COSTS AND COST EFFECTIVENESS OF TRAINING TRADITIONAL BIRTH ATTENDANTS TO REDUCE NEONATAL MORTALITY IN THE 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

Background

• 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?

Setting and Methods• Setting: Lufwanyama, Zambia

• Low population density: 6.4 persons/square kilometer

• High neonatal mortality: ~40/1000 live births

• Methods: Cluster randomized and controlled effectiveness trial• 120 TBAs randomized to intervention/control• Control TBAs continued standard of care• Intervention TBAs trained in two skill sets:

• Neonatal resuscitation protocol• Antibiotics 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

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?

Cost effectiveness analysis• Costs and effectiveness data taken directly from the trial• Cost effectiveness assessed from three perspectives

1. Financial – actual costs incurred during LUNESP

2. Economic – factors in additional costs from a societal perspective

3. 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:

1. Cost per delivery attended

2. Cost effectiveness: per life saved

3. Cost effectiveness: per DALY averted

Results: Costs

Assumed main features of LUNESP except 100% task shifting:1. TBA training2. Program management

Results: Cost effectiveness

Multivariate sensitivity analyses

Parameters varied in Monte Carlo:1. Effect size2. Average No. deliveries/month/TBA3. Training workshop logistic costs4. Costs Monitoring and Supervision

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 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.

Acknowledgements

Our team• Lora Sabin• David Hamer• Anna B Knapp• Nicholas Guerina• Grace Mazala• Joshua Kasimba• William MacLeod

Our Funders• USAID• NIH/NIAID• AAP• UNICEF

backups

Overview of LUNESP study design12

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

Assumptions for scenario analysesParameter 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

Results: Costs for the three models

One-way Sensitivity analyses: key drivers of CE

Multivariate sensitivity analyses