Table 3 Summary of Three Systematic Reviewsa
Aim of Study | Sample / Setting | Design | Major Cost Findings | Health Outcomes | Strengths / Limitations |
|---|---|---|---|---|---|
1. Sandall et al. (2016) Compare effects of midwife-led continuity models with other models for childbearing women and their infants Primary outcomes antenatal, birth & immediate postpartum outcomes Secondary outcomes birth intervention, morbidity, some aspects of resource use & cost United Kingdom √ | Included: 15 RCTs 17 674 women (Canada, Ireland, Australia, UK) Excluded: 22 studies Only 6 of the 15 RCTs measured cost of model; only 4 of the 6 RCTs that measured costs included “mixed risk” pregnant women/high risk pregnancy: Kenny 1994 Rowley 1995 Homer 2001 Tracy 2013 | Systematic review Cochrane Pregnancy & Childbirth Group Trials Register + reference lists of retrieved articles. Selection criteria: published and unpublished trials, pregnant women randomly allocated to midwife-led continuity models of care or other models of care for pregnancy & birth Cost trend reported narratively as RCT cost method varied, e.g. cost analysis; CEA; or not stated | Trend to cost saving effect in midwife-led continuity Cost savings intrapartum care – all studies Antenatal: varied Postnatal: 1 study higher cost/ 1 study no difference Primary 0utcome in midwife – led models (RR) (CI) ↓ regional analgesia (0.85, 0.78 – 0.92) ↓instrumental birth (0.90, 0.83 – 0.97) ↓ pre-term <37 wk (0.76, 0.64 – 0.91) ↓ fetal loss <24 wk (0.84, 0.71 – 0.99) ↑spontaneous vaginal birth (1.05, 1.03 – 1.07) No difference CS or intact perineum Secondary 0utcome midwife – led models: ↓amniotomy; ↓ episiotomy; ↓ fetal loss <24 wks; No labour analgesia; longer labour (MD) 0.50 hrs, No difference for: fetal loss >24 wks; labour induction; A/N admission; A/N haemorrhage; augment labour; PPH; low birthweight; 5 min Apgar < 7; SCBU admission; initiate breastfeeding | Time horizon: RCT (cost included) 1994 – 2013 Women receiving midwife care less likely to have epidural, episiotomies, instrumental birth. Spontaneous vaginal birth rate increased. CS rate no difference. Women less likely to have pre-term birth, lower risk of losing babies < 24wks, More likely to be cared for in labour by a known midwife. No adverse effects compared with other models. Conclusion: most women should be offered midwife-led continuity of care BUT Evidence may not apply to women with serious pregnancy or health complications as these women were not specifically included in all studies / analysis for clinical effectiveness not stratified | Limited evidence CEA for women with complex pregnancy Combined results: low and mixed risk pregnant women 4 studies used different economic evaluation methods -: narrative report as cost assessment inconsistent Strong evidence cost improved in midwifery models for low risk with, reduced intervention + increased satisfaction. Mixed risk studies - ‘interpret with caution’ |
2. Ryan et al. (2013) Analysis of evidence on cost – effectiveness of midwife-led care compared with consultant –led care in UK settings. Estimate potential cost savings to accrue from expansion of midwife – led care in UK Used Section 3 CE of Devane et al. 2010 SR United Kingdom √ | Economic synthesis of 3 RCTs evaluated against guidelines for economic review Drummond and Jefferson (1996) 5796 women Hundley 1995 Young 1997 Begley 2009 Excluded: Flint 1989 (sub-group costing 49 of 1001 women only) | Systematic review 12 electronic databases for cost midwife led models: Cochrane Methodology Register NICE methods + multiple 1-way sensitivity analysis for economic synthesis of costs used 3 RCTs applied to 8 scenarios CE measure used Incremental Net Benefit (INB): expressed as Net Monetary Benefit (NMB) – £ value, and Net Health Benefit (NHB) – QALY, Quality adjusted life year gain | Mean cost saving £12.38 per woman midwife led (ML) care Expansion of ML care to 50% of all eligible women in UK projected aggregate £1.16 mil cost saving/yr Sensitivity analysis: cost change per woman varied from saving £253.38 (37.5 QALYs gained per year) to cost increase £108.12 dependent on assumptions with correspondent aggregate annual savings £23.75 million, or aggregate annual cost increase £10.13 million | Time horizon: RCT (cost included) 1995 – 2009 Three economic analyses used in synthesis of potential cost saving from increasing midwife-led services for eligible maternities. Issues identified around generalizability of findings. High rate of transfer from ML to medical-led care in studies demonstrates ‘risk’ assessment criteria unable to identify all women who will develop complications in pregnancy and labour | Rigorous health economic assessment measures: INB, NMB,QALYs Limited to UK system Excluded RCTs from Australia and other countries where no comparison with consultant-led model Mixed risk pregnancy profile; sub-group analysis show cost results consistent for groups as (RR) fetal loss and neonatal death overlap with 1.00 |
3. Devane, D. et al. (2010). Section 3: assessed CE of midwife-led care compared with consultant –led care. Estimated potential cost savings of expanding midwife-led care in UK (pp. 33–45) United Kingdom √ | Based on 3 of 4 RCTs See 2. above Hundley 1995 2844 women; Young 1997 1299 women; Begley 2009 1653 women | Systematic review see 2. above Sensitivity analysis x 3 based on 8 scenario SA 1: Systematically varying estimated cost savings SA 2: Systematically varying RR for overall fetal loss & neonatal death using low risk and ‘mixed risk’ cases SA 3: Systematically varying assumed uptake of ML service | As published in Ryan, Revill et al. 2013 | Time horizon: RCT (cost included) 1995 – 2009 Expanding midwife –led maternities show: Reduced rate of interventions in ML continuity of care, including: <AN hospitalization Reduced use of regional analgesia in birth, less episiotomy and instrumental delivery & greater numbers of women more likely to experience spontaneous vaginal birth BUT may not extrapolate to women with identified risk factors | Cochrane bias assessment tool used for trial internal validity Not generalisable, small number of studies CE varied with unit size, location and volume |