The authors have declared that no competing interests exist.
A cost-effectiveness study by Sue Goldie and colleagues finds that better family planning, provision of safe abortion, and improved intrapartum and emergency obstetrical care could reduce maternal mortality in India by 75% in 5 years.
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.
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 (∼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.
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.
Every year, more than half a million women—most of them living in developing countries—die from pregnancy- or childbirth-related complications. About a quarter of these “maternal” deaths occur in India. In 2005, a woman's lifetime risk of maternal death in India was 1 in 70; in the UK, it was only one in 8,200. Similarly, the maternal mortality ratio (MMR; number of maternal deaths per 100,000 live births) in India was 450, whereas in the UK it was eight. Faced with the enormous maternal death toll in India and other developing countries, in September 2000, the United Nations pledged, as its fifth Millennium Development Goal (MDG 5), that the global MMR would be reduced to a quarter of its 1990 level by 2015. Currently, it seems unlikely that this target will be met. Between 1990 and 2005, global maternal deaths decreased by only 1% per annum instead of the 5% needed to reach MDG 5; in India, the decrease in maternal deaths between 1990 and 2005 was about 1.8% per annum.
Most maternal deaths in developing countries are caused by severe bleeding after childbirth, infections soon after delivery, blood pressure disorders during pregnancy, and obstructed (difficult) labors. Consequently, experts agree that universal access to high-quality routine care during labor (“obstetric” care) and to emergency obstetrical care is needed to reduce maternal deaths. However, there is less agreement about how to adapt these “ideal recommendations” to specific situations. In developing countries with weak health systems and predominantly rural populations, it is unlikely that all women will have access to emergency obstetric care in the near future—so would beginning with improved access to family planning and to safe abortions (unsafe abortion is another major cause of maternal death) be a more achievable, more cost-effective way of reducing maternal deaths? How would family planning and safe abortion be coupled efficiently and cost-effectively with improved access to intrapartum care? In this study, the researchers investigate these questions by estimating the health and economic outcomes of various strategies to reduce maternal mortality in India.
The researchers used a computer-based model that simulates women through pregnancy and childbirth to estimate the effect of different strategies (for example, increased family planning or increased access to obstetric care) on clinical outcomes (pregnancies, live births, or deaths), costs, and cost-effectiveness (the cost of saving one year of life) in India. Increased family planning was the most effective single intervention for the reduction of pregnancy-related mortality. If the current unmet need for family planning in India could be fulfilled over the next 5 years, more than 150,000 maternal deaths would be prevented, more than US$1 billion saved, and at least half of abortion-related deaths averted. However, increased family planning alone would reduce maternal deaths by 35% at most, so the researchers also used their model to test the effect of combinations of strategies on maternal death. They found that an integrated and stepwise approach (increased family planning and safe abortion combined with consecutively increased skilled birth attendants, improved care before and after birth, reduced home births, and improved emergency obstetric care) could eventually prevent nearly 80% of maternal deaths. All the steps in this strategy either saved money or involved an additional cost per year of life saved of less than US$500; given one suggested threshold for cost-effectiveness in India of the per capita GDP (US$1,068) per year of life saved, these strategies would be considered very cost-effective.
The accuracy of these findings depends on the assumptions used to build the model and the quality of the data fed into it. Nevertheless, these findings suggest that early intensive efforts to improve family planning and to provide safe abortion accompanied by a systematic, stepwise effort to improve integrated maternal health services could reduce maternal deaths in India by more than 75% in less than a decade. Furthermore, such a strategy would be cost-effective. Indeed, note the researchers, the cost savings from an initial focus on family planning and safe abortion provision would partly offset the resources needed to assure that every woman had access to high quality routine and emergency obstetric care. Thus, overall, these findings suggest that MDG 5 may be within reach in India, a conclusion that should help to mobilize political support for this worthy goal.
