Introduction
Methods
Model overview
Bangladesh | |
Located in South Asia, Bangladesh is the third most populous country in the region and one of the most densely populated countries in the world. A recent national survey reported the maternal mortality ratio in Bangladesh to be 196 deaths per 100,000 live births in 2016, with 31% due to haemorrhage (antepartum and postpartum) [13]. The public service delivery structure includes national, district, upazilla (sub-district), union and ward levels [14]. At the union level, union sub-centres and health and family welfare centres provide the first contact between the population and the health care system and a minority of these facilities offer normal delivery services [15]. At the upazilla level, maternal and child welfare centres and upazilla health complexes typically offer normal delivery services and some are equipped to provide caesarean section. Approximately one third of deliveries occur in a private facility and approximately one half of women give birth outside of a health facility [13]. The Government of Bangladesh has outlined a strategy to scale up misoprostol for the prevention of PPH outside of facilities through an advanced distribution model [16]. A 2015–2016 evaluation showed that community distribution of misoprostol had reached 17% of all births in Bangladesh at this stage of program roll out [13]. | |
Ethiopia | |
Ethiopia is located in North-East Africa and, with a population of just over 94 million, it is the second most populous country in Africa. Maternal mortality has decreased substantially in the last decade, and most recent reports estimate a maternal mortality ratio of 422 [17]. The government is the main provider of health care services in the country through a three-tier system consisting of specialist hospitals, general hospitals and primary care units (composed of a network of primary hospitals, health centres and health posts). At the primary care level, emergency obstetric care services are available at some primary hospitals, while health centres provide delivery services and some are equipped to provide basic emergency obstetric care. Each health centre is connected to four health posts, which are staffed by two health extension workers (HEWs). This cadre provide a package of basic curative, promotive and preventative care at the health post or in the home. While national policy in Ethiopia permits use of misoprostol by HEWs, progress towards scale up beyond research areas is uncertain [18, 19]. The Ministry of Health has introduced integrated refresher in-service training to improve the skills of HEWs and to upgrade these health workers from HEW3 to HEW4 (which includes competencies to support skilled attendance at birth). Despite the conduct of pilot programs to explore the feasibility and acceptability of advanced distribution of misoprostol to pregnant women [18, 20], the government of Ethiopia has elected not to adopt this strategy into policy. |
Setting 1 | Setting 2 | Setting 3 | Setting 4 | Setting 5 | |
---|---|---|---|---|---|
Tertiary-level public facilities | Secondary-level public facilities | Primary health facilities and non-facility births attended by a skilled provider | Non-facility births not attended by a skilled provider | Private sector deliveries | |
Settings included in each country | |||||
Bangladesh | Medical Colleges, Specialised hospitals, District hospitals | Upazilla health complex, Maternal and child welfare centres | Union sub-centres, Rural sub-centres, Union health and family welfare centres, Community clinics, out-of-facility deliveries attended by a medically trained provider | Out-of-facility deliveries attended by a TBA, trained TBA, relative, no-one or other. | Private healthcare facilities |
Ethiopia | Specialist hospitals, General hospitals, Primary hospitals | Health centres | Deliveries attended by a HEW (health post or out of facility) | Out-of-facility deliveries attended by a TBA, trained TBA, relative, no-one or other. | Private healthcare facilities |
Uterotonic used for PPH prevention (non-operative deliveries) in status quo | |||||
Bangladesh | Injectable oxytocin | Injectable oxytocin | Injectable oxytocin or misoprostol | Misoprostol | Injectable oxytocin |
