Replacing iron‐folic acid with multiple micronutrient supplements among pregnant women in Bangladesh and Burkina Faso: costs, impacts, and cost‐effectiveness

Abstract

Consumption of multiple micronutrient supplements (MMS) during pregnancy offers additional benefits compared with iron‐folic acid (IFA) supplementation, but the tablets are more expensive. We estimated the effects, costs, and cost‐effectiveness of hypothetically replacing IFA supplements with MMS for 1 year in Bangladesh and Burkina Faso. Using baseline demographic characteristics from LiST and effect sizes from a meta‐analysis, we estimated the marginal effects of replacing IFA with MMS on mortality, adverse birth outcomes, and disability‐adjusted life years (DALYs) averted. We calculated the marginal tablet costs of completely replacing MMS with IFA (assuming 180 tablets per covered pregnancy). Replacing IFA with MMS could avert over 15,000 deaths and 30,000 cases of preterm birth annually in Bangladesh and over 5000 deaths and 5000 cases of preterm birth in Burkina Faso, assuming 100% coverage and adherence. We estimated the cost per death averted to be US$175–185 in Bangladesh and $112–125 in Burkina Faso. Cost per DALY averted ranged from $3 to $15, depending on the country and consideration of subgroup effects. Our estimates suggest that this policy change would cost‐effectively save lives and reduce life‐long disabilities. Improvements in program delivery and supplement adherence would be expected to improve the cost‐effectiveness of replacing IFA with MMS.

Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low‐ and middle‐income countries

“…Similar to existing IFA programs, programmatic inefficiencies and low adherence will increase the cost per outcome averted and dramatically so under some sets of assumptions. Nonetheless, the values reported above for multiple micronutrient supplementation are still likely to compare favorably to those of more complex interventions to prevent preterm birth and infant mortality, such as screening for and managing chronic disease among pregnant women . For example, pneumococcus and rotavirus vaccines and mother's groups to improve maternal/neonatal health were each estimated to cost more than $100 per DALY averted .…”

“…A cost‐effectiveness analysis was performed on the basis of the data provided by all trials and the subset that used equal doses of iron included in the IPD meta‐analysis . The cost per multiple micronutrient tablet will be slightly higher than that of IFA, and the very large volume of tablets required to cover all pregnancies will cause even small differences in the multiple micronutrient supplement versus IFA tablet costs to translate into large outlays.…”

Setting research priorities on multiple micronutrient supplementation in pregnancy

“…The research question that received the lowest score pertains to the marginal cost and benefits of adding each vitamin or mineral to MMS. The group of specialists may have attributed less importance to this question in light of the widely used and well‐established UNICEF/WHO/United Nations University International Multiple Micronutrient Preparation “UNIMMAP” formulation, which has been administered in many of the trials that demonstrated the additional benefits of MMS over IFA and proved to be cost‐effective , . While the addition of a variety of nutrients known to be important during pregnancy (i.e., calcium, magnesium, choline, and n‐3 long‐chain polyunsaturated fatty acids) was proposed in several research questions listed here, it is possible that a consideration of the time and resources that would be required to answer these questions contributed to their relatively lower RPS.…”

“…A series of publications recently put forward by the New York Academy of Sciences (NYAS) presented evidence of the benefits of MMS on maternal and perinatal outcomes (i.e., significant risk reduction of LBW, SGA, preterm birth, and stillbirth), in addition to those provided by iron and folic acid . These publications identify populations in low‐ and middle‐income countries (LMIC), where a switch to MMS would be justified, consistent with the WHO Antenatal Care Guidelines, and would be highly cost‐effective . However, important gaps in knowledge remain in the implementation of MMS in prenatal care programs, which affect the ability of this intervention to achieve optimal performance.…”

Benefits of supplementation with multiple micronutrients in pregnancy

“…A third paper from the task force addresses a question raised in the WHO antenatal care guidelines regarding the cost-effectiveness of MMS. 11 The multiple micronutrient supplement has a small incremental cost compared with IFA because of the additional micronutrients. The switch from IFA to MMS was shown to be very cost-effective in analyses for Bangladesh and Burkina Faso.…”