Alternative Strategies to Reduce Maternal Mortality in India: A Cost-Effectiveness Analysis
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).