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

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Study Justification:
The study aimed to assess the costs of care for women who received different preventative uterotonics and experienced postpartum hemorrhage (PPH) compared to those who did not. The goal was to provide information on the extent to which treatments for bleeding increase the cost of care for women after childbirth. This information is crucial for informed resource allocation and improving maternal health care.
Study Highlights:
1. The study analyzed the costs of direct hospital care for women who received oxytocin or heat-stable carbetocin for PPH prevention in India, Kenya, Nigeria, and Uganda.
2. Data was collected for the cost of stay, PPH interventions, transfusions, and medications for 2966 women.
3. The mean cost of care for women experiencing PPH exceeded the cost of care for women without PPH by 21% to 309%.
4. There was significant variation in costs across hospitals within each country and across countries.
5. The study found that effective prevention of PPH can reduce the cost of care.
Recommendations for Lay Readers and Policy Makers:
1. Improve access to quality, effective uterotonics in low and middle-income countries to reduce maternal deaths from PPH.
2. Allocate resources based on the cost differences between women with and without PPH, ensuring adequate funding for PPH prevention and management.
3. Develop appropriate guidelines for intrapartum care, including the rational selection of quality-assured, effective medicines.
4. Consider the cost implications of different conditions and interventions when evaluating healthcare options.
5. Adapt international recommendations, such as the World Health Organization’s recommendations on uterotonics for PPH prevention, to national contexts.
Key Role Players Needed to Address Recommendations:
1. Government health departments and ministries responsible for maternal health.
2. Healthcare providers, including doctors, nurses, and midwives.
3. Pharmaceutical companies and suppliers of uterotonics.
4. Hospital administrators and managers.
5. Non-governmental organizations (NGOs) working in maternal health.
Cost Items to Include in Planning Recommendations:
1. Cost of disposable apparel and consumables (gowns, gloves, syringes, etc.).
2. Cost of instruments (sterilization fee) and cleaning.
3. Cost of laboratory tests.
4. Fee for use of operating theatre (if applicable).
5. Staff labor cost.
6. Cost of blood and blood products.
7. Cost of additional uterotonics administered.
8. Cost of surgical interventions for PPH treatment.
9. Cost of concomitant medicines administered.
10. Cost of hospital stay.
Please note that the above information is a summary of the study and its findings. For more detailed information, please refer to the publication “Reproductive Health, Volume 18, No. 1, Year 2021.”

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it presents the results of a randomized, double-blind, non-inferiority trial comparing the effectiveness of two uterotonics in preventing postpartum hemorrhage. The study collected data from a large number of women across multiple countries and analyzed the cost of care for women with and without PPH. The findings show a significant difference in the cost of care between the two groups. To improve the evidence, it would be helpful to provide more details on the methodology used to calculate the cost of care and to include the mean costs of care for women receiving oxytocin or heat-stable carbetocin.

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.

