Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review

Mangham-Jefferies, Lindsay; Pitt, Catherine; Cousens, Simon; Mills, Anne; Schellenberg, Joanna

doi:10.1186/1471-2393-14-243

Table 3 Cost-effectiveness results

From: Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review

Strategy	Comparator	Quality	Form of economic evaluation	Measured health effect in	Costing perspective	Used sensitivity analysis	CE result (US$ 2012)	CE measure	GDP-PC (*)	Reference
Cost per DALY averted
MNH services delivered at home, with community mobilization & HSS	Health system strengthening (HSS) at sub-district level	High	Field-based	Newborn	Societal (also reports programme)	Yes	126 (societal), 123 (programme)	per DALY averted	747	[22]
Home-based neonatal care by VHWs	No strategy	Low	Field-based	Newborn	Strategy	No	13	per DALY averted	1489	[39]
Home-based distribution of IPTp	IPTp distributed during ANC	High	Field-based	Newborn	Societal	Yes	3	per DALY averted	547	[59]
Train TBAs & supply clean delivery kits	No strategy	High	Economic Model (primary data)	Newborn	Societal	Yes	188 (project), 79 (10 year forecast)	per DALY averted	1469	[65]
Distribute malaria ITNs at ANC	No strategy	High	Economic Model (primary data)	Infant	Strategy	Yes	61	per DALY averted	272	[33]
Quality improvement collaborative	No strategy	High	Ec Model	Women	Health service provider	Yes	302	per DALY averted	383	[52]
Hospital-based promotion of breastfeeding	No strategy	High	Field-based	Newborn	Health service provider (excl. start-up)	No	164	per DALY averted	2264	[36]
Cost per QALY gained
Outreach clinics by facility staff	Facility-based care	Medium	Field-based	Women	Health service provider & direct user (excl. start-up)	No	In site A/site B): 42/40 (S), 171/67 (C)	per QALY gained	747	[23]
Alternative delivery strategies FP & MCH	FP & MCH services provided at home by government fieldworkers	High	Field-based	Women	Health service provider	No	Range (low-high estimate): 87–139 (S1), 28–46 (S2), 68–109 (C)	per QALY gained	747	[25]
1. Community service points
2. PHC
Cost per life- year saved (or year of life lost averted)
Women’s groups & HSS	HSS	Medium	Field-based	Newborn	Strategy	No	427 (trial), 284 (at scale)	per LYS	747	[18]
1. Women’s groups	No strategy	Medium	Field-based	Women & newborn	Strategy	No	149 (S1), 43 (S2)	per LYS	268	[49]
2. Peer counselling	No strategy	Medium	Field-based	Women & newborn	Strategy	No	149 (S1), 43 (S2)	per LYS	268	[49]
Women’s groups & HSS	HSS	High	Field-based	Newborn	Strategy	Yes	411, (489 incl. HSS)	per LYS	707	[51]
Women’s groups & HSS	HSS	Medium	Field-based	Newborn	Strategy	Yes	53, (77 incl. HSS)	per LYS	1489	[37]
Established Emergency Transport	No strategy	High	Field-based	Woman & newborn	Health service provider (excl. start-up)	Yes	21	per LYS	547	[61]
Outreach maternal health care	MH care at health post	High	Field-based	Woman & newborn	Societal	Yes	148-620	per LYS	512	[34]
Distribute malaria ITNs at ANC	No strategy	High	Economic model (using primary data)	Infant	Strategy	Yes	56	per LYS	272	[33]
HIV testing at ANC:	No strategy	High	Economic model	Newborn	Health service provider	Yes	80 (S1), 37 (S2)	per LYS	1489	[38]
1. nationwide,
2. in high prevalence states
Cost per death averted (or cost per life saved)
Women’s groups & HSS	HSS	Medium	Field-based	Newborn	Strategy	No	13018 (trial), 8670 (at scale)	per death averted	747	[18]
Women’s groups & HSS	HSS	High	Field-based	Newborn	Strategy	Yes	11294, (13457 incl. HSS)	per death averted	707	[51]
Women’s groups & HSS	HSS	Medium	Field-based	Newborn	Strategy	Yes	1457, (2094 incl. HSS)	per death averted	1489	[37]
Women’s groups & Quality improvement at health facilities	No strategy	Low	Field-based	Newborn	Strategy	Yes	6138	per death averted	268	[47, 48]
Home-based neonatal care by VHWs	No strategy	Low	Field-based	Newborn	Strategy	No	294	per death averted	1489	[39]
Home-based management of birth asphyxia by VHWs	Management of birth asphyxia by trained TBAs	Low	Field-based	Newborn	Equipment only	No	25	per death averted	1489	[40]
Train TBAs	No strategy	Low	Inference (from secondary data)	Newborn	Not specified	No	5744-13294	per death averted	747	[26]
Train TBAs & supply clean delivery kits	No strategy	High	Economic model (using primary data)	Newborn	Societal	Yes	4156 (trial), 1988 (10yr forecast)	per death averted	1469	[65]
MNH services delivered at home, with community mobilization & HSS	HSS at sub-district level	High	Field-based	Newborn	Societal (also reports programme)	Yes	3576 (societal), 3536 (programme)	per death averted	747	[22]
Tetanus toxoid (TT) immunization campaign	TT immunization at routine ANC	High	Field-based	Newborn	Strategy	Yes	1564 (S), 338–1438 (C)	per death averted	3557	[42]
Outreach maternal health care	MH care at health post	High	Field-based	Woman & newborn	Societal	Yes	1380-6414	per death averted	512	[34]
Distribute malaria ITNs at ANC	No strategy	High	Economic model (using primary data)	Infant	Strategy	Yes	1462	per death averted	272	[33]
Train midwives in newborn care	No strategy	Medium	Field-based	Newborn	Health service provider	No	402	per death averted	1469	[64]
