Community-based distribution of misoprostol for treatment or prevention of postpartum hemorrhage: Cost-effectiveness, mortality, and morbidity reduction analysis

Article Outline

• Abstract
• 1. Introduction
• 2. Methods
• 3. Results
• 4. Discussion
• Acknowledgments
• References
• Copyright

Abstract 

Objective

To compare the cost-effectiveness of community-based distribution of misoprostol for prevention with misoprostol for treatment of postpartum hemorrhage (PPH).

Methods

A Monte Carlo simulation depicted mortality and anemia-related morbidity attributable to PPH among 3 scenarios of 10000 women delivering at home in rural India: (1) standard management; (2) standard management plus 800µg of sublingual misoprostol for PPH treatment; and (3) standard management plus 600µg of prophylactic oral misoprostol. The model included costs of drugs, birth attendant training, and transport for women who did not respond to misoprostol.

Results

Misoprostol lowered mortality by 70% and 81% in scenarios 2 and 3, respectively. Scenarios 2 and 3 raise costs by 6% and 35%, respectively. Incremental cost per disability-adjusted life year (DALY) saved is estimated at $6 and $170, respectively.

Conclusion

Both interventions were more effective at decreasing mortality and anemia than standard management. The most efficient scale-up plan would focus initially on increasing coverage with the treatment strategy ($6 per DALY).

Keywords: Anemia, Cost-effectiveness, Maternal mortality, Misoprostol, Postpartum hemorrhage

Back to Article Outline

1. Introduction 

In 2005 there were an estimated 535900 maternal mortalities in the world; 99% occurred in less developed nations where women are more vulnerable to adverse outcomes due to poverty, malnutrition, and lack of access to healthcare services [1]. Obstetric hemorrhage is the leading cause of maternal mortality. A recent review of safe motherhood interventions concluded that use of misoprostol for prevention or treatment of postpartum hemorrhage (PPH; >500mL blood loss; severe PPH >1000mL) in home births was likely to produce significant reductions in maternal deaths [2]. Moreover, PPH can exacerbate existing anemias (hemoglobin <11.0g/dL), lead to severe anemia (hemoglobin <7.0g/dL), and is associated with significant long-term morbidity [3], [4].

Understanding the cost-effectiveness of maternal health interventions is a necessity for policy-makers, especially those in low-resource settings. From the perspective of health planners in low-resource countries or of multilateral donors who must make choices constrained by limited funds, the decision to invest in a lifesaving strategy may need to be made on cost per life saved. This analysis compares the cost-effectiveness of misoprostol for treatment versus prevention of PPH at the home or community level.

Misoprostol is an E₁ prostaglandin analog that can be taken orally, rectally, vaginally, or sublingually, does not need refrigeration, and has a long shelf life. There have been over 30 randomized trials with more than 30000 women assessing the efficacy of misoprostol for prophylaxis. The most recent assessment of prophylactic misoprostol is a draft prepared by the 17th Expert Committee on the Selection and Use of Essential Medicines for the World Health Organization, which found that there was insufficient evidence of comparative effectiveness, safety or cost-effectiveness to include misoprostol in their list of essential medicines for the prevention of PPH [5]. However, the majority of studies reviewed were at the facility level. While it appears clear that oxytocin is preferable to misoprostol in situations where parenteral administration is safe and feasible, the evidence is viewed differently at the community level where misoprostol may be the only viable option. A meta-analysis of 3 randomized controlled trials (RCTs) at the community or primary health clinic (PHC) level [6], [7], [8], showed a significant decrease in severe PPH: 2.3% vs 5.7% (3509 women; RR 0.59; 95% CI, 0.41–0.84) and concluded that misoprostol is useful where injectable uterotonics are not available [5], [9].

Opinion articles, guidelines, and case studies have been published that support the widespread distribution of misoprostol at the community level for PPH prevention [2], [10], [11], [12]. A prior cost-effectiveness study of prophylactic misoprostol used in addition to standard management by unskilled providers during home births showed that it could lower mortality by 38% (95% CI, 5–73) at $1401 per life saved [13].

