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).
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
