Cost-effectiveness and benefits of perinatal health interventions in high-income settings: A protocol for a systematic review of economic evaluations.

BACKGROUND: Despite ongoing efforts, perinatal morbidity and mortality persist across all settings, imposing a dual burden of clinical and economic strain. Besides, the fragmented nature of economic evidence on perinatal health interventions hinders the formulation of effective health policies. Our review aims to comprehensively and critically assess the economic evidence for such interventions in high-income countries, where the balance of health outcomes and fiscal prudence is paramount. METHODS AND ANALYSIS: We will conduct a comprehensive search for studies using databases including EconLit (EBSCO), Cost Effectiveness Analysis (CEA) Registry, Medline (Ovid), Embase (Ovid), CINAHL Ultimate (EBSCO), Global Health (Ovid), and PubMed. Furthermore, we will broaden our search to include Google Scholar and conduct snowballing from the final articles included. The search terms will encompass economic evaluation, perinatal health interventions, morbidity and mortality, and high-income countries. We will include full economic evaluations focusing on cost-effectiveness, cost-benefit, cost-utility, and cost-minimisation analyses. We will exclude partial economic evaluations, reports, qualitative studies, conference papers, editorials, and systematic reviews. Date restrictions will limit the review to studies published after 2010 and those in English during the study selection process. We will use the modified Drummond checklist to evaluate the quality of each included study. Our findings will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement. A summary will include estimated costs, effectiveness, benefits, and the incremental cost-effectiveness ratio (ICER). We also plan to conduct a subgroup analysis. To aid comparability, we will standardise all costs to the United States Dollar, adjusting them to their 2022 value using country-specific consumer price index and purchasing power parity. ETHICS AND DISSEMINATION: This systematic review will not involve human participants and requires no ethical approval. We will publish the results in a peer-reviewed journal. TRIAL REGISTRATION: We registered our record on PROSPERO (registration #: CRD42023432232).

A Systematic Review of Methods and Practice for Integrating Maternal, Fetal, and Child Health Outcomes, and Family Spillover Effects into Cost-Utility Analyses.

BACKGROUND: Maternal-perinatal interventions delivered during pregnancy or childbirth have unique characteristics that impact the health-related quality of life (HRQoL) of the mother, fetus, and newborn child. However, maternal-perinatal cost-utility analyses (CUAs) often only consider either maternal or child health outcomes. Challenges include, but are not limited to, measuring fetal, newborn, and infant health outcomes, and assessing their impact on maternal HRQoL. It is also important to recognize the impact of maternal-perinatal health on family members' HRQoL (i.e., family spillover effects) and to incorporate these effects in maternal-perinatal CUAs. OBJECTIVE: The aim was to systematically review the methods used to include health outcomes of pregnant women, fetuses, and children and to incorporate family spillover effects in maternal-perinatal CUAs. METHODS: A literature search was conducted in Medline, Embase, EconLit, Cochrane Collection, Cumulative Index to Nursing and Allied Health Literature (CINAHL), International Network of Agencies for Health Technology Assessment (INAHTA), and the Pediatric Economic Database Evaluation (PEDE) databases from inception to 2020 to identify maternal-perinatal CUAs that included health outcomes for pregnant women, fetuses, and/or children. The search was updated to December 2022 using PEDE. Data describing how the health outcomes of mothers, fetuses, and children were measured, incorporated, and reported along with the data on family spillover effects were extracted. RESULTS: Out of 174 maternal-perinatal CUAs identified, 62 considered the health outcomes of pregnant women, and children. Among the 54 quality-adjusted life year (QALY)-based CUAs, 12 included fetal health outcomes, the impact of fetal loss on mothers' HRQoL, and the impact of neonatal demise on mothers' HRQoL. Four studies considered fetal health outcomes and the effects of fetal loss on mothers' HRQoL. One study included fetal health outcomes and the impact of neonatal demise on maternal HRQoL. Furthermore, six studies considered the impact of neonatal demise on maternal HRQoL, while four included fetal health outcomes. One study included the impact of fetal loss on maternal HRQoL. The remaining 26 only included the health outcomes of pregnant women and children. Among the eight disability-adjusted life year (DALY)-based CUAs, two measured fetal health outcomes. Out of 174 studies, only one study included family spillover effects. The most common measurement approach was to measure the health outcomes of pregnant women and children separately. Various approaches were used to assess fetal losses in terms of QALYs or DALYs and their impact on HRQoL of mothers. The most common integration approach was to sum the QALYs or DALYs for pregnant women and children. Most studies reported combined QALYs and incremental QALYs, or DALYs and incremental DALYs, at the family level for pregnant women and children. CONCLUSIONS: Approximately one-third of maternal-perinatal CUAs included the health outcomes of pregnant women, fetuses, and/or children. Future CUAs of maternal-perinatal interventions, conducted from a societal perspective, should aim to incorporate health outcomes for mothers, fetuses, and children when appropriate. The various approaches used within these CUAs highlight the need for standardized measurement and integration methods, potentially leading to rigorous and standardized inclusion practices, providing higher-quality evidence to better inform decision-makers about the costs and benefits of maternal-perinatal interventions. Health Technology Assessment agencies may consider providing guidance for interventions affecting future lives in future updates.