We calculated the cost of hospital care of women with and without PPH and who received either oxytocin 10 IU or heat-stable carbetocin 100 µg as part of the management of the third stage of labour at nine tertiary referral hospitals (sites) in India, Kenya, Nigeria and Uganda. The CHAMPION trial was a randomized, double-blind, non-inferiority trial comparing the effectiveness in the prevention of PPH of an intramuscular injection of heat-stable carbetocin with oxytocin administered immediately after vaginal birth. The trial methods and results are described in detail elsewhere [10]. Briefly, almost 30,000 women across 23 sites in ten countries were randomly assigned to prophylactic heat-stable carbetocin or oxytocin. The primary outcomes were the proportion of women with blood loss of at least 500 ml or the use of additional uterotonic agents, and the proportion of women with blood loss of at least 1000 ml. Secondary outcomes included the proportion of women having additional interventions to control bleeding. The trial results showed that heat-stable carbetocin was non-inferior to oxytocin. Data from all women who participated in the CHAMPION trial in India, Kenya, Nigeria, and Uganda and who had PPH (n = 1514), as well as a random sample of the same number of women who did not experience PPH (n = 1514), was extracted from the CHAMPION trial database (Fig. 1). One of the ten trial sites was eliminated from this study due to administrative barriers to data collection (n = 62). A total of 2966 records from the CHAMPION trial were therefore included in this study. The four countries were selected because of their high maternal mortality and morbidity rates, climate, and possible difficulties of ensuring the quality of oxytocin due to challenges maintaining the cold chain of oxytocin. Study flow chart The following data, covering the time immediately following administration of the prophylactic uterotonic to the time of discharge from the hospital, were extracted from the CHAMPION trial database to form the basis of the calculation of the cost of care: administration of additional uterotonics; other medical and surgical interventions to treat PPH; blood transfusion and duration of hospital stay. The medical and surgical interventions recorded in the CHAMPION trial patient records and costed in this study were: suturing of the cervix/high vaginal tear; intrauterine balloon/condom tamponade; exploration of the uterine cavity; uterine or hypogastric ligation; manual removal of the placenta; bimanual compression of the uterus and hysterectomy. Uterine compression sutures and manual or surgical correction of uterine inversion were not used for any cases at any of the sites and therefore are not reflected in the results. Excel data collection worksheets were specifically designed for this exercise, modelled on those developed by the Guttmacher Institute for their study estimating the cost of PPH in Egypt [11]. The worksheet design was reviewed by an obstetrician with experience in low income countries and by a local expert panel established in each country by the coordinator of the CHAMPION trial. The correspondent costs were obtained by the CHAMPION trial investigators from each of the participating hospitals. Sites obtained data from various sources including hospital pharmacies, accounting departments, payroll, and government salary data. Table ​Table11 lists all elements included in each of the items costed for the study. Breakdown of costs and details of calculations Cost of disposable apparel (gowns, gloves, caps etc.) + disposable consumables (needles, gauze, syringes etc.) + instruments (sterilization fee) + cleaning + laboratory tests + fee for use of operating theatre (if applicable) + staff labour cost (L) Each surgical intervention was costed as an independent intervention, although some patients may have received more than one intervention concurrently with some costs shared across interventions Monthly salary/hours worked per month x hours devoted to intervention Calculated for all personnel required for the procedure First unit of blood: Cost of apparel + consumables + sterilization charge + laboratory tests + blood product price + cost of labour for blood (LB) Each additional unit of blood: Cost of labour for blood (LB) + blood product price Basic cost of 24 h stay in ward bed x the number of days in hospital from the time of birth to discharge Some patients were discharged within 24 h and with no additional care over basic delivery services. As we did not calculate the cost of delivery specifically (it occurs prior to diagnosis of PPH) these patients’ records would show zero cost. To avoid this, all patients were allocated a minimum of 1 day’s hospital stay as a proxy for the cost of delivery Price of the dose of the uterotonic administered, being either: the price of the individual unit (i.e. tablet, ampoule) multiplied by the units administered or the pack price divided by units in the pack multiplied by the units administered Price of the dose of the medicine administered, being either: the price of the individual unit (i.e. tablet, ampoule) multiplied by the units administered or the pack price divided by units in the pack multiplied by the units administered T2 = Total cost of care HS = Cost of hospital stay I = Costs of a surgical intervention received for treatment of PPH and ΣI = the sum of costs of all surgical interventions received U = Sum of the cost of all additional uterotonics administered for treatment of PPH B = Cost of blood and blood products administered CM = Sum of cost of all concomitant medicines administered HS = Cost of hospital stay I = Costs of a surgical intervention received for treatment of PPH and DT = Cost of the full tray of drugs available for each surgical intervention for PPH treatment U = Sum of the cost of all additional uterotonics administered for treatment of PPH B = Cost of blood and blood products administered The data for concomitant medicines administered during the CHAMPION trial included an extensive list of medicines, many of which were not related to PPH care. It was not possible to isolate the drugs that were administered specifically for the treatment of PPH from the list of concomitant drugs. The cost of the drugs available for each surgical intervention was also collected to complement the cost information. Investigators from each of the countries were requested to list all the drugs used to treat PPH. This list developed per country was named ‘drug tray’ for the purposes of this study The Drug Tray formula was used to validate the results by addressing the uncertainty about the concomitants being related to PPH or not. For the Drug Tray formula, it should be noted that the entirety of the drug tray may not have been used for each intervention depending on each patient’s medical condition. It was not logistically possible to cross-match the concomitants and drug tray data to achieve a more accurate result All prices collected in this study were current at the time of data collection, i.e., between February and July 2018, and not at the time of the CHAMPION trial intervention. The conversion from local currency to US Dollar was made at the time of data collection. Disposable consumables were costed using unit prices provided by the facilities from procurement records. The costs related to the use of non-disposable items, such as surgical instruments, were calculated as the cost of cleaning and sterilization. We did not include depreciation as information on the life of non-disposable items was not available. One on-site meeting with each country investigator was performed by the research team during the data collection period for quality assurance purposes. The total cost of care at the facility for each patient (PPH and no PPH) was computed using three different formulas. These were (1) Total cost of care; (2) Total cost of care including concomitant medicines women received; and (3) Total cost of care including drug tray costs. We did not include the concomitant medicines and drug tray formulas in the main manuscript since, due to variations in the number of medicines used and the contents of the drug trays, the results showed high variability and distracted from the main comparison objective. The concomitant medicines and drug tray formulas are presented in Table ​Table11. The formula used for the total cost of care calculation was: where T1 = Total cost of care, HS = Cost of hospital stay, I = Costs of a surgical intervention received for treatment of PPH and ΣI = the sum of costs of all surgical interventions received, U = Sum of the cost of all additional uterotonics administered for treatment of PPH, B = Cost of blood and blood products administered. The cost of prophylactic uterotonics (oxytocin or heat-stable carbetocin) was not included as their administration occurred prior to diagnosis of PPH. The mean costs of care for women receiving oxytocin or heat-stable carbetocin during the third stage of labour, having PPH or not, were calculated for each site but are not presented in the paper since the two uterotonics were very similar in efficacy.