Please access these Web sites via the online version of this summary at
UNICEF (the United Nations Children's Fund) provides information on
The World Health Organization also provides information on
The
The Millennium Development Goals Report 2009 and its
Computer simulation modeling as applied to health is further discussed at the
Approximately one-quarter of all pregnancy- and delivery-related maternal deaths worldwide occur in India, which has the highest burden of maternal mortality for any single country
Despite consensus on the need for universal access to high-quality intrapartum and emergency obstetrical care (EmOC), uncertainties remain about how to adapt “ideal recommendations” to specific situations
To most effectively leverage India's national commitment to reducing maternal mortality, identifying evidence-based strategies that consider the local context is imperative. Our analysis is motivated by questions that include: What are the fundamental drivers of the effectiveness, cost-effectiveness, and affordability of a package of interventions to reduce maternal mortality? Because adequate facilities, health infrastructure, and skilled human resources will not be readily available in all settings, can we provide interim guidance to policy makers? While no single empirical study can provide clear answers to these questions, a modeling approach within a decision-analytic framework can extend empiric information by extrapolating outcomes beyond the time horizon of a single study, can facilitate synthesis of multiple data sources in an internally consistent and epidemiologically plausible way
Previous model-based studies have provided important insights into the potential high public health value of reducing maternal deaths, however, many of these have not considered the full range of interventions to reduce maternal mortality, such as family planning, safe abortion, and intrapartum care
The best available data were synthesized using a computer-based model that simulates the natural history of pregnancy and relevant comorbidities, aggregates individual outcomes to the population level, and reflects setting-specific epidemiology. Separate models were adapted to urban and rural India using data on antenatal care, family planning, facility births, and skilled birth attendants (SBAs), and information about access to transport, referral facilities, and quality of care. Model outcomes include clinical events (e.g., pregnancies, live births, maternal complications), measures of maternal mortality (e.g., MMR, proportionate mortality ratio [i.e., proportion of deaths that are pregnancy-related among women aged 15–45 y], and lifetime risk of maternal death), population outcomes (e.g., life expectancy), and economic costs.
We evaluated alternative approaches to reducing maternal mortality in settings in India that differ according to underlying maternal risk, health, and socioeconomic status. Interventions can be provided individually or packaged into integrated services. Following standard recommendations for economic evaluation
The computer-based Global Maternal Health Policy Model simulates the natural history of pregnancy (both planned and unintended) and pregnancy- and childbirth-associated complications (
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).
Strategies in the model to reduce maternal mortality consist of improving coverage of effective interventions, which may be provided individually or packaged as integrated services. In addition to family planning, antenatal care (i.e., prenatal care) and treatment of anemia, safe abortion, and postpartum care, the model includes both intrapartum interventions that reduce the incidence of a complication (e.g., misoprostol for postpartum hemorrhage [PPH], clean delivery for sepsis), as well as those that reduce the case fatality rate through appropriate management in a referral facility (
The effectiveness of interventions to either reduce the incidence of complications or to reduce case fatality rates associated with complications depends, in part, on access to specific services (e.g., trained SBA) and to specific levels of facilities (e.g., comprehensive EmOC [cEmOC] with capacity for blood transfusion). Accordingly, the ultimate impact of interventions depends on several setting-specific factors. These include delivery site, presence of birth attendant, quality and type of referral facility, as well as successful referral when necessary. The model therefore explicitly considers the location of delivery, type of assistance, access to basic or comprehensive obstetrical care, and the ability to overcome a series of barriers around the timing of delivery (e.g., recognition of referral need, reliable transport, timely treatment at an appropriate referral facility); these factors collectively determine the health services a woman can access and the specific interventions that would be included (
Delivery setting is differentiated by provider (e.g., family member, traditional birth attendant [TBA], or SBA) and by site (e.g., home versus facility). Facility levels are categorized as (1) birthing centers or health centers, which cannot provide all services necessary to qualify as a basic emergency obstetrical care (bEmOC) facility, but are staffed with SBA who provide expectant management of labor and more reliable referral when necessary than with delivery at home; (2) facilities with bEmOC capacity (e.g., first referral units); and (3) facilities with cEmOC capacity (e.g., district hospitals)
This model also allows us to evaluate phased approaches that involve scaling up access to services over time; the stepwise investments in infrastructure required to assure high-quality intrapartum care are designated as “upgrades.” In addition to reducing unmet need for family planning and unsafe abortion, four consecutively implemented strategies increased skilled attendants, improved antenatal/postpartum care, incrementally shifted births away from home, and improved the availability and quality of EmOC. For women delivering at home or in birthing centers, these “upgrades” also improved recognition of referral need, access to transport, and expedient referral to an appropriate facility (
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 (
All models were built using TreeAge Pro 2008 (TreeAge Software Inc.) and analyzed using IBM/Lenovo Dual-Core VT Pro Desktop computers running Microsoft Windows XP, using Microsoft Excel 2007 and Visual Basic for Applications 6.5 (Microsoft Corp.). We used Monte Carlo simulation to generate the number of per woman events such as pregnancies, live births, facility-based births, and maternal complications.
Selected parameters and assumptions used in the model are provided in
Parameter | Hemorrhage | Obstructed Labor | Hypertensive Disorders | Sepsis | Unsafe Abortion |
Probability of event |
0.114 | 0.047 | 0.035 | 0.050 | 0.128 |
Range | 0.051–0.228 | 0.030–0.074 | 0.025–0.050 | 0.043–0.060 | 0.050–0.250 |
Probability of morbidity |
0.008 | 0.022 | 0.001 | 0.400 | 0.120 |
Range | 0.006–0.010 | 0.018–0.026 | 0.001–0.001 | 0.320–0.480 | 0.096–0.144 |
CFR |
0.010 | 0.007 | 0.017 | 0.013 | 0.003 |
Adjusted CFR |
0.023 | 0.019 | 0.021 | 0.028 | 0.009 |
Range | 0.007–0.030 | 0.005–0.025 | 0.012–0.027 | 0.009–0.036 | 0.002–0.012 |
Attributable mortality |
46.2% (9%–73%) | 14.1% (3%–52%) | 13.7% (0%–18%) | 17.4% (0%–20%) | 8.6% (0%–20%) |
Model-projected attributable mortality | 40.6% | 16.8% | 12.3% | 20.4% | 9.8% |
Decreased incidence |
50%,75% |
— | — | 25%, 50% |
— |
Range |
25%–91% | — | 25%–50% | 0%–60% | 0%–100% |
Decreased CFR |
75% | 95% | 59% | 90% | 98% |
Range |
60%–90% | 76%–100% | 45%–95% | 63%–93% | 50%–100% |
See
Incidence of elective abortion is 0.170, and 75% are assumed to be unsafe in the base case
Specific examples of nonfatal complications include Sheehan's Syndrome following maternal hemorrhage, fistula resulting from obstructed labor, neurological sequelae from eclampsia, pelvic inflammatory disease (PID). Not shown but included are the risk of infertility from PID (0.086) and the risk of severe anemia following maternal hemorrhage (0.09)
CFRs were adjusted based on complication severity (e.g., life threatening complications requiring cEmOC) and underlying severity of anemia
Estimates for distribution of causes of maternal mortality for India are from India overall estimates from Khan et al.
Incidence of sepsis reduced by 50% with SBA and clean delivery in birthing center, bEmOC, and cEmOC; and reduced by 25% with SBA and clean delivery at home
For each baseline estimate, sensitivity analysis was conducted across a plausible range based on literature review; references and assumptions are documented in the
Estimates shown represent average reduction in case fatality rate provided complications necessitating surgery (e.g., cesarean section), blood transfusion, intensive hemodynamic support are treated in cEmOC. Obstructed labor is managed using assisted vaginal delivery with forceps or vacuum and, if necessary, cesarean section; severe pre-eclampsia and eclampsia treated with intravenous hydralazine and magnesium sulfate, in addition to induction of labor or emergency cesarean section when required; sepsis treated with ampicillin, gentamycin, and metronidazole or equivalent regimen followed by an 8-d course of intramuscular gentamycin and oral metronidazole (see
Parameter | India | India, Urban | India, Rural | Rajasthan | Uttar Pradesh, Rural |
Family planning (any method) | 56.3 | 64.0 | 53.0 | 47.2 | 39.7 |
Modern methods | 48.5 | 55.8 | 45.3 | 44.4 | 25.2 |
Pill | 6.4 | 7.0 | 6.2 | 4.5 | 5.2 |
IUD | 3.7 | 6.1 | 2.4 | 3.6 | 3.2 |
TOL | 76.9 | 67.7 | 81.9 | 77.0 | 66.7 |
Condom | 10.9 | 17.9 | 7.3 | 12.8 | 24.6 |
Unmet need | 13.2 | 10.0 | 14.6 | 14.6 | 23.8 |
Prenatal care | 50.7 | 73.8 | 42.8 | 41.2 | 22.6 |
Treatment for anemia |
22.3 | 34.5 | 18.1 | 13.1 | 6.7 |
Total skilled delivery | 48.3 | 75.2 | 39.1 | 41.0 | 23.8 |
Facility delivery |
40.7 | 69.4 | 31.1 | 29.6 | 17.5 |
Home delivery with SBA |
12.8 | 19.0 | 11.6 | 16.2 | 7.6 |
From home to EmOC | 30.4 | 44.4 | 24.4 | 24.4 | 18.1 |
Range | 20–40 | 35–55 | 15–35 | 20–40 | 15–30 |
From HC or BC to EmOC | 54.8 | 68.8 | 48.8 | 48.8 | 36.1 |
Range | 40–65 | 60–80 | 40–60 | 30–55 | 25–45 |
From bEmOC to cEmOC | 67.0 | 81.0 | 61.0 | 61.0 | 45.1 |
Range | 55–80 | 70–90 | 50–70 | 50–70 | 35–55 |
EmOC | 50.0 | 67.5 | 42.5 | 42.5 | 31.5 |
Range | 40–60 | 55–80 | 30–55 | 30–55 | 20–40 |
TFR |
2.68 | 2.07 | 2.98 | 3.21 | 4.13 |
Model-projected TFR |
2.70 | 2.07 | 2.97 | 3.24 | 4.13 |
Model-projected MMR |
440 | 407 | 520 | 524 | 633 |
See
Case fatality rates (CFRs) were adjusted based on complication severity (e.g., life threatening complications requiring cEmOC) and underlying severity of anemia
Routine deliveries in EmOC facilities assume that 90% would be in bEmOC and 10% in cEmOC. Alternative assumptions explored in sensitivity analysis (
Using the empirically calibrated India model, we parameterized the state-level models for Rajasthan and Uttar Pradesh and adjusted for the TFR as reported in NFHS 3
BC, birthing center; HC, health center; IUD, intrauterine device; TOL, female sterilization.
For women delivering at home or in a birthing center, the probability of successful referral depended on overcoming three potential barriers
Model performance was assessed by comparing the distribution of direct causes of maternal mortality, life expectancy, proportionate mortality ratio, MMR, and total fertility rate (TFR) to empiric data
Selected costs used in the model are provided in
Cost Components | Base Case | Range |
Oral contraceptives | 10.64 | 6.03–15.96 |
Injectable contraceptives | 10.20 | 4.92–15.30 |
Condoms | 8.40 | 3.79–12.60 |
Intrauterine device | 9.17 | 2.58–13.76 |
Female sterilization | 18.98 | 9.49–28.47 |
Male sterilization | 12.67 | 6.34–19.01 |
Four visits | 17.82 | 8.54–25.61 |
Incomplete abortion | 8.90 | 4.45–17.80 |
Elective abortion | 21.87 | 10.94–43.74 |
Postabortion complications | 43.40 | 21.70–86.80 |
Home (TBA, SBA) | 4.52, 6.44 | 0–9.66 |
Facility (birthing center, bEmOC, cEmOC) | 14.46, 24.58, 32.54 | 7.23–48.81 |
Misoprostol (home, birthing center) | 0.99 | 0.75–2.00 |
SBA training | 3.40 | 0.62–5.00 |
Home to facility | 3.62–8.13 | 1.81–12.20 |
Birthing/health center/bEmOC to referral facility | 4.88–7.14 | 2.44–10.71 |
Obstructed labor | 70.16 | 12.76–139.38 |
Maternal hemorrhage | 67.99 | 18.40–212.51 |
Puerperal sepsis | 47.92 | 23.15–111.02 |
Severe pre-eclampsia/eclampsia | 65.85 | 33.50–153.62 |
One visit | 4.99 | 1.04–7.49 |
See
Estimates of costs under current standard of care (2006 US$). Estimates for the base case were country-specific and from UNFPA's Reproductive Health Costing Tools Model (RHCTM)
Ranges for sensitivity analyses established on the basis of assumptions and other published literature documented in the
Antenatal care includes tetanus vaccination, syphilis, gonorrhea, chlamydia screening (and treatment), urinalysis, blood tests, treatment for anemia, counseling (e.g., family planning, spacing, intrapartum care).
Postabortion complications assumed to require manual vacuum aspiration, treatment of sepsis in 25%, surgical repair in 25%
Total costs reflect skill level of attendant, level of facility, and drugs and supplies. For example, delivery at birthing center (US$14.46) includes personnel (US$6.44), facility (US$4.52), and drugs and supplies (US$3.50). Other assumptions documented in the
Community-based interventions evaluated in sensitivity analysis included SBA-administered misoprostol to reduce incidence of PPH in deliveries at home and in birthing centers. Costs for misoprostol (US$0.99) and training (upper bound, US$3.40) based on assumptions presented in Sutherland and Bishai
Transport costs include those incurred from home to a referral facility (bEmoc or cEmOC), and those incurred between facilities when necessary (e.g., bEmOC to cEmOC). Assumptions based on literature
Estimates shown represent average total costs using case-specific unit costs weighted by severity. Complications requiring surgery (e.g., cesarean section), blood transfusion, intensive hemodynamic support assumed to require cEmOC. Details of unit cost assumptions for facility-specific treatment documented in
Postpartum care includes examination, iron/folate supplementation, and counseling.
TBA, traditional birth attendant.