Costs and benefits of scaling psychosocial interventions during the perinatal period in England: A simulation modelling study.

BACKGROUND: Globally, guidance recommends the integration of mental health into maternal and child healthcare to address common maternal mental health problems during the perinatal period. However, implementing this in the real-world requires substantial resource allocations. OBJECTIVE: The aim of this study was to estimate the likely costs and consequences linked to scaling the delivery of treatment (in the form of psychosocial interventions) during the perinatal period. DESIGN: Simulation modelling. SETTING(S): England. METHODS: Costs and consequences were modelled for three scenarios of assumed provision of services, whereby one referred to the projected provision under current government plans, with no additional scaling up of treatment. The other two scenarios referred to additional scaling of treatment: in one scenario, this referred to the provision of treatment by midwives and health visitors trained in the routine enquiry about mental health and delivery of psychosocial interventions; in the other scenario this referred to an expanded provision by primary mental health services. For each scenario and in yearly intervals (covering a ten-year period, 2015 to 2024), unit cots and outcomes were assigned to the activities women were assumed to receive (routine enquiry, assessment, treatment, care coordination). All costs were in 2020 pounds sterling. Data sources for the modelling included: published findings from randomised controlled trials; national unit cost source; national statistics; and expert consultation. RESULTS: If the projected treatment gap was to be addressed, an estimated additional 111,154 (50,031) women would be accessing treatment in 2015 (2024). Estimated total costs (including cost offsets) in the scenario of projected provision under current government plans would be £73.5 million in 2015 and £95.2 million in 2024, whilst quality-adjusted life years gained would be 901 and 928 respectively. Addressing the treatment gap through provision by trained midwives and health visitors could mean additional costs of £7.3 million in 2015 but lower costs of £18.4 million in 2024. The additional quality-adjusted life years gained are estimated at 2096 in 2015 and 1418 in 2024. A scenario in which the treatment gap would be met by primary mental health services was likely to be more costly and delivered less health gains. CONCLUSIONS: Findings from this modelling study suggest that scaling the integration of mental health care into routinely delivered care for women during the perinatal period might be economically viable. REGISTRATION: N/A. TWEETABLE ABSTRACT: Integrating mental health into maternal and child healthcare might generate economic benefits new study by @a_annettemaria and @knappem @CPEC_LSE finds #increasing access to treatment for women with perinatal mental health problems.

Societal costs of untreated perinatal mood and anxiety disorders in Vermont.

PURPOSE: To estimate the societal costs of untreated perinatal mood and anxiety disorders (PMADs) in Vermont for the 2018-2020 average annual birth cohort from conception through five years postpartum. METHODS: We developed a cost analysis model to calculate the excess cases of outcomes attributed to PMADs in the state of Vermont. Then, we modeled the associated costs of each outcome incurred by birthing parents and their children, projected five years for birthing parents who do not achieve remission by the end of the first year postpartum. RESULTS: We estimated that the total societal cost of untreated PMADs in Vermont could reach $48 million for an annual birth cohort from conception to five years postpartum, amounting to $35,910 in excess societal costs per birthing parent with an untreated PMAD and their child. CONCLUSION: Our model provides evidence of the high costs of untreated PMADs for birthing parents and their children in Vermont. Our estimates for Vermont are slightly higher but comparable to national estimates, which are $35,500 per birthing parent-child pair, adjusted to 2021 US dollars. Investing in perinatal mental health prevention and treatment could improve health outcomes and reduce economic burden of PMADs on individuals, families, employers, and the state.