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Development of cost-effective uterotonics: Research and development efforts could focus on creating affordable and effective uterotonics specifically designed for use in low and middle-income countries (LMICs). These uterotonics should be stable at higher temperatures, reducing the need for cold chain storage and transportation.

2. Strengthening supply chains: Innovations in supply chain management can help ensure a consistent and reliable availability of uterotonics in LMICs. This could involve implementing technology-based solutions such as real-time tracking systems, automated inventory management, and demand forecasting tools.

3. Telemedicine and remote consultations: Utilizing telemedicine and remote consultations can improve access to maternal health services, especially in remote or underserved areas. Pregnant women can receive medical advice, prenatal care, and postpartum support through virtual platforms, reducing the need for physical travel to healthcare facilities.

4. Community-based interventions: Implementing community-based interventions can help improve access to maternal health services. This could involve training and empowering community health workers to provide basic prenatal and postnatal care, education on safe delivery practices, and early identification of complications.

5. Financial incentives and insurance schemes: Introducing financial incentives and insurance schemes can help reduce the financial burden of maternal healthcare for women in LMICs. This could involve subsidizing the cost of uterotonics, providing cash transfers for transportation to healthcare facilities, or implementing health insurance programs specifically targeting maternal health.

6. Public-private partnerships: Collaborations between public and private sectors can help improve access to maternal health services. This could involve partnerships with pharmaceutical companies to ensure the availability and affordability of uterotonics, or collaborations with technology companies to develop innovative solutions for remote consultations and supply chain management.

These are just a few potential innovations that could be explored to improve access to maternal health. It is important to consider the specific context and challenges of each country or region when implementing these innovations.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health would be to prioritize the availability and affordability of quality-assured, effective uterotonics for the prevention of postpartum hemorrhage (PPH) in low and middle-income countries (LMICs). This recommendation is based on the findings that the cost of care for women experiencing PPH is significantly higher compared to those without PPH, ranging from 21% to 309% higher. By ensuring access to and proper utilization of uterotonics, countries can reduce the incidence of PPH and subsequently reduce the financial burden on healthcare systems.

