Overview
Potential Cost-Effectiveness of Nutrition Interventions to Prevent
Adverse Pregnancy Outcomes in the Developing World
1,2
Dwight J. Rouse
3
Center for Research in Women’s Health, Department of Obstetrics and Gynecology,
University of Alabama at Birmingham, Birmingham, AL 35249
ABSTRACT The potential cost-effectiveness of antenatal nutrition interventions to improve pregnancy outcomes in
the developing world has not undergone formal evaluation. Furthermore, the effectiveness of antenatal care in
improving maternal or fetal and neonatal health has been questioned. However, reasonably compelling evidence
from randomized trials shows that nutrition interventions can prevent both infant (iodine supplementation) and
maternal (vitamin A and
b
-carotene supplementation) deaths, and informal analysis suggests that the cost-
effectiveness of nutrition interventions would be comparable and, in some cases, markedly superior to several
standard antenatal interventions. Future efforts to establish the cost-effectiveness of nutrition interventions in
developing countries will depend on conducting large, pragmatic clinical trials that use region- and resource-
appropriate interventions with mortality or valid, incontrovertibly severe morbidity endpoints. If such trials establish
effectiveness, credible cost-effectiveness analyses can then be performed. J. Nutr. 133: 1640S–1644S, 2003.
KEY WORDS:
cost-effectiveness
nutrition intervention
pregnancy outcomes
developing world
In 1993 the World Health Organization (WHO)
4
(1) esti-
mated the global incidence and associated maternal mortality
from the main obstetric complications worldwide (
Table 1
).
Most maternal mortality occurs in the developing world.
Although less reliably estimable, maternal morbidities such as
anemia, reproductive tract infections and lifelong disabilities
such as obstetric fistulae are assumed to be directly proportional
to maternal mortality. WHO estimates of neonatal deaths and
their causes worldwide are shown in
Table 2
. Like maternal
deaths, neonatal deaths likely represent the end of a disease
continuum,andmanysickinfantsnotillenoughtodiearenone-
theless permanently impaired by pregnancy or birth events. The
linked nature of maternal health and fetal and infant health
is reflected in
Table 3
.
To address the high rates and disproportionate developing
world burden of maternal and neonatal morbidity and mor-
tality, WHO developed the Mother-Baby Package as a universal
mechanism by which to achieve the goals of the International
Safe Motherhood Initiative (1). This initiative was inaugurated
in Nairobi, Kenya, in 1987 and subsequently endorsed by
over 150 countries. Thus, the Mother-Baby Package is both
the de jure and de facto model of developing world pregnancy
and newborn care. It has undergone cost evaluation and it
provides a baseline strategy against which to compare the addi-
tion or substitution of nutrition interventions in pregnancy.
More recently, WHO launched the Making Pregnancy Safer
Initiative, a program with the same broad goals as the Safe
Motherhood Initiative (2).
Economic analysis considerations
Several factors are relevant to the assessment of cost-
effectiveness of developing world pregnancy interventions.
First, because the Mother-Baby Package consists of a cluster of
interventions designed to be integrated with and in most cases
delivered through existing health systems, the package does not
cost the same in all settings. Thus, some variability of the cost of
the package is to be expected, and estimates range from $1 per
capita in poor isolated areas to $6 per capita in settings of lower
fertility and a higher prevalence of hospital deliveries (3). Note
also cost per capita as opposed to cost per pregnancy was used
for the evaluation; although this metric captures the add-on
nature of the package to existing health services, it does not
lend itself to traditional cost-effectiveness analysis. Individual
cost inputs, as a proportion of the total, have been estimated for
the Mother-Baby Package (
Table 4
) (3). Drugs, the most anal-
ogous component of the package to a nutrition intervention,
account foronly asmall proportion (12%,or$0.12–$0.72)ofthe
total cost of the Mother-Baby Package (3).
Second, to the extent that the Mother-Baby Package
depends on existing resources and infrastructure, its costs are
marginal costs; the costs associated with any additional
1
Manuscript prepared for the USAID-Wellcome Trust workshop on ‘‘Nutrition
as a preventive strategy against adverse pregnancy outcomes,’’ held at Merton
College, Oxford, July 18–19, 2002. The proceedings of this workshop are
published as a supplement to
The Journal of Nutrition
. The workshop was
sponsored by the United States Agency for International Development and The
Wellcome Trust, UK. USAID’s support came through the cooperative agreement
managed by the International Life Sciences Institute Research Foundation.
Supplement guest editors were Zulfiqar A. Bhutta, Aga Khan University, Pakistan,
Alan Jackson (Chair), University of Southampton, England, and Pisake Lumbiga-
non, Khon Kaen University, Thailand.
2
Financial support provided by a midcareer investigator award—NICHD #1–
K24HD01375–01.
3
To whom correspondence should be addressed. E-mail: drouse@uab.edu.
4
Abbreviations used: CI, confidence interval; DALY, disability-adjusted life
year; QALY, quality-adjusted life year; WHO, World Health Organization.
0022-3166/03 $3.00
2003 American Society for Nutritional Sciences.
1640S
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pregnancy interventions, which are overlaid on (or substituted
for a component of) the Mother-Baby Package, are likewise
marginal. As such, nutrition interventions with any effective-
ness are likely to be highly cost-effective because the additional
costs of implementing them in the setting of an established
infrastructure and delivery system are low.
