No official measures are recorded for pre eclampsia testing

No official measures are recorded for pre-eclampsia testing rates in LMICs, so we assumed that women are tested for pre-eclampsia if they have attended at least four antenatal care visits (51% of pregnancies). This assumption is conservative; many women will be tested for pre-eclampsia during one of the first three pre-natal visits, especially if these visits occur late in the pregnancy. Our estimate of the survival rate of untreated pre-eclampsia comes from a population-based survey of a cohort of over 20,000 pregnant women in six West African countries (Prual et al., 2000). Nevertheless, the sensitivity analysis includes results from the range of parameter values found in the literature (78.8–85.6%) (Prual et al., 2000; Mwinyoglee et al., 1996). We modeled magnesium sulfate injection as the standard management technique for pre-eclampsia because it has been accepted as the “drug of choice” for treating pre-eclampsia and is included on the WHO\'s list of priority medicines for mothers and children, the package of commodities needed to achieve the Millennium Development Goal 5 (Sheth and Chalmers, 2002). Magnesium sulfate is easy to administer, even in LMICs, and demonstrably extremely effective, with a success rate of 99.2% in a large international trial (Altman et al., 2002). False positives receiving magnesium sulfate should not experience a negative impact on mortality or morbidity. Side effects of the treatment are minimal and rare. The availability of magnesium sulfate is poor in LMICs despite its recent addition to essential drug lists. With little data available about the availability of magnesium sulfate, we used 16% as our best leukotriene receptor antagonists case estimate based on author\'s (Johnson) experience, but also examined a wide range of possible values so that our results are generalizable to many settings. If magnesium sulfate is unavailable, clinicians may provide valium or a lytic cocktail, however these alternatives will have little to no effect on mortality rates. Cost of treatment with magnesium sulfate was estimated as $13 and $18 per treatment in low- and middle-income countries, respectively (Simon et al., 2006). The cost of severe morbidity due to eclampsia is $80 and $722 in low- and middle-income countries, respectively (Simon et al., 2006). To calculate DALYs associated with the 3.8% of cases resulting in permanent disability due to severe complications of pre-eclampsia, we used a health-related quality of life (HRQL) weight of 0.25 (Lee et al., 2010; Åberg et al., 2011; World Health Organization, 2004). The only parameters in the model that vary by device are sensitivity and specificity. The time period of analysis capture outcomes for the entire lifespan of the pregnant women in our simulation.
Results Table 3 shows the main results on the cost-effectiveness of each intervention. Because the DALYs averted for each device were very similar, the results primarily depended on the per-use cost ranking. With the lowest combined per-use cost of 0.204 cents and incremental cost-effectiveness ratio of $93.6 per DALY gained relative to a baseline scenario with no access to testing or treatment, the Microlife semi-automatic blood pressure monitor with the Uristik single-use proteinuria strips was the most cost-effective combination of medical devices to improve the diagnosis of pre-eclampsia. The device combinations on the cost-effectiveness frontier (undominated) were, in order of increasing incremental cost-effectiveness ratio: Nissei DM3000/CLINITEK strip test, the sphygmomanometer/CLINITEK strip test, and the sphygmomanometer/DCA 2000+. The SpotVital blood pressure device and the Multistix proteinuria test were strongly dominated in all combinations. To be on the cost-effectiveness frontier, the SpotVital device would need to have a per-use cost that implies well over 10,000 uses at the quoted price, which is implausible in LMICs. Extended (weak) dominance ruled out two combinations: Nissei DM3000/Uristik and sphygmomanometer/Uristik.