To implement this recommendation, the following steps can be taken:

1. Strengthen the supply chain: Ensure a consistent and reliable supply of quality-assured uterotonics, such as oxytocin and heat-stable carbetocin, in LMICs. This includes addressing challenges in maintaining the cold chain for oxytocin to ensure its effectiveness.

2. Improve affordability: Work towards reducing the cost of uterotonics by negotiating lower prices with manufacturers or exploring options for local production. This can make these life-saving medications more accessible to women in need.

3. Enhance healthcare provider training: Provide comprehensive training to healthcare providers on the proper administration and management of uterotonics during the third stage of labor. This will ensure that uterotonics are used effectively and appropriately to prevent PPH.

4. Develop national guidelines: Based on the cost data and international recommendations, develop or update national guidelines for the prevention and management of PPH. These guidelines should include the rational selection and use of quality-assured uterotonics.

5. Monitor and evaluate: Establish systems for monitoring the availability, utilization, and impact of uterotonics in preventing PPH. Regularly evaluate the effectiveness of interventions and adjust strategies as needed to improve access to maternal health.

By implementing these recommendations, countries can make significant progress in improving access to maternal health and reducing maternal deaths from postpartum hemorrhage.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase availability and affordability of quality-assured uterotonics: Ensuring a steady supply of effective uterotonics, such as oxytocin and heat-stable carbetocin, is crucial for preventing postpartum hemorrhage (PPH). Efforts should be made to improve the availability and affordability of these medications in low and middle-income countries (LMICs) to ensure that all women have access to them during childbirth.

2. Strengthen health systems: Investing in health system strengthening is essential for improving access to maternal health. This includes improving infrastructure, training healthcare providers, and ensuring the availability of essential equipment and supplies. By strengthening health systems, countries can provide better maternal healthcare services and reduce maternal mortality rates.

3. Promote community-based interventions: Implementing community-based interventions can help improve access to maternal health, especially in remote or underserved areas. This can include training community health workers to provide basic maternal healthcare services, conducting awareness campaigns, and establishing referral systems to ensure timely access to higher-level care when needed.

4. Enhance antenatal and postnatal care: Improving antenatal and postnatal care services is crucial for ensuring the well-being of both mothers and newborns. This can be achieved by increasing the number of antenatal and postnatal visits, providing comprehensive care during these visits, and promoting early detection and management of complications.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed using a combination of quantitative and qualitative data. Here is a brief outline of a possible methodology:

1. Define the indicators: Identify key indicators that reflect access to maternal health, such as maternal mortality rates, percentage of women receiving uterotonics, availability of healthcare facilities, etc.

2. Collect baseline data: Gather data on the current status of maternal health access in the target areas. This can include data on healthcare infrastructure, availability of uterotonics, healthcare utilization rates, etc.

3. Develop a simulation model: Create a simulation model that incorporates the identified indicators and their interrelationships. This model should be able to simulate the impact of different interventions on improving access to maternal health.

4. Input intervention scenarios: Define different intervention scenarios based on the recommendations mentioned earlier. For each scenario, input the expected changes in indicators, such as increased availability of uterotonics, improved health system infrastructure, etc.

5. Run simulations: Run the simulation model using the baseline data and the defined intervention scenarios. This will help estimate the potential impact of each intervention on improving access to maternal health.

6. Analyze results: Analyze the simulation results to assess the effectiveness of each intervention scenario. Compare the outcomes of different scenarios to identify the most impactful interventions for improving access to maternal health.

7. Refine and validate the model: Refine the simulation model based on feedback and validation from experts in the field. Ensure that the model accurately represents the complexities of the healthcare system and the potential impact of interventions.

8. Communicate findings: Present the findings of the simulation study to policymakers, healthcare providers, and other stakeholders. Use the results to advocate for the implementation of the most effective interventions and to inform resource allocation decisions.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions on improving access to maternal health. This can guide decision-making and resource allocation to maximize the effectiveness of efforts to improve maternal healthcare.

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