Cost-effectiveness of maternal and neonatal health interventions in Ethiopia: a systematic review and meta-analysis

Despite recent improvements in health service coverage, maternal and neonatal mortality remain major public health concerns in Ethiopia. Evidence regarding cost-effectiveness is crucial for prioritizing interventions within the Essential Health Services Package, particularly in resource-constrained settings. This study aims to systematically review and conduct a meta-analysis on the cost-effectiveness of maternal and neonatal health (MNH) interventions in Ethiopia. We conducted a comprehensive search across multiple databases (PubMed/MEDLINE, Embase, the Cochrane Library, CINAHL, Scopus, Web of Science, African Journals Online; including the Ethiopian Journal of Health Development, Tufts Cost-Effectiveness Analysis Registry, and Google Scholar) from January 2000 to December 2024. A total of twelve studies were included in the qualitative synthesis and meta-analysis. A random-effects meta-analysis was performed for interventions with three or more comparable estimates utilizing the DerSimonian-Laird method. The pooled incremental cost-effectiveness ratios (ICERs) showed high cost-effectiveness for key neonatal interventions: US$6.23 per DALY averted (95% CI: 4.22–8.23; I 2 = 64.10%; n = 4) for neonatal resuscitation and US$8.78 per DALY averted (95% CI: 3.78–13.77; I 2 = 90.98%; n = 3) for neonatal sepsis management. Antenatal care had a pooled ICER of US$91.93 per DALY averted (95% CI: 62.84–121.02; I 2 = 79.65%; n = 5). The overall pooled ICER across all 12 studies was US$15.47 per DALY averted (95% CI: 11.07–19.87; I 2 = 94.14%), but high heterogeneity (primarily due to intervention diversity) severely limits direct comparability; subgroup analyses provide the most reliable insights. Neonatal resuscitation, sepsis management, and antenatal care are cost-effective interventions (all pooled ICERs substantially below commonly referenced Ethiopian contextual benchmarks, such as around 1 × projected 2025 GDP per capita of ≈US$950–1,100 per DALY averted, though we note debates on GDP-based approaches and the importance of opportunity costs and affordability). Community-based scale-up in rural regions can optimize outcomes. PROSPERO registration number: CRD420251182108.