The ENC educational intervention conducted in 2 large Zambian cities was effective in reducing 7-day neonatal mortality.9
This cost analysis documents the cost-effectiveness and relatively low cost of the ENC educational intervention compared with other interventions aimed at reducing neonatal mortality in developing countries.
The study had several strengths. The study design included a multicenter population-based approach with a large sample size, an active baseline to reduce bias, training conducted exclusively by local trainers, and accurate clinic registries. A limitation of the study was that it included data only from births that occurred in low-risk clinics. In resource-poor countries such as Zambia, ~50% of the deliveries are performed by traditional birth attendants in rural communities, either in health centers or in the home.11
The costs per birth of training in ENC in these settings are likely to be higher because birth attendants perform fewer infant deliveries. In a recent large multicountry study that was conducted in 96 rural communities and included a large proportion of home births and traditional birth attendants, ENC training was associated with significantly decreased stillbirths and decreased perinatal mortality in births with birth attendants.11
The master trainer was invited from abroad to conduct the 5-day training on a voluntary basis (only airfare, board, and lodging were included); therefore, the training costs would have been higher if salary had been included. Alternatively, use of a local master trainer would reduce the costs. We did not include cost for salaries of trainers, because training occurred during working hours, although trainee salaries have been included in some cost studies. In our international work, trainees usually have not been paid an additional salary when they were getting trained. Additional expenses required for the care of ill neonates have been estimated to include time for a physician (1 hour), midwife (2 hours), and auxiliary nurse (1 hour per day); the costs of drugs and supplies; and other hospitalization costs.4
We did not include subsequent health care costs of additional survivors, some of whom may have required advanced neonatal care. Because of improved follow-up rates throughout this study, imputation methods9
indicated that the reduction in neonatal mortality was even larger and thus the cost per life saved and cost per DALY averted are likely to be even lower than reported. The calculation of cost per DALY averted assumed no major morbidity nor increased post neonatal risk for mortality according to limited preliminary data with up to 1 year of follow-up.13
A 3-year follow-up of those patients is planned, which will provide better data on which to base DALY calculations. Infants who require resuscitation at birth are likely to be at increased risk for subsequent mortality and major morbidities, thus possibly leading to a decrease in the estimated DALY averted in the current study.
Determining the value of an intervention in a specific country depends on the cost per DALY averted relative to the gross domestic product (GDP) per person of that country, because the government may consider the intervention only if the cost per DALY averted due to an intervention is relatively low in comparison to the GDP. WHO standards suggest that interventions that cost less than 3 times the GDP per capita for each DALY averted represent good value for the money spent.14
The GDP per person in Zambia is about $150015
and the cost per DALY averted was about $5 ($208 cost per life gained).14
Thus ENC training is a relatively good value intervention in local primary health care facilities in Zambia and may be of good value in similar settings in many countries with high neonatal mortality.
Additional evidence of cost-effectiveness can be obtained by reviewing the WHO Choosing Interventions That Are Cost Effective
A cost of about $5 per DALY averted compares favorably with other neonatal interventions reported at all coverage levels (50%–95% coverage) in the WHO African Regional Office East and South Region coverage area, including the community newborn care package ($8 at 50% coverage and $9 at 95% coverage per DALY, in US dollars for the year 2000), normal delivery by a skilled attendant ($37 and $42 per DALY, respectively); tetanus toxoid + normal delivery by a skilled attendant + resuscitation ($27 and $33 per DALY, respectively); community newborn care package + tetanus toxoid ($10 and $13 per DALY, respectively).16
Analyses conducted on other effective interventions to reduce infant mortality in developing countries report $50 per DALY17
for the introduction of improved oxygen systems and $100 per DALY for the administration of a pneumococcal conjugate vaccination.18
Packages of maternal and newborn care interventions may be more cost-effective than individual interventions largely because of the synergistic effects of costs and larger impacts.19
Maternal and neonatal packages of interventions were found to be highly cost-effective in countries in Sub-Saharan Africa and Southeast Asia with high child mortality.19
Therefore, despite the low cost per DALY of some interventions, these interventions can be combined into packages with a common service delivery model to optimize the impact, rather than providing them separately in a vertical manner.20
The reduction in mortality of the ENC package in this study is comparable to that of other very effective interventions.19
Several factors can affect the cost-effectiveness of ENC training. With low baseline mortality, the costs of a program will be relatively higher because the same resources will be required to save fewer lives. Similarly, the variability of population density, specifically the density of births per newborn care provider, can influence cost-effectiveness. Inclusion of home and health-clinic births in sparsely populated areas will increase the cost of the intervention and thus decrease the cost-effectiveness. The expected increase in life expectancy with improved care would further reduce the cost per DALY averted.
Despite the availability of cost-effective interventions for preventing neonatal deaths, their availability is low in resource-poor settings.20
This may in part be attributable to lack of cost-effectiveness data. Analysis of cost-effectiveness can guide decisions about where best to spend limited resources and which interventions (single or package) will best fit the needs of the target population. To accomplish the Millennium Development Goal 4, additional resources will be required to improve the availability of effective perinatal care. Cost-effectiveness should be an important consideration. It has been estimated that more than a million newborn lives could be saved per year with low cost-effective interventions.21
In general, clinical care services are more costly to implement than outreach or family-community services. However, given the great impact compared with outreach or family-community care, clinical care interventions are very cost-effective.20
In addition, intrapartum and postnatal packages have a twofold to threefold greater effect on mortality than antenatal care interventions.20
Training of midwives who deliver in low-risk health clinics in the ENC course is a low-cost intervention that reduced early neonatal mortality in Zambia by 40%.9
Training in ENC in facilities is an important cost-effective intervention that may improve perinatal outcomes worldwide. Training in ENC also significantly decreased stillbirths and perinatal mortality in births with trained birth attendants 11
in a recent, much larger multicountry community-based study. ENC training should be considered by health policy makers as part of the educational programs to reduce perinatal mortality and achieve the 2015 Millennium Developmental Goals. Additional research to evaluate cost-effectiveness of ENC and other perinatal interventions is needed to assist governments in setting priorities to improve perinatal outcomes.