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

Abstract

Background and MethodsTo 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).FindingsUnder 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% reduction in deaths with midwifery and obstetrics increased to 69% when family planning was added; cost decreased from $4,000 to $2,100 per death averted).ConclusionsThis 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.

Better Obstetrics in Rural Nigeria study: evaluating the Nigerian Midwives Service Scheme

“…Fauveau et al (1991) studied a similar midwife program in Bangladesh and found that many home births were still not attended by midwives. Given the dearth of empirical evidence, researchers have attempted to use projection models to estimate the effects of scale-up (Homer et al 2014;Bartlett et al 2014). The results of this evaluation underline the need for caution in generalizing from these estimates.…”

The rising home birth trend in America

“…3,16 These results suggest that midwifery alone can be an efficient and cost-effective option for achieving large reductions in mortality rates. 3 A specific midwifery competency, breastfeeding counseling, is the main reason that midwives have achieved greater reductions in neonatal deaths than obstetricians. 16,17 The majority (86%) of newborns delivered by midwives were exclusively breastfed by 6 weeks of age.…”

“…2 Additionally, healthcare costs will most likely decline due to a reduction of obstetric procedures and interventions. 3 Based on a report released by the Centers for Disease Control, out-of-hospital births have increased by 89% between 2004 and 2012. Of the entire US population, 66% of out-of-hospital births occurred at home, 29% occurred at a freestanding birthing center, and 5% occurred at other locations, such as physician offices.…”

“…10 Reduced rates of obstetric procedures and interventions may result in significant cost savings and increased health benefits for low-risk women who give birth outside of the hospital. 3 For another group of women, opting for a home birth the 1 Memorial Sloan Kettering Cancer Center, New York, NY, USA 2 Gaziosmanpasa University, Department of Obstetrics and Gynecology, Tokat, Turkey main factors that affect their choice of where they will give birth are level of safety, previous negative hospital experience, familiarity of environment, ability to control the environment, process of care. 3,7 A substantial number of women equated medical intervention with reduced safety and reported that they trusted the inherent ability of their body to give birth without interference.…”

“…15 Midwifery services, which include family planning, have been shown to reduce maternal, fetal, and neonatal deaths in one study. 3 In 2009, 62% of home births were attended by midwives -19% by certified nurse -midwives and 43% by certified professional midwives of direct -entry midwives. By contrast, 7% of hospital births were attended by midwives and only 5% of home births were attended by physicians.…”