Cost-effectiveness of mifepristone and misoprostol versus misoprostol alone for the management of missed miscarriage: an economic evaluation based on the MifeMiso Trial

Duby Okeke Ogwulu, Eleanor Williams, Justin Chu, Adam Devall, Leanne Beeson, Pollyanna Hardy, Versha Cheed, Yongzhong Sun, Laura Jones, Jenny La Fontaine, Ruth Bender Atik, Jane Brewin, Kim Hinshaw, Meenakshi Choudhary, Amna Ahmed, Joel Naflalin , Natalie Nunes, Abigail Oliver, Feras Izzat, Kalsang BhatiaIsmail Hassan, Yadava Jeve, Jude Hamilton, Debs Shilpa, Cecilia Bottomley, Jackie Ross, Linda Watkins, Martyn Underwood, Ying Cheong, Chitra S Kumar, Pratima Gupta, Rachel Small, Stewart Pringle, Frances Hodge, Anupama Shahid, Andrew W. Horne, Siobhan Quenby, Ioannis Gallos, Arri Coomarasamy, Tracy Roberts

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Objective: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. Design: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK’s National Health Service (NHS). Setting: Twenty-eight UK NHS early pregnancy units. Sample: A cohort of 711 women aged 16–39 years with ultrasound evidence of a missed miscarriage. Methods: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. Main outcome measures: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). Results: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7–12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI −0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26–£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. Conclusions: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. Tweetable abstract: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.

Original languageEnglish
Pages (from-to)1534-1545
JournalBJOG: An International Journal of Obstetrics & Gynaecology
Issue number9
Early online date10 May 2021
Publication statusE-pub ahead of print - 10 May 2021

Bibliographical note

Funding Information:
The National Institute for Health Research (NIHR) Health Technology Assessment programme (15/160/02) funded this project. A final report of data collected in this study will be published in the NIHR Journals Library. The views expressed in this article are those of the authors and not necessarily those of the UK National Health Service, the NIHR or the UK Department of Health and Social Care. The charity Tommy’s, whose funding supports the UK National Miscarriage Research Network, also supported the project.

Publisher Copyright:
© 2021 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.


  • Cost-effectiveness
  • cost utility
  • economic evaluation
  • management
  • miscarriage
  • model

ASJC Scopus subject areas

  • Obstetrics and Gynaecology


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