Model-estimated life expectancy for a 15-y-old female was 55 y compared to the World Health Organization's (WHO) estimate of 55.1 y
Increased family planning to reduce the unmet need (for spacing and limiting births) by amounts ranging from 25% to 100%, reduced maternal deaths by amounts ranging from 7.0% to 28.1% in rural India and 5.8% to 23.5% in urban India (
Strategy | Lifetime Deaths per 100,000 Women | Reduction in Maternal Deaths | Proportionate Mortality Ratio | Lifetime Risk of Death Due to Maternal Complications | Model-projected Savings for a Single Birth Cohort of 15 y olds (US$) |
Cost Savings for a Single Year (Current Distribution of 15–45 y Olds in India) (US$) |
1,543 | — | 16.4% | 1 in 65 | NA | — | |
Family planning | ||||||
Reduce unmet need 25% (56.7%) | 1,435 | 7.0% | 15.4% | 1 in 70 | 111,357,615 | 60,200,655 |
Reduce unmet need 50% (60.3%) | 1,327 | 14.0% | 14.4% | 1 in 75 | 223,221,615 | 120,611,563 |
Reduce unmet need 75% (64.0%) | 1,218 | 21.1% | 13.4% | 1 in 82 | 335,439,615 | 181,233,496 |
Reduce unmet need 100% (67.6%) | 1,109 | 28.1% | 12.3% | 1 in 90 | 448,188,615 | 242,067,230 |
Safe abortion | ||||||
Increase safe abortion 50% | 1,517 | 1.7% | 16.2% | 1 in 66 | 48,080,115 | 42,078,125 |
Increase safe abortion 75% | 1,473 | 4.5% | 15.8% | 1 in 68 | 130,739,115 | 114,289,234 |
Increase safe abortion 95% | 1,433 | 7.1% | 15.4% | 1 in 70 | 214,460,115 | 167,790,590 |
Family planning and safe abortion | ||||||
Reduce unmet need (56.7%), safe abortion 75% | 1,369 | 11.3% | 14.8% | 1 in 73 | 233,930,115 | 166,870,014 |
Reduce unmet need (60.3%), safe abortion 75% | 1,265 | 18.0% | 13.8% | 1 in 79 | 337,386,615 | 219,568,526 |
Reduce unmet need (64.0%), safe abortion 75% | 1,160 | 24.8% | 12.8% | 1 in 86 | 441,108,615 | 272,385,038 |
Reduce unmet need (67.6%), safe abortion 95% | 1,026 | 33.5% | 11.5% | 1 in 98 | 580,230,615 | 362,579,472 |
842 | — | 9.6% | 1 in 119 | NA | — | |
Family planning | ||||||
Reduce unmet need 25% (66.5%) | 793 | 5.8% | 9.1% | 1 in 126 | 22,089,305 | 12,838,532 |
Reduce unmet need 50% (69.0%) | 743 | 11.7% | 8.6% | 1 in 135 | 44,214,305 | 25,696,437 |
Reduce unmet need 75% (71.5%) | 694 | 17.6% | 8.1% | 1 in 144 | 66,398,305 | 38,578,054 |
Reduce unmet need 100% (74.0%) | 644 | 23.5% | 7.5% | 1 in 155 | 88,611,805 | 51,483,279 |
Safe abortion | ||||||
Increase safe abortion 50% | 822 | 2.4% | 9.4% | 1 in 122 | 11,351,305 | 9,742,159 |
Increase safe abortion 75% | 788 | 6.4% | 9.1% | 1 in 127 | 30,821,305 | 26,413,778 |
Increase safe abortion 95% | 758 | 9.9% | 8.7% | 1 in 133 | 50,438,805 | 36,823,443 |
Family planning and safe abortion | ||||||
Reduce unmet need (66.5%), safe abortion 75% | 741 | 11.9% | 8.6% | 1 in 135 | 51,235,305 | 37,766,193 |
Reduce unmet need (69%), safe abortion 75% | 695 | 17.5% | 8.1% | 1 in 144 | 71,649,305 | 49,126,308 |
Reduce unmet need (71.5%), safe abortion 75% | 648 | 23.0% | 7.6% | 1 in 154 | 92,122,305 | 60,499,204 |
Reduce unmet need (74%), safe abortion 95% | 580 | 31.2% | 6.8% | 1 in 173 | 119,557,305 | 79,270,520 |
See
Model-projected cost savings reflect net costs averted over a woman's reproductive lifespan (ages 15–45 y) applied to the current population of 15 y olds in India stratified by rural (75%) and urban (25%) settings
Cost savings for a single representative year of a successfully implemented strategy were calculated using population-level data from India
In rural India, model-projected TFR is 2.76, 2.56, 2.36, 2.14 with reductions in unmet need of 25%, 50%, 75%, 100%, respectively.
In urban India, model-projected TFR is 1.94, 1.82, 1.71, 1.59 with reductions in unmet need of 25%, 50%, 75%, 100%, respectively.
Increased family planning to reduce the unmet need also reduced the number of deaths attributable to unsafe 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.
Our results suggest that reaching the MDG 5 goal of a 75% reduction in maternal mortality would require investments targeting the intrapartum period, in addition to family planning and safer abortion. Without these additional strategies, the model predicts a ceiling on the level of maternal mortality reduction achievable, ranging from 32% in urban India to 34% in rural India.
