FEASIBILITY AND COST BENEFIT ANALYSIS OF INTRODUCING THROMBOPHILIA SCREENING IN ANTENATAL CARE IN

ZIMBABWE

BY

TATENDA DOROTHY PARAWIRA

R144284R

PROJECT SUBMITTED IN THE PARTIAL FULFILLMENT OF THE REQUIREMENTS OF MASTER OF SCIENCE DEGREE IN

LABORATORY HEMATOLOGY AND TRANSFUSION

HAEMATOLOGY UNIT

DEPARTMENT OF LABORATORY DIAGNOSTIC AND INVESTIGATIVE SCIENCES

FACULTY OF MEDICINE AND HEALTH SCIENCES

 JUNE 2024

SUPERVISOR: DR A. MARAMBA

Certificate of completion of research project

Turn it in Report
ABSTRACT
ACKNOWLEDGEMENTS
Table of Contents
CHAPTER ONE: BACKGROUND AND LITERATURE REVIEW
1.0 Introduction
By definition, thrombophilia is a predisposition to inappropriately form clots (Thrombosis Journal et al 2016). The predisposition to inappropriately
clots can stem from various factors including some genetically acquired factors, in the clotting mechanism acquired changes, or, both an interaction
between some genetic factors and acquired factors. A hereditary thrombophilia results when an inherited factor, such as antithrombin or protein C
deficiency, requires interaction with components that are inherited or acquired before onset of a clinical disorder (Khan S, Dickerman JD et al 2006).
A homozygous abnormality or combination of two or more heterozygous abnormal factors can lead to clinically apparent thrombotic disorders at an
early age (Lane DA, Mannucci PM et al 1996). However, milder heterozygous traits, when existing alone, are more often discovered by laboratory
investigation.

1.0 .1 Clotting and Fibrinolysis

In 1856, Rudolf Virchow proposed a hypothesis to explain the aetiology of pulmonary emboli, which lead to the understanding of the three primary

causes of venous and arterial thrombosis: stasis, injury to the vessel wall and abnormalities in the circulating blood. Subsequently, numerous

investigators elucidated the concept of a haemostatic balance between fibrin formation and fibrin dissolution

1.0.2The coagulation cascade

The coagulation and fibrinolytic systems are two separate but linked enzyme cascades that regulate the formation and breakdown of fibrin. The

blood clotting system or coagulation pathway, like the complement system, is a proteolytic cascade. Each enzyme of the pathway is present in the

plasma as a zymogen (an inactive form), which, on activation, undergoes proteolytic cleavage to release the active factor from the precursor

molecule. The coagulation pathway

functions as a series of positive and negative feedback loops which control the activation process. The ultimate goal of the pathway is to produce

thrombin, which can then convert soluble fibrinogen into fibrin, which forms a clot. The generation of thrombin can be divided into three phases:

the intrinsic and extrinsic pathways that provide alternative routes for the generation of factor X, and the final common pathway which results in

thrombin formation.

Coagulation is initiated when factor VIIa binds to tissue-factor (TF) on the surface of endothelial cells and monocytes at sites of vascular injury. The

TF-factor VII complex activates factor IX and X to factors IXa and Xa, respectively. Factor Va and Xa, together, activate prothrombin to thrombin.

Thrombin has multiple prothrombotic roles: it cleaves soluble fibrinogen to insoluble fibrin that will eventually form the haemostatic plug, and

activates factors V, VIII, XI and XIII. Thrombin also acts to produce an anticoagulant effect by forming an enzyme complex with thrombomodulin

to activate protein C. The tissue factor-VIIa complex is rapidly inactivated by the TF pathway inhibitor.

1.0.3 Natural inhibitors of coagulation

Activated coagulation factors are serine proteases, and their activity is modulated by several naturally occurring plasma inhibitors. The most

important inhibitors of the blood coagulation system are antithrombin, protein C, and protein S, Antithrombin (AT) is a serine proteinase inhibitor

that plays a significant role in the process of coagulation by interaction with its co-factor, heparin. Antithrombin inactivates thrombin directly, and

also inactivates factors IX, X and XI by forming a covalent complex. Protein C is activated by thrombin, a process greatly enhanced by the

interaction of thrombin with thrombomodulin. Activated protein C proteolytically inactivates factors Va and VIIIa on the platelet and endothelial

cell surface and hence serves to block thrombin generation and the subsequent steps in coagulation. Protein C requires protein S, another vitamin K

dependent molecule as a co-factor. The imbalance between reduced inhibitors of coagulation and/or increased activation of coagulation factors lead

to thrombosis (Khan S, Dickerman JD et al 2006)

 1.0.4 Types of thrombophilia
As has been mentioned earlier, thrombophilia can be acquired or genetic. Acquired causes include heparin-induced thrombocytopenia,

antiphospholipid antibody syndrome, neoplasia, oral contraceptive use, obesity, smoking and surgery. Primary disorders or genetic causes of

thrombophilia include factor V Leiden mutation, deficiency antithrombin III, protein C or S, histidine-rich glycoprotein deficiency and

prothrombin-related thrombophilia.

Factor V Leiden Mutation

Factor V Leiden (FVL) is a point mutation of factor V resulting in an elimination of the cleavage site in factor V and factor Va. This genetic

defect increases the risk of thrombosis, especially in homozygous or pseudo-homozygous FVL-mutated individuals. Many individuals with the

mutation will never develop a venous thrombotic event (VTE). FVL is an autosomal dominant genetic condition that exhibits incomplete

penetrance, meaning that not every person with the mutation will develop the disease. (Albagoush SA et al 2023) Normally, factor V synthesis

principally occurs in the liver. Thrombin activates factor V, and once activated, it will convert prothrombin to thrombin. Activated protein C, one

of the principal physiologic inhibitors of coagulation, degrades factor V. In the presence of what is called thrombomodulin, thrombin acts to

decrease clotting by activating protein C; therefore, the concentration and the action of protein C are important determinants in the negative

feedback loop through which thrombin limits its activation. ( Kourlaba G,et al 2016).

Factor V Leiden is an autosomal dominant genetic condition that exhibits incomplete penetrance, meaning that not every person with the

mutation will develop the disease.

Factor V Leiden, also known as factor VR506Q and factor V Arg506 Gln, results from a single-point mutation in the factor V gene (guanine to

adenine at nucleotide 1691), which leads to a single amino acid change (replacement of arginine with glutamine at amino acid 506). This abolishes

the Arg506 cleavage site for activated protein C in Factor V and Va.Factor V Leiden increases the risk of thrombosis as activated protein C, a

natural anticoagulant, can not bind and inactivate factor V as there is a mutation in the binding site on factor V for activated protein C. Therefore,

as factor V is not inactivated, it continues to be active and increases thrombosis risk. ( Albagoush SA et al 2023)

Prothrombin gene mutation

In 1996, Poort et al described single amino acid genetic variation in the 3' untranslated region of the gene that codes for prothrombin. Prothrombin

(factor II) is the precursor to thrombin, the end-product of the coagulation cascade. Prothrombin has procoagulant, anticoagulant and antifibrinolytic

activities and thus a disorder involving prothrombin results in multiple imbalances in haemostasis. The prothrombin G20210A gene mutation is

associated with an elevated risk of deep vein thrombosis, although to a lesser degree than factor V Leiden is (Kujovich JL et al 2021)

Protein C deficiency

Protein C deficiency is inherited in an autosomal dominant manner and is associated with familial venous thrombosis. The gene for protein C is

located on chromosome 2 (2q13–14) and appears to be closely related to the gene for factor IX. The primary effect of activated protein C (APC) is

to inactivate coagulation factors Va and VIIIa, which are necessary for efficient thrombin generation and factor X activation. The inhibitory effect of

APC is markedly enhanced by protein S, another vitamin K-dependent protein.Two major subtypes of heterozygous protein C deficiency (Type I

and Type II) have been delineated using immunologic and functional assays (Gupta A et al 2022)

Type I deficiency – The type I deficiency state is more common. Most affected patients are heterozygous, having a reduced plasma protein C

concentration at approximately 50 percent of normal in both immunologic and functional assays. (Gupta A et al 2022)
 Type II deficiency – Individuals with the type II deficiency state have normal plasma protein C antigen levels with decreased functional activity. A

variety of different point mutations affecting protein function have been identified in this disorder (Gupta A et al 2022)

Protein S deficiency

Protein S serves as a cofactor for activated protein C. There are two homologous genes for protein S: PROS1 and PROS2, which both map to

chromosome 3. Three phenotypes of protein S deficiency have been defined on the basis of total protein S antigen concentrations, free protein S

concentrations, and protein S functional activity. (Dahlbäck B et al 2018)

Type I – The classic type of protein S deficiency is associated with a decreased level of total S antigen (approximately 50% of normal), and marked

reductions in free protein S antigen and protein S functional activity.(Gupta A et al 2022)

Type II – This type of protein S deficiency is characterized by normal total and free protein S levels, but diminished protein S functional activity.
Interestingly, all five mutations originally described in these patients were missense mutations located in the N-terminal end of the protein S
molecule, which includes the domains that interact with activated protein C (Gupta A et al 2022)

Type III – Also known as type IIa, this is characterized by total protein S antigen measurements in the normal range and selectively reduced levels of

free protein S and protein S functional activity to less than approximately 40 percent of normal.

