Background: Understanding the cost-effectiveness and affordability of interventions to reduce maternal and
newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of
community mobilisation through women’s groups and health facility quality improvement, both aiming to
reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted
in rural Malawi in 2008–2010. In this paper, we calculate intervention cost-effectiveness and model the
affordability of the interventions at scale.
Methods: Bayesian methods are used to estimate the incremental cost-effectiveness of the community and
facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi.
Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention
effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider
perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level.
Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were
calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic
product of Malawi in 2013 international $.
Results: The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted
respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and
combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively).
Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292,
EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of
Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal
and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in
Malawi.
Conclusions: Community mobilisation through women’s groups is a highly cost-effective and affordable strategy to
reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality
improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.