Cost-Effectiveness of Folic Acid Supplementation Strategies for Preventing Neural Tube Defects in Ethiopia: A Markov Model Analysis

Abstract Background Neural tube defects (NTDs) are congenital malformations of the brain and spinal cord that result from the incomplete development of the central nervous system. NTDs impose severe lifelong medical and socioeconomic burdens, particularly in low-resource settings such as Ethiopia. Despite the prevalence of NTDs in Africa, including Ethiopia, there is a lack of epidemiological studies on the condition. This study aims to assess the cost-effectiveness of folic acid supplementation for the prevention of NTDs in pregnant women of childbearing age in Ethiopia. Methods A Markov model was constructed to compare the cost and effectiveness of folic acid 0.05 mg supplementation using a restricted societal perspective. Three supplementation strategies were evaluated: supplementation during pregnancy, supplementation when women plan pregnancy, and supplementation for all women of childbearing age. Results pre-conception folic acid use resulted in higher quality-adjusted life years (QALYs) of 0.87, compared to 0.71 QALYs for use at conception. Lifetime costs were $262.8 for folic acid use during conception, $309.7 for pre-conception, and $779.3 for use throughout the childbearing years. Pre-conception and childbearing age use increased QALYs by 0.16 at incremental costs of $46.94 and $516.54, respectively. The cost per QALY was $370.7 for conception, $354.4 for pre-conception, and $891.8 for childbearing age use. The incremental cost-effectiveness ratio (ICER) for pre-conception compared to conception was $284.6 per QALY, below the willingness-to-pay threshold of $783, indicating pre-conception use as a cost-effective strategy. Net monetary benefits (NMB) were $374.6 for pre-conception use, $292.4 for conception, and -$95.1 for childbearing age use, highlighting pre-conception as the most cost-effective approach in preventing NTDs in Ethiopia. Conclusion Pre-conception folic acid supplementation is the most cost-effective approach for preventing NTDs in Ethiopia, yielding greater quality-adjusted life years (QALYs) at a lower incremental cost compared to supplementation at conception or throughout the childbearing years. The favourable incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB) affirm the economic value of pre-conception use, supporting its prioritization as a public health strategy for NTD prevention.