It is cost effective to improve the standard of care for women experiencing miscarriage
Authors: Sarita Sonalkar, Courtney A Schreiber
Journal: The Lancet Global Health (2019)

In The Lancet Global Health, Ilias Goranitis and colleagues1Goranitis I Lissauer DM Coomarasamy A et al.Antibiotic prophylaxis in the surgical management of miscarriage in low-income countries: a cost-effectiveness analysis of the AIMS trial.Lancet Glob Health. 2019; 7: e1280-e1286Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar report on a secondary cost-effectiveness analysis of data from the AIMS study,2Lissauer D Wilson A Hewitt CA et al.A randomized trial of prophylactic antibiotics for miscarriage surgery.N Engl J Med. 2019; 380: 1012-1021Crossref PubMed Scopus (7) Google Scholar a large multinational, randomised, controlled trial evaluating the effectiveness of prophylactic antibiotics for infection prevention in surgical management of miscarriage. The uterine evacuation techniques used for miscarriage treatment in the countries in which women were enrolled included sharp curettage (about 70% of participants) and vacuum aspiration (30%). The AIMS study reported that antibiotic prophylaxis did not result in a significantly lower relative risk of pelvic infection as defined by pragmatic broad criteria;2Lissauer D Wilson A Hewitt CA et al.A randomized trial of prophylactic antibiotics for miscarriage surgery.N Engl J Med. 2019; 380: 1012-1021Crossref PubMed Scopus (7) Google Scholar however, Goranitis and colleagues' analysis highlights a significant absolute risk difference in the effectiveness outcome of −1·3%, which translates to a number needed to treat of 77 women to prevent one infection. The effectiveness outcome appears equivocal based on the negative finding in the AIMS study and the relatively small effect size reported in the secondary cost-effectiveness analysis. However, Goranitis and colleagues found that antibiotic prophylaxis had a high probability of cost effectiveness across a wide range of willingness-to-pay thresholds for pelvic infections avoided. Data for beneficial effects of antibiotic prophylaxis for surgical treatment of miscarriage has until now been lacking, and this study reveals the resultant decreased resource use and cost to the health system with antibiotic use. Especially in low-income and middle-income countries, these findings have important policy implications. The authors of the AIMS study state that they made a careful choice to use the selected regimen of doxycycline and metronidazole, owing to their effectiveness in treating pelvic infection, wide availability, and low cost. Although this regimen was cost-effective on a country level, practices on an individual level might find that two antibiotics are burdensome to implement and expensive. The Society of Family Planning recommends a single dose of doxycycline for prophylaxis before induced abortion.3Achilles SL Reeves MF Society of Family PlanningPrevention of infection after induced abortion: release date October 2010: SFP guideline 20102.Contraception. 2011; 83: 295-309Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar If doxycycline is similarly effective in comparison to doxycycline and metronidazole together, then the single-dose doxycycline alone regimen might be even more cost effective. Absent from the analysis by Goranitis and colleagues1Goranitis I Lissauer DM Coomarasamy A et al.Antibiotic prophylaxis in the surgical management of miscarriage in low-income countries: a cost-effectiveness analysis of the AIMS trial.Lancet Glob Health. 2019; 7: e1280-e1286Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar are data on cost effectiveness of antibiotic prophylaxis for women who received vacuum aspiration rather than sharp curettage. Vacuum aspiration has been shown to result in decreased bleeding and pain with uterine evacuation4Tuncalp O Gulmezoglu AM Souza JP Surgical procedures for evacuating incomplete miscarriage.Cochrane Database Syst Rev. 2010; 9CD001993PubMed Google Scholar compared with sharp curettage. For participants in the AIMS study who underwent vacuum aspiration, 1·3% of women in the antibiotic prophylaxis group and 4·1% in the placebo group were diagnosed with infection, compared with 5·3% (antibiotic prophylaxis group) and 6·0% (placebo group) of women who received sharp curettage. Although the study was not powered for multiple