RESUMEN
OBJECTIVES: In many countries, the healthcare sector is dealing with important challenges such as increased demand for healthcare services, capacity problems in hospitals and rising healthcare costs. Therefore, one of the aims of the Dutch government is to move care from in-hospital to out-of-hospital care settings. An example of an innovation where care is moved from a more specialised setting to a less specialised setting is the performance of an antenatal cardiotocography (aCTG) in primary midwife-led care. The aim of this study was to assess the budget impact of implementing aCTG for healthy pregnant women in midwife-led care compared with usual obstetrician-led care in the Netherlands. METHODS: A budget impact analysis was conducted to estimate the actual costs and reimbursement of aCTG performed in midwife-led care and obstetrician-led care (ie, base-case analysis) from the Dutch healthcare perspective. Epidemiological and healthcare utilisation data describing both care pathways were obtained from a prospective cohort, survey and national databases. Different implementation rates of aCTG in midwife-led care were explored. A probabilistic sensitivity analysis was conducted to estimate the uncertainty surrounding the budget impact estimates. RESULTS: Shifting aCTG from obstetrician-led care to midwife-led-care would increase actual costs with 311 763 (97.5% CI 188 574 to 426 072) and 1 247 052 (97.5% CI 754 296 to 1 704 290) for implementation rates of 25% and 100%, respectively, while it would decrease reimbursement with -7 538 335 (97.5% CI -10 302 306 to -4 559 661) and -30 153 342 (97.5% CI -41 209 225 to -18 238 645) for implementation rates of 25% and 100%, respectively. The sensitivity analysis results were consistent with those of the main analysis. CONCLUSIONS: From the Dutch healthcare perspective, we estimated that implementing aCTG in midwife-led care may increase the associated actual costs. At the same time, it might lower the healthcare reimbursement.
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Presupuestos , Cardiotocografía , Partería , Humanos , Femenino , Países Bajos , Embarazo , Partería/estadística & datos numéricos , Partería/economía , Partería/métodos , Cardiotocografía/métodos , Cardiotocografía/estadística & datos numéricos , Cardiotocografía/economía , Cardiotocografía/normas , Presupuestos/estadística & datos numéricos , Presupuestos/métodos , Adulto , Estudios Prospectivos , Atención Prenatal/estadística & datos numéricos , Atención Prenatal/economía , Atención Prenatal/métodosRESUMEN
OBJECTIVE: To evaluate the relative cost-effectiveness of starting antenatal fetal surveillance at 32 vs. 36 weeks, in medication-treated gestational diabetes. METHODS: We performed a 2017-2022 retrospective cohort study of patients with medication-treated GDM who underwent BPPs. Patients diagnosed before 24 weeks, those delivered before 32 weeks, and those without BPPs or delivery data were excluded. Demographic and outcome data were abstracted by chart review. We performed a cost-effectiveness analysis regarding two outcomes: stillbirth, and decision to alter delivery timing following abnormal BPPs. RESULTS: A total of 652 pregnancies were included. Patients were 49% privately insured, 25% publicly insured, and 26% uninsured. We assumed that each BPP cost $145. In total, 1,284 BPPs occurred after 36 weeks, costing $186,180, and 2,041 BPPs occurred between 32 and 36 weeks, costing an additional $295,945. Twelve deliveries resulted from abnormal BPPs, all after 36 weeks. No stillbirths occurred. The cost to attempt to avoid one stillbirth was $40,177 across all patients. In our sample, starting surveillance at 36 weeks would have theoretically avoided all stillbirths, with cost savings per avoided stillbirth of $51,572 for privately insured patients, $14,123 for publicly insured patients, and $17,799 for patients without insurance. CONCLUSION: Based on this population with no stillbirths and no BPPs dictating delivery before 36 weeks, surveillance after 36 weeks may be safe and cost-effective. Our findings reflect opportunities for shared decision making and potential practice change, with greatest impact for low socioeconomic status patients and those without insurance.
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Análisis Costo-Beneficio , Diabetes Gestacional , Humanos , Femenino , Embarazo , Diabetes Gestacional/tratamiento farmacológico , Diabetes Gestacional/economía , Estudios Retrospectivos , Adulto , Edad Gestacional , Diagnóstico Prenatal/economía , Diagnóstico Prenatal/métodos , Mortinato/epidemiología , Mortinato/economía , Atención Prenatal/economía , Atención Prenatal/métodosRESUMEN
INTRODUCTION: As nearly two-thirds of women presenting at their first antenatal visit are either overweight or obese in urban South Africa, the preconception period is an opportunity to optimise health and offset transgenerational risk of both obesity and non-communicable diseases. This protocol describes the planned economic evaluation of an individually randomised controlled trial of a complex continuum of care intervention targeting women and children in Soweto, South Africa (Bukhali trial). METHODS AND ANALYSIS: The economic evaluation of the Bukhali trial will be conducted as a within-trial analysis from both provider and societal perspectives. Incremental costs and health outcomes of the continuum of care intervention will be compared with standard care. The economic impact on implementing agencies (programme costs), healthcare providers, participants and their households will be estimated. Incremental cost-effectiveness ratios (ICERs) will be calculated in terms of cost per case of child adiposity at age years averted. Additionally, ICERs will also be reported in terms of cost per quality-adjusted life year gained. If Bukhali demonstrates effectiveness, we will employ a decision analytical model to examine the cost-effectiveness of the intervention over a child's lifetime. A Markov model will be used to estimate long-term health benefits, healthcare costs and cost-effectiveness. Probabilistic sensitivity analyses will be conducted to explore uncertainty and ensure robust results. An analysis will be conducted to assess the equity impact of the intervention, by comparing intervention impact within quintiles of socioeconomic status. ETHICS AND DISSEMINATION: The Bukhali trial economic evaluation has ethical approval from the Human Ethics Research Committee of the University of the Witwatersrand, Johannesburg, South Africa (M240162). The results of the economic evaluation will be disseminated in a peer-reviewed journal and presented at a relevant international conference. TRIAL REGISTRATION NUMBER: Pan African Clinical Trials Registry (PACTR201903750173871; https://pactr.samrc.ac.za).