Region | Facility Birth (%) | Transport-Home |
Transport-Facility |
Quality of Care |
Family Planning |
Safe Abortion (%) | Decrease in Maternal Deaths (%) | MMR (Deaths per 100,000 Live Births) | Maternal Deaths as Percent of Deaths Ages 15–45 y | Lifetime Risk of Maternal Death | Lifetime Costs |
Cost-Effectiveness |
|
ICER (US$/YLS) | ICER (% per capita GDP) | ||||||||||||
520 | 16.4 | 1 in 65 | 218.38 | — | |||||||||
Upgrade 1 | 45 | 50 | 65 | 70 | 56.7 | 50 | 17.3 | 460 | 14.0 | 1 in 78 | 212.41 | CS | CS |
Upgrade 2 | 60 | 60 | 75 | 80 | 60.3 | 60 | 33.7 | 397 | 11.5 | 1 in 98 | 218.51 | 150 | 14 |
Upgrade 3 | 75 | 70 | 85 | 90 | 64.0 | 75 | 53.4 | 302 | 8.3 | 1 in 139 | 226.18 | 160 | 15 |
Upgrade 4 | 80 | 75 | 95 | 95 | 67.6 | 95 | 77.1 | 162 | 4.3 | 1 in 282 | 243.46 | 300 | 28 |
407 | 9.6 | 1 in 119 | 184.00 | — | |||||||||
Upgrade 1 | 75 | 60 | 85 | 70 | 66.5 | 50 | 15.8 | 363 | 8.2 | 1 in 141 | 174.91 | CS | CS |
Upgrade 2 | 80 | 75 | 90 | 80 | 69.0 | 60 | 33.3 | 305 | 6.6 | 1 in 178 | 178.30 | 150 | 14 |
Upgrade 3 | 90 | 80 | 92.5 | 90 | 71.5 | 75 | 54.1 | 225 | 4.7 | 1 in 259 | 183.44 | 220 | 21 |
Upgrade 4 | 95 | 85 | 95 | 95 | 74.0 | 95 | 78.5 | 113 | 2.3 | 1 in 553 | 194.97 | 350 | 33 |
Reduction in direct causes of maternal mortality, including abortion-related complications, postpartum hemorrhage, hypertensive disorders, sepsis, and obstructed labor.
Transport encompasses the expedient availability of means of transport (e.g., vehicle, cart), fuel (if needed), driver, and interim attendant care. Facility transport represents a weighted average of transport availability from a health center or birthing center to an EmOC facility and from a bEmOC facility to a cEmOC if indicated. Accuracy of referral need recognition at home and in health center with SBA increase, on average, to 60%, 75%, 90%, and 95% (not shown) with upgrade 1, 2, 3, and 4 in both rural and urban India.
Quality refers to the availability and quality of services at EmOC facilities, including adequate staffing and supplies, expedient attention (e.g., without delay to collect fees or requirement for family to bring supplies), and evidence-based clinical practices.
Family planning refers to contraceptive use for limiting and spacing; shown are values representing the reduction in unmet need by 25%, 50%, 75%, and 100% with upgrade 1, 2, 3, and 4, respectively, for both rural and urban India.
Stepwise improvements in maternal health services are assumed to occur in consecutive phases (e.g., first upgrade 1, then upgrade 2, etc.). Therefore, the incremental cost-effectiveness ratio (US$ per YLS) for each upgrade is calculated as the difference in lifetime costs relative to the difference in lifetime effects, compared with the preceding next best strategy. Cost-effectiveness ratios are also expressed as percent of the per capita GDP (US$1,068), shown in the farthest right column, as interventions with cost-effectiveness ratios of less than the per capita GDP are considered very cost-effective according to criteria proposed by the Commission on Macroeconomics and Health
Status quo (rural India): 31.1% facility births; 11.6% SBA (home births); transport from home (24.4%), primary-level health center (48.8%), bEmOC (61%); recognition of referral need at home (20%), primary-level health center (40%); availability and quality of EmOC (42.5%); 53% family planning.
Status quo (urban India): 69.4% facility births; 19% SBA (home births); transport from home (44%), primary-level health center (69%), bEmOC (81%); recognition of referral need at home (20%), primary-level health center (40%); availability and quality of EmOC (67.5%); 64% family planning.
CS, cost saving; ICER, incremental cost-effectiveness ratio.
Compared to the status quo in rural India (upper section,
Because the stepwise improvements in each component of the integrated package (intrapartum care, family planning, and safe abortion) were assumed to occur in consecutive phases, the incremental cost-effectiveness ratio for each “upgrade” strategy was calculated as the difference in costs relative to the difference in effects, compared with the preceding next best strategy. While the initial strategy was cost saving in both urban and rural India, incremental cost-effectiveness ratios ranged from US$150 to US$300 per YLS in rural India and from US$150 to US$350 per YLS in urban India. Cost-effectiveness ratios are also expressed as percent of the per capita GDP (US$1,068). Even the most intensive and effective strategic package was well below 50% of the per capita GDP.
