cost effectiveness of misoprostol vs. iron
TRANSCRIPT
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Cost Effectiveness of Misoprostol vs. Iron
David Bishai, Tori Sutherland
11 July 2009
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Outline
•Research question•Background on misoprostol•Methods results
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Maternal mortality in India
•Maternal mortality 540/100,000 in India•36% of deaths due to post partum hemorrhage•As of 2003 40% of Indian woman deliver at skilled facilities.
–Numbers increasing due to Accredited Social Health Activist (ASHA) project offering vouchers
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Role of Misoprostol
• A $0.33 tablet for oral, vaginal, or rectal administration•Causes uterine contractions that can stop bleeding•Should not be used until placenta is out•Not as effective as intravenous oxytocin, BUT
–Midwives can be trained to administer it for home births Can lower hemorrhage rates by 50-80% in home births Unknown how many lives saved
•Until institutional deliveries are universal misoprostol can improve outcomes for home births
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Role of Iron
•Iron deficiency anemia affects about 62% of pregnant women in India•With hemoglobin levels low there is less reserve in case of hemorrhage•Pre natal iron can build up a higher reserve and in theory lower mortality
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Question
•Which approach offers cheaper $ per DALY?
–Iron supplementation
–Misoprostol at home births
•Will need model to translate hemorrhage rates to death rates.
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Step 1)Prenatal iron
Iron can shift left tail of curve to right
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Step 2) Misoprostol
Misoprostol can shift bleeding curve to the left
DEATH ZONE
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Step 3) Day 1 deaths from shock
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Step 4) Day 2 deaths from anemia
Death Zone
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Model
•Monte Carlo Model•10,000 Indian Women having a delivery at home•Stata program applies hemoglobin distributions, blood loss distributions, and death distributions stochastically.
–Sensitivity analysis applied
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Results
Scenario Deaths per 10K
Lives saved
Cost per 10,000
Incremental costs
MedianICER
No Intervention
19.5 $20,000
Iron 18.4 1.4 $29,032 $9,032 $2,241
Misoprostol 12 7.5 $30,232 $10,232 $1,401
$1401 per life saved with misoprostol strategy
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Sensitivity analysis
With day 1 mortality +/- 20% misoprostol ICER fluctuates from $1,133 to $1,696
With day 2 mortality +/- 20% ICER ranges $1334 to $1429
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Discussion
•Possible to estimate changes in death rates based on changes in hemorrhage rates using models of shock and anemia
•Both misoprostol and pre natal iron are very in expensive in terms of $ per life saved
–Misoprostol could be a game changer in terms of a vertical intervention that could be put in the hands of a traditional birth attendant.