Asunto(s)
Continuidad de la Atención al Paciente , Análisis Costo-Beneficio , Años de Vida Ajustados por Calidad de Vida , Adulto , Niño , Femenino , Humanos , Embarazo , Continuidad de la Atención al Paciente/economía , Obesidad/terapia , Obesidad/economía , Obesidad Infantil/terapia , Obesidad Infantil/economía , Atención Prenatal/economía , Ensayos Clínicos Controlados Aleatorios como Asunto , SudáfricaRESUMEN
OBJECTIVE: Economic feasibility of eliminating mother-to-child transmission (MTCT) of hepatitis B virus (HBV) in highly endemic African countries remains uncertain. Prevention of MTCT (PMTCT) involves screening pregnant women for hepatitis B surface antigen (HBsAg), identifying those with high viral loads or hepatitis B e antigen (HBeAg), and administering tenofovir prophylaxis to high-risk women. We estimated the costs of integrating PMTCT services into antenatal care in Burkina Faso, based on four different strategies to select women for tenofovir prophylaxis: (1) HBV DNA (≥200 000 IU/mL), (2) HBeAg, (3) hepatitis B core-related antigen rapid diagnostic test (HBcrAg-RDT) and (4) all HBsAg-positive women. METHODS: Using a micro-costing approach, we estimated the incremental economic cost of integrating each strategy into routine antenatal care in 2024, compared to neonatal vaccination alone. Sensitivity analyses explored variations in prevalence, service coverage, test and tenofovir prices. RESULTS: HBcrAg-RDT strategy was the least expensive, with a total economic cost of US$3959689, compared to HBV DNA (US$6128875), HBeAg (US$4135233), and treat-all (US$4141206). The cost per pregnant woman receiving tenofovir prophylaxis varied from US$61.88 (Treat-all) to US$1071.05 (HBV DNA). The Treat-All strategy had the lowest marginal cost due to a higher number of women on tenofovir (66928) compared to HBV DNA (5722), HBeAg (10020), and HBcrAg-RDT (7234). In sensitivity analyses, the treat-all strategy became less expensive when the tenofovir price decreased. CONCLUSION: HBcrAg-RDT minimizes resource use and costs, representing 0.61% of Burkina Faso's 2022 health budget. This study highlights the potential economic feasibility of these strategies and provides valuable resources for conducting cost-effectiveness analyses.
Asunto(s)
Antivirales , Hepatitis B , Transmisión Vertical de Enfermedad Infecciosa , Complicaciones Infecciosas del Embarazo , Atención Prenatal , Tenofovir , Humanos , Femenino , Burkina Faso , Embarazo , Atención Prenatal/economía , Atención Prenatal/métodos , Complicaciones Infecciosas del Embarazo/tratamiento farmacológico , Complicaciones Infecciosas del Embarazo/prevención & control , Tenofovir/uso terapéutico , Tenofovir/economía , Tenofovir/administración & dosificación , Hepatitis B/prevención & control , Hepatitis B/tratamiento farmacológico , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Antivirales/uso terapéutico , Antivirales/economía , Antivirales/administración & dosificación , Tamizaje Masivo/economía , Tamizaje Masivo/métodos , Antígenos e de la Hepatitis B/sangre , Análisis Costo-Beneficio , Antígenos de Superficie de la Hepatitis B/sangre , Adulto , ADN Viral , Virus de la Hepatitis B , Carga ViralRESUMEN
Antecedentes: El departamento del Cauca en Colombia es multiétnico, multicultural y biodiverso, también con grandes diferencias en bajo peso al nacer (BPN), mortalidad perinatal y mortalidad neonatal tardía entre municipios. Objetivo: Determinar la relación de costo-efectividad del control prenatal (CPN) cuando ha tenido buena calidad frente al que ha tenido calidad deficiente con respecto al BPN en el departamento del Cauca entre 2018 y 2020. Método: Evaluación económica con diseño epidemiológico de una cohorte histórica desde la perspectiva de la institución pagadora. Se calculó la razón incremental de costo-efectividad (RICE), análisis de sensibilidad e impacto presupuestal. Resultados: La incidencia de BPN fue del 8,3% (348/4182). La calidad deficiente en el CPN incrementó el riesgo de BPN (OR: 3,38; IC95%: 1,05-8,2) y la buena calidad tuvo una mejor relación de costo-efectividad (RICE: USD 2727,75), con posición dominante frente a la calidad deficiente (6,14 veces el PIB per cápita de ahorro) y con un impacto presupuestal de USD 2.904.392. Conclusiones: La buena calidad del CPN en el departamento del Cauca durante 2018-2020 fue costo-efectiva y dominante por ser de menor costo y mayor efectividad.
