1. Pre-Eclampsia/ Eclampsia Interventions and their Cost Effectiveness Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Steve Hodgins MCHIP/ JSI (presenting), Amada Pomeroy MCHIP/ JSI, Hiwot Belay MCHIP/ JSI, Marge Koblinsky MCHIP/ JSI

2. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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?

3. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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

4. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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 3 rd stage, to prevent post-partum hemorrhage

5. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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.

6. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Maternal – all cause Maternal – PE/E Maternal – PPH Neonatal – all cause Neonatal – prematurity Calcium.20.24 Aspirin.17.14 MgSO 4.41 Oxytocin.27 Iron-folate.25.22 Mortality Reduction Efficacy

7. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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

8. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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

9. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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

10. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 MaternalNeonatal Calcium19190 Aspirin16380 MgSO 4 40 Oxytocin47 Iron-folate130590 Averted deaths/ 100,000 reached

11. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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.

12. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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 guide http://erc.msh.org/mainpage.cfm?file=1.0.htm&module=Dmp&language=English

13. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 Measuring Costs Unit cost ($s) Volume/ beneficiary Volume/ 100,000 reached Cost/ 100,000 reached Calcium.0053-.065/ tablet 25025 million$130,000 - $1,600,000 Aspirin.0015-.0052/ tablet 16016 million$24,000 - $83,000 MgSO 4.93-2.09/ 20cc vial 22000$1,900 - $4,200 Oxytocin.059-.227/ 10iu vial 1100,000$5,900 - $22,700 Iron-folate.0013-.0048/ tablet 18018 million$23,000 - $86,000

14. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 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

15. Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting, 21–25 February 2011 For further information, you can contact me at: shodgins@mchip.net wwww.mchip.net Follow us on: