Cost-Effectiveness of Multiple Micronutrients and Balanced-Energy Protein Supplementation During Antenatal Care in India, Pakistan, Mali and Tanzania: A Dynamic Microsimulation

Background: Antenatal energy and micronutrient supplementation can improve birth outcomes and reduce disease burden but no studies have compared their cost-effectiveness. We compared the cost-effectiveness of multiple micronutrient supplementation (MMS), and balanced-energy protein (BEP) with iron and folic acid (IFA) to quantify their benefit in four countries with high prevalence of maternal undernutrition. Methods: Using estimates from the Global Burden of Disease 2017 Study, we simulated birth cohorts for two years in India, Pakistan, Mali, and Tanzania. 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 attendees receive either MMS, BEP, or targeted-BEP (women with pre-pregnancy BMI <18·5 kg/m2 receive BEP containing MMS while women with BMI ≥18·5 kg/m2 receive MMS). Findings: ICERs for all scenarios were lowest in Pakistan, followed by Mali, India and Tanzania, in line with the baseline trend in attributable burden of low-birthweight. Targeted-BEP averts more DALYs than MMS alone while remaining cost-effective. ICERs for MMS compared to baseline were $9 (95%UI: $5-14) for Pakistan, $13 (95%UI: $7-21) for Mali, $13 (95%UI: $8-20) for India, $44 (95%UI: $20-80) for Tanzania. ICERs for targeted-BEP compared to baseline were $38 (95%UI: 23-54) for Pakistan, $51 (95%UI: 29-80) for Mali, $82 (95%UI: 56-115) for India, and $148 (95%UI: 77-250) for Tanzania. Interpretation: As countries start to invest in replacing IFA with MMS in alignment with recent WHO guidelines, co-implementing targeted-BEP offers a worthwhile and cost-effective strategy that should be considered at the same time to maximise benefits and synergize programme implementation. Funding Statement: Funded by the Bill and Melinda Gates Foundation for this project. Declaration of Interests: ADF has consulted recently for Janssen; SwissRe; Sanofi; Merck for Mothers; and Agathos, Ltd. Other authors have no conflicts of interest to disclose.