There is less evidence to support the widespread use of misoprostol for PPH treatment [5]. There have been 7 uncontrolled studies and 3 RCTs that indicate that treatment with misoprostol can result in reduced or controlled bleeding [14]. Unlike oxytocin, misoprostol cannot be given for both prophylaxis and for immediate treatment of PPH; a minimum of 2 hours should pass between a prophylactic dose and a second dose [9]. Further, if the prophylactic dose was associated with pyrexia or marked shivering, then at least 6 hours should pass between doses [15], [16]. The exact percentage of women who hemorrhage despite misoprostol prophylaxis is unknown; rates range from 6% [6] to 12% [17].

Given these issues, choices may have to be made on the best use of misoprostol in community-based settings. If use of misoprostol is to be implemented by unskilled providers in low-resource settings, should misoprostol be scaled up for prophylaxis or for treatment? Which approach would save more lives as well as be more cost-effective? To help decision-makers answer these questions, we conducted a cost-effectiveness analysis comparing treatment and prevention at the home or community level with unskilled providers. Costs of scaling-up access to misoprostol will be demonstrated using a large state in India with a high maternal mortality ratio (MMR) and high home birth rate.

Back to Article Outline

2. Methods 

To compare the efficacy of misoprostol use for PPH treatment or prevention, this simulation builds on a previous analysis, which was designed to reflect the maternal outcomes for women delivering at home in rural India, where approximately 71% of births occur at home [3]. An estimated 36% of India's annual 540 maternal deaths per 100000 live births are attributable to PPH or anemia [18], [19], [20]. The microsimulation model, the Stochastic Simulator of Hemorrhagic Shock (SSHS), previously used to link intrapartum blood loss and changes in hemoglobin levels to mortality estimates, was modified [13]. Parameters were obtained from peer-reviewed literature [18], [19], [20], regional population-level datasets [3], [21], and expert consultations (personal communication, Dr Thomas Scalea). Fig. 1 outlines the baseline simulation. Fig. 2 describes the two misoprostol interventions and data sources [6], [14]. Standard management is defined as delivery attendance by a village health worker (VHW) without administration of medication. The primary outcome is the comparative reduction of maternal mortality between women who received no misoprostol and those who received either a treatment (800μg) or a prophylactic (600μg) dose of misoprostol. Other measured outcomes are the number of women who experience severe postpartum anemia and an estimate of the disability-adjusted life years (DALYs) attributable to severe anemia.

• 
  • View Large Image
  • Download to PowerPoint

• Fig. 1 

  Conceptual Model for Basic Computer Simulation.

• 
  • View Large Image
  • Download to PowerPoint

• Fig. 2 

  Conceptual model for misoprostol interventions.

The statistical simulations were performed using STATA version 10.0 (Stata Corp, College Station, TX, USA). The results of the simulation were used to calculate the cost-effectiveness of each intervention compared with no intervention. We ran 400 iterations of each simulation.

In the baseline model, 10000 hypothetical women were randomly assigned a hemoglobin and intrapartum blood loss value from population distributions. Each woman was then assigned corresponding mortality probabilities. Hemoglobin measurements from the 2005/06 Indian Demographic and Health Survey (DHS) were used to create a population distribution of hemoglobin in pregnancy [3]. Data on blood loss distributions were drawn from direct observations by physicians at 28 clinics in 6 African countries for 27996 women (Panel 2; [21]) and used to produce 3 superimposed normal distributions, fitted to a 3-component finite mixture model produced by STATA.

In the following distributions, the notation “∼N(μ, σ)” indicates that the data are “distributed normally with a mean of μ and a standard deviation of σ.” The superimposed distributions are: (1) 54%∼N(148, 51); (2) 40%∼N(303, 110); and (3) 6%∼N(722, 409). A recalibration was performed to ensure that this distribution's use resulted in an India-specific expected number of 130 maternal deaths per 100000 live births attributable to PPH. The third distribution was then adjusted to reflect conditions where prophylactic uterotonics are not in use: 10%∼N(890, 409); the 4% increase in volume was derived from the second distribution.