Protein S deficiency is inherited in an autosomal dominant manner and is at least as common as antithrombin and protein C deficiency. The clinical

manifestations are similar to those seen with antithrombin and protein C deficiency. Thrombosis occurs in heterozygotes whose levels of functional

protein S are in the range of 15–50% of normal. (Gupta A et al 2022)

Antithrombin Deficiency
Antithrombin (AT) deficiency is a heterogeneous disorder. AT It is usually inherited in an autosomal dominant fashion, thereby affecting both sexes

equally. There are different AT deficiencies based on the subtypes, as follows (Patnaik MM et al 2008)

Type I – The type I deficiency state results from reduced synthesis of biologically normal protease inhibitor molecules. In these cases, both the

antigenic and functional activity of AT in the blood are reduced. The values are reduced by approximately 50 percent in the heterozygote.

Type II – Type II AT deficiency is produced by a discrete molecular defect within the protein. While the AT immunologic activity is normal in this

deficiency, plasma AT functional activity is markedly reduced leading to risk of thrombosis.

Type III – This type is characterized by normal functional and antigenic antithrombin levels but impaired interaction between AT and heparin.
1.1 Literature Review
1.2.1Background information

Miscarriage in the first and second trimesters of pregnancy is very common, and coagulopathy can be a contributing factor (Abu-Heija A et al

2014). Women with these coagulation factor deficiencies have a higher risk of developing blood clots in the placenta, which can lead to placental

insufficiency and, ultimately, to a miscarriage. Normal pregnancy is associated with increased procoagulants, decreased fibrinolysis, and decreased

anticoagulants to maintain placental haemostasis during pregnancy. Functional protein C or S levels do not typically change significantly during a

normal pregnancy. Only the levels of free protein S fall significantly during the first and second trimesters of pregnancy, but there is no further

decrease during the third trimester. Protein S deficiency is more commonly identified than protein C deficiency, constituting an overall 15-fold

increased risk of recurrent pregnancy loss (Liu X et al 2021)

. Therefore, thrombophilia screening in women who have experienced pregnancy loss may be appropriate, and treatment with low molecular weight

heparin (LMWH) may be an option (Liu X et al 2021)

Proteins C and S are vitamin K-dependent plasma proteins that work together as an integral part of the body’s natural anticoagulant system. They

work through the selective inactivation of Factors Va and VIIIa.

Mutations in protein C and S genes are the main causative factors for their deficiencies. In addition, acquired deficiencies can also occur due to

multiple mechanisms and/or the use of certain drugs. This condition demands even more attention among pregnant women, given the

hypercoagulable state of pregnancy.

1.2.2 Diagnosis of Thrombophilia

The most common hereditary thrombophilia that predispose to venous thrombosis in the Caucasian population are the heterozygous forms of the
factor V Leiden and prothrombin G20210A mutation that are generally detected by direct DNA genotyping (Linnemann B, et al 2019).

Immunologic antigen assays and chromogenic or clot-based activity assays are used to identify deficiencies in the natural coagulation
inhibitors antithrombin, protein C and protein S. Because pre-analytical errors and acquired causes of low antithrombin, protein C or protein S levels

are considerably more common than hereditary deficiencies, all potential conditions that may lower activity levels of the natural coagulation

inhibitors (e.g. concomitant liver disease, pregnancy, anticoagulant therapy) must be considered and excluded before the diagnosis of an inhibitor

deficiency can be made (Linnemann B, et al 2019).

1.2.3 Studies on the prevalence of thrombophilia in recurrent pregnant loss

Many studies have demonstrated that acquired or inherited thrombophilia is associated with recurrent pregnancy loss. A study done in Kosovo in

2015 aimed at assessing the prevalence and role of antithrombin III, protein C and protein S deficiencies and activated protein C resistance in

women with recurrent pregnancy loss in first trimester of pregnancy. The aim of this study was to evaluate the prevalence and role of inherited

thrombophilia in early pregnancy loss, specifically in the first trimester. A total of 104 women (patients) with a history of two or more

miscarriages during the first trimester of pregnancy and 110 women (controls) who had experienced two or more births without a miscarriage were

included in this study. In the patient group, deficiencies of antithrombin, protein C and S were detected in 3 (2.88%), 4 (3.85%), and 6 (5.77%)

cases, respectively. In the control group, ATIII (0%) deficiencies were not detected, and deficiencies for PC (0.9%) and PS (0.9%) were each

detected in 1 patient. The conclusion of this study was that thrombophilia is a causal factor for miscarriages in the first trimester of pregnancy

(Mekaj Y et al 2015)

Similarly, Beenish Mukhtar et al 2023 investigated protein C and S levels in pregnant women with recurrent early pregnancy loss versus normal

pregnancy. They performed a detailed history, examination, and various lab tests on a cohort of 40 females with a history of recurrent first and

second-trimester abortions visiting an outpatient clinic at a multi-specialty hospital in Kashmir, India. All the findings were compared with 40

women with normal pregnancies. 10% of the participants had low protein C and S levels (P=0.277), out of whom 75% (p<0.001) had intrauterine

growth retardation (IUGR) on ultrasound with 67% (p<0.001) having

reduced doppler flow in the umbilical artery. 0.05% of participants had isolated protein S deficiency with no concomitant IUGR seen. Patients with

protein C and S deficiencies were treated with heparin and progesterone and followed up for pregnancy outcomes.

A study done in Syria in 2022 investigated the protein C deficiency and its effects on in-vitro fertilization outcome and recurrent pregnancy loss. A

total of 238 women, who had IVF cycles between January 2012 and December 2017 in a tertiary care hospital were included. The prevalence of

protein C deficiency was 13.45%. There was a significant association between the protein C level and recurrent pregnancy loss (RPL).

Furthermore, the protein C deficiency has an impact on the IVF results.

Hussein Naji Alshammary et al 2015 investigated protein C and S deficiency in recurrent pregnancy loss in Iraq. The aim of the study was to

identify protein C and protein S deficiency in women with recurrent pregnancy loss. 90 women were involved in the study, 45 of them have three

or more miscarriages in the first and second trimester considered as patient group, 45 healthy women at time of full term delivery with at least one

alive child as control group. Full history was taken from patients and controls. Blood investigations were done for protein C and protein S levels by

using ELISA (enzyme linked immune sorbent assay).Platelets count was performed by auto analyzer (Ruby). The results showed a significant

relation of low protein S with recurrent miscarriage (P =0.002) OR=2.250 (95%C.I. 1.764-2.870), while the relation of low protein C with

recurrent miscarriage was not significant (P>0.05). There was a significant association of low protein S and low protein C with the abortion

occurred in the second trimester.

In contrast, Alileza Parand et al 2013 investigated inherited thrombophilia and recurrent pregnant loss. The aim was to determine the frequency of

FII G20210A and FVL polymorphisms as well as protein C and protein S deficiency in a series of patients with recurrent pregnancy loss compared
with control group. The
study group included 90 randomly selected patients with three or more consecutive miscarriages with the same partner in <20 weeks gestation in

2012. The control population consisted of 44 age-matched women with at least one live born child and no history of pregnancy loss. Functional

activity of protein C and S, activated protein C resistance, FVL assay by polymerase chain reaction and prothrombin gene mutation were assessed.

The polymorphism frequencies were recorded for each group and comparisons were made. The mean functional activity of protein C and protein S

were not significantly different between case and control groups (P >0.05). Frequency of protein C deficiency was also not significantly different

between the case and control groups (P=0.906), but frequency of protein S deficiency was significantly higher in patients than controls (P=0.03).

Genotype pattern of the patients and healthy individuals were not significantly different with regard to either FVL or Prothrombin G20210A (P >

0.05).

1.2.4 Cost benefit analysis of screening for thrombophilia in pregnancy

Olivia Wu et al 2005 conducted a study titled “Screening for thrombophilia in high-risk situations: meta-analysis and cost effectiveness

analysis.” One of the objectives of this study was to evaluate the

cost-effectiveness of universal and selective history- based thrombophilia screening relative to no screening in women during pregnancy. Selective

thrombophilia screening based on previous family history/personal history of venous thromboembolism was more cost effective than universal

screening pregnancy. This study is different from our study in that it was comparing the cost effectiveness of screening for thrombophilia in every

pregnant woman as compared to screening for thrombophilia only in pregnant women with second trimester pregnant loss. Our study focuses on

the cost benefit analysis of introducing thrombophilia screening in selected pregnancy women with history of recurrent pregnancy loss, both in

first and second trimesters, in a setting where thrombophilia screening is non-existent in antenatal care because of limited resources.

