A Cost-Effectiveness and Budget Impact Analysis of the Introduction of Heat Stable Carbetocin for Postpartum Hemorrhage Prevention in Nigeria

Background: Nigeria contributes about 28.5% of the global maternal death burden and 22% of these deaths are attributable to postpartum hemorrhage (PPH). The World Health Organization recommends that the administration of a potent uterotonic agent within the first minute of birth is critical to preventing PPH. Studies reveal preponderance of low-quality oxytocin, misoprostol and other uterotonics in Nigeria due to substandard manufacturing practices, weak regulatory oversight, broken cold-chain systems, demanding climactic conditions (high heat; high humidity), inconsistent electricity and falsification of uterotonics. WHO, in its 2018 Recommendations, surmised heat-stable uterotonic agents may be more suitable options, depending on the context. This study evaluates the cost-effectiveness and budget impact of heat-stable carbetocin (HSC) compared to other uterotonic options for PPH prophylaxis. Methods: This is a health-economic evaluation to compare the occurrence of PPH events, costs, and the cost-effectiveness of introducing heat-stable carbetocin versus oxytocin+/-misoprostol for PPH prevention among women delivering in public healthcare facilities in Nigeria. The study utilized a hierarchical decision-tree model, developed from the public healthcare system perspective, that had as inputs demographical, clinical, and economical information, and generated results related to PPH events (categorized as mild-moderate and severe), PPH-related deaths, DALYs (disability adjusted life-years) on account of PPH and PPH-related direct costs to the healthcare system. Results: The cost-effectiveness analysis revealed that in a cohort of 2,548,136 deliveries in Nigeria, HSC can avert 111,652 PPH events, 12,873 severe PPH events, 31,442 DALYs, and 1,165 deaths when compared against oxytocin, at a 4.5% reduction in total cost to the health system. Similar favorable results are associated with heat-stable carbetocin when compared with misoprostol and oxytocin-misoprostol combination. The budget impact analysis revealed that HSC can lead to total cumulative savings of USD $325,114 (₦ 240,743,293 1 ) if scaled up over a 5-year period to 17% market share of prophylactic uterotonics administered in the country. Conclusions: Introduction of HSC for PPH prevention is a cost-effective public health intervention in Nigeria. Health-economic modeling projects HSC to be associated with lower costs to the health system while conferring better maternal health outcomes when compared to oxytocin, misoprostol, or oxytocin-misoprostol combination. [1] At a CBN rate of ₦740.49 to 1 USD (accessed 01/09/2023)