Third, standard cost-effectiveness measures such as U.S.
dollars per deaths averted, U.S. dollars per life-years gained,
U.S. dollars per quality-adjusted life years (QALYs) gained and
U.S. dollars per disability-adjusted life-years (DALYs) gained
may fail to capture the full economic value of a mother,
especially in the developing world where the economic value of
a mother’s life may be underestimated. The DALY was con-
ceptualized by the World Bank and complements the QALY.
Both measures attempt to compress the amount of life and the
quality of life into one metric. The DALY assigns disability
weights to health states (e.g., 0.33 to deafness) whereas the
QALY assigns utility scores (e.g., 0.67 for deafness). Thus
QALYs are years of healthy life lived—counted up from
birth—and DALYs are years of healthy life lost—subtracted
from the expected lifespan (4). These measures, if applied
solely to a mother, are too reductive. As pointed out by
Tinker (3), a mother’s death has serious consequences for
her children. According to a study in Bangladesh, if a woman
dies after delivery, the newborn infant she leaves behind is
almost certain to die (3). Even older children are likely to
suffer; another study in Bangladesh found that children (up to
age 10) whose mothers die are 3–10 times more likely to die
within 2 y than are those with living parents (3).
A study in Tanzania also suggests that a woman’s death has
a negative effect on children’s education by delaying school
enrollment for younger children and causing older children to
leave school to take on household tasks (e.g., cooking, cleaning
and collecting water and firewood) (3). Moreover, a woman’s
death deprives the family of an essential source of income in
many developing countries. This is especially problematic when
a woman heads the household or when her income goes to
meeting basic needs (e.g., food, medicines and school fees)
whereas a man’s income goes to alcohol and cigarettes (3).
Jowett (5) noted that improving the health of women con-
tributes directly to the health of children and more broadly to
reducing poverty. These broad economic effects are hard to
estimate with precision and thus may not be adequately
reflected in summary measures of cost-effectiveness. On the
other hand, standard effectiveness and cost-effectiveness mea-
sures highlight the health and economic burden of pregnancy in
the developing world, even though in this century HIV/AIDS
will continue to cause an increasing proportion of disability and
death (
Table 5
) (5).
The World Bank (6) estimated that in terms of U.S. dollars/
DALY gained, family planning and antenatal and delivery care
are 2 of the 6 most cost-effective clinical services for low-
income countries. For example, antenatal and delivery care was
estimated by the World Bank to cost $60/DALY gained. In
Guinea, antenatal and delivery care at health centers has been
estimated to cost $109/life-year saved (7).
Another consideration in the assessment of the cost
effectiveness of developing world pregnancy interventions is
that antenatal care may not prevent neonatal or maternal
morbidity and mortality. McDonagh (8) reviewed the effec-
tiveness of antenatal care and concluded that there are
substantial grounds to doubt the effectiveness of the procedures
collectively called antenatal care. Antenatal care, as part of
Maternal Child Health Services, was exported from developed
to developing countries because it was believed to be an
appropriate and beneficial service, but the justification for use
under the conditions in developing countries is not apparent.
Questions were first asked about the possible lack of effect of
antenatal care on maternal mortality as early as 1932 and have
not been answered satisfactorily, especially regarding develop-
ing countries.
Thus it is on the above unstable foundation—variable costs
across settings, all costs essentially marginal, traditional mea-
sures of cost-effectiveness probably too reductive and no ef-
fectiveness established for many pregnancy interventions—that
the potential cost-effectiveness of nutrition interventions to
reduce adverse pregnancy outcomes is grounded. Moreover,
it is worth bearing in mind that even for the archetypal and
near universally recommended (9) pregnancy nutrition supple-
ments folate and iron, compelling evidence of effectiveness in
reducing the occurrence of adverse maternal or fetal and neo-
natal outcomes is not available (10–12).
Estimated cost-effectiveness of individual
Mother-Baby Package component interventions
Selected published cost-effectiveness analyses of various
antenatal interventions that are used (or recommended) in the
developing world are summarized in
Table 6
. The literature is
characterized by inconsistency of methodology and outcome
metrics as well inconsistent consideration of potential benefits
TABLE 1
Estimated global incidence and mortality from the
main obstetric complications
1
Obstetric
complications
Incidence
%
Number of
cases
(000s)
Number of
deaths
(000s)
% of all
maternal
deaths
Hemorrhage
10 14,000 127 25
Indirect causes
9 13,500 100 20
Sepsis
8 12,000 76 15
Unsafe abortion
–
2
20,000 67 13
Eclampsia 0.5 700 43 8
Obstructed labor 5 7000 38 8
Other direct causes 3 4000 39 8
Hypertensive disorders
of pregnancy
4.5 6400 22 4
Total 77,600
3
510 100
1
Used with permission (1).
2
Estimated to be equivalent to 10% of all pregnancies.
3
Events, not women.
TABLE 2
Neonatal deaths in developing countries (1993)
1
Cause of death
Number of neonatal
deaths
Proportion of all
newborn deaths (%)
Birth asphyxia 840,000 21.1
Pneumonia 755,000 19.0
Neonatal tetanus 560,000 14.1
Congenital anomalies 440,000 11.1
Birth injuries 420,000 10.6
Prematurity 410,000 10.3
Sepsis and meningitis 290,000 7.2
Others 205,000 5.1
Diarrhea 60,000 1.5
Total 3,980,000 100.0
1
Used with permission (1).
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