Direct costs of prematurity and factors associated with birth and maternal conditions / Custos diretos da prematuridade e fatores associados ao nascimento e condições maternas

ABSTRACT OBJECTIVE To estimate the direct costs due to hospital care for extremely, moderate, and late preterm newborns, from the perspective of a public hospital in 2018. The second objective was to investigate whether factors associated with birth and maternal conditions explain the costs and length of hospital stay. METHODS This is a cost-of-illness study, with data extracted from hospital admission authorization forms and medical records of a large public hospital in the Federal District, Brazil. The association of characteristics of preterm newborns and mothers with costs was estimated by linear regression with gamma distribution. In the analysis, the calculation of the parameters of the estimates (B), with a confidence interval of 95% (95%CI), was adopted. The uncertainty parameters were estimated by the 95% confidence interval and standard error using the Bootstrapping method, with 1,000 samples. Deterministic sensitivity analysis was performed, considering lower and upper limits of 95%CI in the variation of each cost component. RESULTS A total of 147 preterm newborns were included. We verified an average cost of BRL 1,120 for late preterm infants, BRL 6,688 for moderate preterm infants, and BRL 17,395 for extremely preterm infants. We also observed that factors associated with the cost were gestational age (B = -123.00; 95%CI: -241.60 to -4.50); hospitalization in neonatal ICU (B = 6,932.70; 95%CI: 5,309.40-8,556.00), and number of prenatal consultations (B = -227.70; 95%CI: -403.30 to -52.00). CONCLUSIONS We found a considerable direct cost resulting from the care of preterm newborns. Extreme prematurity showed a cost 15.5 times higher than late prematurity. We also verified that a greater number of prenatal consultations and gestational age were associated with a reduction in the costs of prematurity.

RESUMO OBJETIVOS Estimar os custos diretos advindos com a assistência hospitalar a recém-nascidos prematuros extremos, moderados e tardios, sob a perspectiva de um hospital público em 2018. O segundo objetivo foi investigar se fatores associados ao nascimento e às condições maternas explicam os custos e o tempo de permanência hospitalar. MÉTODOS Estudo de custo da doença, com extração de dados a partir das autorizações de internação hospitalares e prontuários de um hospital público de grande porte do Distrito Federal. Estimou-se a associação de características dos recém-nascidos prematuros e das genitoras nos custos por meio de regressão linear com distribuição gamma. Na análise, adotou-se o cálculo dos parâmetros das estimativas (B), com intervalo de confiança de 95% (IC95%). Os parâmetros de incerteza foram estimados pelo intervalo de confiança de 95% e erro padrão por meio do método de Bootstrapping, com 1.000 amostragens. Realizou-se análise de sensibilidade determinística, considerando limites inferiores e superiores do IC95% na variação de cada componente de custo. RESULTADOS Foram incluídos 147 recém-nascidos prematuros. Verificamos um custo médio de R$ 1.120 para prematuros tardios, R$ 6.688 para prematuros moderados e R$ 17.395 para prematuros extremos. Verificamos também que os fatores associados ao custo foram idade gestacional (B = -123,00; IC95% -241,60 a -4,50); internação em UTI neonatal (B = 6.932,70; IC95% 5.309,40-8.556,00) e número de consultas pré-natal (B = -227,70; IC95% -403,30 a -52,00). CONCLUSÕES Verificamos um custo direto considerável advindo da assistência a recém-nascidos prematuros. A prematuridade extrema demonstrou um custo 15,5 vezes maior comparado à tardia. Verificamos ainda que uma maior quantidade de consultas pré-natal e a idade gestacional foram associadas a uma redução dos custos da prematuridade.

Social and economic consequences of the cost of obstetric and neonatal care in Lubumbashi, Democratic Republic of Congo: a mixed methods study.

