Intermittent preventive treatment of
malaria in pregnancy: incremental
Cost-effectiveness of a new delivery
system in Uganda.
AK Mbonye, KS Hansen, IC Bygbjerg,
P Magnussen.
Trans Roy Soc Trop Med Hyg (2008) 102,
685-693.
1
Out line of Presentation:
1.
2.
3.
4.
5.
6.
Epidemiology of malaria in pregnancy
Current malaria prevention interventions
Research Questions
The intervention
Results
Conclusion
2
The Public Health importance of
malaria in pregnancy
Malaria in pregnancy is one of the leading
causes of maternal mortality and morbidity
in malaria endemic countries
Infection of the placenta is asymptomatic
Infection of the placenta interferes with the
transfer of nutrients
This affects fetal nutrition and growth
3
The Public Health importance of
malaria in pregnancy
It contributes 3-15% to maternal aneamia
It contributes 4-19% to low birth weight
It contributes 3-8% to infant deaths
4
Malaria 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
5
What is the uptake of current
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%
6
Current malaria Control
Interventions
Scale up of ITNs
Indoor residual spraying
IPTp
Case management
Home-based management of fevers.
7
Research Questions
Why 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?
8
The intervention
The study was implemented in 9 rural subcounties 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)
9
The intervention
In 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
10
The intervention
The 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.
11
Access to IPTp
Timing of the first dose of SP (23.1 weeks
versus 20.8 weeks), P=0.001
First dose of SP in second trimester (76.1%
versus 92.4 %), P=0.001
Proportion of adolescents at first dose
(28.4% versus 25.0%), P=0.03
Adherence to IPTp (39.9%, versus 67.5%),
P=0.001.
12
Measuring costs of the intervention
Full 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.
13
Measuring costs of the intervention
The cases of anaemia, parasitaemia, and
low birth weight in the two delivery system
were translated into disability-adjusted lifeyears (DALYs).
Having calculated costs and outcomes in
DALYs, it was possible to calculate the
incremental costs, incremental effects and
incremental cost-effective ratios.
14
Incremental costs and effects of IPTp
Health centres
Community
based
Difference
782518
554115
-228403
Supply of IPTp 2558270
3303630
745360
Transport and
time to seek
IPTp
2405307
2448290
42983
Total
5746095
6306035
559940
Costs of full
IPTp
SP pills
15
Incremental costs and effects of IPTp
Health centres
Community
based
No. of women
receiving first
dose
3517
2081
No. of women
receiving full
IPTp
1404
1404
Difference
16
Incremental costs and effects of IPTp
Prevalence at
third
measurement
point
Health centres
Community
based
Difference
Anaemia
682
582
-100
Parasitaemia
128
231
104
Low birth weight
babies
115
84
-31
17
Incremental costs and effects of IPTp
DALYs
Health centres
Community
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
18
Conclusion
Community based delivery increased access
and adherence to IPTp and was cost
effective.
19