There appears to be a substantial agreement in the scientific literature that the subjects who could benefit from screening are those for whom
diagnostic and therapeutic information of clinical relevance could be
obtained (Salvagno GL et al 2007). Testing for thrombophilia would seem to be justified in a limited number

of patients who have precise clinical characteristics and whose risk of vascular complications during pregnancy appears to be substantially raised.

Systematic screening of all pregnant women is not feasible, as confirmed by a series of clinical evaluations of this issue ( Jordaan DJ et al 2005) . In

agreement to the study above, our study focused on thrombophilia screening in pregnant women with recurrent foetal loss and not systematic

screening of all pregnant women, however the approach will be different in that this study seeks to analyse the feasibility in a low resource setting

where thrombophilia screening whether systematically or to limited number is non existent in antenatal care.Furthermore, our study is more of a

“to test or not to test question, basing on the existing infrastructure for coagulation screening,knowledge, skills and expertise of all healthcare that

would be involved in thrombophilia screening of pregnant women with recurrent foetal loss.

In the United Kingdom in 2017, Laura Ormester from the department of obstetrics, St Mary’s Hospital Manchester, conducted a study by the

tittle:” To test or not to test’, arguments for and against thrombophilia testing in obstetrics. The results from the study argued that despite some

observed associations between thrombophilia and adverse pregnancy outcome, the absolute risk is low. Universal thrombophilia screening is

therefore not appropriate. Selective screening leading to prophylaxis based on general thrombophilia status and placenta mediated pregnancy

complications has not been effective in large scale randomised trials. The study therefore concluded that neither universal nor selective

thrombophilia screening is justified for placenta mediated pregnancy complications. It was therefore found to add costs without clear benefit. The

gap of knowledge from this study is that no randomized large-scale trials have been done in Zimbabwe on the effectiveness of prophylaxis in

pregnant women with history of placenta mediated pregnancy loss and therefore we would need a different approach to assess the cost benefit

analysis of introducing thrombophilia screening in Zimbabwe.

Similarly, Hassan Shehata et al 2022 published research on thrombophilia screening in women with current first trimester miscarriage. The

objective of the study was to conclude it was time to stop testing thrombophilia in pregnant women. It was a cohort study and a systematic review

of literature. The findings of the study were that the prevalence of inherited thrombophilia is similar in women with recurrent miscarriages to that

in the general population. Thus, the study concluded that it was not cost effective to investigate or treat inherited or acquired thrombophilia in

women with recurrent pregnancy loss. Due to lack of existing literature on the prevalence of thrombophilia in the Zimbabwean population, our

study will take a different approach in that it will assess the cost-benefit analysis through comparison of different regional and international

suppliers of thrombophilia screening machines and reagents as compared to the current costs of antenatal care in Zimbabwe and the prevalence of

first and second trimester miscarriages in Zimbabwe according to existing literature.

The existing evidence base for inherited thrombophilia and pregnancy complications is largely retrospective, with heterogenicity in different
populations and classifications, thus leading to conflicting results. Currently, universal thrombophilia screening in pregnancy is not advised and
recommendations for which groups in particular should undergo screening vary nationally and internationally. On this subject, Zimbabwe, has a lot
of gaps in research, for example, to date there has been no publications on the prevalence of thrombophilia in pregnant women and the feasibility
of incorporating thrombophilia screening in antenatal screening tests.
Perhaps, this study will be worthwhile to contribute to the body of knowledge of Zimbabwe’s literature on thrombophilia in pregnancy by
providing information on the feasibility and cost benefit analysis of introducing such tests in a limited resource setting such as Zimbabwe.

1.2.5 Knowledge, skills and expertise in thrombophilia screening

On a practical level, thrombophilia screening requires counselling and careful interpretation of both negative and both positive results and its
sensible that thrombophilia screening be done only in circumstances where it will influence management of patients. Knowledge of when and where
and how to perform thrombophilia screening is crucial as a false positive result will not only result in unnecessary treatment but also will have a
negative psychological impact on the pregnant women and their families. It is therefore important to have careful thought before embarking on
introducing thrombophilia screening in pregnant women. This study aim
was to assess feasibility of introducing thrombophilia screening by evaluating the current knowledge, skills and expertise of the healthcare
providers involved in thrombophilia screening of pregnant women.

According to the UK national screening committee (NSC) external review against programme criteria for the antenatal screening for thrombophilia
et al 2016, the following thrombophilia are considered in pregnancy; Factor V Leiden, Prothrombin G2021A mutation, protein C deficiency, protein
S deficiency, antithrombin deficiency, MTHFR mutation, antiphospholipid syndrome, hyperhomocysteinemia and acquired APC resistance. To the
best knowledge of the researcher, no public hospital in Zimbabwe offers such tests.
Parirenyatwa hospital being a referral hospital for complicated pregnancies does not offer these tests. There is no literature or existing body of
knowledge that has information on the theoretical knowledge, expertise and skills of Zimbabwe healthcare workers on thrombophilia screening and
its importance in pregnancy. This study will cover this gap of knowledge, by analysing the feasibility of introducing thrombophilia screening based
on knowledge, skills and expertise of both doctors and medical laboratory scientists.

1.2.6 Prevalence of miscarriages and stillbirth in Zimbabwe

The criteria for a good screening test have been previously defined by Wilson and Junger (Principles and practice of mass screening for disease, et
al 1968). Their ten criteria have largely been upheld as gold standard. One of the broad principles is that the condition should be an important
health problem.

In September 2021, Kushupika Dube published a study titled “Identification of factors associated with stillbirth in Zimbabwe.” It was a cross-
sectional study. The study found out that there was a strong association between prior stillbirth and subsequent stillbirth. Of the women who had a
stillbirth 39/43 (91%) had a previous stillbirth. This shows that recurrent miscarriages are a serious problem in our Zimbabwean community and
the fact that they are recurrent, could mean the real cause at first goes undiagnosed and therefore no prophylactic treatment is offered in subsequent
pregnancies.

Blessmore Chaibva et al 2019, conducted research on adverse pregnancy outcomes, still birth, and early neonatal deaths in Mutare, Zimbabwe. Of
the 346 women, 54 (15.61%) experienced an adverse pregnancy outcome (stillbirth or early neonatal death). Contributing factors to adverse
pregnancy outcomes included birthweight, gestational age, delivery complications and delivery methods. The conclusion from this study was that,
the high prevalence of adverse pregnancy outcomes in Mutare district could be reduced through the provision of quality antenatal care throughout
the continuum of care, pre-, intra and postpartum. The author of the study recommended further studies to explore risk factors associated with high
adverse outcomes.
Perhaps our study could be an extension to this study as it explores the introduction of thrombophilia screening tests for the prevention of high
adverse outcomes in pregnancy.

1.3 Problem statement

The Zimbabwe Antenatal Care protocol excludes thrombophilia screening. Only a pregnancy test, full blood count, HIV test, urinalysis test,
syphilis test, hepatitis B and blood grouping is done in most circumstances (WHO et al 2018). Thrombophilia screening in pregnancy remains a
controversial issue. Current evidence suggests a contributory rather than causative role for thrombophilia in placenta-mediated pregnancy
complication and venous thromboembolism. Screening for thrombophilia in obstetric practice remains in the grey zone because of limited evidence
of a true causal relationship with placenta mediated pregnancy complication and lack of a proven effective intervention (Roger MA et al 2014).
However, miscarriage in the first and second trimesters of pregnancy is very common, and coagulopathy can be a contributing factor.
Protein C and S deficiency are rare, inherited disorders that can increase the risk of thrombophilia. Women with these deficiencies have a higher
risk of developing blood clots in the placenta, which can lead to placental insufficiency and, ultimately, to a miscarriage. In Zimbabwe public
hospitals, currently these tests are not being offered to pregnant women with recurrent foetal loss. In most countries, UK included, protein C and S
testing is mandatory to every woman with recurrent pregnancy loss and pregnant women with family history of thrombosis. Perhaps, this study will
be able to avail the information regarding the feasibility and cost benefit analysis of introducing thrombophilia screening to antenatal care of
women with recurrent pregnancy loss.