BACKGROUND: The aim of this study was to explore and measure the social and economic consequences of the costs of obstetric and neonatal care in Lubumbashi, the Democratic Republic of Congo. METHODS: We conducted a mixed qualitative and quantitative study in the maternity departments of health facilities in Lubumbashi. The qualitative results were based on a case study conducted in 2018 that included 14 respondents (8 mothers of newborns, 2 accompanying family members and 4 health care providers). A quantitative cross-sectional analytical study was carried out in 2019 with 411 women who gave birth at 10 referral hospitals. Data were collected for one month at each hospital, and selected mothers of newborns were included in the study only if they paid out-of-pocket and at the point of care for costs related to obstetric and neonatal care. RESULTS: Costs for obstetric and neonatal care averaged US $77, US $207 and US $338 for simple, complicated vaginal and caesarean deliveries, respectively. These health expenditures were greater than or equal to 40% of the ability to pay for 58.4% of households. At the time of delivery, 14.1% of women giving birth did not have enough money to pay for care. Of those who did, 76.5% spent their savings. When households did not pay for care, mothers and their babies were held for a long time at the place of care. This resulted in the prolonged absence of the mother from the household, reduced household income, family conflicts, and the abandonment of the home by the spouse. At the health facility level, the increase in length of stay did not generate any additional financial benefits. Mothers no longer had confidence in nurses; they were sometimes separated from their babies, and they could not access certain prescribed medications or treatments. CONCLUSION: The government of the DRC should implement a mechanism for subsidizing care and associate it with a cost-sharing system. This would place the country on the path to achieving universal health coverage in improving the physical, mental and social health of mothers, their babies and their households.

Early impact of the implementation of Medicaid episode-based payment reforms in Arkansas.

OBJECTIVE: To evaluate episode-based payments for upper respiratory tract infections (URI) and perinatal care in Arkansas's Medicaid population. STUDY SETTING: Upper respiratory infection and perinatal episodes among Medicaid-covered individuals in Arkansas and comparison states from fiscal year (FY) 2011 to 2014. STUDY DESIGN: Cross-sectional observational analysis using a difference-in-difference design to examine outcomes associated with URI and perinatal episodes of care (EOC) from 2011 to 2014. Key dependent variables include antibiotic use, emergency department visits, physician visits, hospitalizations, readmission, and preventive screenings. DATA COLLECTION: Claims data from the Medicaid Analytic Extract for Arkansas, Mississippi, and Missouri from 2010 to 2014 with supplemental county-level data from the Area Health Resource File (AHRF). PRINCIPAL FINDINGS: The URI EOC reduced the probability of antibiotic use (marginal effect [ME] = -1.8, 90% CI: -2.2, -1.4), physician visits (ME = 0.6, 90% CI: -0.8, -0.4), improved the probability of strep tests for children diagnosed with pharyngitis (ME = 9.4, 90% CI: 8.5, 10.3), but also increased the probability of an emergency department (ED) visit (ME = 0.1, 90% CI: 0.1, 0.2), relative to the comparison group. For perinatal EOCs, we found a reduced probability of an ED visit during pregnancy (ME = 0.1, 90% CI: -0.2, -0.0), an increased probability of screening for HIV (ME = 6.2, 90% CI: 4.0, 8.5), chlamydia (ME = 9.5, 90% CI: 7.2, 11.8), and group B strep-test (ME = 2.6, 90% CI: 0.5, 4.6), relative to the comparison group. Predelivery and postpartum hospitalizations also increased (ME = 1.2, 90% CI: 0.4, 2.0; ME = 0.4, 90% CI: 0.0, 0.8, respectively), relative to the comparison group. CONCLUSION: Upper respiratory infection and perinatal EOCs for Arkansas Medicaid beneficiaries produced mixed results. Aligning shared savings with quality metrics and cost-thresholds may help achieve quality targets and disincentivize over utilization within the EOC, but may also have unintended consequences.

Optimizing PMTCT efforts by repeat HIV testing during antenatal and perinatal care in resource-limited settings: A longitudinal assessment of HIV seroconversion.

