Costs and cost effectiveness of training traditional birth attendants to reduce neonatal mortality

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Costs and cost effectiveness of training traditional birth attendants to reduce neonatal mortality




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Presentations text content in Costs and cost effectiveness of training traditional birth attendants to reduce neonatal mortality

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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

Slide2

Background

Problem: Neonatal Mortality accounts for ~40% of ‘Under Five’ deaths75% due to perinatal conditions: birth

asphyxia, hypothermia and

sepsisIn areas with limited access to health services, Traditional Birth Attendants are a common source of basic obstetrical careResponse: 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?

Slide3

Setting and Methods

Setting: Lufwanyama, ZambiaLow population density: 6.4 persons/square kilometerHigh neonatal mortality:

~40/1000 live births

Methods: Cluster randomized and controlled effectiveness trial120 TBAs randomized to intervention/control

Control 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 infants

Endpoints captured on ~3500 deliveries (97.9% of total enrolled)

Lufwanyama facts:

12 health posts/centers

No physicians

No

hospitals

Slide4

Results of main study

Results from main trial

1 death averted per 56 deliveries attended

Relative 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?

Slide5

Cost effectiveness analysis

Costs and effectiveness data taken directly from the trialCost effectiveness assessed from three perspectivesFinancial – 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

programmaticallyAll costs adjusted for inflation, expressed in constant dollarsDiscount rate of 3%Key Outcomes: Cost per delivery attended

Cost effectiveness: per life savedCost effectiveness: per DALY averted

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Results: Costs

Assumed main features of LUNESP except 100% task shifting:

TBA training

Program management

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Results: Cost effectiveness

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Multivariate sensitivity analyses

Parameters varied in Monte Carlo

:

Effect size

Average No. deliveries/month/TBA

Training workshop logistic costs

Costs Monitoring and Supervision

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Conclusions

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 GDPZambia’s 2010 per capital GDP was 1500 dollars

LUNESP’s interventions were ‘highly cost effective’ - even under most conservative assumptionsIntervention 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.

Slide10

AcknowledgementsOur team

Lora SabinDavid HamerAnna B KnappNicholas GuerinaGrace Mazala

Joshua KasimbaWilliam MacLeod

Our FundersUSAIDNIH/NIAIDAAPUNICEF

Slide11

backups

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Overview 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

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Assumptions for scenario analyses

ParameterBase caseHigh Impact

Conservative

# of TBAs trained together608060

Time for refresher workshop212

Annual

trainings needed

3

3

4

Births/TBA/Month1.293.34

1.21Effect size of intervention

17.9/1000 live births17.9/1000 live births13.4/1000

live births (25% drop)MonitoringMonthly

Every other monthMonthly

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Results: Costs for the three models

Slide15

One-way Sensitivity analyses: key drivers of CE

Slide16

Multivariate sensitivity analyses


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