Maternal Mortality
Maternal mortality refers to the death of women directly due to pregnancy or childbirth. The overwhelming majority of such deaths occur in developing countries. They are mostly preventable with current technology; however, treatments in this area are often complex, requiring more doctors, equipment and medicine, and easier access to facilities both during pregnancy and birth.
The most common causes of maternal mortality are blood loss due to haemorrhaging (25%); infection (15%); eclampsia, a seizure disorder (12%); obstructed labour, in which the baby is prevented by position or size from leaving the womb (8%); and unsafe abortions (13%). The remaining deaths are often caused by indirect factors, such as infections like malaria, HIV, syphilis and hookworm. 1
WHO: World Health Report 2005, p62. . (Close footnote)
Cost-effectiveness
A 2005 BMJ report states that interventions on both community and hospital care are highly cost effective – with the most effective interventions, such as community management of neonatal pneumonia, being in the 1-20 $/DALY range 2 – but that current levels of access to such care are lower than required to meet millennium development targets. 3 The WHO advocates a three-fold strategy to combat maternal mortality:
However, community management of neonatal pneumonia, which was most effective, is already at 95% coverage, so there is not a great deal of room for additional funding. (Close footnote)
Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. Taghreed Adam, Stephen S Lim, Sumi Mehta, Zulfiqar A Bhutta, Helga Fogstad, Matthews Mathai, Jelka Zupan and Gary L Darmstadt BMJ 2005. . (Close footnote)
1. Reduce unwanted and high-risk pregnancies - This can be achieved by education and the provision of contraception. Such measures appear cost-effective (possibly in the 10-50 $/DALY range), mainly due to their low cost, and also help reduce prevalence of STDs and HIV. However, there is limited data available on the cost per DALY of using education and contraception to prevent maternal deaths. 4
Disease Control Priorities in Developing Countries. 2nd edition. Jamison DT, Breman JG, Measham AR, et al., editors. Washington (DC): World Bank; 2006, ch57. (Close footnote)
2. Reduce the number of women who experience complications – Generally this requires better access to care before, during and after pregnancy. For example, STD/HIV prevention and management, tetanus toxoid immunisation, treatment of existing conditions such as malaria and hookworm, testing urine for bacteria, advice regarding nutrition, iron and folate supplementation, and hygienic conditions for birth. The cost-effectiveness of providing such care is estimated by the DCP2 to be $88 per DALY, that is 11.4 DALYs/$1000. 5
Disease Control Priorities in Developing Countries. 2nd edition. Jamison DT, Breman JG, Measham AR, et al., editors. Washington (DC): World Bank; 2006, ch2, ch26. (Close footnote)
3. Reduce the number of deaths from complications – This means access to emergency obstetric care. Examples include provision of caesarean sections for cases of obstructed labour, giving oxytocin to prevent too much blood from being lost from haemorrhaging, and giving antibiotics to treat maternal sepsis. The DCP2 estimates the greatest cost of emergency obstetric care to be doctors. The cost-effectiveness of provision of such emergency care it gives at $87 per DALY, that is 11.5 DALYs/$1000. 6
Disease Control Priorities in Developing Countries. 2nd edition. Jamison DT, Breman JG, Measham AR, et al., editors. Washington (DC): World Bank; 2006, ch2, ch26. (Close footnote)
Beyond direct DALYs saved for mothers, pregnancy related deaths leave children without mothers, which affects their health (girls, in particular, are more likely to survive if their mother is alive), and may hinder their education by forcing them to stay and look after the home, or to go out to work. This indirectly improves the effectiveness of maternal mortality interventions.
Further, interventions which prevent maternal deaths also reduce disabilities, which is not necessarily fully factored into the statistics or quantifiable in terms of DALYs – for example, the DCP analysis does not do this. Finally, some of the worst consequences of maternal mortality may be social rather than physical: for example, women suffering from obstetric fistula (caused by obstructed labour) are frequently ostracised by their communities.
Conclusion
The cost-effectiveness of the interventions which prevent maternal deaths is reduced by the large and unpredictable number of potential complications, by the manpower needed to monitor pregnant women to pick up problems early, and by the high levels of training and equipment needed to deal with severe complications. Many of the most effective interventions require significantly improved access to clinical health facilities and systems before they can be deployed; as such they are more complicated and fragile interventions than bed nets or deworming. Nonetheless such interventions appear reasonably cost-effective and have numerous positive side-effects. We would be interested in investigating and charities that reduce maternal mortality using demonstrated cost-effective methods with our current recommendations.