BACKGROUND: Mother to child transmission (MTCT) of HIV remains a challenge in resource-limited settings. Central to elimination of MTCT is effective Provider Initiated HIV Counseling and Testing (PICT). Research has shown that conducting PICT only at the initial antenatal care (ANC) visit fails to benefit pregnant women who seroconvert later in their pregnancy. This study aimed to determine the most cost effective time to perform repeat HIV testing during ANC and perinatal care (PNC). METHODS: We studied the repeat HIV testing results of pregnant women ≥ 18 and adolescent girls aged 15-17 in the Sauri, Kenya Millennium Villages Project (MVP) site. Nurses provided HIV screening to 1,403 expectant women and 256 adolescent girls following the 1st, 2nd, 3rd and 4th ANC visits, at birth and 6 and 14 weeks postpartum. RESULTS: Five women seroconverted during the study period (incidence proportion 0.41%). One woman seroconverted at the 2nd ANC visit, another one at the 3rd, two at the 4th and one at 6 weeks post-partum. Of all the women who seroconverted, four reported an HIV negative primary partner, while one reported an unknown partner status. None of the participants reported condom use during pregnancy. Two of the seroconverters vertically transmitted HIV to their babies. The results did not suggest a clear pattern of seroconversion during ANC and PNC. CONCLUSIONS: The low rates of seroconversion suggest that testing pregnant women multiple times during ANC and PNC may not be cost effective, but a follow-up test during birth may be protective of the newborn.

Racial and Ethnic Disparities in Perinatal Insurance Coverage.

OBJECTIVE: To measure the association between race-ethnicity and insurance status at preconception, delivery, and postpartum and the frequency of insurance gaps and transitions (disruptions) across these time points. METHODS: We conducted a cross-sectional analysis of survey data from 107,921 women in 40 states participating in the Centers for Disease Control and Prevention's Pregnancy Risk Assessment and Monitoring System from 2015 to 2017. We calculated unadjusted estimates of insurance status at preconception, delivery, and postpartum and continuity across these time points for seven racial-ethnic categories (white non-Hispanic, black non-Hispanic, indigenous, Asian or Pacific Islander, Hispanic Spanish-speaking, Hispanic English-speaking, and mixed race or other). We also examined unadjusted estimates of uninsurance at each perinatal time period by state of residence. We calculated adjusted differences in the predicted probability of uninsurance at preconception, delivery, and postpartum using logistic regression models with interaction terms for race-ethnicity and income. RESULTS: For each perinatal time point, all categories of racial-ethnic minority women experienced higher rates of uninsurance than white non-Hispanic women. From preconception to postpartum, 75.3% (95% CI 74.7-75.8) of white non-Hispanic women had continuous insurance compared with 55.4% of black non-Hispanic women (95% CI 54.2-56.6), 49.9% of indigenous women (95% CI 46.8-53.0) and 20.5% of Hispanic Spanish-speaking women (95% CI 18.9-22.2). In adjusted models, lower-income Hispanic women and indigenous women had a significantly higher predicted probability of uninsurance in the preconception and postpartum period compared with white non-Hispanic women. CONCLUSION: Disruptions in perinatal insurance coverage disproportionately affect indigenous, Hispanic, and black non-Hispanic women. Differential insurance coverage may have important implications for racial-ethnic disparities in access to perinatal care and maternal-infant health.

Estimating the Financial Impact of Reducing Primary Cesareans.

INTRODUCTION: Preventing a primary cesarean birth in nulliparous women with term, singleton, vertex pregnancies (NTSV) is recognized as an important strategy to reduce maternal morbidities and risks to the newborn. Multiple professional organizations are supporting approaches to safely reduce NTSV cesarean rates, including the American College of Obstetricians and Gynecologists; the Society for Maternal-Fetal Medicine; and the Association of Women's Health, Obstetric and Neonatal Nurses. The American College of Nurse-Midwives (ACNM) is leading one such effort as part of its Healthy Birth Initiative: the Reducing Primary Cesareans (RPC) Learning Collaborative. The objective of this study is to estimate the cost savings of a decrease in NTSV cesareans at one hospital participating in the RPC Learning Collaborative. METHODS: All women giving birth at Baystate Medical Center from October 1, 2016, to March 31, 2017, and their newborns were identified by Medicare Severity Diagnosis Related Group (N = 1747). Total hospital costs were calculated using a resource consumption profile for each of 6 groups: women who had vaginal birth, primary cesarean, and repeat cesarean and their linked newborns. A model was developed to estimate cost differences for the first and second births and overall cost savings. RESULTS: For the NTSV birth, total costs for primary cesarean and newborn care were $5989 higher compared with vaginal birth and newborn care. For the subsequent birth, repeat cesareans and newborn care were $4250 higher compared with vaginal birth. In 2016, 69 primary cesareans were prevented, for an actual cost savings of $413,241. Projecting the prevention of 66 subsequent repeat cesareans would result in additional savings of $280,500, for a total savings of $693,741. Apgar score at 5 minutes and length of stay remained unchanged. DISCUSSION: Participation in ACNM's RPC Learning Collaborative led to significant savings in hospital costs during the first year without affecting quality metrics. This cost comparison model could be replicated by other hospitals involved in cesarean reduction endeavors.