Background: The department of Cauca in Colombia is multiethnic, multicultural, and biodiverse, also with large differences in low birth weight (LBW), perinatal mortality, and late neonatal mortality among municipalities. Objective: To determine the cost-effectiveness relationship of antenatal care (ANC) when it has had good quality compared to that which has had poor quality with respect to low birth weight in the department of Cauca between 2018 and 2019. Method: Economic evaluation with epidemiological cohort design historical from the perspective of the payer institution. Incremental cost-effectiveness ratio (RICE), sensitivity analysis, and budgetary impact were calculated. Results: The incidence of LBW was 8.3% (348/4182). Poor quality in ANC increased the risk of LBW (OR: 3.38; CI95%: 1.05-8.2), good quality had a better cost-effectiveness ratio (RICE: USD 2727.75), with dominant position against poor quality (6.14 times the GDP/capita savings) with a budgetary impact of USD 2,904,392. Conclusions: The good quality of the ANC in the department of Cauca during 2018-2020 was cost-effective and dominant because it is lower cost and more effective.
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Humanos , Femenino , Embarazo , Recién Nacido , Atención Prenatal/economía , Recién Nacido de Bajo Peso , Estudios Retrospectivos , Costos de la Atención en Salud , Análisis Costo-BeneficioAsunto(s)
Promoción de la Salud , Atención Prenatal , Reembolso de Incentivo , Cese del Hábito de Fumar , Femenino , Humanos , Embarazo , Conductas Relacionadas con la Salud , Fumar/efectos adversos , Fumar/economía , Cese del Hábito de Fumar/economía , Cese del Hábito de Fumar/métodos , Reembolso de Incentivo/economía , Atención Prenatal/economía , Atención Prenatal/métodos , Motivación , Promoción de la Salud/economía , Promoción de la Salud/métodos , Apoyo Financiero , RecompensaRESUMEN
BACKGROUND: The AFFIRM intervention aimed to reduce stillbirth and neonatal deaths by increasing awareness of reduced fetal movements (RFM) and implementing a care pathway when women present with RFM. Although there is uncertainty regarding the clinical effectiveness of the intervention, the aim of this analysis was to evaluate the cost-effectiveness. METHODS: A stepped-wedge, cluster-randomised trial was conducted in thirty-three hospitals in the United Kingdom (UK) and Ireland. All women giving birth at the study sites during the analysis period were included in the study. The costs associated with implementing the intervention were estimated from audits of RFM attendances and electronic healthcare records. Trial data were used to estimate a cost per stillbirth prevented was for AFFIRM versus standard care. A decision analytic model was used to estimate the costs and number of perinatal deaths (stillbirths + early neonatal deaths) prevented if AFFIRM were rolled out across Great Britain for one year. Key assumptions were explored in sensitivity analyses. RESULTS: Direct costs to implement AFFIRM were an estimated £95,126 per 1,000 births. Compared to standard care, the cost per stillbirth prevented was estimated to be between £86,478 and being dominated (higher costs, no benefit). The estimated healthcare budget impact of implementing AFFIRM across Great Britain was a cost increase of £61,851,400/year. CONCLUSIONS: Perinatal deaths are relatively rare events in the UK which can increase uncertainty in economic evaluations. This evaluation estimated a plausible range of costs to prevent baby deaths which can inform policy decisions in maternity services. TRIAL REGISTRATION: The trial was registered with www. CLINICALTRIALS: gov , number NCT01777022 .
Asunto(s)
Concienciación , Movimiento Fetal , Muerte Perinatal/prevención & control , Mujeres Embarazadas/educación , Mujeres Embarazadas/psicología , Atención Prenatal/métodos , Análisis Costo-Beneficio , Vías Clínicas , Técnicas de Apoyo para la Decisión , Femenino , Costos de la Atención en Salud , Personal de Salud/educación , Humanos , Irlanda , Irlanda del Norte , Educación del Paciente como Asunto , Embarazo , Atención Prenatal/economía , Mortinato , Reino UnidoRESUMEN
BACKGROUND: Malnutrition among women of childbearing age is especially prevalent in Asia and sub-Saharan Africa and can be harmful to the fetus during pregnancy. In the most recently available Demographic and Health Survey (DHS), approximately 10% to 20% of pregnant women in India, Pakistan, Mali, and Tanzania were undernourished (body mass index [BMI] <18.5 kg/m2), and according to the Global Burden of Disease (GBD) 2017 study, approximately 20% of babies were born with low birth weight (LBW; <2,500 g) in India, Pakistan, and Mali and 8% in Tanzania. Supplementing pregnant women with micro and macronutrients during the antenatal period can improve birth outcomes. Recently, the World Health Organization (WHO) recommended antenatal multiple micronutrient supplementation (MMS) that includes iron and folic acid (IFA) in the context of rigorous research. Additionally, WHO recommends balanced energy protein (BEP) for undernourished populations. However, few studies have compared the cost-effectiveness of different supplementation regimens. We compared the cost-effectiveness of MMS and BEP with IFA to quantify their benefits in 4 countries with considerable prevalence of maternal undernutrition. METHODS AND FINDINGS: Using nationally representative