Train new cadre in EmOC:	Obstetricians	High	Field-based	Newborn	Societal	Yes	14092 (CvS1), 3878 (CvS2), 240 (S2vS1)	per death averted	634	[28]
1. Medical doctors
2. Clinical officers
Hospital-based promotion of breastfeeding	Doing nothing	High	Field-based	Newborn	Health service provider (excl. start-up)	No	6894	per death averted	2264	[36]
Improved standard of special neonatal care	Doing nothing	Low	Field-based	Newborn	Equipment only	No	970	per death averted	2184	[56]
Cost per strategy- specific measure
Community health education by midwives	No strategy	Low	Field-based	N/A	Strategy	No	5	per educational interaction	946	[32]
Promotion of NGO health clinics:	No strategy	High	Inference (from secondary data)	N/A	Strategy	Yes	<1 (S1), 15 (S2)	per additional ANC user	747	[21]
1. National media campaign
2. National media campaign & local activities
Establish community contact persons	No strategy	Low	Field-based	N/A	Strategy	No	259	per delivery with complications	1555	[54]
							7	per referral
							37	per assisted delivery
Home-based neonatal care by VHWs	No strategy	Low	Field-based	Newborn	Strategy	No	14	per home-visit for neonatal care	1489	[39]
Home-based neonatal care by VHWs	No strategy	Low	Field-based	N/A	Strategy	No	13	per home-visit for neonatal care	1489	[41]
Home-based distribution of IPTp	IPTp distributed during ANC	High	Field-based	Newborn	Societal	Yes	6 (S), 5 (C)	per women receiving full dose of IPTp	547	[59]
Tetanus toxoid (TT) immunization campaign	TT immunization at routine ANC	High	Field-based	Newborn	Strategy	Yes	20 (S), 7–30 (C)	per woman receiving full TT vaccine	3557	[42]
Vouchers for free MNH care, cash and in-kind transfers	No strategy	Medium	Field-based	N/A	Strategy	Yes	91	per additional delivery with qualified provider	747	[19]
Remove user fees for intrapartum care	No strategy	Medium	Field-based	N/A	Health service provider	No	3	per normal delivery	1032	[57]
							183	per C-section performed
Established emergency transport scheme	No strategy	Low	Field-based	N/A	Strategy	No	44	per obstetric emergency transported	1555	[55]
HIV testing at ANC:	No strategy	High	Economic model (using secondary data)	Newborn	Health service provider	Yes	1060 (S1), 497 (S2)	per HIV infection prevented	1489	[38]
1. nationwide,
2. in high prevalence states
Strategies for abortion care:	No strategy	Medium	Economic Model (using secondary data)	N/A	Health service provider	No	135 (S1), 75 (S2), 102 (S3), 18 (S4)	per abortion case	547	[58]
1 Restricted-conventional
2. Restricted-recommended
3. Liberal-conventional
4. Liberal-recommended
Bamako Initiative	No strategy	Medium	Inference (from secondary data)	N/A	Health service provider	Yes	20 (Benin), 39 (Guinea)	per women receiving at least three antenatal visits	B: 752 G: 591	[27]
Quality improvement collaborative	No strategy	High	Economic Model	Women	Health service provider	Yes	155	per PPH averted,	383	[52]
							3	per delivery
Distribute malaria ITN at ANC	No strategy	High	Field-based	N/A	Strategy	No	13	per ITN delivered to pregnant women	862	[43]
Introduce HIV testing:	No strategy	Medium	Field-based	N/A	Strategy	No	4 (S1), 4 (S2)	per person tested for HIV	946	[31]
1. at ANC
2. at labour
Syphilis testing at ANC	No strategy	Low	Field-based	Newborn	Strategy	No	6399	per adverse pregnancy outcome averted	1469	[63]
Decentralized programme of syphilis control	No strategy	Low	Field-based	Newborn	Strategy	No	293-346	per case of congenital syphilis averted	862	[45]
							114	per case of syphilis treated
Decentralized programme of syphilis control	No strategy	Low	Field-based	Newborn	Strategy	No	252	per case of congenital syphilis averted	862	[46]
							137	per syphilis case treated
Syphilis testing at ANC.	No strategy	Low	Field-based	N/A	Strategy	No	3 (S1), 11 (S2)	per person tested for syphilis	862	[44]
1. on-site
2. standard clinics (off-site)
Improve health and family welfare clinics	No strategy	Low	Inference (from primary and secondary data)	N/A	Strategy	No	14	per consultation	747	[20]
Initiative to promote facility-birth	No strategy	Medium	Field-based	N/A	Health service provider	Yes	1602, (201 excl. cost of strategy)	per facility-birth	634	[29]
Initiative to promote facility-birth	No strategy	Medium	Field-based	N/A	Societal	Yes	209	per facility-birth	634	[30]
Initiative on evidence-based practice in maternal and infant hospital care	No strategy	Medium	Field-based	N/A	Health service provider	No	49	cost saving per birth	3867	[62]
Hospital-based promotion of breastfeeding	No strategy	High	Field-based	Newborn	Health service provider (excl. start-up)	No	58	per neonatal case of diarrhoea averted	2264	[36]
							24	per birth
Train Assistant Medical Officers in EmOC	Physicians	High	Field-based	N/A	Societal	Yes	61 (S),225 (C)	per C-section performed	579	[50]
Train new cadre in EmOC:	Obstetricians	High	sField-based	Newborn	Societal	Yes	248 (S1), 230 (S2), 615 (C)	per C-section performed	634	[28]
1. Medical doctors
2. Clinical officers
Programme on obstetric urogenital fistula	No strategy	Low	Field-based	N/A	Societal	No	1629-1745	per consultation	383	[53]

