4. Cost–Effective Strategies for the Excess Burden of Disease in Developing Countries

Maternal and Neonatal Health

Along with infectious diseases, maternal and neonatal conditions account for a substantial part of the health gap between rich and poor countries; for example, more than 99 percent of maternal deaths occur in the developing world. This differential represents the largest single disparity in public health statistics between low-income and high-income countries. Overall, the average lifetime risk of maternal death is 1 in 4,000 in high-income countries, 1 in 61 in middle-income countries, and 1 in 17 in the lowest-income countries.

"more than 99 percent of maternal deaths occur in the developing world. This differential represents the largest single disparity in public health statistics between low-income and high-income countries."

Death rates during the neonatal period (from birth to 28 days old) also reveal vast differences between rich and poor countries. Only 1 percent of all neonatal deaths occur in high-income countries, where the neonatal mortality rate averages 4 per 1,000 live births. In low-income countries, the average is about 33 per 1,000 live births. The majority of neonatal deaths occur in South Asia because of its sizable population; however, 20 of the countries with the highest neonatal mortality rates are in Sub-Saharan Africa. The highest rates are found in countries where civil wars and political instability have exacerbated poverty, such as Ethiopia, Liberia, and Sierra Leone. In these countries, neonatal mortality rates exceed 50 per 1,000 live births.

International agreements have recognized the importance of reducing maternal and child mortality in low- and middle-income countries. Indeed, two of the eight MDGs address these issues: the fourth goal calls for reducing mortality among children under five by two-thirds and the fifth calls for reducing the maternal mortality ratio by three-fourths, both by 2015. DCP2 stresses that neonatal deaths account for 40 percent of all deaths of children under five, that the first week of life is when 75 percent of these neonatal deaths occur, and that 50 percent of maternal deaths occur in the first week after childbirth.

The maternal and infant mortality rates in a particular country may reveal more about the state of its health system than any other figures. Achieving low maternal and infant mortality rates requires an integrated and well-functioning health care delivery system that reaches communities with education and counseling, helps people avoid unwanted pregnancies, promotes good nutrition, screens for risks, assists healthy births, and responds to obstetric emergencies effectively.

"neonatal deaths account for 40 percent of all deaths of children under five,"

The health sector alone, however, is unlikely to achieve or sustain maternal health improvements in many countries without concomitant social changes to increase girls' education; reduce gender biases in employment and pay; and confront imbalances in bargaining power within the household that affect women's access to nutrition, domestic workload, and physical safety. Nonetheless, the primary focus of DCP2 is health sector interventions, and it shows that many cost-effective interventions to prevent unwanted pregnancies, to make pregnancy and childbirth safer, and to improve neonatal health are available.

"210 million pregnancies occur each year, of which 60 million end in an abortion or with the death of the mother or baby."

Family Planning

Globally, an estimated 210 million pregnancies occur each year, of which 60 million end in an abortion or with the death of the mother or baby.¹¹ Twenty-five percent of all pregnancies, about 52.5 million, end in abortions. More than 500,000 maternal deaths and 4 million neonatal deaths occur annually, but mortality is only one possible negative outcome. Every year, more than 54 million women also suffer from diseases or complications during pregnancy and childbirth. Indeed, conditions associated with maternity represent between 12 and 30 percent of the disease burden among women age 15 to 44 in developing countries. Reproductive health conditions are a major source of the difference in the disease burden between men and women, with women generally leading longer but less healthy lives.

Although pregnancy and childbirth are natural parts of a healthy life, they do entail risks. Women with high blood pressure, heart disease, malaria, anemia, TB, hepatitis, STIs, or HIV/AIDS face substantial risks during pregnancy. Providing appropriate screening, counseling, and contraception services is particularly important for these women. Unwanted pregnancies also have negative consequences. Data are patchy and regional variations are large, but estimates indicate that family planning programs could prevent between 20 and 40 percent of all infant deaths by preventing births among adolescents and older women and permitting intervals of three to five years between pregnancies.

