The Impact and Cost of Scaling up Midwifery and Obstetrics in 58 Low- and Middle-Income Countries

<div><p>Background and Methods</p><p>To guide achievement of the Millennium Development Goals, we used the Lives Saved Tool to provide a novel simulation of potential maternal, fetal, and newborn lives and costs saved by scaling up midwifery and obstetrics services, including family planning, in 58 low- and middle-income countries. Typical midwifery and obstetrics interventions were scaled to either 60% of the national population (modest coverage) or 99% (universal coverage).</p><p>Findings</p><p>Under even a modest scale-up, midwifery services including family planning reduce maternal, fetal, and neonatal deaths by 34%. Increasing midwifery alone or integrated with obstetrics is more cost-effective than scaling up obstetrics alone; when family planning was included, the midwifery model was almost twice as cost-effective as the obstetrics model, at $2,200 versus$4,200 per death averted. The most effective strategy was the most comprehensive: increasing midwives, obstetricians, and family planning could prevent 69% of total deaths under universal scale-up, yielding a cost per death prevented of just $2,100. Within this analysis, the interventions which midwifery and obstetrics are poised to deliver most effectively are different, with midwifery benefits delivered across the continuum of pre-pregnancy, prenatal, labor and delivery, and postpartum-postnatal care, and obstetrics benefits focused mostly on delivery. Including family planning within each scope of practice reduced the number of likely births, and thus deaths, and increased the cost-effectiveness of the entire package (e.g., a 52$4,000 to $2,100 per death averted).</p><p>Conclusions</p><p>This analysis suggests that scaling up midwifery and obstetrics could bring many countries closer to achieving mortality reductions. Midwives alone can achieve remarkable mortality reductions, particularly when they also perform family planning services - the greatest return on investment occurs with the scale-up of midwives and obstetricians together.</p></div

Projected numbers and percentages of deaths averted, by provider and intervention type, under universal coverage.

<p>Projected numbers and percentages of deaths averted, by provider and intervention type, under universal coverage.</p

Projected lives saved and percent reduction by 2015, by coverage scale-up level, provider type, and scope of practice.

1<p>N(% reduction); From a baseline assumed 402,000 maternal deaths, 2.6 million fetal deaths, 3.7 million neonatal deaths and 6.7 million total deaths in 2015. All numbers rounded before calculations. OB: obstetrics; MNC: maternal and neonatal care; FP: family planning.</p

Total deaths averted by midwifery scale-up, by country BEmONC coverage classification, including family planning.

1<p>Percent reduction from no-change scenario.</p

Included <i>LiST</i> interventions and type of death averted by provider type.

<p>Included <i>LiST</i> interventions and type of death averted by provider type.</p

Countries included in analyses (n = 58), ordered by BEmONC baseline level.

<p>Countries included in analyses (n = 58), ordered by BEmONC baseline level.</p

Total deaths averted by midwifery scale-up, including family planning, by region.

<p>Total deaths averted by midwifery scale-up, including family planning, by region.</p

Total cost of scale-up by provider type.

<p>Total cost of scale-up by provider type.</p

Projected numbers of deaths averted under universal coverage, with costs per total deaths averted.

<p>Projected numbers of deaths averted under universal coverage, with costs per total deaths averted.</p

Description of the 12 scale-up scenarios analyzed.

<p>MNC: maternal and newborn Care; FP: family planning.</p