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] 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 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. In a dynamic microsimulation study, Nicole Young and colleagues compare the cost-effectiveness of antenatal multiple micronutrients and balanced-energy protein supplementation with iron and folic acid supplementation in India, Pakistan, Mali and Tanzania. Author summary Why was this study done? Iron and folic acid (IFA) supplementation and IFA-containing multiple micronutrient supplementation (MMS) taken during pregnancy can improve the health of newborns, particularly by increasing their birth weight, which reduces the risk of infant mortality. For pregnant mothers who are undernourished, increased caloric intake through balanced energy protein (BEP) supplementation can provide an additional benefit on birth weight and its associated health outcomes. We conducted this study to compare the costs and benefits of BEP, MMS, and IFA supplementation in areas burdened by low birth weight (LBW) and its associated health detriments. What did the researchers do and find? We estimated the impact of IFA, MMS, and BEP supplementation in India, Pakistan, Mali, and Tanzania by developing an individual-based dynamic microsimulation model of populations of newborns that tracked their health outcomes during the first 2 years of life. We found that supplying MMS to 90% of women who attend antenatal care (ANC) visits resulted in improving morbidity and mortality among children under 2 at a cost of $52 per disability-adjusted life year (DALY) saved for Pakistan, $72 for Mali, $70 for India, and $253 for Tanzania. Supplying BEP (containing MMS) to 90% of women who attend ANC with low body mass index (BMI) and MMS to 90% of women who attend ANC with adequate BMI saved more DALYs than supplying 90% of all women who attend ANC visits with MMS and was similarly cost-effective at $54 per DALY saved relative to existing IFA practice for Pakistan, $73 for Mali, $83 for India, and $245 for Tanzania. What do these findings mean? High coverage of MMS for women at ANC is a cost-effective strategy to improve child health outcomes relative to the existing coverage and practice of supplying only IFA. While supplying BEP (containing MMS) universally to women at ANC has the greatest impact on child health outcomes, targeting BEP for undernourished women and offering MMS to women of adequate BMI is more cost-effective and has greater impact on child health outcomes than supplying MMS alone. Our findings are limited by applying effects of maternal supplementation regimens from clinical trials to the modeled populations, and we did not model subnational variation.