A Cost-Effectiveness Model for Comparing Multiple Micronutrient Supplements to Iron and Folic Acid Supplements During Pregnancy: Applications in Pakistan, Bangladesh, and India

Background - Recent evidence has encouraged low- and middle- income countries to consider transitioning from long-standing iron and folic acid supplementation (IFAS) to multiple micronutrient supplementation (MMS) during pregnancy. However, global guidance is limited. To help countries' decision-making, a cost-effectiveness model to compare the supplementation modalities was developed, and applied to: Pakistan, Bangladesh, and India. Methods - The effectiveness of IFAS relative to MMS during pregnancy was compared using eight health outcomes reported in the literature: maternal anaemia, preterm delivery, small-for-gestational-age newborns, low birth weight, stillbirths, and maternal, neonatal, and infant mortality. Outcomes were aggregated using disability-adjusted life years (DALYs) to derive an overall effectiveness of IFAS and MMS. Costs included the supplements and their distribution through antenatal care. The incremental cost-effective ratio (ICER) for transitioning from IFAS to MMS was calculated for each country, and Monte Carlo simulations were applied to generate a measure of certainty around the results. Findings - In Pakistan, Bangladesh, and India, MMS would avert 11,749, 12,462 and 9,332 more DALYs than IFAS per 100,000 pregnancies, respectively (80.0%, 91.0%, 87.0% certainty). The ICER of transitioning from IFAS to MMS was 15.53, 13.94, and 19.55 USD (2016) per DALY averted, respectively. Interpretation - As per World Health Organization criteria, transitioning from IFAS to MMS is cost-effective. While the effectiveness of MMS is sensitive to the prevalence of various health outcomes, with high confidence 80.0%-91.0% MMS averts more DALYs than IFAS and should re-enter public health discussion in Pakistan, Bangladesh, and India. Funding Information: Nutrition International with a grant from Global Affairs Canada and World Vision Canada. Competing Interest Declaration: All authors declare they have no conflicts of interest.