Cost and impact of scaling up interventions to save lives of mothers and children: taking South Africa closer to MDGs 4 and 5

Figures & data

Fig. 1 Causes of child, newborn and maternal deaths in SA used in the LiST model. Adapted from MRC BOD, 2010.

Table 1 Baseline intervention coverage and achievable scale up by 2015, South Africa

Interventions	Baseline coverage (%)	Possible scale up (%)
Safe abortion services	35	45
Post abortion case management	60	80
Ectopic pregnancy case management	40	40
Antenatal care (4 visits)	50	65
TT – tetanus toxoid vaccination	77	77
Calcium supplementation	5	20
Hypertensive disease case management	40	50
Diabetes case management	10	10
MgSO4 – management of pre-eclampsia	75	85
Foetal growth restriction detection and management	10	15
Skilled birth attendance (SBA)	93	95
Facility delivery (clinic and hospital)	87	90
Unassisted deliveries	5	5
Basic emergency obstetric care (BEMOC)	5	10
Comprehensive emergency obstetric care (CEMOC)	50	75
All deliveries
Clean birth practices	70	95
Immediate assessment and stimulation	70	72
Labour and delivery management	93	93
Neonatal resuscitation	40	50
Antenatal corticosteroids for preterm labour	20	40
Antibiotics for pPRoM	25	35
MgSO4 management of eclampsia	80	95
Active management of the third stage of labour	80	90
Induction of labour for pregnancies lasting 41+ weeks	10	10
Promotion of breastfeeding	25	35
Preventive postnatal care	10	20
Clean postnatal practices	10	10
Complementary feeding – education only	10	20
Complementary feeding – supplementation and education	5	15
Vitamin A supplementation	50	55
Improved water source	91	92
Water connection in the home	69	75
Improved sanitation – utilisation of latrines or toilets	74	80
Hand washing with soap	17	40
Hygienic disposal of children's stools	41	50
BCG	74	95
Polio	74	95
DPT	66	95
Hib	66	95
HepB	74	95
Pneumococcal	64	95
Rotavirus	66	95
Measles	74	95
Maternal Sepsis case management	75	85
Kangaroo mother care	25	40
Case management of severe neonatal infection	44	55
Injectable antibiotics	70	70
Full supportive care	44	60
ORS – oral rehydration solution	50	60
Antibiotics – for treatment of dysentery	80	80
Zinc – for treatment of diarrhoea	10	10
Oral antibiotics: case management of pneumonia in children	73	75
Vitamin A – for treatment of measles	75	75
Therapeutic feeding – for severe wasting	45	55
Treatment for moderate acute malnutrition	10	20

SBA=skilled birth attendance; BEMOC=basic emergency obstetric care; CEMOC=comprehensive emergency obstetric care.

Table 2 Interventions added to LiST

Intervention	Description	Baseline coverage (2010) (%)	Cause of death affected by the intervention	Effect estimate (%)	Affected fraction (%)
Treatment of childhood injuries (27)	Management of all paediatric trauma	50	Injury	50	100
Treatment of childhood TB (28)	Detection and treatment of childhood TB according to WHO guidelines (Rapid advice – 2010)	50	Pneumonia (TB is not split out as a separate cause of death in children in LiST)	99	2.5
Early detection and treatment of HIV in pregnant women	HIV treatment initiated before 20 weeks gestation	20	Indirect maternal	90	80
Treatment of pregnant women with TB (29)	Treatment of both latent infection and TB disease	50	Indirect maternal	90	50
Inter-facility transport for complicated deliveries (30)	Dedicated maternal ambulances for referral of complicated pregnancies between facilities	10	Direct maternal	30	80

Fig. 2 Number of lives saved in 2015 at achievable coverage.

Table 3 Top 15 newborn, child and maternal interventions

	Newborn and child interventions			Maternal interventions
	Intervention	Lives saved	% lives saved	Intervention	Lives saved	% lives saved
1	Antenatal corticosteroids for preterm labour	1,542	12	Labour and delivery management^a	615	49
2	Labour and delivery management^a	1,315	10	Early detection and treatment of HIV (pregnant women)	350	28
3	PMTCT	1,195	9	TB management in pregnant women	158	13
4	ORS – oral rehydration solution	1,153	9	Clean birth practices	47	4
5	Hand washing with soap	898	7	Inter-facility transport	20	2
6	Case management of severe neonatal infection	885	7
7	Water connection in the home	591	5
8	ART	503	4
9	Pneumococcal	490	4
10	Therapeutic feeding – for severe wasting	462	4
11	Treatment of injuries	435
	Total	9,469	75	Total	1,190	94

^aLabour and delivery management counts towards saving both maternal and newborn lives.