Ethiopia | Injectable oxytocin | Injectable oxytocin | Misoprostol | None | Injectable oxytocin |
Uterotonic used for PPH prevention (non-operative deliveries) in intervention scenarioa | |||||
Bangladesh | Inhaled oxytocin | Inhaled oxytocin | Inhaled oxytocin | Inhaled oxytocin | Injectable oxytocin |
Ethiopia | Inhaled oxytocin | Inhaled oxytocin | Inhaled oxytocin | None | Injectable oxytocin |
Input parameters
Demography, maternal mortality and incidence of PPH
Bangladesh | Ethiopia | |||
---|---|---|---|---|
Value | Source | Value | Source | |
Number of women of reproductive age (15–49) (‘000) | 44,998a | UN data 2017 [34] | 24,150a | UN data 2017 [34] |
Fertility rate of women of reproductive age (15–49) | 73a | DHS 2015 [35] | 141a | DHS 2016 [36] |
Maternal mortality ratiob | 205a | BMMS 2016 [13] | 412 | EmONC assessment 2016 [17] |
Maternal deaths due to PPH | 27%a | BMMS 2016 [13] | 31% | EmONC assessment 2016 [17] |
Child survival rate (to age of 12 months) | ||||
If mother survives | 92.4% | Ronsmans et al. 2010 [37] | 95.6% | Moucheraud et al. 2015 [38] |
If mother dies within 42 days of childbirth | 29.6% | Ronsmans et al. 2010 [37] | 18.75% | Moucheraud et al. 2015 [38] |
Incidence of PPH without preventative uterotonics | ||||
Mild | 11.3% | Gallos et al. 2018 [8] | 11.3% | Gallos et al. 2018 [8] |
Severe | 5.9% | Gallos et al. 2018 [8] | 5.9% | Gallos et al. 2018 [8] |
Risk ratio of mild PPH with uterotonics for prevention | ||||
Injectable oxytocin | 0.61 | Gallos et al. 2018 [8] | 0.61 | Gallos et al. 2018 [8] |
Misoprostol | 0.75 | Gallos et al. 2018 [8] | 0.75 | Gallos et al. 2018 [8] |
Inhaled oxytocin | 0.61 | Assumption | 0.61 | Assumption |
Risk ratio of severe PPH with uterotonics for prevention | ||||
Injectable oxytocin | 0.61 | Gallos et al. 2018 [8] | 0.61 | Gallos et al. 2018 [8] |
Misoprostol | 0.73 | Gallos et al. 2018 [8] | 0.73 | Gallos et al. 2018 [8] |
Inhaled oxytocin | 0.61 | Assumption | 0.61 | Assumption |
Efficacy
Place of delivery
Setting 1 | Setting 2 | Setting 3 | Setting 4 | Setting 5 | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Value | Source | Value | Source | Value | Source | Value | Source | Value | Source | |
Bangladesh | ||||||||||
Births taking place at setting | 4.0% | BMMS 2016 [13] | 9.3% | BMMS 2016 [13] | 3.7% | BMMS 2016 [13] | 50.2% | BMMS 2016 [13] | 32.8% | BMMS 2016 [13] |
Births receiving each uterotonic in status quo | ||||||||||
Injectable oxytocin | 90.2% | Health facility survey [15] | 83.9% | Health facility survey [15] | 11% | Health facility survey [15] | 0% | Assumption | 86% | Health facility survey [15] |
Misoprostol | 0% | Assumption | 0% | Assumption | 69% | 42%b | Quaiyum et al. 2014 [41] | 0% | Assumption | |
Births receiving each uterotonic in intervention scenarioa | ||||||||||
Injectable oxytocin | 63% | BMMS 2016 [13] | 20% | BMMS 2016 [13] | 0% | Assumption | 0% | Assumption | 86% | BMMS 2016 [13] |
Misoprostol | 0% | Assumption | 0% | Assumption | 0% | Assumption | 0% | Assumption | 0% | Assumption |
Inhaled oxytocin | 28% | Assumption | 64% | Assumption | 80% | Assumption | 42% b | Assumption | 0% | Assumption |
Ethiopia | ||||||||||
Births taking place at setting | 9.5% | EmONC assessment 2016 [17] | 58.4% | EmONC assessment 2016 [17] | 4.5% | Sibley et al. 2014 [18] | 25.5% | Sibley et al. 2014 [18] | 2.1% | EmONC assessment 2016 [17] |
Births receiving each uterotonic in status quo | ||||||||||
Injectable oxytocin | 81% | EmONC assessment 2016 [17] | 81% | EmONC assessment 2016 [17] | 0% | Assumption | 0% | Assumption | 81% | EmONC assessment 2016 [17] |
Misoprostol | 0% | Assumption | 0% | Assumption | 84%c | Health facility survey [42] | 0% | Assumption | 0% | Assumption |
Births receiving each uterotonic in intervention scenarioa | ||||||||||
Injectable oxytocin | 2% | EmONC assessment 2016 [17] | 0% | Assumption | 0% | Assumption | 0% | Assumption | 81% | EmONC assessment 2016 [17] |
Misoprostol | 0% | Assumption | 0% | Assumption | 0% | Assumption | 0% | Assumption | 0% | Assumption |
Inhaled oxytocin | 78% | Assumption | 81% | Assumption | 84% c | Assumption | 0% | Assumption | 0% | Assumption |
Current use of uterotonics
Rollout of IHO
Cost
Bangladesh | Ethiopia | |||