comparisons, the magnitude of these differences deserves attention. Based on these findings, changing practice to use vacuum aspiration rather than sharp curettage, even without antibiotic prophylaxis, could result in a greater decrease in infection than the universal use of prophylactic antibiotics. The use of antibiotics in the vacuum aspiration group resulted in an absolute risk difference of −2·8%, which translates to an number needed to treat of 35. Although it appears to be cost effective to use antibiotics as prophylaxis for sharp curettage and vacuum aspiration for miscarriage, the cost effectiveness of sharp versus vacuum evacuation would also be an important analysis. Equipment for manual vacuum aspiration is inexpensive (about US$10) and the total cost of a procedure including personnel, consumables, medication, equipment, and laboratory supplies was estimated in a South African study to be about $70.5Lince-Deroche N Fetters T Sinanovic E Devjee J Moodley J Blanchard K The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa.PLoS One. 2017; 12e0174615Crossref PubMed Scopus (11) Google Scholar Although training of providers in manual vacuum aspiration requires investment, the AIMS study suggests that such a large decrease in infection using the combined strategies of vacuum aspiration and prophylactic antibiotics would result in significant offset of costs. Future research should consider hybrid implementation effectiveness designs to compare sharp curettage versus vacuum aspiration. Regardless of future research directions, countries should use their resources to invest in programmes to expand the use of manual vacuum aspiration and medical management over sharp curettage. Medical management, with misoprostol for incomplete abortion, and mifepristone and misoprostol for missed abortion, is another effective option treatment option6Schreiber CA Creinin MD Atrio J Sonalkar S Ratcliffe SJ Barnhart KT Mifepristone pretreatment for the medical management of early pregnancy loss.N Engl J Med. 2018; 378: 2161-2170Crossref PubMed Scopus (60) Google Scholar and is cost-effective.7Nagendra D Schreiber CA Koelper N Sonalkar S Loza-Avalos S Harvie H Abstract: cost effectiveness of mifepristone pretreatment for the medical management of nonviable early pregnancy.Obstet Gynecol. 2019; 133: 6Crossref PubMed Google Scholar, 8Rausch M Lorch S Chung K Frederick M Zhang J Barnhart K A cost-effectiveness analysis of surgical versus medical management of early pregnancy loss.Fertil Steril. 2012; 97: 355-360Summary Full Text Full Text PDF PubMed Scopus (48) Google Scholar The results of this cost-effectiveness analysis are important not only in the context of miscarriage, but also in the context of induced abortion. Globally, nearly 50% of induced abortions are considered unsafe owing to a scarcity of trained providers or appropriate methods.9Guttmacher InstituteInduced abortion worldwide: global incidence and trends.https://www.guttmacher.org/fact-sheet/induced-abortion-worldwideDate: 2018Date accessed: July 18, 2019Google Scholar Self-managed medical abortion is frequently used in settings where induced abortion in the health-care setting is inaccessible10Erdman JN Jelinska K Yanow S Understandings of self-managed abortion as health inequity, harm reduction and social change.Reprod Health Matters. 2018; 26: 13-19Crossref PubMed Scopus (18) Google Scholar and, depending on the method used, frequently results in the need for surgical treatment by a medical provider to complete the process. With millions of women enduring induced abortion and miscarriage each year and thus requiring surgical treatment, investment in women's health with training in vacuum aspiration and use of antibiotic prophylaxis will not only be an investment in the financial health of countries but in the health of women and families. SS reports funding from the US National Institutes of Health. CAS reports non-financial support from Athenium , outside of the submitted work, and has patent pending (number 62/777 369 ). Antibiotic prophylaxis in the surgical management of miscarriage in low-income countries: a cost-effectiveness analysis of the AIMS trialAntibiotic prophylaxis is more effective and less expensive than no antibiotic prophylaxis. Policy makers in various settings should be confident that antibiotic prophylaxis in miscarriage surgery is cost-effective. Full-Text PDF Open Access