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

Goldie, Sue J.; Sweet, Steven; Carvalho, Natalie; Natchu, Uma Chandra Mouli; Hu, Delphine

doi:10.1371/journal.pmed.1000264

Cited by 95 publications

(83 citation statements)

References 45 publications

(81 reference statements)

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“…It is likely that there are no significant costs associated with antenatal care in Indian households but this does not hold true in the case of institutional deliveries, regardless of whether these are in a public or private facility. Perhaps the high OOPE associated with delivery care explains the lack of progress in the uptake of institutional births in India in recent decades [1,3,4,[12][13].…”

Section: Discussionmentioning

confidence: 99%

“…The progress in improving maternal health, as envisaged in the UN Millennium Development Goals (MDGs), critically depends on the availability, affordability and effective use of reproductive health services [1][2][3][4]. India is one of the rapidly developing economies where health challenges are myriad at the population level, yet trends in key maternal and child health indicators are showing little or no sign of progress [2].…”

Section: Introductionmentioning

confidence: 99%

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The Burden of Maternal Health Care Expenditure in India: Multilevel Analysis of National Data

Leone

James

Padmadas

2012

Matern Child Health J

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Word countResults: Over 80% of households reported paying for maternal health care services, with those using private care facilities paying almost four times more than those using public facilities. Multilevel analyses show evidence of high burden of maternal health care expenditure, which varied significantly across states according to the level of health care utilisation, and with considerable heterogeneity at the household and community levels. Conclusion:Maternal health care services in India are offered free at the point of delivery, yet many families face significant out-of-pocket expenditures.The recent governmental policy interventions to encourage institutional births by providing nominal financial assistance is a welcome step but this might not help to compensate mothers for other indirect expenditures, especially those living in rural areas and poorer communities who are increasingly seeking care in private facilities.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The Burden of Maternal Health Care Expenditure in India: Multilevel Analysis of National Data

Leone

James

Padmadas

2012

Matern Child Health J

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“…2 For example, simulation-based studies have estimated that up to one third of maternal deaths, and up to half of newborn deaths, may be prevented by increasing coverage rates for skilled attendance at delivery (Bhutta et al 2014;Goldie et al 2010;Graham, Bell & Bullough 2001). 3 There is, therefore a strong global push to increase rates of use of maternal and child health services, particularly antenatal care, institutional deliveries, and postnatal care.…”

Section: Introductionmentioning

confidence: 99%

Better Obstetrics in Rural Nigeria study: evaluating the Nigerian Midwives Service Scheme

Okeke¹,

Glick²,

Abubakar³

et al. 2017

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The International Initiative for Impact Evaluation (3ie) is an international grant-making NGO promoting evidence-informed development policies and programmes. We are the global leader in funding, producing and synthesising high-quality evidence of what works, how, why and at what cost. We believe that better and policy-relevant evidence will make development more effective and improve people's lives. 3ie impact evaluations3ie-supported impact evaluations assess the difference a development intervention has made to social and economic outcomes. 3ie is committed to funding rigorous evaluations that include a theory-based design, use the most appropriate mix of methods to capture outcomes and are useful in complex development contexts. About this report SummaryLimited availability of skilled providers, particularly in rural areas, is thought to be an important constraint to increasing rates of use of maternal and child health services in low-and middle-income countries. There are, however, few well-identified studies of the relationship between the supply of skilled workers and outcomes. In this project, we studied the effects of a government program in Nigeria that sought to alleviate supply-side constraints by deploying skilled midwives to primary health facilities in rural communities, to provide round-the-clock access to skilled care.We evaluate the impact of the Midwives Service Scheme (MSS), a government program introduced in 2009 to increase access to skilled care in underserved rural areas in Nigeria. At rollout, the MSS deployed nearly 2,500 midwives to 652 primary health care centers across 36 states. To evaluate the impact of the program, we surveyed 7,104 women with a birth within the preceding five years in 386 communities across 12 states. The intervention group consisted of communities that participated in the initial rollout; the comparison group consisted of communities that would receive the program approximately three years later. To understand implementation challenges and contextualize the quantitative results, we carried out a nested qualitative study in three states, consisting of in-depth interviews and focus group discussions with policymakers, providers, childbearing women, and community stakeholder groups.Overall, we found that the program's effects were smaller than anticipated. The main effect was a 7.3-percentage-point increase in antenatal care use in program clinics (about 12 percent relative to baseline levels) and a 5-percentage-point increase in overall use of antenatal care (6 percent relative to baseline levels) within the first year of the program. We found suggestive but not conclusive evidence of a small increase in skilled birth attendance, but this was confined to the south, where there were fewer challenges with midwife retention. We did not find any significant improvements in postnatal visits or child immunizations. Given this, it is not surprising that we did not find any evidence of improvements in maternal and child health.Our data allow us to shed some light on why ...

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“…Comparisons may be drawn with other countries where abortion has been legal for several decades (Turkey, India), but unmet need for safe abortion services remains high (Goldie, Sweet et al 2010;Mihciokur, Akin et al 2015). Until access to safe abortion services is substantially improved in Zambia, especially outside of major urban centres, the devastating health and economic consequences of unsafe abortion will persist.…”

Section: Discussionmentioning

confidence: 99%

Research authors’ reply to Barlow and Barr and Taylor-Robinson

Stavropoulou

Parmar

Ioannidis

2016

BMJ

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This is the accepted version of the paper.This version of the publication may differ from the final published version. Permanent repository link: AbstractZambia has one of the most liberal abortion laws in sub-Saharan Africa. However, rates of unsafe abortion remain high with negative health and economic consequences. Little is known about the economic burden on women of abortion care-seeking in low income countries. The majority of studies focus on direct costs (e.g.: hospital fees). This paper estimates the individual-level economic burden of safe and unsafe abortion care-seeking in Zambia, incorporating all indirect and direct costs. It uses data collected in 2013 from a tertiary hospital in Lusaka, (n=112) with women who had an abortion. Three treatment routes are identified: i) safe abortion at the hospital ii) unsafe clandestine medical abortion initiated elsewhere with post-abortion care at the hospital and iii) unsafe abortion initiated elsewhere with post-abortion care at the hospital. Based on these three typologies, we use descriptive analysis and linear regression to estimate the costs for women of seeking safe and unsafe abortion and to establish whether the burden of abortion care-seeking costs is equally distributed across the sample.Around 39% of women had an unsafe abortion, incurring substantial economic costs before seeking post-abortion care. Adolescents and poorer women are more likely to use unsafe abortion. Unsafe abortion requiring post-abortion care costs women 27% more than a safe abortion. When accounting for uncertainty this figure increases dramatically. For safe and unsafe abortions, unofficial provider payments represent a major cost to women.This study demonstrates that despite a liberal legislation, Zambia still needs better dissemination of the law to women and providers and resources to ensure abortion service access. The policy implications of this study include: the role of pharmacists and mid-level providers in the provision of medical abortion services; increased access to contraception, especially for adolescents; and, elimination of demands for unofficial provider payments.

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

Abstract: 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.

Cited by 95 publications

References 45 publications

The Burden of Maternal Health Care Expenditure in India: Multilevel Analysis of National Data

The Burden of Maternal Health Care Expenditure in India: Multilevel Analysis of National Data

Better Obstetrics in Rural Nigeria study: evaluating the Nigerian Midwives Service Scheme

Research authors’ reply to Barlow and Barr and Taylor-Robinson

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