estimates from the 2017 GBD study, we conducted an individual-based dynamic microsimulation of population cohorts from birth to 2 years of age in India, Pakistan, Mali, and Tanzania. We modeled the effect of maternal nutritional supplementation on infant birth weight, stunting and wasting using effect sizes from Cochrane systematic reviews and published literature. We used a payer's perspective and obtained costs of supplementation per pregnancy from the published literature. We compared disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs) in a baseline scenario with existing antenatal IFA coverage with scenarios where 90% of antenatal care (ANC) attendees receive either universal MMS, universal BEP, or MMS + targeted BEP (women with prepregnancy BMI <18.5 kg/m2 receive BEP containing MMS while women with BMI ≥18.5 kg/m2 receive MMS). We obtained 95% uncertainty intervals (UIs) for all outputs to represent parameter and stochastic uncertainty across 100 iterations of model runs. ICERs for all scenarios were lowest in Pakistan and greatest in Tanzania, in line with the baseline trend in prevalence of and attributable burden to LBW. MMS + targeted BEP averts more DALYs than universal MMS alone while remaining cost-effective. ICERs for universal MMS compared to baseline IFA were $52 (95% UI: $28 to $78) for Pakistan, $72 (95% UI: $37 to $118) for Mali, $70 (95% UI: $43 to $104) for India, and $253 (95% UI: $112 to $481) for Tanzania. ICERs for MMS + targeted BEP compared to baseline IFA were $54 (95% UI: $32 to $77) for Pakistan, $73 (95% UI: $40 to $104) for Mali, $83 (95% UI: $58 to $111) for India, and $245 (95% UI: $127 to $405) for Tanzania. Study limitations include generalizing experimental findings from the literature to our populations of interest and using population-level input parameters that may not reflect the heterogeneity of subpopulations. Additionally, our microsimulation fuses multiple sources of data and may be limited by data quality and availability. CONCLUSIONS: In this study, we observed that MMS + targeted BEP averts more DALYs and remains cost-effective compared to universal MMS. As countries consider using MMS in alignment with recent WHO guidelines, offering targeted BEP is a cost-effective strategy that can be considered concurrently to maximize benefits and synergize program implementation.
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Análisis Costo-Beneficio/tendencias , Proteínas en la Dieta/economía , Ácido Fólico/economía , Hierro/economía , Micronutrientes/economía , Atención Prenatal/economía , Adolescente , Adulto , Estudios de Cohortes , Proteínas en la Dieta/administración & dosificación , Suplementos Dietéticos/economía , Años de Vida Ajustados por Discapacidad/tendencias , Ingestión de Energía , Femenino , Ácido Fólico/administración & dosificación , Humanos , India/epidemiología , Recién Nacido , Hierro/administración & dosificación , Masculino , Malí/epidemiología , Micronutrientes/administración & dosificación , Persona de Mediana Edad , Pakistán/epidemiología , Embarazo , Atención Prenatal/tendencias , Tanzanía/epidemiología , Adulto JovenAsunto(s)
Vacunas contra Hepatitis B , Hepatitis B/diagnóstico , Hepatitis B/prevención & control , Tamizaje Masivo/normas , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/prevención & control , Atención Prenatal/normas , Toma de Decisiones Clínicas , Análisis Costo-Beneficio , Femenino , Hepatitis B/economía , Vacunas contra Hepatitis B/economía , Humanos , Tamizaje Masivo/economía , Aceptación de la Atención de Salud , Embarazo , Complicaciones Infecciosas del Embarazo/economía , Atención Prenatal/economía , Medición de Riesgo , Estados UnidosRESUMEN
OBJECTIVE: To evaluate the cost effectiveness of universal screening for hepatitis B immunity and vaccination among pregnant women in the United States. METHODS: We designed a decision-analytic model to evaluate the outcomes, costs, and cost effectiveness associated with universal hepatitis B virus (HBV) immunity screening in pregnancy with vaccination of susceptible individuals compared with no screening. A theoretical cohort of 3.6 million women, the approximate number of annual live births in the United States, was used. Outcomes included cases of HBV, hepatocellular carcinoma, decompensated cirrhosis, liver transplant and death, in addition to cost and quality-adjusted life-years (QALYs). Model inputs were derived from the literature, and the willingness-to-pay threshold was $50,000 per QALY. Univariate sensitivity analyses and Monte Carlo simulation models were performed to evaluate the robustness of the results. RESULTS: In a theoretical cohort of 3.6 million women, universal HBV immunity screening and vaccination resulted in 1,702 fewer cases of HBV, seven fewer cases of decompensated cirrhosis, four fewer liver transplants, and 11 fewer deaths over the life expectancy of a woman after pregnancy. Universal screening and vaccination were found to be cost effective, with an incremental cost-effectiveness ratio of $1,890 per QALY. Sensitivity analyses demonstrated the model was robust even when the prevalence of HBV immunity was high and the annual risk of HBV acquisition low. CONCLUSION: Among pregnant women in the United States, universal HBV immunity screening and vaccination of susceptible persons is cost effective compared with not routinely screening and vaccinating.