1.4 Justification

Many thrombophilia related miscarriages are missed and underdiagnosed in Zimbabwe public hospitals as thrombophilia screening are not offered
to pregnant women with recurrent foetal loss. To date, no publication has been made on the prevalence of hereditary thrombophilia in pregnant
women suffering from recurrent foetal loss in Zimbabwe to the best knowledge of the researcher. It is worthwhile to first. investigate the feasibility
and cost benefit analysis of introducing such test in a limited resource setting such as Zimbabwe. Normal pregnancy is associated with increased
procoagulants, decreased fibrinolysis, and decreased anticoagulants to maintain placental haemostasis during pregnancy (Alshammary H et al 2015).
However, hypercoagulability due to deficiency of any antithrombotic factors leads to placental thrombosis, hypoperfusion, foetal growth retardation,
foetal death, and subsequent foetal losses. Protein S deficiency is more commonly identified than protein C deficiency, constituting an overall 15-
fold increased risk of
 recurrent pregnancy loss. Therefore, thrombophilia screening in women who have experienced pregnancy loss may be appropriate (Lalan DM et al
2012). There are often limited resources and information to guide obstetricians in the management of recurrent foetal loss. This called for a study
to assess the feasibility and cost benefit analysis of introducing such a fundamental panel of tests to women with recurrent pregnancy loss in a
resource limited setting such as Zimbabwe.

1.5 Objectives

1.5.1 General objective

The aim of study was to assess the feasibility and cost benefit analysis of introducing screening tests for the presence of protein C and S deficiency
among known pregnant females with one or more foetal losses receiving care at Parirenyatwa Group of Hospital.

1.5.2 Specific objectives

1. To assess knowledge of thrombophilia and importance of thrombophilia screening in antenatal care among Parirenyatwa doctors and medical
laboratory scientists

2. To assess skills and expertise needed in thrombophilia screening among laboratory workers and doctors at Parirenyatwa hospital

3.To determine the cost -benefit analysis of introducing thrombophilia screening in Antenatal care in Zimbabwe.
Chapter 2
2.0 Materials and Methods

2.1 Study design

This study was carried out as a cross-sectional questionnaire-based study among healthcare professionals at Parirenyatwa Central Hospital Antenatal
Unit

2.2 Study setting

This study was carried out at Parirenyatwa Group of Hospital Antenatal Unit

2.3 Study population

Doctors in gynaecology and obstetrics unit, doctors in haematology department and medical laboratory scientists at Parirenyatwa Group of Hospitals.

2.4 Sampling techniques

All healthcare doctors in the antenatal care and those who work in the diagnostic laboratory were included.

2.5 Sample size determination

Sample size was determined using Cochran’s Sample Size formulae

The confidence interval of 95% and the precision level of 5%.

Sample Size N = Z 2 pq/d 2 Z is the Z value at 95% Confidence interval which is 1.96

P is the proportion of healthcare professionals involved in obstetrics medicine and haematology.

q is 1-p and d is the degree of precision and in this study we will use 5% level = 0.05
Calculated Sample size = (1.96) 2 (0.05)(0.95)/0.05 2 = 72

The calculated sample size was 72 participants and hence a sample size of 72 participants was used for this study. Data obtained from a minimum
number of 72 participants from the obstetrics department, haematology department and from the medical laboratory was statistically significant to
assess the feasibility and cost benefit analysis of introducing thrombophilia screening in antenatal care in Zimbabwe.

2.6 Study period

The study was carried out from 1 May 2024 to 31 June 2024

2.7 Inclusion criteria

 Medical doctors involved in obstetrics and gynaecology

 Medical doctors in the haematology department

 Medical laboratory scientists at Parirenyatwa Group of Hospitals

2.8 Exclusion criteria

 Medical doctors who were not involved in the antenatal care unit and in obstetrics.

 Medical doctors in haematology and those in obstetrics who were not willing to participate in the study and those who were on leave during the
study period.

 Medical laboratory scientists who were not willing to participate in the study and those who were on leave during the study period.

2.9 Ethical considerations

Permission to carry out the research project was sought from the medical director and the chief laboratory scientist at Parirenyatwa group of
hospitals. Data obtained from the study was used for research purposes only and no names were used in the study. All results were recorded and
saved on a password protected personal computer that was only accessible to the researcher. Informed consent was sought from all participants.
Ethical approval was sought from the Joint Research Ethics Committee for the University of Zimbabwe (JREC).

2.10 Data collection

A structured questionnaire was distributed among the healthcare workers of each profession involved in antenatal care at PGH. Before distributing
the questionnaires, the purpose and course of study was explained to the participants and only after obtaining written informed consent, the
participants were recruited as per eligibility criteria. The participant enrolled were then offered the questionnaire and requested to return completed
questionnaires within 48hours.

2.11 Data analysis

2.11.1 Analysis of data on the feasibility of introducing thrombophilia screening in antenatal care.

The feasibility was determined by two variables namely;

1. Existing theoretical knowledge on the importance of thrombophilia screening in the antenatal care of pregnant women with recurrent foetal
loss among healthcare workers.
2. Skills and expertise needed in thrombophilia screening among involved healthcare workers at Parirenyatwa hospital.

Data was collected and analysed using excel 2016 and Epi info version 7 software. Descriptive statistics were used to describe the scale, thus
measures of central tendency (mean and standard deviation). Bar charts, histograms, and frequency polygons were used to display the distribution of
the data collected. Categorical data was reported as proportions with 95% confidence interval and a p value.

2.11.2 Methodology for the cost benefit analysis of introducing thrombophilia screening tests in pregnant women with recurrent foetal loss.

Currently, Parirenyatwa hospital laboratory utilises the sysmex CA-600 coagulation machine for all coagulation tests. The CA-600 system is a
compact, fully automated coagulation analyser which utilises the proven optical detection technology and the same reagent system of Sysmex
coagulation family analysers. It offers high performance automation for clotting assays in true random access
(https://www.sysmex-ap.com/product/ca-600/).

The machine thus is not currently able to carry out other thrombophilia screening tests, including Protein S which is part of the objectives of this
study. Therefore analysis of the cost benefit analysis also looked at the prospects of getting a new machine which would be able to incorporate
Protein S deficiency screening and various other thrombophilia screening tests.

The possible solution was to upgrade to sysmex CN3000. The study only focused on the acquisition of Sysmex CN6000 because its an upgrade to
the current machine being used at Parirenyatwa hospital so it brings the advantages of familiarity to the users, secondly we have local distributors of
the machine in the country, which is FIMA enterprises private limited.

Firstly, a comparison between the current machine being used by Parirenyatwa vs Sysmex CN was done in terms of the specifications as shown by
the table below.

Sysmex CA 600 Sysmex CN 6000

Detection principles Clotting: scattered light Multi-wavelength detector for transmitted light at 340, 405, 575, 660 and 800 nm
detection method

Detection 4 LEDs with wavelength 660 26 channels for clotting, chromogenic and immunoassays (8 of these channels are
channel/method nm for clotting assays also be used for platelet aggregation assays)

Parameters 5-parameter random Up to 60 parameters can be analysed simultaneously

analysis simultaneously

Throughput PT: 60 tests/hour PT: 450 tests/hour

PT/APTT/Fbg: 42 tests/hour PT/APTT: 401 tests/hour

Sampling Continuous-access 10 sample Continuous loading of maximum 5 racks of 6 tubes each with standard sampler or
 rack 20 racks of 6 tubes each with optional sampler, cap-piercing functionality
1 dedicated STAT position

Quality control X-bar control, Levy-Jennings X-bar control, Levy-Jennings control

control Multi-rule (Westgard Rule) monitoring
6 files with maximum 180 40 files with maximum 1,200 data points each
points each

Data storage Up to 600 samples / maximum Up to 10,000 sample results with reaction curves
3,000 tests

Printer Internal printer List or Graphic Printer (optional)

Dimensions 566 x 490 x 490 mm, 42 kg 720 × 1,350 × 906 mm (with trash box), 230 kg (approximate)
(WxHxD)/weights (approximate) 1060 x 1,350 x 1,030 mm (with optional sampler/wagon and trash box), 330 kg
(approximate)

Table1: Differences between the current status quo machine and the new machine for purchase.

Secondly, a comparison in different assays offered by the two different machines was done as shown by the table below

Assays currently offered by the Assays offered by the proposed machine

current machine at Parirenyatwa Sysmex CN6000
Sysmex CA600

  PT
PT  APTT
 APTT  Fibrinogen
 Fibrinogen  Thrombin Time
 Thrombin Time  Batroxobin Time
 Batroxobin Time  Factor Deficiency
 Factor Deficiency  Lupus Anticoagulant
 Lupus Anticoagulant:  Protein C Pathway: ProC Global, Protein C
 Protein C Pathway ;ProC Global, Reagent, Berichrom Protein C, Protein S Ac,
Protein C Reagent Innovance Free Protein S Antigen
 Antithrombin
 D-Dimer
 Von Willebrand Factor
 Heparin
 Direct Thrombin Inhibitors
 Direct Factor Xa Inhibitors
 Platelet Aggregation

Table 2: Different assays offered by the different machines

A quick online search was then done to compare the prices of purchasing the CN3000/CN6000 equipment and different prices were obtained from
different suppliers as shown by the table below.