"family planning programs could prevent between 20 and 40 percent of all infant deaths"

Family planning can reduce unwanted pregnancies and help couples achieve their desired family size. Access to effective contraception is key. The unmet need for contraception is defined as the number of women who wish to avoid pregnancy but are not using contraception. The unmet need for contraception is highest in Sub-Saharan Africa, where an estimated 19.4 percent of women would like to avoid becoming pregnant but are not using any contraceptive. Major obstacles to meeting the need for contraception include lack of knowledge, health concerns, and social disapproval. With some variation across countries and contexts, these factors are more significant than contraceptive supply, availability, or cost. In countries where demand for contraception is mostly satisfied, such as Brazil, Colombia, and Vietnam, there are lower fertility rates and lower maternal mortality. By contrast, in Sub-Saharan Africa, the share of women with unmet needs sometimes exceeds the share of women who are using contraception.

"Each year, unsafe abortions cause some 80,000 deaths, accounting for about 13 percent of the disease burden among women of reproductive age."

When women have unwanted pregnancies, many will seek an abortion whether or not it is legal or socially acceptable. In 1995, an estimated 35.5 million abortions were performed in developing countries. Most legal abortions take place in China and elsewhere in Asia, but because of population size and high fertility rates, the bulk of illegal abortions also occur in Asia. In countries where abortion is illegal, it is far riskier. Each year, unsafe abortions cause some 80,000 deaths, accounting for about 13 percent of the disease burden among women of reproductive age. The mortality rate for unsafe abortions ranges from 100 to 600 per 100,000 procedures, compared with a mortality rate for safe abortions of only 0.6 deaths per 100,000 procedures. Many of those who survive an unsafe abortion suffer from disabilities.

Contraception for those who wish to avoid a pregnancy can be permanent, long-term, or temporary. Permanent methods involve sterilization for women or men. This is the most popular and effective method of contraception: the 187 million sterilized women worldwide account for 34 percent of all contraceptive practices. Male sterilization by means of vasectomy is a simpler and safer procedure than female sterilization, but is less common. Nevertheless, the estimated 40 to 50 million sterilized men worldwide account for 8 percent of contraceptive practices. Intrauterine devices are the second most common method of contraception, used by 150 million women worldwide. These devices are long-term methods of contraception, as they are inserted in the uterus and prevent pregnancy until they are removed.

Temporary methods include pills, skin implants, and injectable products that alter a woman's hormone cycle to prevent conception. Although these methods are safe and effective, they can also cause irregular bleeding, a problem for women in societies that bar or restrict women from certain activities during menstruation. WHO estimates that 10 to 30 percent of women abandon these contraceptive methods for this reason. Other temporary methods include barriers, the most common of which are condoms. Unlike other forms of contraception, condoms are unique in providing protection against STIs. Male condoms account for about 4 percent of contraceptive use among couples of reproductive age. Strategies for meeting the demand for contraceptive services include education and outreach, subsidies, free distribution, and measures to facilitate or encourage sterilization(box 4.3). Social marketing refers to a variety of strategies that adopt traditional commercial marketing techniques to promote socially beneficial behaviors, products, and services. Typically such programs will promote products, such as condoms, through the mass media. They will also repackage the products and promote them in ways that are effective within a particular culture and context. Sometimes governments will partner with commercial manufacturers to market existing brands. Social marketing programs have expanded contraceptive sales and use in many countries.

"The cost of family planning programs is between US$5,000 and US$35,000 per maternal death averted, between US$1,300 and US$5,000 per infant death averted."

The cost of family planning programs is between US$5,000 and US$35,000 per maternal death averted, between US$1,300 and US$5,000 per infant death averted, and after including other health impacts along with averted deaths, between US$30 and US$60 per DALY averted. Interventions appear to be more cost-effective in South Asia and Sub-Saharan Africa than in East Asia and the Pacific. Cost-effectiveness within regions also varies by as much as two orders of magnitude because of differences in fertility rates, risks of mortality, and existing contraceptive prevalence rates.

Overall, the evidence is strong enough to show that family planning is cost-effective, but not strong enough to show which programs are the most cost-effective. The cost of contraception is not usually a major barrier to acceptance. Rather, social mores and health concerns are larger obstacles. Proximity to services and availability of supplies are also relevant. To be effective, programs need to ascertain local obstructions to family planning and then design an appropriate response.

