Abstract
ObjectiveTo assess the cost-effectiveness of a non-pneumatic anti-shock garment (NASG) for obstetric hemorrhage in tertiary hospitals in Egypt and Nigeria.MethodsWe combined published data from pre-intervention/NASG-intervention clinical trials with costs from study sites. For each country, we used observed proportions of initial shock level (mild: mean arterial pressure [MAP] >60 mmHg; severe: MAP ≤60 mmHg) to define a standard population of 1,000 women presenting in shock. We examined three intervention scenarios: no women in shock receive the NASG, only women in severe shock receive the NASG, and all women in shock receive the NASG. Clinical data included frequencies of adverse health outcomes (mortality, severe morbidity, severe anemia), and interventions to manage bleeding (uterotonics, blood transfusions, hysterectomies). Costs (in 2010 international dollars) included the NASG, training, and clinical interventions. We compared costs and disability-adjusted life years (DALYs) across the intervention scenarios.ResultsFor 1000 women presenting in shock, providing the NASG to those in severe shock results in decreased mortality and morbidity, which averts 357 DALYs in Egypt and 2,063 DALYs in Nigeria. Differences in use of interventions result in net savings of $9,489 in Egypt (primarily due to reduced transfusions) and net costs of $6,460 in Nigeria, with a cost per DALY averted of $3.13. Results of providing the NASG for women in mild shock has smaller and uncertain effects due to few clinical events in this data set.ConclusionUsing the NASG for women in severe shock resulted in markedly improved health outcomes (2–2.9 DALYs averted per woman, primarily due to reduced mortality), with net savings or extremely low cost per DALY averted. This suggests that in resource-limited settings, the NASG is a very cost-effective intervention for women in severe hypovolemic shock. The effects of the NASG for mild shock are less certain.
Highlights
The global health agenda has prioritized reduction of maternal mortality for the last two decades
Obstetric hemorrhage is the most significant contributor to maternal mortality.[6],[7] Delays in identifying hemorrhage, reaching tertiary care facilities, and receiving definitive care such as blood transfusions and surgeries are factors that lead to maternal deaths in limited-resource settings
We examined three intervention scenarios: (a) no use of the non-pneumatic anti-shock garment (NASG) for any woman in shock; (b) women in severe shock receive the NASG and women in mild shock receive standard care; and (c) all women in shock receive the NASG, regardless of initial shock status
Summary
The global health agenda has prioritized reduction of maternal mortality for the last two decades. Obstetric hemorrhage is the most significant contributor to maternal mortality.[6],[7] Delays in identifying hemorrhage, reaching tertiary care facilities, and receiving definitive care such as blood transfusions and surgeries are factors that lead to maternal deaths in limited-resource settings. Implementation of evidence-based maternal mortality interventions is limited by availability of resources and often depends on the strength of the health system.[9] Strategies that target women with intrapartum complications that can be managed with basic emergency obstetric care have been shown to be effective in reducing maternal mortality.[10] Interventions that can be used broadly within the health system have the most potential for making a large-scale impact. Use of misoprostol for community-based treatment of postpartum hemorrhage (PPH) is considered highly cost-effective, with an incremental cost per disability adjusted life year (DALY) of $6.[11]
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