Asunto(s)
Análisis Costo-Beneficio , Vacunas contra Hepatitis B/economía , Hepatitis B , Tamizaje Masivo/economía , Complicaciones Infecciosas del Embarazo , Atención Prenatal/economía , Adulto , Biomarcadores/sangre , Estudios de Cohortes , Técnicas de Apoyo para la Decisión , Femenino , Hepatitis B/sangre , Hepatitis B/diagnóstico , Hepatitis B/economía , Hepatitis B/prevención & control , Anticuerpos contra la Hepatitis B/sangre , Humanos , Cadenas de Markov , Tamizaje Masivo/métodos , Modelos Económicos , Método de Montecarlo , Embarazo , Complicaciones Infecciosas del Embarazo/sangre , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/economía , Complicaciones Infecciosas del Embarazo/prevención & control , Atención Prenatal/métodos , Años de Vida Ajustados por Calidad de Vida , Estados UnidosRESUMEN
Introduction: Despite penicillin being the drug of choice for the treatment of syphilis, many pregnant women who test positive for syphilis do not receive the drug as recommended by the Ministry of Health, contributing to the increase in costs associated with congenital syphilis. Objective: This study aims to estimate the incremental cost-effectiveness ratio of administering at least one dose of 2.4 million IU of benzathine penicillin in the first trimester of pregnancy as soon as the result of a positive rapid treponemal test performed during antenatal care in primary care units of the Brazilian National Health System. Methods: An analytical model was proposed based on a decision tree. The perspective of the analysis was the one used in The Brazilian National Health System. The clinical outcomes were abortion, prematurity, neonatal death, stillbirth, and congenital syphilis, estimated in terms of disability-adjusted life-years. Only direct costs were considered. Deterministic and probabilistic sensitivity analyses were performed. Results: The model predicted that the most efficient strategy is the one that includes the administration of penicillin in primary care for cases of gestational syphilis. This strategy is more effective, although more costly. The cost per disability-adjusted life-years averted with the use of this strategy was estimated at R$49.79 (US$ 10.67). Conclusion: The prenatal strategy in primary care units that includes the administration of penicillin to pregnant women with syphilis during the first trimester of pregnancy has the greatest potential to be cost-effective.
Introdução: A despeito de a penicilina ser o medicamento de escolha para o tratamento da sífilis, muitas gestantes com teste positivo para sífilis não recebem o medicamento como recomendado pelo Ministério da Saúde, concorrendo para o aumento dos custos associados à sífilis congênita. Objetivo: Estimar a razão de custo-efetividade incremental da administração de pelo menos uma dose de 2,4 milhões de Unidades Internacionais de penicilina benzatina no primeiro trimestre de gravidez, tão logo se tenha o resultado de um teste rápido treponêmico positivo realizado na consulta pré-natal em unidades de atenção primária do Sistema Único de Saúde. Métodos: Um modelo analítico foi proposto a partir de uma árvore de decisão. A perspectiva da análise foi a do Sistema Único de Saúde. Os desfechos em saúde foram aborto, prematuridade, morte neonatal, natimorto e sífilis congênita, estimados em termos de anos de vida ajustados a incapacidades (disability-adjusted life-years). Apenas os custos diretos foram considerados. Análises de sensibilidade determinística e probabilística foram realizadas. Resultados: O modelo previu que a estratégia mais eficiente é aquela que inclui a administração da penicilina na atenção primária aos casos de sífilis gestacional. Embora essa estratégia possa representar maior custo, apresenta maior efetividade. O custo por disability-adjusted life-years evitado com o uso dessa estratégia foi estimado em R$49,79. Conclusão: A estratégia de pré-natal nas unidades de atenção primária que inclui a administração da penicilina em gestantes com sífilis ainda no primeiro trimestre de gestação é a que apresenta o maior potencial para ser custo-efetiva.
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Humanos , Femenino , Embarazo , Penicilina G Benzatina/uso terapéutico , Atención Prenatal/economía , Atención Primaria de Salud , Sífilis Congénita/prevención & control , Penicilina G Benzatina/economía , Primer Trimestre del Embarazo , Análisis Costo-BeneficioRESUMEN
Pregnancy presents a unique challenge to economic evaluation, requiring methods that can account for both maternal and fetal outcomes. The ethical challenges to healthcare presented by pregnancy are well understood, but these have not yet been incorporated into cost-effectiveness approaches. Economic evaluations of pregnancy currently take an ad hoc approach to outcome valuation, opening the door to biased estimates and inconsistent resource allocation. We summarize the limitations of current economic evaluation methods and outline key areas for future work.
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Años de Vida Ajustados por Calidad de Vida , Anticoncepción/economía , Análisis Costo-Beneficio , Toma de Decisiones , Femenino , Humanos , Prioridad del Paciente/economía , Embarazo , Resultado del Embarazo/economía , Atención Prenatal/economíaRESUMEN
Importance: Policy makers are considering insurance expansions to improve maternal health. The tradeoffs between expanding Medicaid or subsidized private insurance for maternal coverage and care are unknown. Objective: To compare maternal coverage and care by Medicaid vs marketplace eligibility. Design, Setting, and Participants: A retrospective cohort study using a difference-in-difference research design was conducted from March 14, 2020, to April 22, 2021. Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation. Participants included women aged 18 years or older from the 2011-2018 Pregnancy Risk Assessment Monitoring System survey. Exposures: Eligibility for Medicaid or marketplace coverage under the Affordable Care Act. Main Outcomes and Measures: Outcomes included coverage in the preconception and postpartum periods, early and adequate prenatal care, and postpartum checkups and effective contraceptive use. Results: The study population included 11â¯432 women age 18 years and older (32% age 18-24 years, 33% age 25-29 years, 35% age ≥30 years) with incomes 100% to 138% FPL: 7586 in a Medicaid state (exposure group) and 3846 in a nonexpansion marketplace state (comparison group). Women in marketplace states were younger, had higher educational level and marriage rates, and had less racial and ethnic diversity. Medicaid relative to marketplace eligibility was associated with increased Medicaid coverage (20.3 percentage points; 95% CI, 12.8 to 30.0 percentage points), decreased private insurance coverage (-10.8 percentage points; 95% CI, -13.3 to -7.5 percentage points), and decreased uninsurance (-8.7 percentage points; 95% CI, -20.1 to -0.1 percentage points) in the preconception period, increased postpartum Medicaid (17.4 percentage points; 95% CI, 1.7 to 34.3 percentage points) and increased adequate prenatal care (4.4 percentage points; 95% CI, 0.1 to 11.0 percentage points) in difference-in-difference models. No evidence of significant differences in early prenatal care, postpartum check-ups, or postpartum contraception was identified. Conclusions and Relevance: In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential importance of reducing financial barriers for the population with low incomes.
