Alternative strategies to reduce maternal mortality in India: a cost-effectiveness analysis

Abstract

Background: Approximately one-quarter of all pregnancy- and delivery-related maternal deaths worldwide occur in India. Taking into account the costs, feasibility, and operational complexity of alternative interventions, we estimate the clinical and population-level benefits associated with strategies to improve the safety of pregnancy and childbirth in India.

Methods and findings: Country- and region-specific data were synthesized using a computer-based model that simulates the natural history of pregnancy (both planned and unintended) and pregnancy- and childbirth-associated complications in individual women; and considers delivery location, attendant, and facility level. Model outcomes included clinical events, population measures, costs, and cost-effectiveness ratios. Separate models were adapted to urban and rural India using survey-based data (e.g., unmet need for birth spacing/limiting, facility births, skilled birth attendants). Model validation compared projected maternal indicators with empiric data. Strategies consisted of improving coverage of effective interventions that could be provided individually or packaged as integrated services, could reduce the incidence of a complication or its case fatality rate, and could include improved logistics such as reliable transport to an appropriate referral facility as well as recognition of referral need and quality of care. Increasing family planning was the most effective individual intervention to reduce pregnancy-related mortality. If over the next 5 y the unmet need for spacing and limiting births was met, more than 150,000 maternal deaths would be prevented; more than US$1 billion saved; and at least one of every two abortion-related deaths averted. Still, reductions in maternal mortality reached a threshold ( approximately 23%-35%) without including strategies that ensured reliable access to intrapartum and emergency obstetrical care (EmOC). An integrated and stepwise approach was identified that would ultimately prevent four of five maternal deaths; this approach coupled stepwise improvements in family planning and safe abortion with consecutively implemented strategies that incrementally increased skilled attendants, improved antenatal/postpartum care, shifted births away from home, and improved recognition of referral need, transport, and availability/quality of EmOC. The strategies in this approach ranged from being cost-saving to having incremental cost-effectiveness ratios less than US$500 per year of life saved (YLS), well below India's per capita gross domestic product (GDP), a common benchmark for cost-effectiveness.

Conclusions: Early intensive efforts to improve family planning and control of fertility choices and to provide safe abortion, accompanied by a paced systematic and stepwise effort to scale up capacity for integrated maternal health services over several years, is as cost-effective as childhood immunization or treatment of malaria, tuberculosis, or HIV. In just 5 y, more than 150,000 maternal deaths would be averted through increasing contraception rates to meet women's needs for spacing and limiting births; nearly US$1.5 billion would be saved by coupling safe abortion to aggressive family planning efforts; and with stepwise investments to improve access to pregnancy-related health services and to high-quality facility-based intrapartum care, more than 75% of maternal deaths could be prevented. If accomplished over the next decade, the lives of more than one million women would be saved.

Figure 1. Schematic of the model.

Upper panel: Model simulates the natural history of pregnancy (both planned and unintended) and pregnancy- and childbirth-associated complications. Case fatality rates for complications depend on severity and comorbidity. General intervention categories (open red boxes) include family planning for spacing or limiting births, antenatal or prenatal care (and treatment of anemia), safe abortion, intrapartum care (e.g., active management of labor), basic and comprehensive EmOC, and postpartum care. Interventions can reduce the incidence or severity of a complication or can reduce the case fatality rate through appropriate treatment. Lower panel: Model reflects the intervention pathway during labor and delivery, including location (home, birthing or health center, bEmOC, cEmOC), attendant (family member, traditional birth attendant [TBA], or SBA), and three potential barriers to effective treatment in the event of a complication, including recognition of referral need, transfer (e.g., transport), and timely quality care in an appropriate EmOC facility. Management of labor and delivery depends on attendant (e.g., SBA, clean delivery) and site (e.g., expectant management in birthing center, active management in EmOC facility), as does access to specific levels of treatment (e.g., blood transfusion only available in cEmOC).

Figure 2. Stepwise improvements in scaling up maternal services.

Four strategies that scale up access to critical maternal health services in consecutive phases are designated as upgrade 1, upgrade 2, upgrade 3, and upgrade 4. Shown are the percent increases in facility-based delivery, SBAs, recognition of referral need (by SBA at birthing/health center), transport (to appropriate referral facility), and availability/quality of EmOC (including adequate staff/supplies, appropriate clinical treatment, immediate attention), for rural and urban India. Shifts from home births assume a 70% shift to health centers/birthing centers and a 30% shift to EmOC; for routine births in EmOC, we assume 90% bEmOC and 10% cEmOC. Alternatives evaluated in sensitivity analysis (Results and Text S1).

Figure 3. Averted deaths with family planning and safe abortion.

Averted deaths attributable to unsafe abortion in rural India by addressing need for family planning (green shading) and providing 75% safe abortion (blue shading). Magnitude of additional averted abortion-related deaths with improved access to safe abortion depends on the amount of unmet need for contraception.

Figure 4. Health and economic outcomes in rural Uttar Pradesh.

Upper panel. Reduction in maternal deaths and cost-effectiveness with stepwise approaches to improve maternal health in rural Uttar Pradesh. The vertical axis (from bottom to top) shows outcomes associated with increased access to family planning and safe abortion. The horizontal axis (from left to right) displays outcomes associated with investments in high-quality health-center–based intrapartum care, which involved stepwise improvements in SBAs, recognition of referral need, and antenatal/postpartum care, incrementally shifted births away from home, and improved transport, availability, and quality of EmOC. Each cell represents a unique strategy; the reduction in maternal deaths shown is relative to current conditions (far lower left corner). Shading reflects cost-effectiveness ratios, compared to status quo (pink, cost saving; blue,