Maternal Conditions

Family planning reduces the disease burden associated with pregnancy by averting unwanted pregnancies.¹² For women who are pregnant, a variety of maternal conditions (understood to occur in the period from conception to 42 days postpartum) can lead to death or disability even though pregnancy and childbirth are not inherently pathological. Providing care during normal, healthy pregnancy and childbirth while ensuring a state of readiness to deal with potential health problems is the goal of safe motherhood programs.

Of the 210 million pregnancies worldwide each year, some 500,000 end in maternal death, and each year more than 54 million women suffer from diseases or complications related to pregnancy and childbirth. Thirteen countries—Afghanistan, Angola, Bangladesh, China, Democratic Republic of Congo, Ethiopia, India, Indonesia, Kenya, Nigeria, Pakistan, Tanzania, and Uganda—account for 70 percent of all maternal deaths because of varying effects of population size, low incomes, and poor health care. Together South Asia and Sub-Saharan Africa account for 74 percent of the global burden of maternal conditions. Complications experienced by mothers also lead directly to many stillbirths and neonatal deaths each year, and several studies have shown that the survival prospects for a baby whose mother dies are low.

Just five conditions account for three-quarters of maternal deaths: hemorrhage, sepsis, hypertensive disorder, obstructed labor, and unsafe abortion. Many of these conditions can be effectively mitigated through prenatal screening and skilled attendants, and differences in access to such care explain a large part of the regional disparities. For example, fewer than 30 percent of women in the poorest countries have access to skilled birth attendants, compared with more than 98 percent of women in the world's richest countries. Yet progress on this front is frustratingly slow: the regional average for birth attendants in Sub-Saharan Africa has increased by only 0.2 percent per year in the past decade (figure 4.2).
[Figure 4.2]

"the regional average for birth attendants in Sub-Saharan Africa has increased by only 0.2 percent per year in the past decade"

Given the nature of pregnancy and childbirth, no single intervention or approach can fully address their associated disease burden. The only relevant analysis is to compare alternative packages that differ by content and means of distribution. For example, a comprehensive safe motherhood strategy might include the following range of interventions:

• adolescent reproductive health education and services

• community education on safe motherhood and newborn care

• prenatal care and counseling, including nutritional supplements, blood pressure screening, STI screening, treatment for syphilis, breastfeeding advice, tetanus toxoid immunization, and treatment of urinary tract infections

• skilled assistance at delivery

• care for obstetric complications and emergencies

• postpartum care.

Other than avoiding unwanted pregnancies, averting problems in maternity involves ensuring general good health, especially adequate nutrition. Complications should be prevented or treated if they occur. Interventions can be population-based or personal; can occur during pregnancy, labor and delivery, or postpartum; and may vary by level of care, whether in the home, at a primary health care facility, or in a hospital.

Population-based interventions address two major risk factors: lack of contraception and maternal undernutrition. Undernutrition is manifested in two ways: being underweight and/or stunted and being deficient in micronutrients, principally iron and vitamin A. Because undernutrition is often chronic, long term, and intergenerational, when and how interventions will be most effective is not clear. Efforts can concentrate on women when they are young, during pregnancy, or while they are of reproductive age. Personal interventions cover a wide range of services that share one important characteristic: they need to be integrated in a continuum. That continuum ranges over time, that is, from conception to the postpartum period; over space, encompassing the home, primary health services, and referral for sophisticated care when necessary; and across caregivers, potentially including outreach workers, public health workers, midwives, nurse-attendants, doctors, and surgeons.

"four prenatal visits with a health care provider can be cost-effective. Training for such providers should include how to recognize danger signs and arrange for rapid transfer to an appropriate facility in the event of an emergency"

Studies have shown that four prenatal visits with a health care provider can be cost-effective. Training for such providers should include how to recognize danger signs and arrange for rapid transfer to an appropriate facility in the event of an emergency, and should also emphasize the use of skilled attendants during childbirth. Other essential elements of prenatal care include prevention and treatment of malaria and anemia, screening and treatment for syphilis, and immunization against tetanus. Nutritional supplementation is often included, but its effectiveness and cost-effectiveness are not conclusively established.