In contrast to these integrated strategies, implementing only the stepwise intrapartum care upgrades—without family planning and safe abortion—was less effective and less cost-effective. The incremental cost-effectiveness ratios ranged from US$490–US$1,060 in rural India and US$200–US$990 per YLS in urban India (
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, <US$250/YLS; green, <US$500/YLS; purple, <US$750/YLS; orange, US$890/YLS). See text for details. Lower panel. Sensitivity analysis depicting the impact of improving only one component of intrapartum care services in rural Uttar Pradesh. Base case and improvements for each component are shown in numbers below the component name (e.g., quality of EmOC is 31.5% in the base case, improvements of 50%–100% were assessed). In settings where most deliveries occur at home, linkage of services in multiple domains is a critical determinant of reduction in maternal deaths. Even large improvements in skilled birth attendants for nonfacility births (yellow bar), recognition of referral need (pink bar), transport (green bar), or quality of EmOC (purple bar) fail to reduce mortality more than 2%–5% if other interdependent components are not improved as well. In contrast, even modest improvements in all four components, as shown in upgrade 1 (blue bar), reduce mortality by 22%. Cost-effectiveness of the integrated strategy ranged from cost saving to US$170 per YLS compared with US$700 to US$4,900 per YLS for single unlinked improvements.
In
For deliveries at home and in birthing centers in rural Uttar Pradesh, removing only one “delay” in accessing EmOC had minimal impact (<5%) on lowering maternal mortality and was not cost-effective (e.g., US$700–US$4,900 per YLS) (
Universal antenatal care by itself averted fewer than 2% of maternal deaths; however, if enhanced antenatal care increased the probability of either facility-based delivery or SBA-attended birth (linked with accurate referral and transport) from 31% to 60%, health benefits increased 5-fold (
As a greater proportion of routine deliveries shifted from home to facilities, we assumed 70% would shift to birthing centers or health centers staffed by SBA and 30% to facilities with full EmOC capacity. Although the differential benefits of routine delivery in birthing/health centers versus bEmOC was dependent on expedient transfer from a center to referral EmOC if needed, provided this was assured, both approaches were cost-effective. In contrast, when we varied assumptions about the proportion of routine deliveries in cEmOC versus bEmOC, cost-effectiveness results changed drastically; as routine deliveries shifted to cEmOC, the incremental cost-effectiveness ratios became much less attractive, ranging from US$8,300 to US$27,000 per YLS.
Rural India | Family Planning |
Safe Abortion (%) | Facility Birth (%) | Transport-Home |
Transport-Facility |
Quality of Care |
Incremental Benefits and Cost-Effectiveness of Community-Based Misoprostol |
||
Decrease in Maternal Deaths | Lives Saved with Addition of Community-based Misoprostol |
Cost-Effectiveness | |||||||
56.7 | 50 | 45 | 50 | 65 | 70 | ||||
12.3% | 16,992 | Cost saving |
|||||||
60.3 | 60 | 60 | 60 | 75 | 80 | ||||
13.0% | 17,612 | Cost saving |
|||||||
64.0 | 75 | 75 | 70 | 85 | 90 | ||||
10.2% | 13,983 | Cost saving |
|||||||
67.6 | 95 | 80 | 75 | 95 | 95 | ||||
6.9% | 9,470 | Cost saving |
Family planning refers to contraceptive use for limiting and spacing; shown are values representing the reduction in unmet need by 25%, 50%, 75%, and 100% with upgrades 1, 2, 3, and 4, respectively.
Transport encompasses the expedient availability of means of transport (e.g., vehicle, cart), fuel (if needed), driver, and interim attendant care.
Quality refers to the availability and quality of services at EmOC facilities, including adequate staffing and supplies, and evidence-based clinical practices.
Community-based interventions assume SBA-administered misoprostol for births at home and birthing centers/health centers with a 50% (25%–60%) reduction in PPH
Population-level incremental benefits (lives saved) associated with the community-based misoprostol intervention (compared to the same strategy without the community-based misoprostol intervention). These were calculated by applying model-projected outcomes to population-level data from rural India
We have identified several strategic options that would cost-effectively reduce maternal mortality in both rural and urban India. Our principal findings are that early intensive efforts to improve family planning and provide safe abortion, accompanied by a systematic stepwise effort to scale up intrapartum and EmOC, could reduce maternal mortality by 75%. Despite the inherent uncertainty in data and assumptions used in the analysis, four critical themes emerge as robust.