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Determinación de la Elegibilidad/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Medicaid/estadística & datos numéricos , Atención Posnatal/estadística & datos numéricos , Atención Prenatal/estadística & datos numéricos , Adulto , Estudios de Cohortes , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Humanos , Seguro de Salud/estadística & datos numéricos , Patient Protection and Affordable Care Act/estadística & datos numéricos , Atención Posnatal/economía , Pobreza , Embarazo , Atención Prenatal/economía , Estudios Retrospectivos , Estados Unidos , Adulto JovenRESUMEN
The lack of health infrastructure in developing countries to provide women with modern obstetric care and universal access to maternal and child health services has largely contributed to the existing high maternal and infant deaths. Access to basic obstetric care for pregnant women and their unborn babies is a key to reducing maternal and infants´ deaths, especially at the community-level. This calls for the strengthening of primary health care systems in all developing countries, including Ghana. Financial access and utilization of maternal and child health care services need action at the community-level across rural Ghana to avoid preventable deaths. Financial access and usage of maternal and child health services in rural Ghana is poor. Lack of financial access is a strong barrier to the use of maternal and child health services, particularly in rural Ghana. The sustainability of the national health insurance scheme is vital in ensuring full access to care in remote communities.
Asunto(s)
Servicios de Salud del Niño/organización & administración , Mortalidad Infantil , Servicios de Salud Materna/organización & administración , Mortalidad Materna , Servicios de Salud del Niño/economía , Atención a la Salud/economía , Atención a la Salud/organización & administración , Países en Desarrollo , Femenino , Ghana , Accesibilidad a los Servicios de Salud/economía , Humanos , Lactante , Muerte del Lactante/prevención & control , Recién Nacido , Muerte Materna/prevención & control , Servicios de Salud Materna/economía , Programas Nacionales de Salud/economía , Embarazo , Atención Prenatal/economía , Atención Prenatal/organización & administración , Población RuralRESUMEN
INTRODUCTION: poor access to maternal health services is a one of the major contributing factors to maternal deaths in low-resource settings, and understanding access barriers to maternal services is an important step for targeting interventions aimed at promoting institutional delivery and improving maternal health. This study explored access barriers to maternal and antenatal services in Kaputa and Ngabwe; two of Zambia´s rural and hard-to-reach districts. METHODS: a concurrent mixed methods approach was therefore, undertaken to exploring three access dimensions, namely availability, affordability and acceptability, in the two districts. Structured interviews were conducted among 190 eligible women in both districts, while key informant interviews, in-depth interviews and focus group discussions were conducted for the qualitative component. RESULTS: the study found that respondents were happy with facilities´ opening and closing times in both districts. By comparison, however, women in Ngabwe spent significantly more time traveling to facilities than those in Kaputa, with bad roads and transport challenges cited as factors affecting service use. The requirement to have a traditional birth attendant (TBA) accompany a woman when going to deliver from the facility, and paying these TBAs, was a notable access barrier. Generally, services seemed to be more acceptable in Kaputa than in Ngabwe, though both districts complained about long queues, being delivered by male health workers and having delivery rooms next to male wards. CONCLUSION: based on the indicators of access used in this study, maternal health services seemed to be more accessible in Kaputa compared to Ngabwe.
Asunto(s)
Accesibilidad a los Servicios de Salud , Servicios de Salud Materna/estadística & datos numéricos , Partería/estadística & datos numéricos , Atención Prenatal/métodos , Adolescente , Adulto , Femenino , Grupos Focales , Humanos , Entrevistas como Asunto , Salud Materna , Servicios de Salud Materna/economía , Servicios de Salud Materna/provisión & distribución , Persona de Mediana Edad , Partería/economía , Embarazo , Atención Prenatal/economía , Población Rural , Factores Socioeconómicos , Adulto Joven , ZambiaRESUMEN
INTRODUCTION: the objective was to describe establishment cost, essential services provided and operating costs of maternity waiting homes (MWH) in Ethiopia. METHODS: a cross-sectional study was carried out from December 2017 to June 2018 in eight health facilities with maternity waiting homes (MWH) in the Gurage Zone of Ethiopia. MWH users exit interviews and observational checklists were used to collect data on essential services provided. Cost-related data were retrieved from relevant records in the health facilities. RESULTS: most clinical services and basic amenities were available and provided for MWH users. The average capital costs of a MWH were $2,245 US with fixed costs of $1,476 US per year. The personnel cost for a MWH was $1,439 US per year. The average annual running cost of a MWH was $1,303 US per year. The average estimated MWH utilization and delivery costs was $16.9 US per woman. CONCLUSION: most MWHs provided essential clinical services and basic amenities. The majority of the cost of a MWH was attributed to building construction costs. If building cost is annualized, the unit cost of a MWH service is in an acceptable range which encourage government considering expansion of the service in rural area.