Women and infants run the greatest risks of disability and death during and just after delivery. In this period, skilled attendants with the possibility of referral to a more sophisticated level of care can be critical. The exact definition of skilled attendants is itself a subject of debate, but the MDGs propose the proportion of deliveries attended by a health professional (doctor, nurse, or trained midwife) as a proxy indicator. The rate of skilled attendants at birth varies substantially across developing regions and across socioeconomic groups within countries, ranging from 48 percent in Sub-Saharan Africa to 59 percent in South Asia and 82 percent in Latin America and the Caribbean.

DCP2 evaluates several different proposed packages of care that would improve the coverage and/or the quality of routine maternal care. The three most cost-effective packages, all of which include nutritional supplementation, range in cost from US$77 to US$104 per DALY averted in Sub-Saharan Africa to US$150 per DALY averted in South Asia. Direct costs are higher in Sub-Saharan Africa but are offset by greater effectiveness because of the higher prevalence of maternal problems (box 4.4).

"About 1 million infants die during their first day of life, another 2 million die during the subsequent week, and a further 1 million die before reaching one month of age."

Neonatal Conditions

The risk of death is greatest during the first 28 days of life (neonatal mortality).¹³ About 1 million infants die during their first day of life, another 2 million die during the subsequent week, and a further 1 million die before reaching one month of age. These figures are showing little improvement. In 1980, the infant mortality rate (deaths occurring from birth to one year, including the postneonatal period) in low- and middle-income countries was approximately 88 per 1,000 live births (figure 4.3). Of these, 28 deaths occurred in the early neonatal period, the first week of life. By 2000, the infant mortality rate had fallen to 62 per 1,000 live births; however, almost all the progress was in the late neonatal or postneonatal periods. The rate of early neonatal deaths hardly diminished, declining only to 25 per 1,000 live births in 2000. The MDG of reducing mortality among children under five by two-thirds by 2015 cannot be achieved without addressing mortality in the first 28 days of life.
[Figure 4.3]

"The MDG of reducing mortality among children under five by two-thirds by 2015 cannot be achieved without addressing mortality in the first 28 days of life."

"Up to 40 percent of neonatal deaths could be averted with home- and community-based solutions."

Appropriate interventions are not highly complex. Up to 40 percent of neonatal deaths could be averted with home- and community-based solutions. Sometimes they require no more than keeping an infant warm, breastfeeding regularly, and protecting against infection by means of proper hygiene and/or timely treatment with antibiotics (box 4.5). In many cases appropriate care is available, but gaps occur in the quality or continuity of care. The difference between obtaining care and obtaining adequate care can mean the difference between life and death (boxes 4.6 and 4.7). Delays in access to care are also an important factor contributing to maternal and neonatal deaths. Such delays occur for many different reasons, for example, failure to recognize the need for clinical attention, cultural norms that inhibit the use of medical services, limited physical or financial access to health care facilities, and delays in receiving care once at a facility.

Strategies to improve neonatal survival that focus only on the supply of health care within facilities will therefore fail unless they are integrated with efforts to improve families' practices and to encourage people to make use of health care services. In many cases, this requires appropriate attention to addressing cultural barriers to care, such as training female birth attendants when having male attendants assist at a birth is culturally improper or allowing new mothers and their babies to leave the home in the first weeks of life if an emergency arises, and financial barriers, including service fees and transportation costs.

"several packages of services that address care of the newborn in the first 28 days of life.are universally applicable and are feasible even without skilled health care professionals."

DCP2 reviews several packages of services that address care of the newborn in the first 28 days of life. Some of these interventions are universally applicable and are feasible even without skilled health care professionals. Others require skilled attention, are more complex, or rely on critical medical supplies. Packages of interventions that have a high impact and are feasible in most contexts can be divided into five groups: family care of the newborn, essential newborn care, resuscitation of the newborn, care for low birthweight babies, and emergency care. The first two emphasize maintaining warmth, breastfeeding, and employing hygiene (including proper care of the umbilical cord and hand washing). The latter three require some training, although resuscitation can often be accomplished with simple equipment costing less than US$5.

