significantly associated with PPH maternal death.

Among the 3,278 women who experienced PPH, 178 (5.4 %) of them died before hospital discharge. The factors that were significantly associated with PPH maternal mortality were: age over 35 years, living in Mali, residing outside the region location of the hospital, prepartum severe anemia, forceps or vacuum delivery, birth weight greater than 4000 grs, transfusion, transfer to another hospital. There was a smaller risk of PPH maternal death in hospitals with gynecologist-obstetrician than those with only a general practitioner trained in emergency obstetric care (EmOC).

Our findings may have direct implications for preventing PPH maternal death in resource poor settings. In particular, we suggest anemia should be diagnosed and treated before delivery and inter-hospital transfer of women should be improved, as well as the management of blood banks for a quicker access to transfusion. Finally, an extent training of general practitioners in EmOC would contribute to the decrease of PPH maternal mortality.

Full article at:  http://ht.ly/SSAfl 

By: Julie Tort^1238*, Patrick Rozenberg⁴⁵, Mamadou Traoré⁶, Pierre Fournier⁷ and Alexandre Dumont¹²

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