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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
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]
  1. Note: multiple cost-effectiveness measures are reported for some strategies.
  2. *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.
  3. Acronyms used:
  4. 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.