Implementation of an international standardized set of outcome indicators in pregnancy and childbirth in Kenya: Utilizing mobile technology to collect patient-reported outcomes.

BACKGROUND: Limited data exist on health outcomes during pregnancy and childbirth in low- and middle-income countries. This is a pilot of an innovative data collection tool using mobile technology to collect patient-reported outcome measures (PROMs) selected from the International Consortium of Health Outcomes Measurement (ICHOM) Pregnancy and Childbirth Standard Set in Nairobi, Kenya. METHODS: Pregnant women in the third trimester were recruited at three primary care facilities in Nairobi and followed prospectively throughout delivery and until six weeks postpartum. PROMs were collected via mobile surveys at three antenatal and two postnatal time points. Outcomes included incontinence, dyspareunia, mental health, breastfeeding and satisfaction with care. Hospitals reported morbidity and mortality. Descriptive statistics on maternal and child outcomes, survey completion and follow-up rates were calculated. RESULTS: In six months, 204 women were recruited: 50% of women returned for a second ante-natal care visit, 50% delivered at referral hospitals and 51% completed the postnatal visit. The completion rates for the five PROM surveys were highest at the first antenatal care visit (92%) and lowest in the postnatal care visit (38%). Data on depression, dyspareunia, fecal and urinary incontinence were successfully collected during the antenatal and postnatal period. At six weeks postpartum, 86% of women breastfeed exclusively. Most women that completed the survey were very satisfied with antenatal care (66%), delivery care (51%), and post-natal care (60%). CONCLUSION: We have demonstrated that it is feasible to use mobile technology to follow women throughout pregnancy, track their attendance to pre-natal and post-natal care visits and obtain data on PROM. This study demonstrates the potential of mobile technology to collect PROM in a low-resource setting. The data provide insight into the quality of maternal care services provided and will be used to identify and address gaps in access and provision of high quality care to pregnant women.

Are stage-based health information messages effective and good value for money in improving maternal newborn and child health outcomes in India? Protocol for an individually randomized controlled trial.

BACKGROUND: Evidence is limited on the effectiveness of mobile health programs which provide stage-based health information messages to pregnant and postpartum women. Kilkari is an outbound service that delivers weekly, stage-based audio messages about pregnancy, childbirth, and childcare directly to families in 13 states across India on their mobile phones. In this protocol we outline methods for measuring the effectiveness and cost-effectiveness of Kilkari. METHODS: The study is an individually randomized controlled trial (iRCT) with a parallel, partially concurrent, and unblinded design. Five thousand pregnant women will be enrolled from four districts of Madhya Pradesh and randomized to an intervention or control arm. The women in the intervention arm will receive Kilkari messages while the control group will not receive any Kilkari messages as part of the study. Women in both arms will be followed from enrollment in the second and early third trimesters of pregnancy until one year after delivery. Differences in primary outcomes across study arms including early and exclusive breastfeeding and the adoption of modern contraception at 1 year postpartum will be assessed using intention to treat methodology. Surveys will be administered at baseline and endline containing modules on phone ownership, geographical and demographic characteristics, knowledge, practices, respectful maternity care, and coverage for antenatal care, delivery, and postnatal care. In-depth interviews and focus group discussions will be carried out to understand user perceptions of Kilkari, and more broadly, experiences providing phone numbers and personal health information to health care providers. Costs and consequences will be estimated from a societal perspective for the 2018-2019 analytic time horizon. DISCUSSION: Kilkari is the largest maternal messaging program, in terms of absolute numbers, currently being implemented globally. Evaluations of similar initiatives elsewhere have been small in scale and focused on summative outcomes, presenting limited evidence on individual exposure to content. Drawing upon system-generated data, we explore linkages between successful receipt of calls, user engagement with calls, and reported outcomes. This is the first study of its kind in India and is anticipated to provide the most robust and comprehensive evidence to date on maternal messaging programs globally. TRIAL REGISTRATION: Clinicaltrials.gov, 90075552, NCT03576157 . Registered on 22 June 2018.

