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Context There is a substantial lack of inter-facility referral systems for emergency obstetrical and neonatal care in rural areas of sub-Saharan Africa. Data on the costs and cost-effectiveness of such systems that reduce preventable maternal and neonatal deaths are scarce.Setting We aimed to determine the cost-effectiveness of a non-governmental organisation (NGO)-run inter-facility referral system for emergency obstetrical and neonatal care in rural Southern Madagascar by analysing the characteristics of cases referred through the intervention as well as its costs.Design We used secondary NGO data, drawn from an NGO’s monitoring and financial administration database, including medical and financial records.Outcome measures We performed a descriptive and a cost-effectiveness analysis, including a one-way deterministic sensitivity analysis.Results 1172 cases were referred over a period of 4 years. The most common referral reasons were obstructed labour, ineffective labour and eclampsia. In total, 48 neonates were referred through the referral system over the study period. Estimated cost per referral was US$336 and the incremental cost-effectiveness ratio (ICER) was US$70 per additional life-year saved (undiscounted, discounted US$137). The sensitivity analysis showed that the intervention was cost-effective for all scenarios with the lowest ICER at US$99 and the highest ICER at US$205 per additional life-year saved. When extrapolated to the population living in the study area, the investment costs of the programme were US$0.13 per person and annual running costs US$0.06 per person.Conclusions In our study, the inter-facility referral system was a very cost-effective intervention. Our findings may inform policies, decision-making and implementation strategies for emergency obstetrical and neonatal care referral systems in similar resource-constrained settings.

Objectives We aimed to determine the rate of catastrophic health expenditure incurred by women using maternal healthcare services at faith-based hospitals in Madagascar.Design This was a secondary analysis of programmatic data obtained from a non-governmental organisation.Setting Two faith-based, secondary-level hospitals located in rural communities in southern Madagascar.Participants All women using maternal healthcare services at the study hospitals between 1 March 2019 and 7 September 2020 were included (n=957 women).Measures We collected patient invoices and medical records of all participants. We then calculated the rate of catastrophic health expenditure relative to 10% and 25% of average annual household consumption in the study region.Results Overall, we found a high rate of catastrophic health expenditure (10% threshold: 486/890, 54.6%; 25% threshold: 366/890, 41.1%). Almost all women who required surgical care, most commonly a caesarean section, incurred catastrophic health expenditure (10% threshold: 279/280, 99.6%; 25% threshold: 279/280, 99.6%). The rate of catastrophic health expenditure among women delivering spontaneously was 5.7% (14/247; 10% threshold).Conclusions Our findings suggest that direct patient costs of managing pregnancy and birth-related complications at faith-based hospitals are likely to cause catastrophic health expenditure. Financial risk protection strategies for reducing out-of-pocket payments for maternal healthcare should include faith-based hospitals to improve health-seeking behaviour and ultimately achieve universal health coverage in Madagascar.