lufwanyama neonatal survival study Christopher J Gill MD MS Center for Global Health and Development Department of International Health Boston University School of Public Health ICIUM 2012 Antalya Turkey ID: 760188
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Slide1
Costs and cost effectiveness of training traditional birth attendants to reduce neonatal mortality in the lufwanyama neonatal survival study
Christopher J. Gill MD MSCenter for Global Health and DevelopmentDepartment of International HealthBoston University School of Public HealthICIUM 2012, Antalya Turkey
LuNeSP
Slide2Background
Problem:
Neonatal Mortality accounts
for
~40
% of ‘Under Five’ deaths
75% due to perinatal conditions: birth
asphyxia, hypothermia
and
sepsis
In areas with limited access to health services, Traditional Birth Attendants are a common source of basic obstetrical care
Response:
The Lufwanyama Neonatal Survival Project (LUNESP) assessed the effectiveness of training TBAs in skills targeting birth asphyxia, hypothermia and sepsis.
Question:
What is the cost effectiveness of this strategy?
Slide3Setting and Methods
Setting: Lufwanyama, ZambiaLow population density: 6.4 persons/square kilometerHigh neonatal mortality: ~40/1000 live birthsMethods: Cluster randomized and controlled effectiveness trial120 TBAs randomized to intervention/controlControl TBAs continued standard of careIntervention TBAs trained in two skill sets:Neonatal resuscitation protocolAntibiotics with Facilitated Referral Primary endpoint: mortality by day 28 among live-born infantsEndpoints captured on ~3500 deliveries (97.9% of total enrolled)
Lufwanyama facts:
12 health posts/centers
No physicians
No
hospitals
Slide4Results of main study
Results from main trial1 death averted per 56 deliveries attendedRelative risk reduction 0.55 (95% CI 0.33 to 0.90)Absolute risk reduction of 18 deaths / 1000 live births
Death Rate on Day of Delivery:
19.9/1000 births (control) vs. 7.8/1000 births (intervention)
RR = 0.4, 95% CI 0.19-0.83
Key Question: But is it cost effective?
Slide5Cost effectiveness analysis
Costs and effectiveness data taken directly from the trial
Cost effectiveness assessed from three perspectives
Financial
– actual costs incurred during LUNESP
Economic
– factors in additional costs from a societal perspective
10-year forecasted economic analysis
– models the cost effectiveness of the LUNESP interventions if applied
programmatically
All costs adjusted for inflation, expressed in constant dollars
Discount rate of 3%
Key Outcomes:
Cost per delivery attended
Cost effectiveness: per life saved
Cost effectiveness: per DALY averted
Slide6Results: Costs
Assumed main features of LUNESP except 100% task shifting:
TBA training
Program management
Slide7Results: Cost effectiveness
Slide8Multivariate sensitivity analyses
Parameters varied in Monte Carlo
:
Effect size
Average No. deliveries/month/TBA
Training workshop logistic costs
Costs Monitoring and Supervision
Slide9Conclusions
WHO classification of cost effectiveness of interventions:
‘Cost effective’ if a DALY averted is less than three times per capita GDP
‘Highly cost effective’ if less than per capita GDP
Zambia’s 2010 per capital GDP was 1500 dollars
LUNESP’s interventions were ‘highly cost effective’ - even under most conservative assumptions
Intervention will be maximally cost effective in settings where TBAs are busier, and where local ownership of program is complete.
This approach can be recommended as high value for money.
Slide10Acknowledgements
Our teamLora SabinDavid HamerAnna B KnappNicholas GuerinaGrace MazalaJoshua KasimbaWilliam MacLeod
Our Funders
USAID
NIH/NIAID
AAP
UNICEF
Slide11backups
Slide12Overview of LUNESP study design
12
Randomization of TBAs
Intervention TBAs:Trained in AFR + NRP
Control TBAs:Existing standard of care
Deliveries
Deliveries
Stillbirths
Stillbirths
Live births
Live births
Week One
Week One
Week Four
Week Four
Death
Death
Death
Death
Data collector
assessments
Verbal autopsies
Statistical analysis
STUDY OVERVIEW
Slide13Assumptions for scenario analyses
Parameter
Base case
High Impact
Conservative
# of TBAs trained
together
60
80
60
Time for refresher workshop
2
1
2
Annual
trainings needed
3
3
4
Births/TBA/Month
1.29
3.34
1.21
Effect size of intervention
17.9/1000
live births
17.9/1000 live births
13.4/1000
live births (25% drop)
Monitoring
Monthly
Every
other month
Monthly
Slide14Results: Costs for the three models
Slide15One-way Sensitivity analyses: key drivers of CE
Slide16Multivariate sensitivity analyses