title: Optimizing treatment for the prevention of pre-eclampsia/eclampsia in Nepal: is calcium supplementation during pregnancy cost-effective?
abstract: BACKGROUND
  In Nepal, pre-eclampsia/eclampsia (PE/E) causes an estimated 21% of maternal deaths annually and contributes to adverse neonatal birth outcomes. Calcium supplementation has been shown to reduce the risk of PE/E for pregnant women and preterm birth. This study presents findings from a cost-effectiveness analysis of a pilot project, which provided calcium supplementation through the public sector to pregnant women during antenatal care for PE/E prevention as compared to existing PE/E management in Nepal.
  
  
  METHODS
  Economic costs were assessed from program and societal perspectives for the May 2012 to August 2013 analytic time horizon, drawing from implementing partner financial records and the literature. Effects were calculated as disability-adjusted life years (DALYs) averted for mothers and newborns. A decision tree was used to model the cost-effectiveness of three strategies delivered through the public sector: (i) calcium supplementation in addition to the existing standard of care (MgSO4); (ii) standard of care, and (iii) no treatment. Uncertainty was assessed using one-way and probabilistic sensitivity analyses in TreeAge Pro.
  
  
  RESULTS
  The costs to start-up calcium introduction in addition to MgSO4were $44,804, while the costs to support ongoing program implementation were $72,852. Collectively, these values correspond to a program cost per person per year of $0.44. The calcium program corresponded to a societal cost per DALY averted of $25.33 ($25.22-29.50) when compared against MgSO4treatment. Primary cost drivers included rate for facility delivery, costs associated with hospitalization, and the probability of developing PE/E. The addition of calcium to the standard of care corresponds to slight increases in effect and cost, and has a 84% probability of cost-effectiveness above a WTP threshold of $40 USD when compared to the standard of care alone.
  
  
  CONCLUSIONS
  Calcium supplementation for pregnant mothers for prevention of PE/E provided with MgSO4for treatment holds promise for the cost-effective reduction of maternal and neonatal morbidity and mortality associated with PE/E. The findings of this study compare favorably with other low-cost, high priority interventions recommended for South Asia. Additional research is recommended to improve the rigor of evidence available on the treatment strategies and health outcomes.
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205 USA.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Feldhaus
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205 USA.
authors.forename: Amnesty E
authors.initials: AE
authors.lastname: LeFevre
authors.affiliation: Jhpiego, Oasis Building, Patan Dhoka, Lalitpur, Nepal.
authors.forename: Chandra
authors.initials: C
authors.lastname: Rai
authors.affiliation: Jhpiego, Oasis Building, Patan Dhoka, Lalitpur, Nepal.
authors.forename: Jona
authors.initials: J
authors.lastname: Bhattarai
authors.affiliation: Jhpiego, 615 Thames Street, St# 200, Baltimore, MD 21231 USA.
authors.forename: Deirdre
authors.initials: D
authors.lastname: Russo
authors.affiliation: Maternal and Child Health Integrated Program, Jhpiego, 1776 Massachusetts Avenue, NW, Washington, DC 20036 USA.
authors.forename: Barbara
authors.initials: B
authors.lastname: Rawlins
authors.affiliation: Ministry of Health, Government of Nepal, Teku, Kathmandu Nepal.
authors.forename: Pushpa
authors.initials: P
authors.lastname: Chaudhary
authors.affiliation: Jhpiego, Oasis Building, Patan Dhoka, Lalitpur, Nepal.
authors.forename: Kusum
authors.initials: K
authors.lastname: Thapa
keywords: Antenatal care; Calcium; Cost-effectiveness; Eclampsia; Low-income countries; Magnesium sulfate; Maternal mortality; Micronutrients; Nepal; Pre-eclampsia