Goodman, David M., Rohit Ramaswamy, Marc Jeuland et al., “The Cost Effectiveness of a Quality Improvement Program to Reduce Maternal and Fetal Mortality in a Regional Referral Hospital in Accra, Ghana,” PLOS One 12, no.7 (July 2017), doi:10.1371/journal.pone.0180929

URL: journals.plos.org/plosone/article?id=10.1371/journal.pone.0180929

Abstract

Objective: To evaluate the cost-effectiveness of a quality improvement intervention aimed at reducing maternal and fetal mortality in Accra, Ghana.

Design: Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis.

Methods: Data were collected on the cost and outcomes of a 5-year Kybele-Ghana Health Service Quality Improvement (QI) intervention conducted at Ridge Regional Hospital, a tertiary referral center in Accra, Ghana, focused on systems, personnel, and communication. Maternal deaths prevented were estimated comparing observed rates with counterfactual projections of maternal mortality and case-fatality rates for hypertensive disorders of pregnancy and obstetric hemorrhage. Stillbirths prevented were estimated based on counterfactual estimates of stillbirth rates. Cost-effectiveness was then calculated using estimated disability-adjusted life years averted and subjected to Monte Carlo and one-way sensitivity analyses to test the importance of assumptions inherent in the calculations.

Main outcome measure: Incremental Cost-effectiveness ratio (ICER), which represents the cost per disability-adjusted life-year (DALY) averted by the intervention compared to a model counterfactual.

Results: From 2007–2011, 39,234 deliveries were affected by the QI intervention implemented at Ridge Regional Hospital. The total budget for the program was $2,363,100. Based on program estimates, 236 (±5) maternal deaths and 129 (±13) intrapartum stillbirths were averted (14,876 DALYs), implying an ICER of $158 ($129-$195) USD. This value is well below the highly cost-effective threshold of $1268 USD. Sensitivity analysis considered DALY calculation methods, and yearly prevalence of risk factors and case fatality rates. In each of these analyses, the program remained highly cost-effective with an ICER ranging from $97-$218.

Conclusion: QI interventions to reduce maternal and fetal mortality in low resource settings can be highly cost effective. Cost-effectiveness analysis is feasible and should regularly be conducted to encourage fiscal responsibility in the pursuit of improved maternal and child health.

Low-income countries face heightened demand and supply barriers related to comprehensive emergency obstetric care. This study highlighted cost-effective interventions that can greatly reduce the number of maternal and fetal years of healthy life lost due to death or disability. However, due to the study’s stance that it “does not intend to resolve the ethical debate about assigning value to life lost in utero,” these cost-effective interventions may look different when considering the various causes of death in utero.