Cost-effectiveness of antenatal multiple micronutrients and balanced energy protein supplementation compared to iron and folic acid supplementation in India, Pakistan, Mali, and Tanzania: A dynamic microsimulation study

Abstract

Background Malnutrition among women of childbearing age is especially prevalent in Asia and sub-Saharan Africa and can be harmful to the fetus during pregnancy. In the most recently available Demographic and Health Survey (DHS), approximately 10% to 20% of pregnant women in India, Pakistan, Mali, and Tanzania were undernourished (body mass index [BMI] <18.5 kg/m2), and according to the Global Burden of Disease (GBD) 2017 study, approximately 20% of babies were born with low birth weight (LBW; <2,500 g) in India, Pakistan, and Mali and 8% in Tanzania. Supplementing pregnant women with micro and macronutrients during the antenatal period can improve birth outcomes. Recently, the World Health Organization (WHO) recommended antenatal multiple micronutrient supplementation (MMS) that includes iron and folic acid (IFA) in the context of rigorous research. Additionally, WHO recommends balanced energy protein (BEP) for undernourished populations. However, few studies have compared the cost-effectiveness of different supplementation regimens. We compared the cost-effectiveness of MMS and BEP with IFA to quantify their benefits in 4 countries with considerable prevalence of maternal undernutrition. Methods and findings Using nationally representative estimates from the 2017 GBD study, we conducted an individual-based dynamic microsimulation of population cohorts from birth to 2 years of age in India, Pakistan, Mali, and Tanzania. We modeled the effect of maternal nutritional supplementation on infant birth weight, stunting and wasting using effect sizes from Cochrane systematic reviews and published literature. We used a payer’s perspective and obtained costs of supplementation per pregnancy from the published literature. We compared disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs) in a baseline scenario with existing antenatal IFA coverage with scenarios where 90% of antenatal care (ANC) attendees receive either universal MMS, universal BEP, or MMS + targeted BEP (women with prepregnancy BMI <18.5 kg/m2 receive BEP containing MMS while women with BMI ≥18.5 kg/m2 receive MMS). We obtained 95% uncertainty intervals (UIs) for all outputs to represent parameter and stochastic uncertainty across 100 iterations of model runs. ICERs for all scenarios were lowest in Pakistan and greatest in Tanzania, in line with the baseline trend in prevalence of and attributable burden to LBW. MMS + targeted BEP averts more DALYs than universal MMS alone while remaining cost-effective. ICERs for universal MMS compared to baseline IFA were $52 (95% UI: $28 to $78) for Pakistan, $72 (95% UI: $37 to $118) for Mali, $70 (95% UI: $43 to $104) for India, and $253 (95% UI: $112 to $481) for Tanzania. ICERs for MMS + targeted BEP compared to baseline IFA were $54 (95% UI: $32 to $77) for Pakistan, $73 (95% UI: $40 to $104) for Mali, $83 (95% UI: $58 to $111) for India, and $245 (95% UI: $127 to $405) for Tanzania. Study limitations include generalizing experimental findings from the literature to our populations of interest and using population-level input parameters that may not reflect the heterogeneity of subpopulations. Additionally, our microsimulation fuses multiple sources of data and may be limited by data quality and availability. Conclusions In this study, we observed that MMS + targeted BEP averts more DALYs and remains cost-effective compared to universal MMS. As countries consider using MMS in alignment with recent WHO guidelines, offering targeted BEP is a cost-effective strategy that can be considered concurrently to maximize benefits and synergize program implementation.

Examining the Birth Weights of Children in India: Impact of Iron-Folic Acid Supplements during Pregnancy

“…In this paper, no association is found for women who took IFA tablet for less than 3 months. This finding is consistent with the analysis of (2,3,13,14) which also used nationally representative NFHS (National Family Health Survey) data. Having shown this relationship, this looks really challenging for public health while IHDS data is clearly indicating that almost 55 percent of pregnant women either do not take IFA at all or consume IFA for less than prescribed 100 days (Table 1).…”

“…Globally more than 20 million infants are born with low birth weight and India alone produces almost forty percent of all Lower Birth Weight (LBW) children born in developing countries (1) . Low birth weight has adverse health consequences including neonatal mortality, morbidity, many chronic diseases in later life as well (2)(3)(4)(5)(6)(7)(8)(9) .…”

“…Public health intervention like micronutrient supplementation during pregnancy in many countries have shown positive impact on infant birth weight and early development in childhood (2)(3)(4)(5)(6)(7) .…”

“…The Iron-Folic acid (IFA) intervention during pregnancy has been reported to be vital determinant of birth weight (2,3,8,9) . As per the national guidelines, pregnant women should take IFA tablets daily for at least 100 days (10) .…”

Mathematical modelling to estimate the impact of maternal and perinatal healthcare services and interventions on health in sub-Saharan Africa: A scoping review

“…Following title screening, the abstracts of 150 papers were screened (including all papers from hand-searching) using the inclusion criteria followed by full-text screening of 90 most relevant. Of these studies a further 30 were excluded leaving a final total of 60 papers for review (27–86). Figure 1 provides a diagrammatic representation of the search and screening processes within this review.…”