The majority of the cost data came from one large community intervention that involved training of rural volunteer health workers in India [22]. Misoprostol (CIPLA, Mumbai, India) price data came from an international average [23]. A previous analysis found that the cost of treating side effects of misoprostol was negligible [24]. Additional costs shown are in Table 1 [11], [25], [26], [27].

Table 1. Cost parameters.

Parameter a	Quantity	Source
Number of delivery providers to attend 10000 births b	83	[11], [25]
Cost of 1 home delivery	$2	[22]
Opportunity cost of provider training time	$2	[22]
Cost of 1-day training per provider; materials and teachers c	$2.01	[26], [27]
Cost of 600µg misoprostol	$0.66	[23]
Cost of 800µg misoprostol	$0.88	[23]
Cost of 2-hour, 80km trip by car from village to hospital	$12.50	[22]
Number of women who failed misoprostol used for prevention and were transported (75% of total number who failed)	59
Number of women who failed misoprostol used for treatment and were transported (75% of total number who failed)	42

^a Cost Equations:

(1) Cost model for standard care simulation: C=Birth attendant fee for 10000 deliveries.

(2) Cost model for misoprostol-prevention arm: C=Birth attendant fee for 10000 deliveries+birth attendant misoprostol training cost+birth attendant time cost+misoprostol cost (600µg×10 000)+cost of side effects.

(3) Cost model for misoprostol-treatment arm: C=Birth attendant fee for 10000 deliveries+birth attendant misoprostol training cost+birth attendant time cost+misoprostol cost (800µg x 1000)+cost of side effects.

^b Baseline is the average of a high and low estimate from the literature (331 and 25).

^c Baseline is the average of a high and low estimate from the literature ($3.40 and $0.62).

Mortality attributable to hemorrhage was considered a direct function of blood loss and was labeled “Day 1 mortality.” All women who lost 40%–75% of their total blood volume faced a constantly increasing quadratic probability of mortality; women who lost less than 40% of their blood volume had less than 1% probability of mortality, and women who lost more than 75% were presumed to have died (personal communication, Dr Thomas Scalea).

In the misoprostol-prevention model, data were taken from an RCT conducted at the community level in India; there was a 50% decrease in acute PPH (500–1000mL) cases, which was modeled by randomly assigning 50% of cases to a blood loss value of less than 500mL, and an 80% decrease in severe PPH cases (≥1000mL), which was modeled by randomly assigning 80% of cases to a blood loss value of less than 1000mL [6]. In the misoprostol-treatment model, results were obtained from a hospital-based, multicenter, randomized, placebo-controlled, double-blind trial [14]. In this trial, 10% of women who did not receive prophylactic oxytocin bled 700mL or greater. When treated with 800µg of sublingual misoprostol, 9% of those women continued to hemorrhage [14]; this was modeled by randomly assigning 91% of women who bled more than 750mL to a normal blood loss distribution (mean 972±274mL) and by assigning the other 9% to the severe hemorrhage distribution [14]. To model a limited resource situation, only 75% of women experiencing potentially fatal hemorrhage were transported by car for 2 hours, or 80km, to a hypothetical comprehensive emergency obstetric care (CEmOC) facility, while the other 25% remained in the community.

Cost-effectiveness calculations were carried out in accordance with standard guidelines [28]. The perspective is that of the health sector with a decision-maker responsible for 10000 pregnant women giving birth at home in one year. This decision-maker is assumed to have a fixed budget to spend on improving the outcomes for home births. Costs included fixed costs of training birth attendants, drug costs, and the birth attendant's delivery fee. Costs are expressed in US dollars (2009) adjusted for purchasing power parity. Birth attendant training was assumed to depreciate because of turnover and would require retraining as dictated by local conditions and levels of skill. DALYs were calculated as the sum of years of life lost due to death (YLL) and years of life lost due to disability (YLD). YLL were based on a mean age of maternal death in India of 35years [29]. Life expectancy in India at 35 is an additional 37years undiscounted. However, with 3% discounting, this comes to the value of 23years, which is used in the calculations. YLD were calculated assuming a severe anemia disability weight of 0.093 [30] and a duration of severe anemia assumed to be 6months. The 6-month assumption was tested across a range from 1month to 12months. Across this range, none of the cost-effectiveness ratios were altered by more than 5%.