---|---|---|---|---|
Value | Source | Value | Source | |
Intervention up-front costs | ||||
Advocacy costsa | $ 321,105 | MoH informant | $ 80,563 | MoH informant |
Up-front training costsa | $ 96,255 | MoH informant and health sector plan [16] | $ 39,531 | MoH informant |
Health worker training costs (per facility)a | $ 226 | Health sector plan [16] | $ 324 | MoH informant |
Number of facilities providing delivery care for each delivery setting | ||||
Setting 1 | 78 | 95 | EmONC assessment 2016 [17] | |
Setting 2 | 471 | 3567 | EmONC assessment 2016 [17] | |
Setting 3 | 1828 | N/Ab | ||
Ongoing PPH prevention costs | ||||
Drug cost (per dose) | ||||
Injectable oxytocin | $ 0.34c | Drug administration informant | $ 0.37d | Public supply agency informant |
Misoprostol | $ 0.34e | Drug administration informant | $ 0.60f | International drug price indicator |
Inhaled oxytocin | $ 0.50g | Assumption | $ 0.50g | Assumption |
Disposal costs (per 100 doses) | ||||
Injectable oxytocin | $ 1.33 | Sarker et al. 2015 [43] | $ 0.28 | Sarker et al. 2015 [43] |
Misoprostol | $ - | Assumption | $ - | Assumption |
Inhaled oxytocin | $ 1.42 | Sarker et al. 2015 [43] | $ 0.42 | Sarker et al. 2015 [43] |
Wastage rates | ||||
Injectable oxytocin | 5% | Pecenka et al. 2017 [44] | 5% | Pecenka et al. 2017 [44] |
Misoprostol | 5% | Vlassoff et al. 2016 [45] | 5% | Vlassoff et al. 2016 [45] |
Inhaled oxytocin | 7% | Local clinicians | 7% | Local clinicians |
PPH treatment costs | ||||
% of PPH cases after a facility birth that receive treatmenth | 90% | Assumption | 90% | Assumption |
% of PPH cases after a home birth that seek treatment in a facilityh | ||||
Public | 32.8% | BMMS 2016 [13] | 50.5% | Worku et al. 2013 [46] |
Private | 44.1% | BMMS 2016 [13] | 1.6% | Worku et al. 2013 [46] |
Average length of hospital stay | ||||
Mild | 2 days | Hospital administrators | 2 days | Hospital administrators |
Severe | 5 days | Hospital administrators | 5 days | Hospital administrators |
Cost of treating mild PPHa | ||||
Public | $79 | Hospital administrators and clinicians | $31 | Akalu et al. 2012 [31] Pearson et al. 2011 [32] Lara et al. 2007 [33] |
Private | $122 | Hospital administrators and clinicians | $73 | Akalu et al. 2012 [31] Pearson et al. 2011 [32] Lara et al. 2007 [33] |
Cost of treating severe PPHa | ||||
Public | $176 | Hospital administrators and clinicians | $199 | Akalu et al. 2012 [31] Pearson et al. 2011 [32] Lara et al. 2007 [33] |
Private | $272 | Hospital administrators and clinicians | $356 | Akalu et al. 2012 [31] Pearson et al. 2011 [32] Lara et al. 2007 [33] |
Sensitivity analyses
Deterministic sensitivity analyses
Scenario analyses
Structural uncertainty analyses
Probabilistic sensitivity analysis
Results
Bangladesh | Ethiopia | |||||
---|---|---|---|---|---|---|
Status quo | Intervention | Averted | Status quo | Intervention | Averted | |
PPH cases, non-severe | 291,978 | 278,813 | 13,165 | 297,868 | 295,672 | 2197 |
PPH cases, severe | 150,947 | 145,467 | 5479 | 155,178 | 154,264 | 914 |
Maternal deaths | 1806 | 1730 | 76 | 4418 | 4388 | 30 |
Maternal life years lost | 46,429 | 44,475 | 1954 | 111,767 | 111,000 | 767 |
Child deaths | 1135 | 1088 | 48 | 3394 | 3371 | 23 |
Child life years lost | 33,480 | 32,071 | 1409 | 97,284 | 96,616 | 668 |
Bangladesh | Ethiopia | |||||
---|---|---|---|---|---|---|
Status quo | Intervention | Incremental | Status quo | Intervention | Incremental | |
Costs, $000 | ||||||
Intervention start-up costsa | 955 | 955 | 1308 | 1308 | ||
On-going PPH preventionb | 783 | 985 | 202 | 840 | 1108 | 268 |
PPH treatment | 52,479 | 50,606 | − 1873 | 31,141 | 31,007 | − 134 |
Total costs | 53,262 | 52,546 | − 716 | 31,981 | 33,423 | 1443 |
ICERs | ||||||
$ per PPH case averted | Cost-saving | 464 | ||||
$ per maternal death averted | Cost-saving | 47,557 | ||||
$ per maternal life year saved | Cost-saving | 1880 | ||||
$ per maternal and child life year saved | Cost-saving | 1005 | ||||
ICERs (ongoing costs only) | ||||||
$ per PPH case averted | Cost-saving | 43 | ||||
$ per maternal death averted | Cost-saving | 4435 | ||||
$ per maternal life year saved | Cost-saving | 175 | ||||
$ per maternal and child life year saved | Cost-saving | 94 |