Fig 1.
Decision tree showing the delivery pathway trajectory and outcomes considered in the analysis.
The delivery pathway trajectory i.e., place of delivery (health facility versus non-health facility birth) and assistance at delivery (skilled assistance, traditional birth attendant, relative or friend and unassisted delivery) is defined by wealth quintile from the Uganda Demographic and Health Survey. We follow women through to the immediate postpartum period in which they may receive prophylactic uterotonics (or not), may experience postpartum hemorrhage (or not), may access emergency obstetric care or not and may recover or die due to postpartum hemorrhage. We allow access to emergency obstetric care to vary by delivery pathway. Further, we account for the potential of misoprostol misuse through stillbirth or uterine rupture outcomes. This model structure is used to project the costs and outcomes (incident postpartum hemorrhage, mortality due to postpartum hemorrhage and disability adjusted life years) of a cohort of pregnant women in Uganda.
Table 1.
Parameters to compute a woman’s probable delivery pathway trajectory: base case probabilities (sensitivity ranges) by wealth quintile, UDHS 2011[5].
Table 2.
Probabilities of receiving uterotonics and probabilities of accessing emergency obstetric care by delivery pathway trajectory.
Table 3.
Probabilities of PPH, treatment efficacy of uterotonics and case fatality rate of PPH.
Table 4.
Results of the cost-effectiveness analysis (cost per life saved and cost per DALYs averted).
Values in brackets are 95% Credibility Intervals for incremental costs and outcomes from the PSA.
Table 5.
Incremental costs, incremental outcomes and incremental cost-effectiveness ratios stratified by wealth quintile.
Fig 2.
Tornado diagram of univariate sensitivity analysis.
The diagram shows the impact of the 10 most influential parameters on the incremental cost per DALY averted from a governmental perspective
Fig 3.
Tornado diagram of univariate sensitivity analysis.
The diagram shows the impact of the 10 most influential parameters on the incremental cost per DALY averted from a modified societal perspective
Fig 4.
Incremental cost-effectiveness scatter plot showing the distribution of 10,000 incremental cost and DALY averted pairs.
The green cloud shows the analysis from the governmental perspective and the purple cloud shows the analysis from the modified societal perspective. The dashed red line represents the lower threshold of willingness to pay per DALY averted (one times the GDP of Uganda) and the solid red line represents the higher threshold of willingness to pay per DALY averted (three times the GDP of Uganda).
Fig 5.
Cost effectiveness acceptability curve obtained from the probabilistic sensitivity analysis.
The curves show the proportion of probabilistic iterations (out of 10,000) in which prenatal misoprostol distribution is cost-effective under different thresholds of willingness to pay for a DALY averted. The green curve shows the analysis from the governmental perspective and the purple curve shows the analysis from the modified societal perspective. The dashed red line represents the lower threshold of willingness to pay per DALY averted (one times the GDP of Uganda) and the solid red line represents the higher threshold of willingness to pay per DALY averted (three times the GDP of Uganda)