First, increasing effective family planning is the most effective individual intervention to reduce pregnancy-related mortality. If the unmet need was met in rural and urban India by 2012, our results imply that the lives of 168,000 women would be saved by the end of 2015. The cost savings over that time period would exceed US$1 billion. Because strategies to increase contraceptive options for limiting and spacing do not require the same level of infrastructure as improving intrapartum care, targeting these strategies toward rural areas with high TFRs is a promising way to initiate equitable improvements in maternal health.
Second, two distinct—yet synergistic—approaches, family planning and safe abortion, can reduce deaths from unsafe abortion. Enhanced access to family planning by itself reduces demand for elective abortion and consequently reduces deaths attributable to unsafe abortion. In fact, reducing the unmet need for contraception can prevent one of every two abortion-related deaths. Furthermore, just a fraction of the cost savings from family planning would fully fund an intervention to provide safe abortion and postabortion care.
Third, despite the substantial health and economic benefits associated with family planning and safe abortion, there is a threshold above which further reductions in mortality are impossible. MDG 5 will therefore not be achievable without involving integrated interventions that ensure reliable access to high-quality intrapartum and EmOC. These interventions could be implemented, however, in a staged, scale-up fashion.
While formidable effort and financial investment would be required to scale up maternal health services over time, we identified a number of phased approaches that would ultimately prevent four out of five maternal deaths. Coupled with stepwise improvements in family planning and safe abortion, these approaches incrementally shifted home births to birthing centers or facilities with EmOC, and improved both access to SBAs as well as accurate recognition of referral need, transport, and availability/quality of EmOC. Successful implementation of these strategies would be expected to dramatically reduce the MMR, proportionate mortality ratio, and lifetime risk of maternal death.
Fourth, despite the possible variation in pace associated with scaling up maternal health services in India, systematic and consecutive phases will be cost-effective. Our results showed that—when coupled with family planning and safe abortion—both early initial strategies and late intensive strategies resulted in cost-effectiveness ratios that were just a fraction of India's per capita GDP; these would unarguably be considered very cost-effective
Although our general findings are consistent with earlier suggestions that interventions to reduce maternal mortality are good public health investments
We may have underestimated both effectiveness and cost-effectiveness by excluding effects of certain indirect indicators and interventions. Although we purposely focused on maternal mortality, if we included neonatal health and survival, for example, most strategies would be even more cost-effective due to associations between place of birth and presence of a skilled attendant, with neonatal and maternal deaths
Other limitations in our analysis stem from its inherent reliance on high-quality data about maternal mortality specifically. While our calibration of setting-specific models allows us to better represent within-country differences in baseline risk, coverage, and capacity than previous studies, high-quality empiric evidence for the effectiveness of comprehensive strategies to reduce maternal mortality and morbidity is often either lacking or inconsistent. More studies quantifying the benefits of community-level interventions on preventing maternal morbidity remain a priority
Shiffman and Smith
With regard to the external community, we have tried to provide a range of outcomes that can be used to create effective “take home” messages for different target audiences. For example, in only 5 y, more than 150,000 lives could be saved just from increasing contraception rates by a few percentage points; nearly US$1.5 billion could be saved by adding safe abortion to family planning efforts; and finally, with stepwise investments to provide facility-based intrapartum care, the majority of maternal deaths could be prevented. In the next decade, this accomplishment would save the lives of 1 million Indian women.
Finally, by placing and prioritizing safe motherhood in the context of other global health priorities
The Indian government has initiated several policies to improve maternal health
In particular, it is clear from our analysis that an initial focus on family planning, especially in rural poor areas, will significantly prevent pregnancy-related deaths, reduce deaths from unsafe abortion, and save resources. Providing universal access to safe abortion will further augment these benefits. The cost savings from these two strategies will partially offset the resources required to invest in the necessary infrastructure that would assure every woman access to high-quality intrapartum care and EmOC. While MDG 5 is unlikely to be met without assuring access to health-center–based intrapartum care, implementation of a phased stepwise approach, designed to reach this goal while reflecting the current realities and most feasible initial approaches in different settings, is absolutely within reach.
Supplemental material accompanying the article. Part I, overview of model; part II, overview of model parameterization, calibration, performance; part III, overview of costs and estimates; part IV, supplemental results; part V, references.
(0.53 MB PDF)
We are appreciative of the administrative assistance from Meredith O'Shea, and constructive feedback on the model assumptions (Dan Grossman, Kelly Blanchard, Carol Levin).
basic emergency obstetrical care
comprehensive emergency obstetrical care
emergency obstetrical care
gross domestic product
Millennium Development Goal
maternal mortality ratio
postpartum hemorrhage
skilled birth attendant
total fertility rate
year of life saved