Intermittent preventive treatment of malaria in pregnancy: incremental Cost-effectiveness of a new delivery system in Uganda.

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Intermittent preventive treatment of Intermittent preventive treatment of malaria in pregnancy: incremental malaria in pregnancy: incremental Cost-effectiveness of a new delivery Cost-effectiveness of a new delivery system in Uganda. system in Uganda.

AK Mbonye, KS Hansen, IC Bygbjerg, P Magnussen.

Trans Roy Soc Trop Med Hyg (2008) 102,685-693.

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Out line of Presentation:Out line of Presentation:

1. Epidemiology of malaria in pregnancy2. Current malaria prevention

interventions 3. Research Questions4. The intervention5. Results6. Conclusion

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The Public Health importance of The Public Health importance of malaria in pregnancymalaria in pregnancy

Malaria in pregnancy is one of the leading causes of maternal mortality and morbidity in malaria endemic countriesInfection of the placenta is asymptomaticInfection of the placenta interferes with the transfer of nutrientsThis affects fetal nutrition and growth

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The Public Health importance of The Public Health importance of malaria in pregnancymalaria in pregnancy

It contributes 3-15% to maternal aneamiaIt contributes 4-19% to low birth weight It contributes 3-8% to infant deaths

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Malaria prevention in pregnancyMalaria 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

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What is the uptake of current What is the uptake of current malaria prevention interventions?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%

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Current malaria Control Current malaria Control InterventionsInterventions

Scale up of ITNsIndoor residual sprayingIPTpCase managementHome-based management of fevers.

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Research QuestionsResearch QuestionsWhy 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?

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The interventionThe interventionThe 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)

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The interventionThe interventionIn 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

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The interventionThe interventionThe 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.

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

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Measuring costs of the interventionMeasuring costs of the interventionFull 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.

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Measuring costs of the interventionMeasuring costs of the interventionThe 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.

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Incremental costs and effects of IPTpIncremental costs and effects of IPTpHealth centres Community

basedDifference

Costs of full IPTpSP pills 782518 554115 -228403

Supply of IPTp

2558270 3303630 745360

Transport and time to seek IPTp

2405307 2448290 42983

Total 5746095 6306035 559940

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Incremental costs and effects of IPTpIncremental costs and effects of IPTpHealth centres

Community based

Difference

No. of women receiving first dose 3517 2081No. of women receiving full IPTp 1404 1404

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Incremental costs and effects of IPTpIncremental costs and effects of IPTpPrevalence at third measurement point

Health centres

Community based

Difference

Anaemia 682 582 -100

Parasitaemia 128 231 104

Low birth weight babies

115 84 -31

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Incremental costs and effects of IPTpIncremental costs and effects of IPTpDALYs Health

centresCommunity based

Difference

Aneamia 1.0 0.9 -0.1

Parasitaemia 0.5 0.8 0.3

Low birth weight babies

1110.2 810.5 -299.8

Total 1111.7 812.2 -299.5

CE ratio costs per DALY averted

1869

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ConclusionConclusionCommunity based delivery increased access and adherence to IPTp and was cost effective.