Cost Effectiveness of Misoprostol vs. Iron
David Bishai, Tori Sutherland
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11 July 2009

Outline
•Research question
•Background on misoprostol
•Methods results
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Maternal mortality in India
•Maternal mortality 540/100,000 in India
•36% of deaths due to post partum hemorrhage
•As of 2003 40% of Indian woman deliver at skilled
facilities.
–Numbers increasing due to Accredited Social Health
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Activist (ASHA) project offering vouchers
Date

Role of Misoprostol
• A $0.33 tablet for oral, vaginal, or rectal administration
•Causes uterine contractions that can stop bleeding
•Should not be used until placenta is out
•Not as effective as intravenous oxytocin, BUT
–Midwives can be trained to administer it for home births
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 Can lower hemorrhage rates by 50-80% in home births
Date
 Unknown how many lives saved
•Until institutional deliveries are universal misoprostol
can improve outcomes for home births

Role of Iron
•Iron deficiency anemia affects about 62% of
pregnant women in India
•With hemoglobin levels low there is less reserve in
case of hemorrhage
•Pre natal iron can build up a higher reserve and in
theory lower mortality
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Question
•Which approach offers cheaper $ per DALY?
–Iron supplementation
–Misoprostol at home births
•Will need model to translate hemorrhage rates to
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death rates.
Date

Step 1)Prenatal iron
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Iron can shift left tail of curve to right

Step 2) Misoprostol
DEATH
ZONE
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Misoprostol can shift bleeding curve to the left

Step 3) Day 1 deaths from shock
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Step 4) Day 2 deaths from anemia
Death
Zone
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Model
•Monte Carlo Model
•10,000 Indian Women having a delivery at home
•Stata program applies hemoglobin distributions,
blood loss distributions, and death distributions
stochastically.
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–Sensitivity analysis applied
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Results
Scenario Deaths Lives Cost per Incremental Median
per 10K saved 10,000 costs ICER
No 19.5 $20,000
Interventio
n
Iron 18.4 1.4 $29,032 $9,032 $2,241
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Misoprostol 12Date 7.5 $30,232 $10,232 $1,401
$1401 per life saved with misoprostol strategy

Sensitivity analysis
With day 1 mortality +/- 20% misoprostol ICER
fluctuates from $1,133 to $1,696
With day 2 mortality +/- 20% ICER ranges $1334 to
$1429
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Discussion
•Possible to estimate changes in death rates based
on changes in hemorrhage rates using models of
shock and anemia
•Both misoprostol and pre natal iron are very in
expensive Presenter’s Name $ per life saved
in terms of
Date
–Misoprostol could be a game changer in terms of a
vertical intervention that could be put in the hands of a
traditional birth attendant.