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APHA Scientific Session and Event Listing

Sarah E.K. Bradley¹, David M. Bishai, MD MPH PhD², Ndola Prata, MD, MSc³, and Nichole Young-Lin, MPH³. (1) Department of Population and Family Health Sciences, Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205, (410) 740-0061, sebradle@jhsph.edu, (2) Bloomberg School of Public Health, Department of Population and Family Health Sciences, 615 N. Wolfe St Room E4622, Baltimore, MD 21205, (3) University of California, Berkeley, 314 Warren Hall, Berkeley, CA 94720

Background: PPH is the largest single cause of maternal death worldwide. For the millions of women in resource-poor settings who deliver at home with TBAs, PPH is an even greater threat. A 2005 intervention trial with 849 participants in Kigoma, Tanzania found TBA-administered rectal misoprostol to be a low-cost, easy-to-use technology for reducing severe PPH, even after home births without a medically trained attendant.

Methods: We conducted a cost-effectiveness analysis from the medical sector perspective by applying PPH incidence estimates from the Kigoma trial to a hypothetical cohort of 10,000 women giving birth under standard treatment (TBA referral to hospital after blood loss ≥ 500ml), and a hypothetical cohort of 10,000 women giving birth attended by TBAs who would be trained to recognize PPH and to administer 1000μg of misoprostol rectally at blood loss ≥ 500ml. We calculated direct costs of TBA training, salaries, medication, referral, hospitalization, IV fluids and blood transfusions in the intervention and non-intervention model. We then used the costs and outcomes of each strategy to calculate the cost effectiveness ratio. We ran each model for baseline, low, and high assumptions to represent a range of costs, incidence of PPH, and effectiveness of misoprostol based on medical literature.

Results: Preliminary estimates suggest that the strategy of training TBAs to recognize PPH and administer misoprostol could prevent 1,647 cases of severe PPH (range: 810 - 2920) per 10,000 births. The intervention could also save $115,335 in costs of referral, IV therapy and transfusions (range: $13,991 - $1,563,593 per 10,000 births. Because the misoprostol strategy both prevents severe disease and saves money, it is said to “dominate” the standard approach which relies on TBAs referring women with PPH to hospitals.

Conclusion: Our findings suggest that in areas where TBA-attended home births are the norm, training TBAs to administer misoprostol for the treatment of PPH has the potential to both save money in countries with limited health resources and improve the health of mothers across the developing world.

Learning Objectives:

• Advocate for the approval of misoprostol in developing countries (misoprostol is not approved for use in the vast majority of Africa and much of Asia).
• Explain why TBA-administered misoprostol is a cost-effective protocol.
• Articulate four ways in which TBA-administered misoprostol could reduce postpartum hemorrhage-related mortality and morbidity.
• List five ways a TBA-administered misoprostol stragtegy could save money.
• Describe a new approach to training TBAs or other local health providers to recognize and treat postpartum hemorrhage with misoprostol.

Keywords: Maternal Morbidity, Cost Issues

Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: Misoprostol is currently not approved for use in the vast majority of Africa and parts of Asia. However, this paper describes a cost-effectiveness analysis only, not the direct use of the product.

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