Prevention of postpartum haemorrhage: cost consequences analysis of misoprostol in low-resource settings

BMC Pregnancy and Childbirth

Jane Robertson¹  Fei-Li Zhao¹  Danielle L. Lang¹ 

[1] Clinical Pharmacology, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia

关键词: Cost-consequences analysis;    Postpartum haemorrhage;    Misoprostol;   

Others  :  1233976
DOI  :  10.1186/s12884-015-0749-z

 received in 2013-03-27, accepted in 2015-11-18,  发布年份 2015

【 摘 要 】

Background

While inferior to oxytocin injection in both efficacy and safety, orally administered misoprostol has been included in the World Health Organization Model List of Essential Medicines for use in the prevention of postpartum haemorrhage (PPH) in low-resource settings. This study evaluates the costs and health outcomes of use of oral misoprostol to prevent PPH in settings where injectable uterotonics are not available.

Methods

A cost-consequences analysis was conducted from the international health system perspective, using data from a recent Cochrane systematic review and WHO’s Mother-Baby Package Costing Spreadsheet in a hypothetical cohort of 1000 births in a mixed hospital (40 % births)/community setting (60 % births). Costs were estimated based on 2012 US dollars.

Results

Using oxytocin in the hospital setting and misoprostol in the community setting in a cohort of 1000 births, instead of oxytocin (hospital setting) and no treatment (community setting), 22 cases of PPH could be prevented. Six fewer women would require additional uterotonics and four fewer women a blood transfusion. An additional 130 women would experience shivering and an extra 42 women fever. Oxytocin/misoprostol was found to be cost saving (US$320) compared to oxytocin/no treatment.

If misoprostol is used in both the hospital and community setting compared with no treatment (i.e. oxytocin not available in the hospital setting), 37 cases of PPH could be prevented; ten fewer women would require additional uterotonics; and six fewer women a blood transfusion. An additional 217 women would experience shivering and 70 fever. The cost savings would be US$533.

Sensitivity analyses indicate that the results are sensitive to the incidence of PPH-related outcomes, drug costs and the proportion of hospital births.

Conclusions

Our findings confirm that, even though misoprostol is not the optimum choice in the prevention of PPH, misoprostol could be an effective and cost-saving choice where oxytocin is not or cannot be used due to a lack of skilled birth attendants, inadequate transport and storage facilities or where a quality assured oxytocin product is not available. These benefits need to be weighed against the large number of additional side effects such as shivering and fever, which have been described as tolerable and of short duration.