Asunto(s)
Costos de la Atención en Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud , Servicios de Salud Materna/organización & administración , Atención Prenatal/organización & administración , Adulto , Estudios Transversales , Etiopía , Femenino , Humanos , Entrevistas como Asunto , Servicios de Salud Materna/economía , Embarazo , Atención Prenatal/economía , Adulto JovenRESUMEN
INTRODUCTION: In spite of the countless initiatives of the Ghana government to improve the quality of maternal healthcare, Upper West Region still records poor childbirth outcomes. This study, therefore, explored women's perception of the quality of maternal healthcare they receive in the Wa Municipality of the Upper West Region of Ghana. MATERIALS AND METHODS: This is a qualitative cross-sectional study of 62 women who accessed maternal healthcare in the Wa Municipality of Ghana. We analysed the transcripts using the analytic inductive technique. An inter-coding technique (testing for inter-coding agreement) was employed. The iterative coding process resulted in a coding scheme with four main themes. We used peer-debriefing technique in ensuring credibility and trustworthiness. RESULTS: Logistics and equipment; referral service; empathic service delivery; inadequacy of care providers; affordability of service; satisfaction with services received; as well as experience and service delivery were the parameters used by the women in assessing quality maternity care. A number of gaps were reported in the healthcare system including limited healthcare providers, limited beds and inefficient referral system. Conversely, some of them reported that some healthcare providers offered empathetic healthcare. Contrary views were expressed with respect to satisfaction with maternity care. CONCLUSION: Government and all stakeholders seeking to enhance quality of maternal health and accelerate the attainment of the third Sustainable Development Goal need to reconsider the financing of service delivery at health institutions. Indeed, our findings have illustrated that routine workshops on empathetic healthcare are required in efforts to increase the rate of facility-based childbirth, and thereby subside maternal mortality and all adverse pregnancy outcomes.
Asunto(s)
Madres , Parto , Adulto , Estudios Transversales , Parto Obstétrico/métodos , Femenino , Ghana/epidemiología , Humanos , Masculino , Servicios de Salud Materna/organización & administración , Satisfacción del Paciente , Embarazo , Atención Prenatal/economía , Investigación Cualitativa , Calidad de la Atención de Salud , Resultado del Tratamiento , Adulto JovenRESUMEN
Importance: Access to prenatal and postpartum care is restricted among women with low income who are recent or undocumented immigrants enrolled in Emergency Medicaid. Objective: To examine the association of extending prenatal care coverage to Emergency Medicaid enrollees with postpartum contraception and short interpregnancy interval births. Design, Setting, and Participants: This cohort study used a difference-in-differences design to compare the staggered rollout of prenatal care in Oregon with South Carolina, a state that does not cover prenatal or postpartum care. Linked Medicaid claims and birth certificate data from 2010 to 2016 were examined for an association between prenatal care coverage for women whose births were covered by Emergency Medicaid and subsequent short IPI births. Additional maternal and infant health outcomes were also examined, including postpartum contraceptive use, preterm birth, and neonatal intensive care unit admission. The association between the policy change and measures of policy implementation (number of prenatal visits) and quality of care (receipt of 8 guideline-based screenings) was also analyzed. Statistical analysis was performed from August 2020 to March 2021. Exposures: Medicaid coverage of prenatal care. Main Outcomes and Measures: Postpartum contraceptive use, defined as receipt of any contraceptive method within 60 days of delivery; short IPI births, defined as occurring within 18 months of a previous pregnancy. Results: The study population consisted of 26â¯586 births to women enrolled in Emergency Medicaid in Oregon and South Carolina. Among these women, 14â¯749 (55.5%) were aged 25 to 35 years, 25â¯894 (97.4%) were Black, Hispanic, Native American, Alaskan, Pacific Islander, or Asian women or women with unknown race/ethnicity, and 17â¯905 (67.3%) lived in areas with urban zip codes. Coverage of prenatal care for women in Emergency Medicaid was associated with significant increases in mean (SD) prenatal visits (increase of 10.3 [0.9] prenatal visits) and prenatal quality. Prenatal care screenings (eg, anemia screening: increase of 65.7 percentage points [95% CI, 54.2 to 77.1 percentage points]) and vaccinations (eg, influenza vaccination: increase of 31.9 percentage points [95% CI, 27.4 to 36.3 percentage points]) increased significantly following the policy change. Although postpartum contraceptive use increased following prenatal care expansion (increase of 1.5 percentage points [95% CI, 0.4 to 2.6 percentage points]), the policy change was not associated with a reduction in short IPI births (-4.5 percentage points [95% CI, -9.5 to 0.5 percentage points), preterm births (-0.6 percentage points [95% CI, -3.2 to 2.0 percentage points]), or neonatal intensive care unit admissions (increase of 0.8 percentage points [95% CI, -2.0 to 3.6 percentage points]). Conclusions and Relevance: This study found that expanding Emergency Medicaid benefits to include prenatal care significantly improved receipt of guideline-concordant prenatal care. Prenatal care coverage alone was not associated with a meaningful increase in postpartum contraception or a reduction in subsequent short IPI births.