Supplier Cost of machine (Including shipping

machine)

Sysmex company through FIMA Enterprises 16000-18000 usd

Zimbabwe

Sinothinker Technology Co.,Limited 19000-21000 usd

Siemens Healthneers 17500-19000 usd

Table 3 :Different prices for the new machine from different suppliers.
The Sysmex company through FIMA enterprises (regional supplier) was then chosen by the researcher as it’s a local company and is able to provide
servicing, providing reagents and sufficient training conveniently. A price quotation was then obtained for all the other services.
After all the information was gathered, a cost benefit analysis was then performed as follows:
Cost benefit ratio = Benefits/Costs
The cost benefit analysis was done in 4 stages
 Stage 1; Identified all relevant costs and benefits
 Stage 2; Assigned a monetary value to each
 Forecasted future costs and benefits
 Compiled data, interpreted and made a decision.
The present net value was calculated by the formula below
The following rules were used to interpret the net present value
NPV > 0 = The present value of money coming in is more than the money going out. The investment is good since the money earned from the
investment is more than the money invested
NPV = 0 = When the money earned from the investment is equal to the money invested
NPV < 0 = The money earned from the investment is less than the money invested

Costs One time cost Yearly costs Year 2

(USD) Year 1

Equipment purchase 16000

Accessory purchase 2000 4000

Cost of installation 3000

User Training 1500 700

Service contract 2000/year 2000

Computer and software 3000

T and M Service 1500 minimum 1500

Reagent supply 900 10800 10800

Total costs 26400 14300 19000

Benefits Immediate Benefits Future benefits/year1 Year 2

Prevention of miscarriages due to thrombophilia in pregnancy 2000 24000 30000

Provision of other thrombophilia screening tests 4000 48000 48000

Better data management 1500 6000 6000

More efficient staff 4000 48000 48000

 Total benefits 11500 126000 132000
Table 4. Cost benefit analysis table

Net present value calculation

Net Present Value Formula Rules
There are certain signs that are used in the net present value formula that determine whether the investment is good or bad. They are as follows:
NPV > 0 = The present value of money coming in is more than the money going out. The investment is good since the money earned from the
investment is more than the money invested
NPV = 0 = When the money earned from the investment is equal to the money invested
NPV < 0 = The money earned from the investment is less than the money invested

Net benefit= total benefits - totals costs = 11500- 26400 (Usd) = Negative 14900 Usd
Time of cash flow= 0 (current)
Discount rate= 10%
Net present value = - 14900
Chapter 3: Results and Analysis
The study had two different questionnaires, one for the doctors and one for the medical laboratory scientists as such results and analysis will be
divided into two parts. The first part will present and analyse results from medical laboratory scientists and the second part will present and analyse
results from doctors.

3.1 Restatement of the research objectives

1. To assess knowledge of thrombophilia and importance of thrombophilia screening in antenatal care among Parirenyatwa doctors and medical
laboratory scientists
2. To assess skills and expertise needed in thrombophilia screening among laboratory workers and doctors at Parirenyatwa hospital

3.To determine the cost -benefit analysis of introducing thrombophilia screening in Antenatal care in Zimbabwe

3.2 Medical laboratory scientists results and analysis

A total number of 35 questionnaires were distributed and 30 questionnaires were responded to. The response rate for medical laboratory scientists
was 86%.

3.2.1 Demographics of medical laboratory scientists’ participants

The study collected demographic data from the sampled participants on five demographics which were gender, age, educational status, department
they work in and years in service.

A total number of twenty-four (80%) participants were aged between twenty-five years (25) and forty-five (45) years and six (20%) participants were
less than twenty-five (25) years of age as illustrated by figure 1 below.

Figure 1: Age distribution among medical laboratory scientists

Twenty- three (76.7%) participants were females and seven (23.3%) were males as illustrated by the figure 2 below.

Figure 2: Gender distribution among medical laboratory scientists

The majority of the participants (70%) were degree holders, 23 % were diploma hold and 7% were diploma holders as illustrated by figure 3 below.

Figure 3: Educational status of the medical laboratory scientists

9(30%) of the participants works in biochemistry department, 10(33.3%) of the participants works in haematology department, 4 (13.3 %) works in
histology department, 3(10%) works in microbiology department, 3(10%) works in serology department, and 3(10%) works in transfusion
department as illustrated by figure 4 below.

Figure 4: Different departments of the medical laboratory scientists.

15(50%) of the participants had less than 3 years of work experience, whilst 7(23.3%) of the participants had about 3 to 5 years of experience and
8(26.7%) had over 5 years of experience as illustrated by figure 5 below.
Figure 5: Years of work experience of the participants
Question/ response n (number %
of (percentage
participants) of
participants)
1.Are you familiar with the term hemostasis?

Yes 30 100%
No 0 0%
2. Are you familiar with the terms natural and acquired inhibitors of coagulation?
3.2.2 Knowledge of
thrombophilia and the
Yes 28 93.3% importance of thrombophilia
No 2 6.7% screening in antenatal care
3. Thrombophilias considered include Factor V Leiden, Prothrombin mutation, Protein among medical laboratory
C and S deficiency, Antithrombin deficiency MTHFR mutation, Antiphospholipid
scientists
syndrome, Hyperhomocysteinaemia and Acquired C resistance
Table 1: Survey questions and
True 15 50% results
False 0 0%
Not sure 15 50%
4. Do you have knowledge on the risk of thrombophilia in pregnancy?

Yes 21 70%
No 9 30% The results (Table 1 above)
5. Are you familiar with Protein C, S and antithrombin deficiencies in hemostatic showed that all the
disorders?
participants (100%) were
Yes 25 83.3% familiar with the term
No 5 16.7%
6. Protein C and S deficiency are core elements of thrombophilia screening that aid haemostasis and the majority
in confirming diagnosis, classification of thrombophilia, and monitoring patients (93.3%) were further aware of
with recurrent pregnancy loss?
natural and acquired inhibitors
Strongly agree 6 20% of coagulation. 50% of the
Agree 14 46.7%
participants knew the profile
Not sure 10 33.3%
Disagree 0 0% of all tests included in
Strongly disagree 0 0%
thrombophilia screening,
7. Protein C and S deficiency improve diagnosis and long-term management of
antenatal care patients with recurrent pregnancy loss? whilst 50 % were not sure of
the thrombophilia screening profile of tests. However, the majority (70%) were aware of the increased risk of thrombophilia in pregnancy. Over half
the participants (66.7 %) agreed that protein C and S deficiency are core elements of thrombophilia screening that aid in diagnosis, classification,
monitoring thrombophilia in patients with recurrent pregnancy loss. Only the minority (10%) of the participants had ever attended any local
webinars, conferences offering training on thrombophilia screening in pregnancy whilst only 6.7% had attended any international training
programs on thrombophilia screening in pregnancy. 86.7% of the participants had never received any theoretical training on thrombophilia
screening techniques at work.
Question/ response n (number %
of (percentage
participants) of
participants)
1. Have you ever performed any thrombophilia screening test?

Yes 4 13.3%
No 26 86.7%
2. Have you ever received any requests for thrombophilia screening? 3.2.3 Skills and expertise
needed in thrombophilia
Yes 4 13.3% screening among laboratory
No 26 86.7% workers
3. Do you know the type of samples suitable for thrombophilia screening?
Table 2: Survey questions and
Yes 23 76.7 results
No 7 23.3
4. Are you able to collect the samples for thrombophilia screening?
The results from table 2 above
Yes 20 66.7%
showed that the majority
No 10 33.3%
5. Do you know the preservative used for thrombophilia screening samples? (86.7%) of medical laboratory
scientists had never performed
Yes 25 83.3%
No 5 16.7% any thrombophilia screening
6. Are you familiar with the storage requirements for thrombophilia screening samples? tests. Free text responses were
Yes 28% 93.3% excluded from the table above,
No 2% 6.7% however all the medical
7. Do you have any experience in calibrating, and maintenance of any coagulation
machine? laboratory scientists listed PT,
Yes 30 100% APTT, and INR as some of the
No 0 0%
8. Are you able to interpret Protein C and S deficiency results? coagulation tests they have
Yes 12 40% experience in running. Only
No 18 60%
the minority (13.3 %) of
9. I’m confident of my skills in the preparation of reagents and running of Protein C
and S deficiency test? medical laboratory scientists
Strongly agree 6 8%
had ever received the
Agree 14 6.3%
Not sure 20 66.7%
Disagree 0 19%
Strongly disagree 0 0%
thrombophilia screening profile request. 76.7% participants were aware of the samples suitable for thrombophilia screening and 20 out of the 30
participants (66.7%) stated that they were able to collect the right specimen required for thrombophilia screening. All the participants had experience
in calibration and maintenance of at least one coagulation automated analysers. Less than 50% of the participants stated that there were able to
interpret Protein C and S deficiency results. Over 80% of the participants had no confidence in their skills on the preparation of reagents and running
of protein C and S deficiency test