"the best way to improve newborn care is to fill the gap in what should be a continuum of care that includes prenatal services, skilled birth attendance, and follow-up support through the first month of life."

Creating a separate program for newborn care does not make sense. Rather, the best way to improve newborn care is to fill the gap in what should be a continuum of care that includes prenatal services, skilled birth attendance, and follow-up support through the first month of life. Adding newborn interventions to existing services (DCP2, chapter 63) or introducing them along with basic services where these are lacking would be more cost-effective than trying to introduce neonatal interventions in isolation.

Interventions to improve neonatal health and mortality rates are often simple, but require a functioning network of health services capable of providing continuity during the prenatal, birthing, and postpartum periods. Extending these services into marginalized urban and rural areas is the biggest challenge. As a first step, simple approaches can be implemented in even the poorest settings to improve family practices, particularly with regard to cleanliness, warmth, and breast-feeding. Where basic health care services are available, introducing training and equipment for well-tested interventions such as neonatal resuscitation and case management of infections is feasible, but fully addressing the problem of neonatal survival requires plugging the gaps in the continuity of care and strengthening the network of health care services and outreach. This means assuring that professional midwives can attend births and provide follow-up attention, that families learn when to seek health care, and that health care is readily accessible.

"basic maternal and child health services that would reduce neonatal mortality by 6 percent to as much as 41 percent, would cost between US$2 and US$10 per capita."

DCP2 finds that modest expenditures can have a significant effect on neonatal survival. For example, in Sub-Saharan Africa, providing basic maternal and child health services that would reduce neonatal mortality by 6 percent to as much as 41 percent, depending on the preexisting coverage of primary services and the baseline neonatal mortality rate, would cost between US$2 and US$10 per capita. An additional US$0.21 to US$0.95 in spending per capita could reduce neonatal deaths by as much as 71 percent. Estimates put the specific costs of adding neonatal resuscitation training, equipment, refresher courses, and supervision at less than US$0.02 per capita for an anticipated reduction in neonatal mortality of around 5 percent in Africa and South Asia.

"Spending in India would have to be doubled and in Africa would have to be tripled to provide the basic maternal and child health care package along with the special interventions related to neonatal survival."

While some resource-poor countries have demonstrated success, the process of building a functional system, especially for clinical care, takes time. Even though the costs appear small relative to spending in middle- and high-income countries, they are large relative to current spending on health care in low-income countries. Spending in India would have to be doubled and in Africa would have to be tripled to provide the basic maternal and child health care package along with the special interventions related to neonatal survival. International funding is therefore necessary to reduce the disease burden in low-income countries associated with neonatal conditions.

Notes

¹ This section is based on DCP2, chapters 17 and 18.

² See DCP2, chapter 52.

³ See DCP2, chapter 37.

⁴ See DCP2, chapter 16.

⁵ This section is based on DCP2, chapter 16.

⁶ In 2000, the Group of Eight nations met in Okinawa, Japan, and informally set targets for reducing TB cases and deaths by 2010. The United Nations MDGs set targets for halving the number of cases and deaths by 2015 relative to their levels in 1990, and WHO is monitoring progress toward these targets.

⁷This section is based on DCP2, chapter 21.

⁸ This section is based on DCP2, chapters 16, 19, 20, 25, and 27.

⁹ This section is based on DCP2, chapters 19 and 41.

¹⁰ The one important qualification to this approach is concern about mother to child transmission of HIV. The best practice in such cases would be safe replacement feeding for the child of an HIV-positive mother. However, when a mother's HIV status is unknown in countries with high HIV prevalence, a decision has to be made that balances the risks of HIV transmission against the likely benefits of exclusive breastfeeding (DCP2, chapter 19).

¹¹ This section is based on DCP2, chapter 57.

¹² This section is based on DCP2, chapter 26.

¹³ This section is based on DCP2, chapter 27.