Table 4 Projected incremental costs and effects of maternal interventions in 2015

	Additional lives saved	Incremental costs (US$)	Life years gained	Cost (US$)/LY gained
Pregnancy
Calcium supplementation	5	3,608,980	136	26,622
Hypertensive disease case management	13	204,209	352	579^a
MgSO4 – management of pre-eclampsia	12	4,094,663	325	12,585^b
Sub-total	30	7,907,851	813
Childbirth
Clean birth practices	47	3,439,886	1,274	2,699^a
Labour and delivery management	615	−13,413,196	16,674	−804^a
Antibiotics for pPRoM	10	361,066	271	1,332^a
MgSO4 management of eclampsia	16	3,642,612	434	8,397^b
Active management of the third stage of labour	10	2,413,870	271	8,903^b
Sub-total	698	−3,555,762	18,924
Total	728	4,352,089	19,737

US$ = United States Dollars. ^aInterventions highly cost-effective (less than US$7,500); ^binterventions cost-effective (between US$7,500 and US$22,500). The following interventions are not included because unit cost estimates were not available: inter-facility transport, TB management and early detection and treatment of HIV in pregnancy, hence the total additional lives saved presented in this table are approximately half of the estimated 1,263 with achievable coverage.

Table 5 Projected incremental costs and effects of newborn and child interventions in 2015

Interventions	Additional lives saved	Incremental costs (US$)	Life years gained	Cost (US$)/LY gained
Childbirth
Clean birth practices	46	3,439,886	2,760	1,246^a
Immediate assessment and stimulation	98	4,145,317	5,880	705^a
Labour and delivery management	1,315	−13,413,196	78,900	−170^a
Neonatal resuscitation	134	20,853	8,040	3^a
Antenatal corticosteroids for preterm labour	1,542	3,113,747	92,520	34^a
Antibiotics for preterm rapture of membranes	198	361,066	11,880	30^a
Sub-total	3,333	−2,332,327	199,980
Preventive
Breastfeeding promotion	427	227,904,210	25,620	8,896^b
Appropriate complementary feeding	117	47,036,977	7,020	6,700^a
Hand washing with soap	898	4,098,071	53,880	76^a
Hygienic disposal of children's stools	154	1,802,872	9,240	195^a
Sub-total	1,596	280,842,130	95,760
Vaccines
DPT	5	3,038,430	300	10,128^b
Hib	423	3,506,228	25,380	138^a
Pneumococcal	490	11,795,798	29,400	401^a
Rotavirus	149	10,886,954	8,940	1,218^a
Measles	386	4,488,290	23,160	194^a
Sub-total	1,453	33,715,700	87,180
Curative after birth
Kangaroo mother care	338	523,723	20,280	26^a
Oral rehydration solution	1,153	−9,609,885	69,180	−139^a
Oral antibiotics: case management of pneumonia in children	107	−356,569	6,420	−56^a
Therapeutic feeding – for severe wasting	462	14,709,388	27,720	531^a
Sub-total	2,060	5,266,657	123,600
HIV
ART	503	61,368,745	30,180	2,033^a
PMTCT	1,195	−11,038,195	71,700	−154^a
Subtotal	1,698	50,330,550	101,880
Total	10,140	367,822,710	608,400

US$=United States Dollars. ^aInterventions highly cost-effective (less than US$7,500); ^binterventions cost-effective (between US$7,500 and US$22,500). The following interventions are not included because unit cost estimates were not available: TB and injury management, water connection in the home, improved sanitation, management of severe neonatal infection, micronutrient supplementation and treatment for moderate acute malnutrition, hence the total additional lives saved presented in this table are approximately half of the estimated 10,140 with achievable coverage.

Table 6 Selected outcomes of the scenario analysis with 95% coverage

Outcome	Estimate
Under 5 mortality rate (U5MR)	23/1,000
Neonatal mortality rate (NMR)	9/1,000
Maternal mortality rate (MMR)	116/100,000
Additional newborn and child lives saved	27,213
Additional maternal lives saved	1,680
Additional costs of scaling up to 95%	US$2.1 billion

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