3.2.4 Years in service vs knowledge of thrombophilia and thrombophilia screening in pregnancy

Two sample t-test with equal variances with STATA data analytical package
Ho = There is no significant difference between number of years in service and knowledge of thrombophilia screening tests.
H1 = There is significant difference between number of years in services and knowledge of thrombophilia screening

The hypothesis was tested at 95% significance and the assumptions were that data is normally distributed and that data was collected at random. The
decision rule used was to reject ho when P value is less than 0.05
Knowledge of thrombophilia and the importance of thrombophilia screening in pregnancy was found to not be the same in participants with different
number of years in service. (p value= 0.06). Medical laboratory scientists with over 5 years’ experience had more knowledge on thrombophilia and
thrombophilia screening tests as compared to medical laboratory scientists with less than 5 years’ experience. The results are shown in the table 3
below:

Group Obs Mean Std.Err Std.Dev 95%Conf.

Interval
1 23 13.02439 1.002733 6.420622 15.05099
2 7 15.82353 1.102962 6.431318 18.06752
Combined 30 14.29333 0.7545116 6.534262 12.78994
diff -2.799139 1.490402 -5.769506 .1712279
Diff= mean (1)- mean (2) t=1.8781
Ho: diff=0 degrees of freedom=73

Ha: diff<0 Ha: diff! =0 Ha: diff>0

Pr(T<t)=0.0322 Pr([T]>[t]) =0.0644 Pr (T>t) = 0.9678

3.3 Medical doctors’ results and analysis

A total number of 37 questionnaires were distributed and 29 questionnaires were responded to. The response rate for was 78%.

3.3.1 Demographics of medical doctors as participants

The study collected demographic data from the sampled participants which included gender, age, educational status, and years in service.

19 (66%) participants were females and 10 (34%) were males as illustrated by the figure 6 below.

Sex

Females
34%
Males

66%

Figure 6: Gender distribution among medical doctors

Among the 29 doctors that participated in the study, 20 (69%) were between 25 to 45 years of age and 9 (31%) were above 45 years of age as
illustrated by figure 7 below.
Figure 7: Age distribution among medical doctors
 26(90%) of the medical doctors had over 5 year working
Age distributi on among medical doctors experience and 4(10%) had less than 5 years working
experience as illustrated by figure 8 below.
Age distrubution

20

2 5 -4 5 Ab o ve 4 5

Year s of wor k exper ience

Years of work experience

>5 years

<5 years

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Figure 8: Years of work experience among doctors.

21(72%) of the participants were degree holders whilst 9(28%) had masters degrees as illustrated by figure 9 below.

Educational status

Masters

Degree

0% 10% 20% 30% 40% 50% 60% 70% 80%

Educational status

Figure 9: Educational status of medical doctors

Question/ response n (number %
of (percentage
participants) of
participants)
1.Are you familiar with the term hemostasis?

Yes 29 100%
No 0 0%
3.3.2 Knowledge of
2. Are you familiar with the terms natural and acquired inhibitors of coagulation?
thrombophilia and the
importance of thrombophilia
Yes 29 100% screening in antenatal care
No 0 0% among medical doctors
3. Thrombophilias considered include Factor V Leiden, Prothrombin mutation, Protein
C and S deficiency, Antithrombin deficiency MTHFR mutation, Antiphospholipid
syndrome, Hyperhomocysteinaemia and Acquired C resistance

True 23 79% Table 4: Survey questions and

False 0 0% results
Not sure 6 21%
4. Do you have knowledge on the risk of thrombophilia in pregnancy?
Table 4 above showed that all
Yes 29 100% the doctors (100%) were well
No 0 0%
5. What kind of knowledge do you have on the risk of thrombophilia in pregnancy? aware of the term haemostasis
and the natural and acquired
Theoretical 22 76%
Working 5 17% inhibitors of coagulation.
Both 2 7% Majority (79%) of the doctors
6. What kind of knowledge do you have on recurrent miscarriages?
Theoretical 3 10% were knowledgeable of the
Working 0 0% profile of tests involved in
Both 26 90%
thrombophilia screening. All
7. Protein C and S deficiency are core elements of thrombophilia screening that aid
in confirming diagnosis, classification of thrombophilia, and monitoring patients the participants were in
with recurrent pregnancy loss?
agreement of the increased
Strongly agree 6 20% risk of thrombophilia in
Agree 14 47%
pregnancy, however 76% only
Not sure 10 33 %
Disagree 0 0%
Strongly disagree 0 0%
8. There is a significant association between the protein C and S deficiency with
had theoretical knowledge, whilst 17% had working knowledge and 7% had both theoretical and working knowledge. On knowledge of recurrent
miscarriages,90 % of the participants had both theoretical and working knowledge whilst the minority (10%) only had theoretical knowledge. 67% of
the participants were in agreement that protein C and S deficiency are core elements of thrombophilia screening that aid in
confirming diagnosis, classification of thrombophilia, and monitoring patients with recurrent pregnancy loss whilst 33% were not sure. 50% of
the doctors were not sure of the correlation between the protein C and S deficiency with recurrent pregnancy loss (RPL) while 43 % agreed that
there was a correlation and 7% disagreed that there is some sort of correlation. In terms of trainings on thrombophilia screening in pregnancy
over 90% of the participants had never attended any both locally and internationally (96% for international conferences and 93% for local
conferences. Furthermore 87% had never received theoretical training on thrombophilia screening in pregnancy at work.
Question/ response n (number %
of (percentage
participants) of
participants)
1. Have you ever referred patients with recurrent pregnancy loss for thrombophilia
screening?

3.3.3 Skills and expertise in

Yes 3 10%
thrombophilia screening
No 26 90%
among medical doctors
2. Have you ever requested specifically protein C and S deficiency in any antenatal
patient? Table 5: Survey questions and
results
Yes 0 0%
No 29 100%
3. If you answered no to question 1 or 2, what could be the reason?
The table above showed that
a) I don’t think it was a necessary test to request 7 24%
b) Tests not available 22 76% the majority (90%) of the
c) I don’t know about the tests 0 0% participants had never
d) Test too expensive on the patient
4. If thrombophilia screening tests are made readily available at the hospital, would referred of requested
you request such tests for pregnant women with recurrent loss? thrombophilia screening in

Yes 23 79% patients with recurrent

No 6 21% miscarriages, and all of them
5. In the absence of protein C and S deficiency tests, do you have alternative
(100%) had never specifically
thrombophilia tests you prefer women with recurrent pregnancy loss to have done?
requested protein C and S.
The leading reason (76%) for
Yes 23 79%
No 6 21% not requesting the tests was
6. Are you aware of any laboratories currently offering thrombophilia screening that the test was not
tests?
Yes 2 7% available, and 24% gave a
No 27 93% reason that the test wasn’t
7. Do you agree that thrombophilia screening tests are not readily available currently?
Yes 29 100% necessary. 79% of the
No 0 0% participants stated that they
8. Are you able to collect the samples for thrombophilia screening?
would be willing to request
Yes 29 100%
No 0 0%
9. Do you know the preservative used for thrombophilia screening samples?
the protein C and S test if the tests were to be made readily available to Parirenyatwa hospital. 93% of the participants were not aware of any
other laboratory that offered protein C and S deficiency tests. Furthermore, 93% Of the doctors were not able to interpret protein C and S
deficiency results. However, all the participants stated that they were able to collect the required samples and 93% knew the preservatives
required in test tubes. Only 41% of the participants knew the storage requirements for thrombophilia screening.

3.4 Cost benefit analysis of introducing thrombophilia screening tests to Parirenyatwa for pregnant women with recurrent miscarriages .

Costs One time cost Yearly costs Year 2

(USD) Year 1

Equipment purchase 16000

Accessory purchase 2000 4000

Cost of installation 3000

User Training 1500 700

 Service contract 2000/year 2000

Computer and software 3000

T and M Service 1500 minimum 1500

Reagent supply 900 10800 10800

Total costs 26400 14300 19000

Benefits Immediate Benefits Future benefits/year1 Year 2

Prevention of miscarriages due to thrombophilia in pregnancy 2000 24000 30000

Provision of other thrombophilia screening tests 4000 48000 48000

Better data management 1500 6000 6000

More efficient staff 4000 48000 48000

Total benefits 11500 126000 132000

Table 6: Cost benefit analysis calculation table

From the table above, the net present value was calculated using the formula below
Net benefit= total benefits - totals costs = 11500- 26400 (Usd) = - 14900 (Usd)
Time of cash flow= 0 (current)
Discount rate= 10%
Net present value = - 14900 Usd (negative value)

CHAPTER 4: DISCUSSION AND CONCLUSION

4.1 DISCUSSION

This chapter presents the study conclusions, summary of findings, recommendations for each objective and areas of further study.