An exploratory cost-effectiveness analysis: Comparison between a midwife-led birth unit and a standard obstetric unit within the same hospital in Belgium.

OBJECTIVE: The objective of this study was to compare midwife-led and consultant-led obstetrical care for women with uncomplicated low-risk pregnancies. We estimated costs and maternal outcomes in both units to achieve a cost-effectiveness ratio. DESIGN: The cost-analysis was made according to the "intention to treat" concept in order to minimize bias associated with the non-randomization of participants. At the obstetric-led unit, women received care from both midwives and medical staff while those in the alternative structure called 'Le Cocon' only received care from midwives. SETTING: The obstetric-led unit of the Erasme University-Hospital in Brussels and its alongside midwife-led unit. PARTICIPANTS: The study population included all low-risk pregnant women from 1 March 2014 until 31 October 2015 who were affiliated to the MLOZ (Mutualités Libres-Onafhankelijke Ziekenfondsen; third Belgian statutory health care insurer). INTERVENTIONS: The cost calculation involved a bottom-up approach. The health care consumption of each participant was obtained from MLOZ's data. The study included costs occurred the beginning of pregnancy until 3 months post-partum. Clinical data were extracted from the patient medical records. FINDINGS: Compared to the traditional obstetric-led unit, the alternative midwife-led unit was associated with a cost reduction for the national payer (∆ = -€397.39, p = 0.046) and for the patient (∆ = - €44.19, p = 0.016). There were no significant differences in rates of caesarean, instrumental birth and epidural analgesia between MLU and OLU. A sensitivity analysis was performed (Appendix C) but does not change the overall results and conclusions. KEY CONCLUSIONS: Due to the small size of the samples, no statistical differences were found. More analysis is needed to evaluate the cost-effectiveness regarding the use of epidural analgesia, caesarean and instrumental birth rates in the midwife-led unit. IMPLICATIONS FOR PRACTICE: Given the economical findings, this could contribute to reduce health expenditures for both women (out of pocket) and state (public payer via health care insurers).

A cost-effectiveness analysis of maternal and neonatal health interventions in Ethiopia.

Ethiopia is one of the sub-Saharan African countries contributing to the highest number of maternal and neonatal deaths. Coverage of maternal and neonatal health (MNH) interventions has remained very low in Ethiopia. We examined the cost-effectiveness of selected MNH interventions in an Ethiopian setting. We analysed 13 case management and preventive MNH interventions. For all interventions, we used an ingredients-based approach for cost estimation. We employed a static life table model to estimate the health impact of a 20% increase in intervention coverage relative to the baseline. We used disability-adjusted life years (DALYs) as the health outcome measure while costs were expressed in 2018 US$. Analyses were based on local epidemiological, demographic and cost data when available. Our finding shows that 12 out of the 13 interventions included in our analysis were highly cost-effective. Interventions targeting newborns such as neonatal resuscitation (institutional), kangaroo mother care and management of newborn sepsis with injectable antibiotics were the most cost-effective interventions with incremental cost-effectiveness ratios of US$7, US$8 and US$17 per DALY averted, respectively. Obstetric interventions (induction of labour, active management of third stage of labour, management of pre-eclampsia/eclampsia and maternal sepsis, syphilis treatment and tetanus toxoid during pregnancy) and safe abortion cost between US$100 and US$300 per DALY averted. Calcium supplementation for pre-eclampsia and eclampsia prevention was the least cost-effective, with a cost per DALY of about US$3100. Many of the MNH interventions analysed were highly cost-effective, and this evidence can inform the ongoing essential health services package revision in Ethiopia. Our analysis also shows that calcium supplementation does not appear to be cost-effective in our setting.

Conditional cash transfers to retain rural Kenyan women in the continuum of care during pregnancy, birth and the postnatal period: protocol for a cluster randomized controlled trial.

