Triple return on investment: the cost and impact of 13 interventions that could prevent stillbirths and save the lives of mothers and babies in South Africa

The time of labor, birth and the first days of life are the most vulnerable period for mothers and children. Despite significant global advocacy, there is insufficient understanding of the investment required to save additional lives. In particular, stillbirths have been neglected. Over 20 000 stillbirths are recorded annually in South Africa, many of which could be averted. This analysis examines available South Africa specific stillbirth data and evaluates the impact and cost-effectiveness of 13 interventions acknowledged to prevent stillbirths and maternal and newborn mortality. Multiple data sources were reviewed to evaluate changes in stillbirth rates since 2000. The intervention analysis used the Lives Saved tool (LiST) and the Family Planning module (FamPlan) in Spectrum. LiST was used to determine the number of stillbirths and maternal and neonatal deaths that could be averted by scaling up the interventions to full coverage (99%) in 2030. The impact of family planning was assessed by increasing FamPlan's default 70% coverage of modern contraception to 75% and 80% coverage. Total and incremental costs were determined in the LiST costing module. Cost-effectiveness measured incremental cost effectiveness ratios per potential life years gained. Significant variability exists in national stillbirth data. Using the international stillbirth definition, the SBR was 17.6 per 1 000 births in 2013. Full coverage of the 13 interventions in 2030 could reduce the SBR by 30% to 12.4 per 1 000 births, leading to an MMR of 132 per 100 000 and an NMR of 7 per 1 000 live births. Increased family planning coverage reduces the number of deaths significantly. The full intervention package, with 80% family planning coverage in 2030, would require US$420 million (US$7.8 per capita) annually, which is less than baseline costs of US$550 million (US$10.2 per capita). All interventions were highly cost-effective. This is the first analysis in South Africa to assess the impact of scaling up interventions to avert stillbirths. Improved coverage of 13 interventions that are already recommended could significantly impact the rates of stillbirth and maternal and neonatal mortality. Family planning should also be prioritized to reduce mortality and overall costs.