The incremental cost effectiveness ratio (ICER) is the standard approach to guide a choice of strategies. To calculate an ICER for a strategy option, one computes the ratio of the additional cost required to scale up from the lower to the next higher cost alternative divided by the additional DALYs saved by scaling up to the next alternative. ICERs are preferable to simply dividing costs by DALYs, because in practice, decision-makers scale up their programs incrementally.

Back to Article Outline

3. Results 

For a population of 10000 women delivering at home, the misoprostol-treatment package saves 9.4 lives relative to standard management while prophylactic misoprostol saves an additional 1.4 (10.8 total) lives relative to standard management (Table 2). Costs rise from $20 000 for standard management to $21212 for the misoprostol-treatment package and $26933 for the misoprostol-prevention package (Fig 3). The burden of disease from maternal hemorrhage is calculated as 325 DALYs per 10000 women for standard management, but can be reduced to as low as 76 DALYs using misoprostol. Between 6% and 22% of the DALYs due to PPH are due to disability from anemia. In addition, there is an average reduction of 18% of severe anemia cases in the prophylactic model and a 5% reduction in the treatment model compared with the standard management scenario.

Table 2. Outcomes and cost-effectiveness ratios.

	Deaths	Severe anemia cases (SD)	YLL a	YLD b	DALYs	Lives saved	DALYs saved	Total cost	∆ Cost	ICER
Standard care	13.38	428 (10.97)	305	20	325.4			$20000
Misoprostol-treatment	3.97	405 (10.09)	91	19	109.5	9.4	215.9	$21212	$1212	$6
Misoprostol-prevention	2.59	361 (7.66)	59	17	75.9	1.4	33.6	$26933	$5721	$170

• 
  • View Large Image
  • Download to PowerPoint

• Fig. 3 

  Costs versus lives saved by intervention.

A decision to switch from standard management to misoprostol-treatment would save an additional 216 DALYs and would incur an additional cost of $1212. This implies an ICER of $6 per DALY ($1212/216). A decision to switch from misoprostol for treatment to misoprostol for prevention saves an additional 33.6 DALYs and incurs an additional cost of $5721. This implies an ICER of $170 per DALY ($5721/33.6).

The costs needed to scale-up a misoprostol package to a region or nation with high home birth prevalence are detailed in Table 3. Data from Uttar Pradesh were used to illustrate calculation steps [31]. In a region with approximately 3888000 home births and a MMR of 440, the total cost for the misoprostol treatment package would be $1640181. Each year, this intervention would save an estimated 2994 women, who would otherwise have died from PPH. Comparative costs for a misoprostol prevention package as well as adding on the costs of transport to a CEmOC facility for both treatment and prevention scenarios are also shown in Table 3.

Table 3. Package cost calculations: Uttar Pradesh case study.

Step	Treatment	Prevention
1. Determine the annual total of home births, multiply by 83 and then divide by 10000 to determine the average number of village health workers needed for intervention (may be scaled up or down pending documented need) a	32370 health providers	32370health providers
2. Multiply provider number by $4.01 (average cost of training and opportunity cost per provider)	$1298037	$1298037
3. For treatment, multiply annual sum of home births by 0.1 (10% all women who will hemorrhage) and multiply that number by $0.88 (cost of 800µg misoprostol for hemorrhage treatment; substitute local cost if available); b for prevention, multiply total number of home births by $0.66 (cost of 600µg misoprostol)	$342144	$2566080
Total: Misoprostol treatment or prevention package	$1640181	$3864117
4. For treatment, to calculate the total cost of transport to a CEmOC facility for all women who do not respond to misoprostol treatment, multiply the number of women who experienced hemorrhage by 0.09. For prevention, multiply the number of women who experienced uncontrolled hemorrhage by a standard figure below. c Multiply both outputs again by 0.75 to account for 75% coverage. Take the resulting number and multiply it by an established figure for a 2-hour transport by car to a CEmOC facility (adjust transport price by regional considerations). d	$328050	$286738
Total: Misoprostol treatment or prevention+CEmOC transport package	$1968231	$4150855

