Cost-effectiveness of Emergency Obstetric Care in Bomet County: Comparing Ambulance Transfer and Self-referral

Abstract

Background: Obstetric complications are difficult to predict and may require referral, expedited by ambulance use. We conducted a cost-effectiveness analysis among women admitted with obstetric emergencies through comparing ambulance transfers and self-referrals in a predominantly rural setting in Kenya. Methods: A cross-sectional study compared women who had been admitted with obstetric emergencies delivered by either ambulance or self-referral at Longisa country referral hospital (LCRH) between January to June 2019. A cost-effectiveness analysis (CEA) was adopted using a healthcare system perspective being the county government of Bomet. Direct costs needed for ambulance, self-referral and clinical care were calculated. Every woman admitted with a pregnancy-related complication was assessed using the adapted sub-Saharan African Maternal Near Miss (MNM) criteria. Each referred woman was categorized as: ‘necessary referral’ meaning that they were managed for either MNM or potentially life-threatening complications (PLTC) and ‘unnecessary referral’ meaning those with no obstetric complications. Incremental cost effectiveness ratio (ICER) for referral was considered attractive or very attractive interventions when costs per life years gained (LYG) were below $150 and $30, respectively. Results: Overall, 2804 women (96.3%) were self-referrals, while 108 ambulance transfers occurred (3.7%). Main indications for ambulance transfer were prolonged labor (n=21; 19.4%), pre-eclampsia/eclampsia (n=19; 17.6%) and sepsis/peritonitis following cesarean section (n=15; 13.9%). Necessary referrals were considered to have occurred in 81/108 (75%) for ambulance transfers versus 239/2804 (9.3%) self-referrals. If all necessary referral cases had exclusively used ambulance services (ambulance + self-referrals), then the total intervention costs would be $90,112 and LYG 6095, equivalent to ICER of $14.8 per LYG. Women with unnecessary referrals by ambulance were 27/108 (25%) versus self-referrals in 2565/2804 (91.5%) showing that these women could have been managed in sub-county hospitals or health centers. Conclusions: Cost-effectiveness of reasonably well-targeted ambulance services on women with MNM or PLTC in our setting was very attractive.