This document discusses strategies to improve maternal and newborn health in Haiti. It analyzes providing skilled birth assistance and antenatal care. Providing skilled care during birth reduces maternal and newborn mortality and has benefit-cost ratios of 7.8-25.9. Expanding antenatal care and implementing a comprehensive maternal and newborn care package could reduce Haiti's maternal mortality ratio by 65% and has benefit-cost ratios of 4-26. Priorities include increasing access to skilled care during birth, antenatal care, family planning and investing in the health system.

1. Providing skilled care
before and during birth
Karin Stenberg, World Health Organization
Ludovic Queuille, Panamerican Health Organization, Port-au-Prince, Haiti
Rachel Sanders, Avenir Health, Washington DC, USA
Marcus Cadet, Ministry of Public Health and Population, Port-au-Prince, Haiti
Haiti Priorise conference, Port-au-Prince April 29-May 2, 2017

2. High rates of maternal and newborn mortality
• Progress made, but access to skilled maternity care remains limited
• 37% - births with skilled assistance (EMMUS V, 2012) vs 20,6% in 1995/1995 (EMMUS II, 1994-1995)
• 359 - Maternal Mortality Ratio (MMR = deaths per 100,000 live births) in 2015 (UN estimate) while
EMMUS IV estimated 630 in 2005-2006
• 1 in 90 – the risk that Haitian women have of dying due to pregnancy or child birth (UN).
• 3 maternal deaths, 17 stillbirths, and 18 newborn deaths – occur every day (UN)
• These deaths are largely preventable, and a big societal loss
• The intrinsic value of health
• Intergenerational effects
• Orphans at risk of mortality, illness, vulnerability
• Broader societal consequences
• Reduced household financial stability, social stability
• Lower economic growth (productivity loss)

3. 1st analyzed solution
Access to skilled assistance during birth
Photo UNFPA

4. Access to skilled assistance during birth
Skilled assistance at birth for normal
(uncomplicated) delivery
(SBA normal delivery – P2)
Midwifes working in teams, provide care for
• Normal delivery
• Neonatal resuscitation
• Clean postnatal practices
Skilled assistance at birth including referral and
management of complications
(SBA-comprehensive – P3)
Midwifes working in teams, provide and manage:
• Emergency obstetric care
• Maternal complications
• Newborn complications
Demonstrated cost-effectiveness: Adam et al (2005), DCP3 (2016)

5. Estimating costs
• Inputs-based costing, by year:
• Commodities: drugs, supplies
• Supply chain costs and commodity waste
• Service delivery (inpatient & outpatient) operational costs
• Midwife salaries
• Training midwifes (1 midwife per 175 births/year)
• Programme support
• Cost per birth
• Normal, without complications USD2014 93 / HTG2014 4205
• Comprehensive, with mgt complications USD 2014 128 /
HTG2014 5788
• WHO Spectrum-GCEA/ UN-OneHealth Tool (LiST)
• Projected number of births and complications 2017-2036
• A comprehensive, country-tailored analysis

6. Estimating benefits
• SBA-normal averts > 1,700 deaths/year
• SBA-comprehensive > 5,200 deaths/year
• Newborn deaths strongest contributor to
health outcomes
• Averted deaths converted to Healthy Life
Years (HLYs)
• HLYs valued at 1, 3 and 8 x GDP/capita
Deaths averted per year
• Interventions act on specific cause of death

7. Benefit-Cost Ratios
Intervention Discount rate
Benefits 2018-
2036
(HTG bn)
Costs
2018-2036
(HTG bn) BCR
Skilled assistance for
normal delivery
3% 105 9 11.6
5% 59 8 7.8
12% 15 5 3.4
Skilled delivery including
referral and management
of complications
3% 312 12 25.9
5% 177 10 17.5
12% 46 6 7.5
Benefits are valued at 3x GDP

8. 2nd analyzed solution
Antenatal care + a broader Maternal and Newborn
care package

9. Antenatal care + a broader Maternal and
Newborn care package
Antenatal care • Tetanus toxoid immunization
• Syphilis detection and treatment
• Ectopic pregnancy case management
• Hypertensive disorder case management
• Management of pre-eclampsia (with magnesium
sulphate)
An expanded comprehensive maternal and
newborn care package
• Antenatal care (P1), as above
• SBA-normal (P2)
• SBA-comprehensive (P3)
• Safe abortion and post abortion care

10. Estimating costs
• Same approach as above (detailed inputs per service)
• Cost per birth:
• Antenatal care USD2014 82 ( HTG 3,708)
• Expanded package USD2014 135 ( HTG 6,105)
• Cost per capita to reach 95% coverage:
• Antenatal care: USD 1.15 (HTG 52)
• Expanded package: USD 1.95 (HTG 88)
• Average annual cost (USD2014 ) for 95% coverage:
• Antenatal care: USD 14 million (HTG 633 million)
• Expanded package: USD 23.5 million (HTG 1,063 million )

11. Estimating benefits (health outcomes)
Maternal Mortality Ratio
The expanded
comprehensive
package (P5) would
reduce MMR by 65%
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
P1 P2 P3 P5
Maternal Newborn Stillbirths
Deaths averted by year

12. Benefit-Cost Ratios
Benefits are valued at 3x GDP
Intervention Discount
Benefits
2018-2036
(HTG bn)
Costs
2018-2036
(HTG bn) BCR
Antenatal care
3% 44 8 5.9
5% 25 6 4.0
12% 7 4 1.7
Expanded
Comprehensive
package
3% 348 13 26.0
5% 198 11 17.6
12% 51 7 7.6
BCR (5% discount rate)
0
2
4
6
8
10
12
14
16
18
20

13. Discussion
• Reduce direct (out of pocket) payments for maternal and newborn
care (MNH)
• Prioritize and rationalize available resources towards MNH
• Improve health system performance
• Increase public funding for health
• Effective implementation of the Emergency Obstretric Care strategy
• Train and retain midwifes
• Reduce demographic pressure (family planning, education and socio-
economic development)