Back to Article Outline

4. Discussion 

Misoprostol use for home deliveries could result in decreased mortality and DALYs, at an ICER of $6 for treatment and $170 for prevention. Compared with standard management, this could mean an increase of 9.4 lives saved with treatment or an additional 1.4 lives saved (10.8 total) for a prevention model. The cost difference between standard management and treatment would be $1212 per 10000 women, while expansion to prevention would add another $5721 per 10000 women. There is no universally accepted threshold for considering an intervention “cost-effective.” The Commission for Macroeconomics and Health has proposed that interventions whose cost per DALY averted is less than gross domestic product (GDP) per capita is defined as “very cost-effective” [32]. The estimated GDP per capita in India is $2600; either switching from standard management to misoprostol treatment or from misoprostol treatment to misoprostol prevention would be “very cost-effective.”

Given that few women delivering at home in India receive either prophylaxis or treatment for PPH, these results suggest that a first step could be instituting a treatment package at $6.00 per DALY averted. By world standards, there are extremely few public health interventions that can avert DALYs as cheaply. The government of India currently spends more than this on most public health interventions. For example, diabetes prevention with metformin costs $119 per DALY averted [33].

To proceed with the large-scale distribution of misoprostol for either indication, evidence-based guidelines—tailored for a variety of birth attendants—must be developed and implemented to address appropriate use in settings where lack of trained staff, monitoring, and access to CEmOC can present barriers to safe usage. It is important that misoprostol is not used inappropriately to induce or augment labor as the dose for these indications is much lower (25–50µg, which is 12%–20% of one standard 200µg pill), and even a small dose taken before delivery can result in hyperstimulation, uterine rupture, and maternal or fetal demise [15].

Looking only at cost per life saved, treatment is significantly more cost-effective than prevention. However, cost per life saved is not the only measure of success of a project; in this simulation, the prophylactic misoprostol cohort experienced fewer deaths and fewer cases of severe anemia compared with the treatment group. Other PPH morbidity was not considered. Further, for women residing in remote rural areas with an underlying anemia and with impassable roads or limited access to transportation if transfer is needed, waiting until 500mL of blood is lost for treatment may be too late.

A model that is somewhere between primary prevention and standard treatment for PPH, such as “early treatment,” could be implemented. This could entail not waiting for a PPH diagnosis of 500mL, but providing misoprostol for any blood loss greater than 350mL, which was the 75th percentile in a large community-based placebo trial that measured blood loss [6]. Currently, this strategy cannot be modeled with a cost-effectiveness analysis as there are no data for assumptions or parameters. At a minimum, a trial of “early treatment” might be warranted; it may have greater cost savings than the primary prevention model, while avoiding the higher rates of death and anemia noted with the standard treatment only model.

While cost-effectiveness simulation is a promising addition to clinical trials, it does not supercede the need for rigorous RCTs. There are some limitations to note with any cost-effectiveness simulation [34]. In this particular one, an improved quadratic hemorrhage-mortality model was used along with a cheaper misoprostol dose ($0.66 vs $1), which account for the differences in mortality reduction and cost per life saved between this simulation and a previous simulation with prophylactic misoprostol [13]. However, the relationship between blood loss and mortality is not known with absolute certainty, and initial assumptions create some uncertainty over the absolute number of lives saved by each intervention.

The costs and effects of CEmOC care were not simulated in this analysis. Therefore, the simulation and calculations end at transport. Women who do not receive prophylaxis, but are only treated for PPH, will have a greater need for transport. Further, the model does not factor in the necessary differences in training for prevention or treatment. Prevention guidelines recommend administration of a uterotonic within 1–5 minutes after the delivery of the baby. Learning when to administer a treatment dose is more complex, as visual estimation of postpartum blood loss is highly inaccurate [35], and standardized measuring tools, such as drapes or fracture pans would add to the costs. This analysis does not capture the logistics, storage, or distribution requirements of large quantities of misoprostol needed for prevention, nor how to manage stock outs.

