1. Providing skilled care
before and during birth
Karin Stenberg, World Health Organization
Ludovic Queuille, Panamerican Health Organization, Port-au-Prince, Haiti
Rachel Sanders, Avenir Health, Washington DC, USA
Marcus Cadet, Ministry of Public Health and Population, Port-au-Prince, Haiti
Haiti Priorise conference, Port-au-Prince April 29-May 2, 2017
2. High rates of maternal and newborn mortality
• Progress made, but access to skilled maternity care remains limited
• 37% - births with skilled assistance (EMMUS V, 2012) vs 20,6% in 1995/1995 (EMMUS II, 1994-1995)
• 359 - Maternal Mortality Ratio (MMR = deaths per 100,000 live births) in 2015 (UN estimate) while
EMMUS IV estimated 630 in 2005-2006
• 1 in 90 – the risk that Haitian women have of dying due to pregnancy or child birth (UN).
• 3 maternal deaths, 17 stillbirths, and 18 newborn deaths – occur every day (UN)
• These deaths are largely preventable, and a big societal loss
• The intrinsic value of health
• Intergenerational effects
• Orphans at risk of mortality, illness, vulnerability
• Broader societal consequences
• Reduced household financial stability, social stability
• Lower economic growth (productivity loss)
4. Access to skilled assistance during birth
Skilled assistance at birth for normal
(uncomplicated) delivery
(SBA normal delivery – P2)
Midwifes working in teams, provide care for
• Normal delivery
• Neonatal resuscitation
• Clean postnatal practices
Skilled assistance at birth including referral and
management of complications
(SBA-comprehensive – P3)
Midwifes working in teams, provide and manage:
• Emergency obstetric care
• Maternal complications
• Newborn complications
Demonstrated cost-effectiveness: Adam et al (2005), DCP3 (2016)
5. Estimating costs
• Inputs-based costing, by year:
• Commodities: drugs, supplies
• Supply chain costs and commodity waste
• Service delivery (inpatient & outpatient) operational costs
• Midwife salaries
• Training midwifes (1 midwife per 175 births/year)
• Programme support
• Cost per birth
• Normal, without complications USD2014 93 / HTG2014 4205
• Comprehensive, with mgt complications USD 2014 128 /
HTG2014 5788
• WHO Spectrum-GCEA/ UN-OneHealth Tool (LiST)
• Projected number of births and complications 2017-2036
• A comprehensive, country-tailored analysis
6. Estimating benefits
• SBA-normal averts > 1,700 deaths/year
• SBA-comprehensive > 5,200 deaths/year
• Newborn deaths strongest contributor to
health outcomes
• Averted deaths converted to Healthy Life
Years (HLYs)
• HLYs valued at 1, 3 and 8 x GDP/capita
Deaths averted per year
• Interventions act on specific cause of death
7. Benefit-Cost Ratios
Intervention Discount rate
Benefits 2018-
2036
(HTG bn)
Costs
2018-2036
(HTG bn) BCR
Skilled assistance for
normal delivery
3% 105 9 11.6
5% 59 8 7.8
12% 15 5 3.4
Skilled delivery including
referral and management
of complications
3% 312 12 25.9
5% 177 10 17.5
12% 46 6 7.5
Benefits are valued at 3x GDP
9. Antenatal care + a broader Maternal and
Newborn care package
Antenatal care • Tetanus toxoid immunization
• Syphilis detection and treatment
• Ectopic pregnancy case management
• Hypertensive disorder case management
• Management of pre-eclampsia (with magnesium
sulphate)
An expanded comprehensive maternal and
newborn care package
• Antenatal care (P1), as above
• SBA-normal (P2)
• SBA-comprehensive (P3)
• Safe abortion and post abortion care
10. Estimating costs
• Same approach as above (detailed inputs per service)
• Cost per birth:
• Antenatal care USD2014 82 ( HTG 3,708)
• Expanded package USD2014 135 ( HTG 6,105)
• Cost per capita to reach 95% coverage:
• Antenatal care: USD 1.15 (HTG 52)
• Expanded package: USD 1.95 (HTG 88)
• Average annual cost (USD2014 ) for 95% coverage:
• Antenatal care: USD 14 million (HTG 633 million)
• Expanded package: USD 23.5 million (HTG 1,063 million )
11. Estimating benefits (health outcomes)
Maternal Mortality Ratio
The expanded
comprehensive
package (P5) would
reduce MMR by 65%
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
P1 P2 P3 P5
Maternal Newborn Stillbirths
Deaths averted by year
13. Discussion
• Reduce direct (out of pocket) payments for maternal and newborn
care (MNH)
• Prioritize and rationalize available resources towards MNH
• Improve health system performance
• Increase public funding for health
• Effective implementation of the Emergency Obstretric Care strategy
• Train and retain midwifes
• Reduce demographic pressure (family planning, education and socio-
economic development)
