PS2-8
COST-EFFECTIVENESS OF A MOBILE ANTENATAL CARE (MAC) OUTREACH PROGRAM IN MALAWI
Method: We assessed implementation of the MAC program in the Malawi district of Ntcheu between 2000 and 2012. The program—conducted by nurses and community health workers—offers antenatal care to pregnant women with limited geographic access to healthcare services. We used program-specific and hospital-level data from the Ntcheu district, as well as WHO data on maternal mortality before 2000. Program effectiveness was based on number of deliveries conducted by skilled health workers, antenatal care visits (total, first trimester only), and number of maternal deaths, as well as disability-adjusted life years (DALYs) calculated based on life expectancy of child-bearing women in the district (mean age 27 years). We included program-specific costs for Ntcheu district (e.g., personnel, outreach transportation) and donors (e.g., insecticide-treated bed nets), as well as patient travel time to services. Incremental cost-effectiveness ratios are in 2012 US$/DALY averted using a societal perspective and 3% annual discount rate. Cost-effectiveness thresholds were based on 3x GDP/capita for Malawi (3x $262). We examined uncertainty using deterministic and probabilistic sensitivity analysis.
Result: During the program period, number of antenatal visits increased from 27,600 to 39,800 (+44%), while health facility deliveries increased from 11,700 to 14,800 (+26%), averting 1,227 maternal deaths. Total program costs were $1,570,000, of which 54% was borne by the Ntcheu district, 26% by pregnant women, and 20% by donors. Compared to no program, the MAC program cost each pregnant woman an additional $11 and averted 0.21 DALYs (2600 DALYs averted for the entire Ntcheu district) annually, for an incremental cost-effectiveness ratio of $51/DALY averted. In deterministic sensitivity analysis, estimates did not exceed the cost-effectiveness threshold. Similarly, in probabilistic sensitivity analysis, the program had a mean incremental cost-effectiveness ratio of $72/DALY averted (95% CI, $33–$175/DALY averted). Scaled to the national level, the MAC program would annually avert as many as 63,000 DALYs in Malawi at a cost of $521,000.
Conclusion: Mobile antenatal care clinics are a highly cost-effective approach for reducing maternal mortality in Malawi and similar settings. Efforts to scale the district program to the national level could facilitate achievement of Malawi’s maternal health targets.