To reach United Nations Millennium Development Goal 5, reducing maternal mortality by 75%, promising interventions need to be scaled up to make a population-level impact. The cost, safety, and efficacy of each intervention must be carefully weighed before distribution programs are rolled out. The results of this cost effectiveness simulation may provide decision-makers with additional information about which strategy is feasible and effective, what clinical trials researchers should pursue, and which interventions may be considered for large-scale implementation.

Back to Article Outline

Acknowledgments 

Dr Bishai was supported by Future Health Systems, a research policy consortium funded by the Department for International Development (DFID).

Back to Article Outline

References 

1. Hill K, Thomas K, AbouZahr C, Walker N, Say L, Inoue M, et al. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet. 2007;370(9595):1311–1319
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (133 KB)
   • CrossRef
2. Prata N, Graff M, Graves A, Potts M. Avoidable maternal deaths: Three ways to help now. Glob Public Health. 2009;4(6):575–587
   • View In Article
   • CrossRef
3. International Institue of Population Studies. In: National Family Health Survey (NFHS-3), 2005-06, India. vol. I:Mumbai: IIPS; 2007;
   • View In Article
4. Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007;62(6):393–399
   • View In Article
   • MEDLINE
   • CrossRef
5. World Health Organization. Unedited Draft Report of the 17th Expert Committee on the Selection and Use of Essential Medicines. Geneva: WHO; 2009;
   • View In Article
6. Derman RJ, Kodkany BS, Goudar SS, Gellar SE, Naik VA, Bellad MD, et al. Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial. Lancet. 2006;368(9543):1248–1253
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (95 KB)
   • CrossRef
7. Hoj L, Cardoso P, Nielsen BB, Hvidman L, Nielsen J, Aaby P. Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial. BMJ. 2005;331(7519):723
   • View In Article
   • CrossRef
8. Walraven G, Blum J, Dampha Y, Sowe M, Morison L, Winikoff B, et al. Misoprostol in the management of the third stage of labour in the home delivery setting in rural Gambia: a randomised controlled trial. BJOG. 2005;112(9):1277–1283
   • View In Article
   • MEDLINE
   • CrossRef
9. Alfirevic Z, Blum J, Walraven G, Weeks A, Winikoff B. Prevention of postpartum hemorrhage with misoprostol. Int J Gynecol Obstet. 2007;99(Suppl 2):S198–S201
   • View In Article
10. International Confederation of Midwives and International Federation of Gynaecology and Obstetrics. Prevention and treatment of post-partum haemorrhage: New advances for low resource settings. Int J Gynecol Obstet. 2007;97(2):160–163
    • View In Article
11. Prata N, Mbaruku G, Campbell M, Potts M, Vahidnia F. Controlling postpartum hemorrhage after home births in Tanzania. Int J Gynaecol Obstet. 2005;90(1):51–55
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (73 KB)
    • CrossRef
12. Sanghvi H, Changpong G, Fishel J, Ahmed S, Zulkarnin M. Prevention of Postpartum Hemorrhage Study, West Java, Indonesia. Baltimore: JHPIEGO; 2004;
    • View In Article
13. Sutherland T, Bishai DM. Cost-effectiveness of misoprostol and prenatal iron supplementation as maternal mortality interventions in home births in rural India. Int J Gynecol Obstet. 2009;104(3):189–193
    • View In Article
14. Blum J. Development of evidence-based regimens on misoprostol. Current evidence: Misoprostol for PPH treatment. In: Misoprostol for prevention and treatment of post-partum hemorrhage (PPH): Current knowledge and future directions. Seattle: Gates Foundation; 2009;
    • View In Article
15. Alfirevic Z, Weeks A. Oral misoprostol for induction of labour. Cochrane Database Syst Rev. 2006;CD001338
