COST-EFFECTIVENESS OF STRATEGIES TO REDUCE MATERNAL MORBIDITY AND MORTALITY IN INDIA

Purpose:  In 2005, an estimated 117,000 maternal deaths occurred in India, reflecting the highest burden of maternal mortality for any single country and accounting for one quarter of all maternal deaths worldwide. To inform national policy decisions on how to best achieve Millennium Development Goal 5 (MDG5) of a 75% reduction in maternal mortality, we comparatively evaluated the health and economic outcomes of strategies targeting different components of pregnancy and childbirth.
Methods: Incorporating the best available data from India and South Asia, we developed a state-transition model which simulates the natural history of pregnancy and its complications. Cohorts of Indian women, beginning at age 15, are followed throughout their lifetime. We compared the costs (2006 US$) and benefits (QALYs) associated with several strategies to a country-specific scenario that simulates current practice and coverage levels in India, calibrated to survey based data on maternal outcomes. These included increasing coverage of single interventions (i.e., prenatal care, family planning, safe abortion, intrapartum care, skilled birth attendants, basic and comprehensive access to emergency obstetrical care (EmOC), postpartum care), and strategic packages in which the coverage levels are increased for general categories of interventions (e.g., skilled birth attendants and access to emergency obstetrical care in a birthing center). For interventions at delivery, we model 5 delivery settings with differential costs and effects.
Results:  Among single interventions, increasing coverage of family planning by 13% to meet unmet demand was the least costly, and reduced maternal mortality by 26%.  In comparison, universal access to skilled birth attendants with tightly linked referral to basic EmOC, had an incremental cost-effectiveness ratio (ICER) of $63 per QALY and reduced maternal mortality by 74%.  Relative to the current standard of care, strategic packages of services saved $15 -59 per woman and reduced maternal mortality and morbidity by 28-91% and 28-85%, respectively.  While nine strategic packages were capable of achieving MDG5, not all would be feasible in the short-term, requiring scale-up and capacity building. However, several strategies less dependent on health system capacity still provided substantial life-saving benefits.
Conclusions: While MDG5 will be best achieved through universal provision of intrapartum care in facilities with basic EmOC, substantial health gains can be realized in the short-term by rapidly enhancing access to family planning and safe abortion.