Which ways to improve maternal and newborn health are cost effective?
More than one third of countries in the world – including nearly all of Sub-Saharan Africa – will fail to meet the Sustainable Development Goals’ benchmarks for maternal and newborn health if current trends continue, according to Duke University researchers. Donors are already investing substantial resources toward these issues: US$3.1 billion in development aid went to maternal and newborn health in 2017 alone. So which strategies should donors focus on to make sure their funds have the most impact?
Training women’s groups and implementing home-based newborn care have been shown to be both effective in terms of saving lives and cost-effective by the standards of the World Health Organization.
Women’s groups’ effectiveness tended to be measured in terms of the cost per newborn death averted, which ranged from US$2,094 for a program in India to US$13,457 for a program in Nepal. In that Indian study, the newborn mortality rate per 1,000 live births (NMR) was 42.9 in the study group, compared with 59.1 in the control group. In that study in Nepal, the NMR was 26.2 in the study group, compared with 36.9 in the control group.
Home-based care for newborns tended to be measured differently, with respect to the cost per ‘Disability-Adjusted Life Year’ (DALY) saved. The cost per DALY saved ranged from US$13 for a program in India to US$126 for a program in Bangladesh. For that study in India, the NMR was 25 in the study group compared with 62 in the control group. In Bangladesh, the rate was 31.2 per 1,000 in the study group compared with 43.1 in the control group.
The evidence discussed here comes from a systematic review which included results from 43 separate studies conducted around the world. Evidence from systematic reviews is more reliable than results from a single study which may not be replicable. This review includes studies of a number of different types of interventions, most of which were conducted in South Asia and Sub-Saharan Africa.
The interventions promoting women’s groups all had a similar strategy: they trained literate women to run monthly women’s meetings within their own communities. At these meetings the women would identify problems and implement local solutions like starting community funds, organizing schemes to provide stretchers, and supplying clean delivery kits (like these). These studies were conducted in Bangladesh, India, Malawi, and Nepal.
The programs which provided home-based newborn care used more diverse strategies. Of the four studies included in the review, one trained community health workers, one trained volunteer health workers, one trained community resource persons, and one trained traditional birth assistants. Although these workers had somewhat different tasks in each context, all provided home-based newborn care. These studies were conducted in Bangladesh, India, Uganda, and Zambia.
Beyond the promising findings on the above two types of intervention strategies, the biggest insight from this (and other) systematic reviews is the paucity of cost considerations in the impact evaluation field.
Therefore, there may be other interventions which are both effective and cost effective – but not enough evidence is available to know for sure. Including cost analyses in impact evaluations appears to be challenging. Developing better evidence about costs is the topic of a pair of sessions this month as part of 3ie’s Virtual Evidence Weeks, a series of online discussions about developing and using evidence for development.
Even though this systematic review focused only on studies that analyzed costs as well as effectiveness, it had trouble comparing the disparate measures of cost-effectiveness used in different contexts. The interventions discussed here were among those it could compare, because they had all been evaluated with measures that could fit the World Health Organization’s definitions of cost-effectiveness.
That WHO standard depends both on the costs of the intervention as well as the GDP per capita of the country where it took place. It is based on calculations of improvements in Disability-Adjusted Life Years (DALY) or other similar measures. As the review notes, these cost-effectiveness standards have been criticized for their reliance on national-level GDP, since they value people’s lives differently based on what country they live in.
For more information on this review, the full text and 3ie’s quality assessment are here. Beyond this study, there are hundreds more systematic reviews and thousands more impact evaluations accessible at our newly-updated Development Evidence Portal.