4.2 Restatement of research objectives

The main aim of the study was to assess the feasibility and cost benefit analysis of introducing screening tests for the presence of protein C and S
deficiency among known pregnant females with one or more fetal losses receiving care at Parirenyatwa Group of Hospital.
4.2.1 Specific objectives

1. To assess knowledge of thrombophilia and importance of thrombophilia screening in antenatal care among Parirenyatwa doctors and medical
laboratory scientists

2. To assess skills and expertise needed in thrombophilia screening among laboratory workers and doctors at Parirenyatwa hospital

3.To determine the cost -benefit analysis of introducing thrombophilia screening in Antenatal care in Zimbabwe

4.3 Summary of major findings

The studies established key findings in relation to the research objectives outlined above, from the analysis of results in the chapter three. These
findings are thus summarised below:

4.3.1 Assessment of knowledge of thrombophilia and importance of thrombophilia screening in antenatal care among Parirenyatwa doctors
and medical laboratory scientists

Medical laboratory scientists’ participants were all familiar with the term haemostasis and the majority were further aware of natural and acquired
inhibitors of coagulation. Overall, the theoretical knowledge on thrombophilia was satisfactory, however half of the participants were not
knowledgeable on the profile of tests included in thrombophilia screening revealing that there was a gap in knowledge. In terms of training, only the
minority had ever attended any local webinars, conferences or international training programs on thrombophilia screening in pregnancy. Medical
laboratory scientists went on further to reveal that the majority had never received any training on thrombophilia screening techniques at
Parirenyatwa on thrombophilia screening techniques.

Similarly, medical doctors were well aware of the theoretical aspects of haemostasis and the natural and acquired inhibitors of coagulation. Majority
of the doctors were knowledgeable of the profile of tests involved in thrombophilia screening. All the participants were in agreement of the increased
risk of thrombophilia in pregnancy, however the majority only had theoretical knowledge, whilst the minority had both theoretical and working
knowledge. On knowledge of recurrent miscarriages, most of the participants had both theoretical and working knowledge whilst only a few had
theoretical knowledge. Half of the participants were not sure of the correlation between the protein C and S deficiency with recurrent pregnancy
loss (RPL). In terms of trainings on thrombophilia screening in pregnancy over 90% of the participants had never attended any both locally and
internationally. Furthermore, the majority had never received theoretical training on thrombophilia screening in pregnancy at work.

4.3.2 Assessment of skills and expertise needed in thrombophilia screening among laboratory workers and doctors at Parirenyatwa hospital

The majority of medical laboratory scientists had never performed any thrombophilia screening tests. All the medical laboratory scientists listed PT,
APTT, and INR as some of the coagulation tests they have experience in running. Only the minority of medical laboratory scientists had ever
received the thrombophilia screening profile request. Over three quarters of the participants were aware of the samples suitable for thrombophilia
screening and over half participants stated that they were able to collect the right specimen required for thrombophilia screening. All the participants
had experience in calibration and maintenance of at least one coagulation automated analysers. Less than half of the participants stated that there
were able to interpret Protein C and S deficiency results. Over 80% of the participants had no confidence in their skills on the preparation of reagents
and running of protein C and S deficiency test.

The majority of the participants had never referred or requested thrombophilia screening in patients with recurrent miscarriages, and all of them
had never specifically requested protein C and S. The leading reason for not requesting the tests was that the test was not available, and the least
reason was that the test wasn’t necessary. Over half of the participants stated that they would be willing to request the protein C and S test if the
tests were to be made readily available to Parirenyatwa hospital. Majority of the participants were not aware of any other laboratory that offered
protein C and S deficiency tests. Furthermore, 93% of the doctors were not able to interpret protein C and S deficiency results. However, all the
participants stated that they were able to collect the required samples and knew the preservatives required in test tubes.

4.3.3 Determining the cost -benefit analysis of introducing thrombophilia screening in Antenatal care in Zimbabwe

The cost benefit analysis of purchasing new equipment was performed and the net present value was found to be a negative value of:

Net present value = - 14900 Usd (negative value)

The following rules were used to interpret the net present value
NPV > 0 = The present value of money coming in is more than the money going out. The investment is good since the money earned from the
investment is more than the money invested

NPV = 0 = When the money earned from the investment is equal to the money invested

NPV < 0 = The money earned from the investment is less than the money invested

The purchasing of new equipment for thrombophilia screening at Parirenyatwa hospital is therefore at the present moment not feasible, as the net
present value is less than zero. It is therefore not a good investment.

4.4 Discussion of study findings

The studies established key findings in relation to the research objectives outlined above, from the analysis of results in the chapter three. These
findings are thus discussed below:

4.4.1 Discussion on the knowledge of thrombophilia, importance of thrombophilia screening, skills and expertise needed in thrombophilia
screening.

Practically, thrombophilia screening requires counselling and careful interpretation of both negative and both positive results and its sensible that
thrombophilia screening to be done only in circumstances where it will influence management of patient. Knowledge of when and where and how to
perform thrombophilia screening is crucial as a false positive result will not only result in unnecessary treatment but also will have a negative
psychological impact on the pregnant women and their families. It was therefore important to have careful thought before embarking on introducing
thrombophilia screening in pregnant women. This study aim was to assess feasibility of introducing thrombophilia screening by evaluating the
current knowledge, skills and expertise of the healthcare providers involved in thrombophilia screening of pregnant women. Results from the study
revealed that there was a huge gap of knowledge, skills and expertise needed in thrombophilia screening in both doctors and medical laboratory
scientists and thus currently, without any interventions such as public health awareness, trainings and educational courses on thrombophilia in
pregnancy, it is not feasible to introduce thrombophilia screening right away. The reasons being that, firstly, doing the test at the moment may not
influence management of patient because of lack of knowledge from the doctors in interpretation of protein C and S deficiency tests results.
Secondly, the test may be under-utilized as they may not be ordered as often as they should, leading to wastage of reagents due to expiry. The third
reason would be that there is an increased risk of errors from the laboratory side, because of lack of experience and knowledge in interpretation of
results, hence false positives and false negatives may increase in such a critical test.

There is a gap in body of knowledge as according to literature review done by the researcher, there were no studies done in Zimbabwe yet on
thrombophilia screening in pregnancy or the prevalence of thrombophilia in pregnant women with recurrent pregnancy loss. The results of this study
further supported the assertion as 50% of the doctors were not sure of the correlation between the protein C and S deficiency with recurrent
pregnancy loss (RPL). Furthermore, the majority (90%) of the doctors had never referred of requested thrombophilia screening in patients with
recurrent miscarriages, and all of them (100%) had never specifically requested protein C and S. The study went on to further reveal that 93% of
the doctors were not able to interpret protein C and S deficiency results. From the medical laboratory aspect, majority (86.7%) of medical
laboratory scientists had never performed any thrombophilia screening tests. Less than 50% of the participants stated that there were able to interpret
Protein C and S deficiency results. Over 80% of the participants had no confidence in their skills on running thrombophilia screening tests. This gap
of knowledge and skills among both medical laboratory scientists and medical doctors on thrombophilia screening could be attributed to the lack of
research studies on the actual prevalence of thrombophilia in pregnancy in Zimbabwe, and secondly to the lack of availability of this test in the
country in most medical laboratories because of the expenses of these kind of tests, both private and public laboratories according to a quick search
done by the author.

A study done in Syria in 2022 investigated the protein C deficiency and its effects on in-vitro fertilization outcome and recurrent pregnancy loss. A
total of 238 women, who had IVF cycles between January 2012 and December 2017 in a tertiary care hospital were included. The prevalence of
protein C deficiency was 13.45%. There was a significant association between the protein C level and recurrent pregnancy loss (RPL). Similarly,
Hussein Naji Alshammary et al 2015 investigated protein C and S deficiency in recurrent pregnancy loss in Iraq. The aim of the study was to identify
protein C and protein S deficiency in women with recurrent pregnancy loss. 90 women were involved in the study, 45 of them have three or more
miscarriages in the first and second trimester considered as patient group, 45 healthy women at time of full-term delivery with at least one alive child
as control group. The results showed a significant relation of low protein S with recurrent miscarriage (P =0.002) OR=2.250 (95%C.I. 1.764-2.870),
while the relation of low protein C with recurrent miscarriage was not significant (P>0.05). There was a significant association of low protein S and
low protein C when the abortion occurred in the second trimester. According to these studies, clearly there is need to introduce thrombophilia
screenings in pregnant women with recurrent pregnancy loss, however without scientific studies , scientific trainings through webinars and
conferences it is currently not feasible to introduce thrombophilia screening tests in pregnancy women with recurrent pregnancy loss at Parirenyatwa
hospitals as the reception of this test and utilization will be greatly impacted by lack of knowledge and lack of skills among both medical doctors and
medical laboratory scientists. Perhaps scientific trainings could be the starting point to raise awareness before the feasibility of introducing the test
could be looked at again.

