Cost of hospital care of women with postpartum haemorrhage in India, Kenya, Nigeria and Uganda: a financial case for improved prevention

Abstract

Objective Access to quality, effective lifesaving uterotonics in low and middle-income countries (LMICs) remains a major barrier to reducing maternal deaths from postpartum haemorrhage (PPH). Our objective was to assess the costs of care for women who receive different preventative uterotonics, and with PPH and no-PPH so that the differences, if significant, can inform better resource allocation for maternal health care. Methods The costs of direct hospital care of women who received oxytocin or heat-stable carbetocin for prevention of PPH in selected tertiary care facilities in India, Kenya, Nigeria, and Uganda were assessed. We collected data from all women who had PPH, as well as a random sample of women without PPH. Cost data was collected for the cost of stay, PPH interventions, transfusions and medications for 2966 women. We analyzed the difference in cost of care at a facility level between women who experienced a PPH event and those who did not. Key findings The mean cost of care of a woman experiencing PPH in the study sites in India, Kenya, Nigeria, and Uganda exceeded the cost of care of a woman who did not experience PPH by between 21% and 309%. There was a large variation in cost across hospitals within a country and across countries. Conclusion Our results quantify the increased cost of PPH of up to 4.1 times that for a birth without PPH. PPH cost information can help countries to evaluate options across different conditions and in the formulation of appropriate guidelines for intrapartum care, including rational selection of quality-assured, effective medicines. This information can be applied to national assessment and adaptation of international recommendations such as the World Health Organization’s recommendations on uterotonics for the prevention of PPH or other interventions used to treat PPH. Trial registration HRP Trial A65870; UTN U1111-1162-8519; ACTRN12614000870651; CTRI/2016/05/006969, EUDRACT 2014–004445-26. Date of registration 14 August 2014 Plain English summary Access to quality, effective lifesaving medicines in low and middle-income countries remains a major barrier to reducing maternal deaths from bleeding after childbirth. Information on to what extent treatments for bleeding increases the cost of care of women after childbirth is important for informed resource allocation. We collected data from all women who had bleeding after childbirth, as well as a random sample of women without bleeding in selected hospitals in India, Kenya, Nigeria, and Uganda. Cost data was collected for the cost of stay and interventions to manage bleeding for 2966 women. We compared the difference in cost of care between women who experienced a bleeding event and those who did not. The mean cost of care of a woman with bleeding in the study sites exceeded the cost of care of a woman who did not experience PPH by between 21% and 309%. There was a large variation in cost across hospitals within a country and across countries. Our results indicate an increased cost of bleeding of up to 4.1 times that for birth without bleeding. Effective prevention reduces the cost of care. Cost information can help countries to evaluate options across different conditions and in the formulation of appropriate guidelines for intrapartum care, including rational selection of quality-assured, effective medicines. This information can be applied to national assessment and adaptation of international recommendations such as the World Health Organization’s recommendations on medications for the prevention of bleeding after childbirth or other interventions used to treat bleeding.

Implementing Heat-Stable Carbetocin for Postpartum Haemorrhage Prevention in Low-Resource Settings: A Rapid Scoping Review

“…Moosivand et al also used a decision tree model applied to the Iranian context but over a one-year timeframe and with a human capital approach to estimate indirect costs [ 31 ]. Theunissen et al collected the costs of direct hospital care (stay, medications, transfusions) of women who received oxytocin or HSC in India, Kenya, Nigeria, and Uganda [ 32 ]. Farhad et al mentioned uterotonic costs per patient in the conclusion of their effectiveness study but did not detail the methods used for this analysis [ 23 ].…”

“…Moosivand et al did not detail the modelling population [ 31 ]. Theunissen et al analysed the data of a total of 2966 women: 1481 had PPH and received either preventive oxytocin (742) or HSC (739), and 1485 without PPH (preventive oxytocin: 741, HSC: 744) [ 32 ].…”

“…These countries were part of the larger ten-country study by Widmer et al, which also included another lower-middle-income country (Egypt), three upper-middle-income countries (Argentina, South Africa, and Thailand), and two high-income countries (Singapore and the United Kingdom) [ 7 ]. The remaining studies were based overwhelmingly in Bangladesh (5: Akhter et al [ 21 ], Farhad et al [ 23 ], Kabir et al [ 25 ], Nahaer et al [ 27 ], and Razzaque et al [ 29 ]), followed by Egypt (2: Elbohoty et al [ 24 ] and Maged et al [ 26 ]), Iran (2: Moosivand et al [ 32 ] and Taheripana et al [ 28 ]), and the Philippines (Briones et al [ 30 ]).…”

“…In Iran, Moosivand et al concluded that HSC was not cost-effective, except in the scenario with the highest price of oxytocin and other costs in the private sector [ 31 ]. Theunissen et al used a public sector price for HSC, which was competitive to that of oxytocin [ 32 ]. Although the authors initially intended to compare the costs between HSC and oxytocin, they did not present this comparison in the main body of the paper because the clinical effects were similar with both.…”

Accessing quality‐assured medicines for pregnancy complications in lower‐ and middle‐income countries

“…The impact of substandard or falsified anti-malarial drugs has a huge negative cost implication in LMICs, 6 while the cost of hospital care of women with PPH is considerably more than those without bleeding, something that can be reduced by using quality-assured medicines. 7 It is not inevitable that substandard products reach women who need them for their own survival and/or the survival of their newborn, but countries must ensure that the only medicines available are quality-assured (SRA-approved or WHO-prequalified). To support this commitment requires countries to address issues and take actions in several areas.…”