    • View In Article
16. Blum J, Alfirevic Z, Walraven G, Weeks A, Winikoff B. Treatment of postpartum hemorrhage with misoprostol. Int J Gynecol Obstet. 2007;99(Suppl 2):S202–S205
    • View In Article
17. Miller S, Tudor C, Thorsten V, Nyima , Kalyang , Sonam , et al. Randomized double masked trial of Zhi Byed 11, a Tibetan traditional medicine, versus misoprostol to prevent postpartum hemorrhage in Lhasa, Tibet. J Midwifery Womens Health. 2009;54(2):133–141.e1
    • View In Article
    • CrossRef
18. AbouZahr C. Maternal Mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA. Geneva: World Health Organization; 2003;
    • View In Article
19. Barnett S, Nair N, Tripathy P, Borghi J, Rath S, Costello A. A prospective key informant surveillance system to measure maternal mortality - findings from indigenous populations in Jharkhand and Orissa, India. BMC Pregnancy Childbirth. 2008;8:6
    • View In Article
    • CrossRef
20. Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066–1074
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (2366 KB)
    • CrossRef
21. Banks E, Meirik O, Farley T, Akande O, Bathija H, Ali M. Female genital mutilation and obstetric outcome: WHO collaborative prospective study in six African countries. Lancet. 2006;367(9525):1835–1841
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (102 KB)
    • CrossRef
22. McCord C, Premkumar R, Arole S, Arole R. Efficient and effective emergency obstetric care in a rural Indian community where most deliveries are at home. Int J Gynecol Obstet. 2001;75(3):297–307discussion 308-9
    • View In Article
23. In:  McFayden JE editors. International drug price indicator guide. Boston: Management Sciences for Health; 2006;
    • View In Article
24. Bradley SE, Prata N, Young-Lin N, Bishai DM. Cost-effectiveness of misoprostol to control postpartum hemorrhage in low-resource settings. Int J Gynecol Obstet. 2007;97(1):52–56
    • View In Article
25. Assisstance Afghanistan. In: Appeal for Afghanistan profile of submissions under thermatic group. Assistance Afghanistan; 1999;
    • View In Article
26. Fauveau V, Stewart K, Khan SA, Chakraborty J. Effect on mortality of community-based maternity-care programme in rural Bangladesh. Lancet. 1991;338(8776):1183–1186
    • View In Article
    • Abstract
    • CrossRef
27. AIM for SEVA. Proposal for maternal and child health care along with mobile dispensary. In: All India Movement for Seva. 2005;
    • View In Article
28. Drummond M, O'Brien B, Stoddart G, Torrance G. Methods for the Economic Evaluation of Health Care Programmes. Second Edition. London: Oxford University Press; 1997;
    • View In Article
29. Bhat PN. Maternal mortality in India: an update. Stud Fam Plann. 2002;33(3):227–236
    • View In Article
    • MEDLINE
30. Murray C, Lopez A. The Global Burden of Disease. Cambridge: Harvard Press; 1996;
    • View In Article
31. Ministry of Health and Family Welfare, Govt. of India: Uttar Pradesh vital statistics. Available at: http://www.mohfw.nic.in/NRHM/State%20Files.up.htm. Accessed June 12, 2009.
    • View In Article
32. World Health Organization. Making Choices in Health: WHO Guide to Cost Effectiveness Analysis. Geneva: World Health Organization; 2003;
    • View In Article
33. Chow J, Darley S, Laxminarayan R. Cost-effectiveness of disease interventions in India. Washington DC: Resources for the Future; 2007;
    • View In Article
34. Briggs AH. Handling uncertainty in cost-effectiveness models. Pharmacoeconomics. 2000;17(5):479–500
    • View In Article
    • MEDLINE
    • CrossRef
35. Patel A, Goudar SS, Geller SE, Kodkany BS, Edlavitch SA, Wagh K, et al. Drape estimation vs. visual assessment for estimating postpartum hemorrhage. Int J Gynecol Obstet. 2006;93(3):220–224
    • View In Article