4.4.2 Discussion on the cost -benefit analysis of introducing thrombophilia screening in antenatal care in Zimbabwe

The cost benefit analysis of purchasing new equipment was performed and the net present value was found to be a negative value of:

Net present value = - 14900 Usd (negative value)

The purchasing of new equipment for thrombophilia screening at Parirenyatwa hospital is therefore at the present moment not feasible, as the net
present value is less than zero. It is therefore not a good investment.

Due to the gaps in Zimbabwe literature in thrombophilia screening in pregnancy, there were unfortunately no similar studies to compare this study’s
results to. However, studies in other countries assessed the cost benefit analysis in different ways as illustrated in literature review, where the actual
costs of running the tests or purchasing equipment for that series of tests did not seem to be an issue as these are readily available tests in developed
countries.

The study looked at the option of purchasing new equipment as the current equipment at Parirenyatwa hospital is not able to carry out most
thrombophilia screening tests (see methodology). Other equipment acquisition options such as leasing or renting were out of scope of this study,
perhaps could be added as an extension to this study in further research. The other option could have been of referring the tests to other laboratories
but at the present moment it appears the tests is unavailable in most laboratories. Findings from this research revealed that 93% of the medical
doctors were not aware of any other laboratory that offered protein C and S deficiency tests.
The total costs of acquisition of the equipment therefore included a lot of direct costs such as trainings, reagent supply, servicing, installation among
many others and the perceived benefits were outweighed by the costs. The investment was thus not feasible. Perhaps a way to make the costs feasible
would be to look out for donors who could help with the provision of the equipment to Parirenyatwa hospital with sufficient reagent supplies and
trainings.

4.5 Conclusions
There are several conclusions drawn from the research findings in accordance with the research objectives. The conclusions are as follows:
Thrombophilia screening in women with recurrent pregnancy loss is non-existent in Zimbabwe. There are currently no research studies published on
the prevalence of thrombophilia in pregnant women with recurrent pregnancy loss in Zimbabwe thus the knowledge of the importance of the tests is
limited. Doctors and medical laboratory scientists have limited practical knowledge and expertise in thrombophilia screening in pregnancy. The test
therefore, if introduced, could be severely underutilized and results interpretation and subsequent patient management would be highly questionable.
Based on current existing knowledge, skills and expertise of both medical doctors and laboratory scientists it was concluded that it is not feasible to
introduce thrombophilia screening in women with recurrent pregnancy loss at Parirenyatwa hospital. However, there are solutions to assist in making
it feasible such as scientific researches, seminars, and trainings on thrombophilia in pregnancy. Last but not least the cost benefit analysis carried out
revealed that it is not economically feasible to acquire new machine as it turned to be a bad investment based on net present value calculations.

4.6 Study limitations

 Time limitation: This study was limited by the small number of participants who volunteered to take part as well as the short duration of 3
months.
 Literature Limitations: Topic lacks enough local empirical literature

4.7 Recommendations
 A follow-up study should be conducted using larger sample size and a longer period.
 An extension of the study on the cost benefit analysis using other various ways of equipment acquisition such as leasing and renting and
donor fundings.
  Local and international trainings, scientific conferences, and webinars on thrombophilia screening in pregnancy for both doctors and medical
laboratory scientists.

4.8 Areas for further research

 For further research, the study recommends scientific research on the prevalence of thrombophilia in pregnant women with recurrent fetal loss
in Zimbabwe to add to the body of knowledge
 Determination of the frequency of FII G20210A and FVL polymorphisms as well as protein C and protein S deficiency in a series of patients
with recurrent pregnancy loss compared with control group in Zimbabwe.

REFERENCES
Khan S, Dickerman JD. Hereditary thrombophilia. Thromb J. 2006 Sep 12;4:15. doi: 10.1186/1477-9560- 4-15. PMID: 16968541; PMCID: PMC1592479

Lane DA, Mannucci PM, Bauer KA, et al. Inherited thrombophilia: part 1. Thromb Haemost. 1996;76:651. [PubMed]
[Google Scholar] [Ref list]

Esmon CT, Protein C. The regulation of natural anticoagulant pathways. Science. 1987;235:1348.
[PubMed] [Google Scholar] [Ref list]

Albagoush SA, Koya S, Chakraborty RK, et al. Factor V Leiden Mutation. [Updated 2023 Apr 8]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534802/

Kourlaba G, Relakis J, Kontodimas S, Holm MV, Maniadakis N. A systematic review and meta-analysis of the epidemiology and burden of venous
thromboembolism among pregnant women. Int J Gynaecol Obstet. 2016 Jan;132(1):4-10. [PubMed] [Reference list]

Kujovich JL. Prothrombin Thrombophilia. 2006 Jul 25 [Updated 2021 Feb 4]. In: Adam MP, Mirzaa GM, Pagon RA, et al., editors. GeneReviews®
[Internet]. Seattle (WA): University of Washington, Seattle; 1993-2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1148/

Gupta A, Patibandla S. Protein C Deficiency. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2023 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK542222/

Alhenc-Gelas M, Gandrille S, Aubry ML, Aiach M. Thirty-three novel mutations in the protein C gene. French INSERM network on molecular
abnormalities responsible for protein C and protein
S. Thromb Haemost. 2000 Jan;83(1):86-92. [PubMed] [Reference list]

Dahlbäck B. Vitamin K-Dependent Protein S: Beyond the Protein C Pathway. Semin Thromb Hemost. 2018 Mar;44(2):176-184. [PubMed]
[Reference list]m,

Patnaik MM, Moll S. Inherited antithrombin deficiency: a review. Haemophilia. 2008 Nov;14(6):1229- 39. doi: 10.1111/j.1365-2516.2008.01830.x.
PMID: 19141163.

Abu-Heija A. Thrombophilia and Recurrent Pregnancy Loss: Is heparin still the drug of choice? Sultan Qaboos Univ Med J. 2014 Feb;14(1):e26-36. doi:
10.12816/0003333. Epub 2014 Jan 27. PMID: 24516750; PMCID: PMC3916273.
Liu X, Chen Y, Ye C, Xing D, Wu R, Li F, Chen L, Wang T. Hereditary thrombophilia and recurrent pregnancy loss: a systematic review and meta-
analysis. Hum Reprod. 2021 Apr 20;36(5):1213- 1229. doi: 10.1093/humrep/deab010. PMID: 33575779.

Linnemann B, Hart C. Laboratory Diagnostics in Thrombophilia. Hamostaseologie. 2019 Feb;39(1):49-

 61. doi: 10.1055/s-0039-1677840. Epub 2019 Jan 31. PMID: 30703819.

Mekaj Y, Lulaj S, Daci F, Rafuna N, Miftari E, Hoxha H, Sllamniku X, Mekaj A. Prevalence and
role of antithrombin III, protein C and protein S deficiencies and activated protein C
resistance in Kosovo women with recurrent pregnancy loss during the first trimester of
pregnancy. J Hum Reprod Sci. 2015 Oct-Dec;8(4):224-9. doi: 10.4103/0974-1208.170407.
PMID: 26752858; PMCID: PMC4691975.

Mukhtar B, Garg R, Ibrahim G, Batra J. Investigating protein C and S levels in pregnant women
with recurrent early pregnancy loss versus normal pregnancy. J Med Life. 2023
Jan;16(1):160-166. doi: 10.25122/jml-2022-0267. PMID: 36873128; PMCID:
PMC9979182.

Sabouni R, Gorra Al Nafouri M, Hanafi I, Al Droubi I, Alhalabi M. Activated protein C resistance

impact on Syrian candidates for in vitro fertilisation and the benefit of anticoagulation
therapy: a retrospective cohort study. J Obstet Gynaecol. 2022 Oct;42(7):3285-3289. doi:
10.1080/01443615.2022.2113509. Epub 2022 Sep 8. PMID: 36074026.

Parand A, Zolghadri J, Nezam M, Afrasiabi A, Haghpanah S, Karimi M. Inherited thrombophilia

and recurrent pregnancy loss. Iran Red Crescent Med J. 2013 Dec;15(12):e13708. doi:
10.5812/ircmj.13708. Epub 2013 Dec 5. PMID: 24693393; PMCID: PMC3955508.