【 授权许可】

   
2015 Lang et al.

【 参考文献 】

• [1]Chong YS, Su LL. Misoprostol for preventing PPH: some lessons learned. Lancet. 2006; 368:1216-8.
• [2]Ronsmans C, Graham WJ. Maternal mortality: Who, when, where, and why. Lancet. 2006; 368:1189-200.
• [3]Khan KS, Wojdyla D, Say L, Gulmezoglu AM, van Look PFA. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006; 367:1066-74.
• [4]WHO recommendations for the prevention of postpartum haemorrhage. World Health Organization, Geneva; 2012. [http://www. who.int/reproductivehealth/publications/maternal_perinatal_health/9789241548502/en/index.html]
• [5]Management of the third stage of labour to prevent post-partum haemorrhage. Joint statement. 2006. [http://www. who.int/pmnch/events/2006/figo2006statementeng.pdf]
• [6]WHO guidelines for the management of postpartum haemorrhage and retained placenta. World Health Organization, Geneva; 2009. [http://whqlibdoc. who.int/publications/2009/9789241598514_eng.pdf]
• [7]Begley C, Gyte G, Devane D, McGuire W, Weeks AD. Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2010: CD007412: doi:007410.001002/14651858.
• [8]World Health Organization, Department of Reproductive Health and Research: Proportion of births attended by a skilled health worker: 2008 updates. http://www. who.int/reproductivehealth/publications/maternal_perinatal_health/2008_skilled_attendants/en/index.html webcite
• [9]Post-market quality surveillance project: maternal healthcare products (oxytocin and ergometrine) on the Ghanaian market. Report of first round. 2013. [http://www. usp.org/sites/default/files/usp_pdf/EN/PQM/ghana-mch_mqm_report_final-mar_27_2013_rdct.pdf]
• [10]McCormick ML, Sanghvi HC, Kinzie B, McIntosh N. Preventing postpartum hemorrhage in low-resource settings. Int J Gynaecol Obstet. 2002; 77:267-75.
• [11]World Health Organization. The selection and use of essential medicines: report of the WHO Expert Committee, March 2011 (including the 17th WHO model list of essential medicines and the 3rd WHO model list of essential medicines for children). WHO Technical Report Series; No. 965. http://www. who.int/medicines/publications/essentialmeds_committeereports/en/index.html webcite
• [12]Chu C, Brhlikova P, Pollock A. Rethinking WHO guidance: review of evidence for misoprostol use in the prevention of postpartum haemorrhage. J R Soc Med. 2012; 105:336-47.
• [13]World Health Organization. Application for deletion of misoprostol from WHO EML. http://www. who.int/selection_medicines/committees/expert/19/applications/misoprostol2/en/index.html webcite
• [14]Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2012; 8: Article ID CD000494
• [15]Summary of the report of the 19th meeting of the WHO expert committee on the selection and use of essential medicines. 2013. [www. who.int/entity/selection_medicines/committees/expert/19/EC19_Executive_summary_Final_web_8Jul2013.pdf]
• [16]Bradley SE, Prata N, Young-Lin N, Bishai DM. Cost-effectiveness of misoprostol to control postpartum hemorrhage in low-resource settings. Int J Gynecol Obstet. 2007; 97:52-6.
• [17]Sutherland T, Meyer C, Bishai DM, Geller S, Miller S. Community-based distribution of misoprostol for treatment or prevention of postpartum hemorrhage: cost-effectiveness, mortality, and morbidity reduction analysis. Int J Gynaecol Obstet. 2009; 108:289-94.
• [18]Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GL. Methods for the Economic Evaluation of Health Care Programmes. Oxford University Press. 2005
• [19]World Health Organization. Mother-baby package costing spreadsheet; 1999. http://www. who.int/reproductivehealth/publications/maternal_perinatal_health/RHR_99_17/en/index.html webcite
• [20]International drug price indicator guide. 2011. [http://erc. msh.org/mainpage.cfm?file=1.0.htm&module=dmp&language=english]
• [21]Oladapo O. Misoprostol for preventing and treating postpartum hemorrhage in the community: a closer look at the evidence. Int J Gynaecol Obstet. 2012; 119:105-10.
• [22]U.S. Bureau of Labor Statistics. CPI Inflation Calculator (2012). http://www. bls.gov/data/inflation_calculator.htm webcite
• [23]Hundley V, Avan B, Sullivan C, Graham W. Should oral misoprostol be used to prevent postpartum haemorrhage in home-birth settings in low-resource countries? A systematic review of the evidence. BJOG. 2013; 120:277-87.
• [24]Derman RJ, Kodkany BS, Goudar SS, Geller SE, Naik VA, Bellad MB et al.. Oral misoprostol in preventing postpartum hemorrhage in a community setting. Lancet. 2006; 368:1248-53.
• [25]Nasreen H, Nahar S, Mamun M, Afsana K, Byass P. Oral misoprostol for preventing postpartum haemorrhage in home births in rural Bangladesh: how effective is it? Glob Health Action. 2011 4 doi:10.3402/gha.v4i0.7017.
• [26]Prata N, Gessessew A, Abraha A, Holston M, Potts M. Prevention of postpartum hemorrhage: options for home births in rural Ethiopia. Afr J Reprod Health. 2009; 13:87-95.
• [27]Allen R, O’Brien MB. Uses of misoprostol in obstetrics and gynecology. Rev Obstet Gynecol. 2009; 2:159-68.
• [28]Benchimol M, Gondry J, Mention J, Gagneur O, Boulanger J. Role of misoprostol in controlled delivery [Place du misoprostol dans la direction de la delivrance]. J Gynecol Obstet Biol Reprod. 2001; 30:576-83.
• [29]Hofmeyr GJ, Nikodem VC, de Jager M, Drakely A, Gilbart B. Oral misoprostol for labour third stage management: randomised assessment of side effects. In Proceedings of the 17th Conference on Priorities in Perinatal Care Durban, South Africa; 1998.
• [30]Hofmeyr GJ, Nikodem VC, de Jager M, Drakely A. Side effects of oral misoprostol in the third stage of labour: a random allocation placebo controlled trial. J Obstet Gynaecol. 2000; 20:S40-1.
• [31]Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff B et al.. Misoprostol in the management of the third stage of labour in the home delivery setting in rural Gambia: a randomised controlled trial. BJOG. 2005; 112:1277-83.
• [32]Mobeen N, Durocher J, Zuberi NF, Jahan N, Blum J, Wasim S et al.. Administration of misoprostol by trained traditional birth attendants to prevent postpartum hemorrhage in homebirths in Pakistan: a randomised placebo controlled trial. BJOG. 2011; 118:353-61.
• [33]Rajbhandari S, Hodgins S, Sanghvi H, McPherson R, Pradhan YV, Baqui AH et al.. Expanding uterotonic protection following childbirth through community-based distribution of misoprostol: operations research study in Nepal. Int J Gynaecol Obstet. 2010; 108(3):282-8.
• [34]Sanghvi H, Ansari N, Prata NJ, Gibson H, Ehsan AT, Smith JM. Prevention of postpartum hemorrhage at home birth in Afghanistan. Int J Gynaecol Obstet. 2010; 108(3):276-81.
• [35]Prata N, Ejembi C, Fraser A, Shittu O, Minkler M. Community mobilization to reduce postpartum hemorrhage in home births in northern Nigeria. Soc Sci Med. 2012; 74(8):1288-96.
• [36]Alfirevic Z, Blum J, Walraven G, Weeks A, Winikoff B. Prevention of postpartum hemorrhage with misoprostol. Int J Gynaecol Obstet. 2007; 99:198-201.