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Christopher J. Gill MD MS Center for Global Health and Development

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

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Christopher J. Gill MD MS Center for Global Health and Development

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  1. 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 LuNeSP

  2. 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?

  3. 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

  4. Resultsof main study 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 • 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 Key Question: But is it cost effective?

  5. Cost effectiveness analysis • Costs and effectiveness data taken directly from the trial • Cost effectiveness assessed from three perspectives • Financial – 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 programmatically • All costs adjusted for inflation, expressed in constant dollars • Discount rate of 3% • Key Outcomes: • Cost per delivery attended • Cost effectiveness: per life saved • Cost effectiveness: per DALY averted

  6. Results: Costs • Assumed main features of LUNESP except 100% task shifting: • TBA training • Program management

  7. Results: Cost effectiveness

  8. Multivariate sensitivity analyses Parameters varied in Monte Carlo: Effect size Average No. deliveries/month/TBA Training workshop logistic costs Costs Monitoring and Supervision

  9. 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.

  10. 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

  11. backups

  12. STUDY OVERVIEW Overview of LUNESP study design Data collector assessments Statistical analysis Intervention TBAs: Trained in AFR + NRP Live births Week One Week Four Deliveries Stillbirths Death Death Randomization of TBAs Verbal autopsies Stillbirths Death Death Control TBAs: Existing standard of care Live births Week One Week Four Deliveries

  13. Assumptions for scenario analyses

  14. Results: Costs for the three models

  15. One-way Sensitivity analyses: key drivers of CE

  16. Multivariate sensitivity analyses

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