Economic evaluation of maternal healthcare services for Indigenous and rural people: a systematic review

Early Abstract:

Background: Indigenous and rural populations worldwide continue face persistent maternal health inequities driven by geographic isolation, cultural barriers, socioeconomic constraints, and historical mistrust of healthcare systems. While targeted maternal health programs have been implemented, there remains limited evidence on their economic effectiveness. This systematic review was conducted to assess the cost-effectiveness of antenatal, intrapartum, and postnatal interventions in Indigenous and rural contexts, with the goal of informing resource allocation and policy reform. This is the first comprehensive global synthesis of full economic evaluations in Indigenous and rural maternal health. 
Methodology: Following PRISMA 2020 guidelines, we searched six major databases (PubMed, Cochrane Library, HTA databases, ProQuest, CEA Registry, and CRD) and relevant grey literature for full economic evaluations published between January 2004 and April 2025. Eligible studies had to report both costs and health outcomes for maternal health interventions in Indigenous and/or rural populations. Titles, abstracts, and full texts were screened independently by two reviewers, with disagreements resolved by consensus. Data were extracted using a piloted template and assessed for methodological quality using the CHEC-Extended checklist, while risk of bias was appraised using the ECOBIAS tool. Costs were converted to 2024 USD and adjusted for purchasing power parity to allow cross-country comparison. Due to heterogeneity in interventions and outcomes, findings were synthesised in narratively and grouped by intervention type. 
Results: From 1,095 records, 42 studies reporting 50 full economic evaluations across 25 countries met inclusion criteria. The majority were cost-effectiveness analyses (n=30) or cost-utility analyses (n=15). Over half of the included evaluations scored ≥95% on the CHEC-Extended tool, indicating strong methodological rigour, although limitations were noted in the frequent use of narrow healthcare payer perspectives and incomplete sensitivity analyses. Five main categories of intervention emerged: community-based and culturally adapted models (e.g., participatory women’s groups, Birthing on Country); clinical and diagnostic innovations, such as misoprostol distribution for postpartum haemorrhage prevention and rapid syphilis screening; health system strengthening strategies, including ambulance services, emergency obstetric referrals, and mentorship programs; digital and mHealth tools; and financial incentives, particularly when integrated with quality improvement measures, with ICERs ranging from 8.52 to 2001 per DALY averted.
Conclusions: Culturally tailored, community-embedded, and system-integrated maternal health interventions consistently delivered high economic value in Indigenous and rural populations. These findings reinforce the importance of embedding cultural identity, community leadership, and health system linkages into maternal health programming. The evidence suggests that investment in such models not only reduces inequities but also optimizes resource use. Future research should address the paucity of evaluations in postpartum care, incorporate broader societal perspectives, extend follow-up periods to capture long-term outcomes, and expand analysis in high-income Indigenous contexts where evidence remains limited. 
Keywords: community-based interventions, cost-effectiveness analysis, culturally adapted care, economic evaluation, financial incentives, health system strengthening, Indigenous populations, maternal health care, mHealth, rural health services.