Background: To estimate the cost-effectiveness of an ambulance-based referral system an dedicated to emergency\nobstetrics and neonatal care (EmONC) in remote sub-Saharan settings.\nMethods: In this prospective study performed in Oromiya Region (Ethiopia), all obstetrical cases referred to the\nhospital with the ambulance were consecutively evaluated during a three-months period. The health professionals\nwho managed the referred cases were requested to identify those that could be considered as undoubtedly\neffective. Pre and post-referral costs included those required to run the ambulance service and the additional\ncosts necessary for the assistance in the hospital. Local life expectancy tables were used to calculate the number\nof year saved.\nResults: A total of 111 ambulance referrals were recorded. The ambulance was undoubtedly effective for 9 women\nand 4 newborns, corresponding to 336 years saved. The total cost of the intervention was 8299 US dollars. The\ncost per year life saved was 24.7 US dollars which is below the benchmarks of 150 and 30 US dollars that define\nattractive and very attractive interventions. Sensitivity analyses on the rate of effective referrals, on the costs of the\nambulance and on the discount rate confirmed the robustness of the result.\nConclusions: An ambulance-based referral system for EmONC in remote sub-Saharan areas appears highly\ncost-effective.
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