Note: multiple cost-effectiveness measures are reported for some strategies.
*Gross domestic product per capita (GDP-PC) in US$ 2012 prices is included as a benchmark against which to consider the cost per DALY averted, cost per QALY gained and cost per life-year saved. The WHO considers strategies and interventions to be cost-effective if the cost per DALY averted is less than three times the GDP-PC and highly cost-effective if less than the GDP-PC.
Acronyms used:
ANC: antenatal care; C: comparator; CHW: community health worker; C-section: caesarean section; DALY: disability-adjusted life-year; EmOC: emergency obstetric care; excl.: excluding; FP: family planning; HSS: health system strengthening; Incl.: including; ITNs: insecticide-treated bed nets; IPTp: intermittent preventive treatment in pregnancy; MCH: maternal and child health; MNCH: maternal, newborn, and child health; MNH: maternal and newborn health; NGO: non-governmental organisation; QALY: quality-adjusted life-year; TBA: traditional birth attendant; PHC: primary health care; S: strategy; TT: tetanus toxoid; VHWs: village health workers; WHO: World Health Organization.

Back to article page

ISSN: 1471-2393

Contact us

Submission enquiries: bmcpregnancyandchildbirth@biomedcentral.com
General enquiries: ORSupport@springernature.com

BMC Pregnancy and Childbirth

Contact us