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Table 5 Primary Articles Revieweda Study results

From: Cost-effectiveness of continuity of midwifery care for women with complex pregnancy: a structured review of the literature

Study

Major Cost Findings

Health Outcomes

Strengths / Limitations

1. Gao, Y. et al. (2014)

Cost saving AUS $ 703 / mother-infant episode for MGP cohort was not statistically significant (p=0.566)

MGP (midwifery model):

↓birth cost -$ 411, p=0.049

↓SCN cost – $ 1 767, p=0.144

↑ AN cost + $ 272, p<0.001

↑PN cost + $ 277, p<0.001

↑infant readmission costs + $ 476, p=0.05

↑travel cost = $ 115, p=0.001

Time horizon:

Midwife cohort – all Aboriginal mothers who gave birth between Sept 2009 - June 2011 (and their infants)

Baseline cohort – all Aboriginal mothers who gave birth between Jan 2004 – Dec 2006 (and their infants)

Women who received midwife model had more antenatal care, more ultrasounds, were more likely to be admitted to hospital in antenatal period, had equivalent birth outcomes (i.e. mode of birth; pre-term birth; low birth weight) compared with baseline cohort. Babies in midwife model admitted to Special Care Nursery had significantly reduced length of stay

Mixed risk; small sample

Cost assumptions used for economic analysis – expert opinion not primary data

Missing data (3.7% – 24.5%); 51% all cases = missing data;

Time trend confounding;

Hostel costs & transport costs not included

2. Tracy, S.K. et al. (2013).

Median cost saving of $ 566 AUS / woman with Caseload / named midwife

Time horizon: Dec 2008 – May 2011

Birth interventions reduced in midwifery model

30% > spontaneous onset of labor;

↓ analgesia;

↓elective caesarean;

No significant difference for overall rate of caesarean between groups.

Similar safe outcomes for mothers and babies between groups

Registered Trial: ACTRN12609000349246

All pregnancy risk status

No stratification of risk profile

Defined eligibility, inclusion/exclusion criteria

Study sufficiently powered (80%) and Type 1 error 5%

Sample bias challenged external validity

Cross-overs – did not receive assigned model of care

Non-masking of group allocation from clinicians

3. Jan S. et al. (2004).

Net cost estimate AUS$1, 200 per client – calculated by subtracting cost savings to other centers

Daruk Antenatal service saw 245 women for 339 pregnancies during study

Time horizon: Women birthing between Oct 1990 – Dec 1996

No significant difference in service birth weights or perinatal survival

Daruk Antenatal care = Gestational age @ 1’st visit lower; mean number AN visits higher; attendance for AN tests better

Women strongly positive toward midwife model for relationship, trust, accessibility, flexibility, information, empowerment and family-centered care

Mixed risk pregnancy

Evaluation framework, both quant and qual methods

Focused on antenatal care attendance and access; costs were broader than used in conventional economic analyses - included birth outcomes and antenatal attendance in a subsequent pregnancy

Assumptions in sensitivity analyses / estimated downstream health costs

4. Homer C.S. et al. (2001).

Mean cost/woman: CMWC A$2 579 vs SHC A$3 483

Excluding neonatal costs:

CMWC A$1 504 (1449–1559; 95%CI) v

SHC A$1 643 (1563–1729 95%CI)

Mean cost saving 9 areas SHC – CMCW:

Antenatal +28.84

Day Assessment Unit -5.42

Antenatal inpatient +38.74

On-call cost -21.81

Labour / birth +68.83

Hospital Postnatal care 43.85

Domiciliary care -11.06

Special Care Nursery +2801.28

Total/woman +904.09

Time horizon: 1997 – 1998 (not specific)

Caesarean rate: CMWM 13.3% vs SHC 17.8%

(OR . 0.6, 95% CI 0.4±0.9, P = 0.02)

No other significant differences were detected among women or babies for clinical outcomes or events during labour and birth between care models

Cost analysis alongside RCT;

10 000 bootstrap replications

Mixed risk sample;

Costs included resource use, clinician travel, neonate care;

No equipment, capital or program development costs;

No transfer rates;

Caseload/midwife key to cost saving;

Not possible to determine optimal caseload numbers; unclear if data analyzed by intention to treat

5. Rowley, M.J. et al. (1995).

Mean cost ↓4.5% per birth:

Team MW v Routine care

A $3 324 vs A $3 475

Time horizon: May 1991 – June 1992

Included first AN visit to 6 weeks after birth

Team MW women: higher AN class attendance

OR 1.73; 95% CI:1.23-2.42

↓ birth interventions 36% vs 24%

OR; 1.73 (1.28 – 2.34); p<0.001

↓ pethidine use 0.32 (0.22 – 0.46)

↓ newborn resuscitation 0.59 (0.41 – 0.86)

Maternal satisfaction with team care was greater on 3 elements: information giving; participation in decision-making, and relationships with caregivers. Less cost than routine care and fewer adverse maternal and neonatal outcomes

Cost study alongside RCT

Included women of all pregnancy risk status

Model was team midwifery care, not caseload continuity

Costs based only on DRGs; i.e. top – down cost only / not detailed. Unable to compare with other economic evaluations

6. Kenny, P. et al. (1994).

Team Midwifery vs Standard Care: Avg costs

AN cost/woman

High risk

$ 427 vs $ 456

Low risk

$ 135 vs $ 133

Average additional cost per birth / woman

$ 4.21 vs $ 9.36

PN cost/woman:

Hospital stay $ 356.64 vs $ 397.26 (earlier discharge)

Domiciliary $45.45 vs $45.80

Time horizon: Sept 1992 – July 1993

Significant differences: manipulative vaginal birth, episiotomy & perineal tears.

Women in team midwife care reported higher levels of satisfaction over 3 periods of antenatal, birth and postnatal care with information, communication and midwife attitude and skill

RCT Level 1 evidence;

All risk pregnancy included;

Discrete costs:

AN, birth and PN

Robust, bottom-up costing;

Team midwife model, not caseload;

Low risk of bias, although blinding not stated;

Loss to follow up - 19 in TM vs 22 in SHC

  1. aStudies are presented in reverse chronologic order; √ denotes a minimum score of 6 (from possible 8) quality appraisal questions; Studies 2, 4, 5 and 6 = randomised controlled trial with linked economic evaluation