Asunto(s)
Intervalo entre Nacimientos/estadística & datos numéricos , Conducta Anticonceptiva/estadística & datos numéricos , Emigrantes e Inmigrantes/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Atención Prenatal/estadística & datos numéricos , Adulto , Intervalo entre Nacimientos/etnología , Servicios de Planificación Familiar/economía , Servicios de Planificación Familiar/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud/economía , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Cobertura del Seguro/economía , Medicaid , Aceptación de la Atención de Salud/etnología , Periodo Posparto , Pobreza/etnología , Pobreza/estadística & datos numéricos , Embarazo , Atención Prenatal/economía , Factores de Tiempo , Inmigrantes Indocumentados/estadística & datos numéricos , Estados UnidosRESUMEN
Zimbabwe has made large strides in addressing HIV. To ensure a continued robust response, a clear understanding of costs associated with its HIV program is critical. We conducted a cross-sectional evaluation in 2017 to estimate the annual average patient cost for accessing Prevention of Mother-To-Child Transmission (PMTCT) services (through antenatal care) and Antiretroviral Treatment (ART) services in Zimbabwe. Twenty sites representing different types of public health facilities in Zimbabwe were included. Data on patient costs were collected through in-person interviews with 414 ART and 424 PMTCT adult patients and through telephone interviews with 38 ART and 47 PMTCT adult patients who had missed their last appointment. The mean and median annual patient costs were examined overall and by service type for all participants and for those who paid any cost. Potential patient costs related to time lost were calculated by multiplying the total time to access services (travel time, waiting time, and clinic visit duration) by potential earnings (US$75 per month assuming 8 hours per day and 5 days per week). Mean annual patient costs for accessing services for the participants was US$20.00 [standard deviation (SD) = US$80.42, median = US$6.00, range = US$0.00-US$12,18.00] for PMTCT and US$18.73 (SD = US$58.54, median = US$8.00, range = US$0.00-US$ 908.00) for ART patients. The mean annual direct medical costs for PMTCT and ART were US$9.78 (SD = US$78.58, median = US$0.00, range = US$0.00-US$ 90) and US$7.49 (SD = US$60.00, median = US$0.00) while mean annual direct non-medical cost for US$10.23 (SD = US$17.35, median = US$4.00) and US$11.23 (SD = US$25.22, median = US$6.00, range = US$0.00-US$ 360.00). The PMTCT and ART costs per visit based on time lost were US$3.53 (US$1.13 to US$8.69) and US$3.43 (US$1.14 to US$8.53), respectively. The mean annual patient costs per person for PMTCT and ART in this evaluation will impact household income since PMTCT and ART services in Zimbabwe are supposed to be free.
Asunto(s)
Fármacos Anti-VIH/economía , Costo de Enfermedad , Infecciones por VIH/economía , Costos de la Atención en Salud/estadística & datos numéricos , Gastos en Salud/estadística & datos numéricos , Transmisión Vertical de Enfermedad Infecciosa/economía , Adulto , Fármacos Anti-VIH/uso terapéutico , Terapia Antirretroviral Altamente Activa , Análisis Costo-Beneficio/estadística & datos numéricos , Estudios Transversales , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/transmisión , Infecciones por VIH/virología , Humanos , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Embarazo , Atención Prenatal/economía , ZimbabweRESUMEN
BACKGROUND: Reducing poverty and improving access to health care are two of the most effective actions to decrease maternal mortality, and conditional cash transfer (CCT) programmes act on both. The aim of this study was to evaluate the effects of one of the world's largest CCT (the Brazilian Bolsa Familia Programme (BFP)) on maternal mortality during a period of 11 years. METHODS: The study had an ecological longitudinal design and used all 2548 Brazilian municipalities with vital statistics of adequate quality during 2004-2014. BFP municipal coverage was classified into four levels, from low to consolidated, and its duration effects were measured using the average municipal coverage of previous years. We used negative binomial multivariable regression models with fixed-effects specifications, adjusted for all relevant demographic, socioeconomic, and healthcare variables. RESULTS: BFP was significantly associated with reductions of maternal mortality proportionally to its levels of coverage and years of implementation, with a rate ratio (RR) reaching 0.88 (95%CI 0.81-0.95), 0.84 (0.75-0.96) and 0.83 (0.71-0.99) for intermediate, high and consolidated BFP coverage over the previous 11 years. The BFP duration effect was stronger among young mothers (RR 0.77; 95%CI 0.67-0.96). BFP was also associated with reductions in the proportion of pregnant women with no prenatal visits (RR 0.73; 95%CI 0.69-0.77), reductions in hospital case-fatality rate for delivery (RR 0.78; 95%CI 0.66-0.94) and increases in the proportion of deliveries in hospital (RR 1.05; 95%CI 1.04-1.07). CONCLUSION: Our findings show that a consolidated and durable CCT coverage could decrease maternal mortality, and these long-term effects are stronger among poor mothers exposed to CCT during their childhood and adolescence, suggesting a CCT inter-generational effect. Sustained CCT coverage could reduce health inequalities and contribute to the achievement of the Sustainable Development Goal 3.1, and should be preserved during the current global economic crisis due to the COVID-19 pandemic.