1. 1 Intermittent preventive treatment of malaria in pregnancy: incremental Cost-effectiveness of a new delivery system in Uganda. AK Mbonye, KS Hansen, IC Bygbjerg, P Magnussen. Trans Roy Soc Trop Med Hyg (2008) 102, 685-693.

2. 2 Out line of Presentation: 1. Epidemiology of malaria in pregnancy 2. Current malaria prevention interventions 3. Research Questions 4. The intervention 5. Results 6. Conclusion

3. 3 The Public Health importance of malaria in pregnancy Malaria in pregnancy is one of the leading causes of maternal mortality and morbidity in malaria endemic countries Infection of the placenta is asymptomatic Infection of the placenta interferes with the transfer of nutrients This affects fetal nutrition and growth

4. 4 The Public Health importance of malaria in pregnancy It contributes 3-15% to maternal aneamia It contributes 4-19% to low birth weight It contributes 3-8% to infant deaths

5. 5 Malaria prevention in pregnancy The impact of malaria prevention in pregnancy using chemoprophylaxis with routine anti-malarial drugs and intermittent preventive treatment with sulfadoxine-pyrimethamine is well known. However uptake of these interventions is low

6. 6 What is the uptake of current malaria prevention interventions? The proportion of pregnant women who get intermittent preventive treatment (IPTp) for malaria in pregnancy is low at 16.6% Those who use insecticide nets (ITNs) are 11.3%

7. 7 Current malaria Control Interventions Scale up of ITNs Indoor residual spraying IPTp Case management Home-based management of fevers.

8. 8 Research Questions Why is uptake of malaria prevention interventions low? Is it possible to improve uptake with the current delivery outlets? Are there alternative delivery outlets? How cost-effective are the alternative delivery outlets?

9. 9 The intervention The study was implemented in 9 rural sub- counties of Mukono district; a highly endemic area for Malaria. Within each sub county at least two parishes were randomly selected. Three health centres (grade III and Kawolo District Hospital were selected as control clusters)

10. 10 The intervention In total 21 parishes tested the community based delivery system while 4 tested IPTp at health units. 51 community resource persons were trained to offer IPTp. To measure the outcomes of the intervention, several measurements were made at recruitment, at receiving the second dose of SP and at delivery

11. 11 The intervention The focus of the analysis was to assess the effectiveness of the new delivery system over the traditional health units. The incremental effect of the new delivery system were the differences in the proportions of anaemia, parasitaemia, and low birth weight between the two study arms at the third measurement point.

12. 12 Access to IPTp Timing of the first dose of SP (23.1 weeks versus 20.8 weeks), P=0.001 First dose of SP in second trimester (76.1% versus 92.4 %), P=0.001 Proportion of adolescents at first dose (28.4% versus 25.0%), P=0.03 Adherence to IPTp (39.9%, versus 67.5%), P=0.001.

13. 13 Measuring costs of the intervention Full costs of providing IPTp at health centres, at the community and those incurred by pregnant women while seeking IPTp were captured. Costs were classified into three categories: cost of SP tablets, costs related to the supply of SP, and costs incurred by pregnant women.

14. 14 Measuring costs of the intervention The cases of anaemia, parasitaemia, and low birth weight in the two delivery system were translated into disability-adjusted life- years (DALYs). Having calculated costs and outcomes in DALYs, it was possible to calculate the incremental costs, incremental effects and incremental cost-effective ratios.

15. 15 Incremental costs and effects of IPTp Health centresCommunity based Difference Costs of full IPTp SP pills 782518554115-228403 Supply of IPTp25582703303630745360 Transport and time to seek IPTp 2405307244829042983 Total57460956306035559940

16. 16 Incremental costs and effects of IPTp Health centresCommunity based Difference No. of women receiving first dose 35172081 No. of women receiving full IPTp 1404

17. 17 Incremental costs and effects of IPTp Prevalence at third measurement point Health centresCommunity based Difference Anaemia682582-100 Parasitaemia128231104 Low birth weight babies 11584-31

18. 18 Incremental costs and effects of IPTp DALYsHealth centresCommunity based Difference Aneamia1.00.9-0.1 Parasitaemia0.50.80.3 Low birth weight babies 1110.2810.5-299.8 Total1111.7812.2-299.5 CE ratio costs per DALY averted 1869

19. 19 Conclusion Community based delivery increased access and adherence to IPTp and was cost effective.