**4.6 Unaffordability due to high cost of prophylactic anti-D**

Anti-D related HDFN often result from the transplacental passage of maternal allo-antibodies directed against foetal red cell antigens inherited from the father affects the foetus or neonate. Majority of the mothers becomes sensitised following small feto-maternal haemorrhages during pregnancy and at delivery of the first Rh D-positive infant. These antibodies can potentially cause HDFN in successive Rh D-positive infants. Implementation of universal access to prophylactic anti-D given during antenatal and post-partum period following the delivery of a Rh D positive baby can help prevent primary Rh D immunisation and risk of HDFN in subsequent pregnancies [129]. It is recommended that routine antenatal anti-D prophylaxis (RAADP) is offered to all non-sensitised pregnant women who are Rh D negative to reduce the risk of sensitization and by extension D-related HDFN [130]. The World Health Organisation (WHO) recommends that antenatal prophylaxis with anti-D immunoglobulin should be given to non-sensitised Rh-negative pregnant women at 28 and 34 weeks of gestation to prevent Rh D alloimmunization. It is estimated that single dose of anti-D can cost around US\$ 50 (500 IU) to US\$ 87 (1500 IU), depending on the brand and local taxes. Therefore, the cost of antenatal prophylaxis for two 500 IU doses could be as much as US\$ 100 per woman. Additional costs will include screening for blood typing in settings where Rh blood tests are not currently performed [131]. However, providing anti-D prophylaxis universally to all Rh D negative non-sensitised pregnant women is not cheap. The cost benefit analysis of preventing sensitization, HDFN and its related physical disabilities, mental retardation and death of affected children supports investing in the implementation of this policy by responsible government who believes that every life count. Routine antenatal anti-D prophylaxis provides a cost effective intervention for preventing HDFN in non-sensitised Rh D-negative pregnant women [132]. Health economic model indicates a significant cost per quality-adjusted life-year (QALY) gained by the implementation of RAADP given to Rh D-negative primigravidae versus no RAADP is between £9000 and £15,000, and for RAADP given to all RhD-negative women rather than to Rh D-negative primigravidae only is between £20,000 and £35,000. It is suggested that a programme of routine prophylaxis would be cost saving if HDFN were eradicated by its implementation [130]. The National Institute for Health and Clinical Excellence reported that when RAADP for all Rh D-negative women was compared with that for primigravidae, the additional cost per incident of sensitisation prevented ranged from £2900 to £8200 depending on the regimen used. The cost per HDFN-associated foetal loss avoided was £42,000–120,000. It does make economic sense for African government to rise to their responsibilities by proving universally anti-D prophylaxis to all non-sensitised Rhesus D negative women. There is also potential to significantly reduce the cost of implementing RAADP by these governments investing on facilities to non-invasive determination of foetal D genotyping for all non-sensitised Rh D negative pregnant women. This will help identify women who are carrying Rhesus D negative mothers who will not require the prophylaxis. Also, because the prevalence of Rh D negative status is significantly lower among Nigerians (6%) [133] compared to the West ≥15% [134], it is likely to cost African countries a lot less to implement universal access to anti-D prophylaxis [135].
