Effect of training traditional birth attendants on neonatal mortality (Lufwanyama Neonatal Survival Project): randomised controlled study

Objective To determine whether training traditional birth attendants to manage several common perinatal conditions could reduce neonatal mortality in the setting of a resource poor country with limited access to healthcare

Costs and Cost-Effectiveness of Training Traditional Birth Attendants to Reduce Neonatal Mortality in the Lufwanyama Neonatal Survival Study (LUNESP)

The Lufwanyama Neonatal Survival Project (“LUNESP”) was a cluster randomized, controlled trial that showed that training traditional birth attendants (TBAs) to perform interventions targeting birth asphyxia, hypothermia, and neonatal sepsis reduced all-cause neonatal mortality by 45%. This companion analysis was undertaken to analyze intervention costs and cost-effectiveness, and factors that might improve cost-effectiveness.We calculated LUNESP's financial and economic costs and the economic cost of implementation for a forecasted ten-year program (2011–2020). In each case, we calculated the incremental cost per death avoided and disability-adjusted life years (DALYs) averted in real 2011 US dollars. The forecasted 10-year program analysis included a base case as well as ‘conservative’ and ‘optimistic’ scenarios. Uncertainty was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. The estimated financial and economic costs of LUNESP were $118,574 and$127,756, respectively, or $49,469 and$53,550 per year. Fixed costs accounted for nearly 90% of total costs. For the 10-year program, discounted total and annual program costs were $256,455 and$26,834 respectively; for the base case, optimistic, and conservative scenarios, the estimated cost per death avoided was $1,866,$591, and $3,024, and cost per DALY averted was$74, $24, and$120, respectively. Outcomes were robust to variations in local costs, but sensitive to variations in intervention effect size, number of births attended by TBAs, and the extent of foreign consultants' participation.Based on established guidelines, the strategy of using trained TBAs to reduce neonatal mortality was ‘highly cost effective’. We strongly recommend consideration of this approach for other remote rural populations with limited access to health care

Items included in cost analysis.

1<p>Some travel expenses of the US-based neonatologist were defrayed due to cost-sharing related to airline tickets and local food and accommodation. In the financial analysis, costs incorporated these savings.</p

Results of one-way sensitivity analysis on the incremental cost per birth attended, cost per death avoided, and cost per DALY averted of LUNESP package of neonatal interventions: 2011–2020 program (2011 US$).

<p>Results of one-way sensitivity analysis on the incremental cost per birth attended, cost per death avoided, and cost per DALY averted of LUNESP package of neonatal interventions: 2011–2020 program (2011 US$).</p

Summary of the financial costs of the LUNESP intervention: 2006–08.

1<p>In-country costs were converted to US dollar values at the following average annual ZMK/US$ exchange rates: 3557 (2006), 4114 (2007), and 3818 (2008) <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0035560#pone.0035560-OANDA1" target="_blank">[6]</a>.</p>2<p>60 TBAs.</p>3<p>Discount rate = 3%.</p

Multivariate sensitivity analysis of key uncertain variables and incremental cost per birth attended, cost per death avoided, and cost per DALY averted of LUNESP package of neonatal interventions: 2011–2020 neonatal survival program (2011 US$).

1<p>20,000 trials were run for each simulation.</p>2<p>Monte-carlo simulation values are the median value.</p

Program cost-effectiveness: 2006–08 and 2011–20.

1<p>Death of a neonate = 21.9 DALYs averted, estimated by the formula given by Murray, 1994.</p>2<p>All costs expressed in real 2011 US$, with annual values discounted at 3%.</p