BACKGROUND: Antenatal care (ANC), facility delivery and postnatal care (PNC) are proven to reduce maternal and child mortality and morbidity in high-burden settings. However, few pregnant rural women use these services sufficiently. This study aims to assess the impact, cost-effectiveness and scalability of conditional cash transfers to promote increased contact between pregnant women or women who have recently given birth and the formal healthcare system in Kenya. METHODS: The intervention tested is a conditional cash transfer to women for ANC health visits, a facility birth and PNC visits until their newborn baby reaches 1 year of age. The study is a cluster randomized controlled trial in Siaya County, Kenya. The trial clusters are 48 randomly selected public primary health facilities, 24 of which are in the intervention arm of the study and 24 in the control arm. The unit of randomization is the health facility. A target sample of 7200 study participants comprises pregnant women identified and recruited at their first ANC visit over a 12-month recruitment period and their subsequent newborns. All pregnant women attending one of the selected trial facilities for their first ANC visit during the recruitment period are eligible for the trial and invited to participate. Enrolled mothers are followed up at all health visits during their pregnancy, at facility delivery and for a number of visits after delivery. They are also contacted at three additional time points after enrolling in the study: 5-10days after enrolment, 6 months after the expected delivery date and 12 27 months after birth. If they have not delivered in a facility, there is an additional follow-up 2 wees after the expected due date. The impact of the conditional cash transfers on maternal healthcare services and utilization will be measured by the trial's primary outcomes: the proportion of all eligible ANC visits made during pregnancy, delivery at a health facility, the proportion of all eligible PNC visits attended, the proportion of referrals attended during the pregnancy and the postnatal period, and the proportion of eligible child immunization appointments attended. Secondary outcomes include; health screening and infection control, live birth, maternal and child survival 48 h after delivery, exclusive breastfeeding, post-partum contraceptive use and maternal and newborn morbidity. Data sources for the measurement of outcomes include routine health records, an electronic card-reader system and telephone surveys and focus group discussions. A full economic evaluation will be conducted to assess the cost of delivery and cost effectiveness of the intervention and the benefit incidence and equity impact of trial activities and outcomes. DISCUSSION: This trial will contribute to evidence on the effectiveness and cost-effectiveness of conditional cash transfers in facilitating health visits and promoting maternal and child health in rural Kenya and in other comparable contexts. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03021070 . Registered on 13 January 2017.

Client satisfaction with existing labor and delivery care and associated factors among mothers who gave birth in university of Gondar teaching hospital; Northwest Ethiopia: Institution based cross-sectional study.

BACKGROUND: There are many reasons for mothers not receiving modern obstetric care, being dissatisfied by health care deliveries is one of the major factors. There are limited studies about maternal satisfaction with labor and delivery care services in Ethiopia and particularly in the study area. Therefore, the aim of this study was to better understand client satisfaction on existing labor and delivery care service and associated factors among mothers who gave birth in the University of Gondar Teaching Hospital, Ethiopia. METHODS: This institution based cross-sectional study was conducted at the University of Gondar Referral Hospital. 593 mothers who gave birth between July and September 2016 were enrolled. Study participants were selected by systematic random sampling. A standardized, interviewer-administered questionnaire was used to collect data. Descriptive and summary statistics were performed. A linear regression model was fitted and variables having a P value of ≤0.05 in the multivariable model were considered statistically significant. RESULT: Overall, 31.3% of mothers were satisfied by the existing labor and delivery care. Living in rural areas (-2.9%; 95% CI: -5.75,-0.12) and the presence of a co-morbidity (-3.2%; 95%CI:-5.70, -0.72) were the factor which have a negative influence on maternal satisfaction. On the other hand, travel time to reach to the hospital (hours) (0.79%; 95% CI: 0.07, 1.52), birth by episiotomy or assisted vaginal delivery (6.3%; 95%CI: 1.56, 11.04), and receiving cost-free maternal health services (6.66%; 95%CI: 3.31, 10.01) were the factors that had positive influence. CONCLUSION: The level of satisfaction of laboring mothers with the labor and delivery care services was poor. Rural residency and chronic medical co-morbidity were negatively associated with level of satisfaction while travel time, mode of delivery, and payment free delivery service had a statistically significant positive influence on satisfaction.

The impact of a history of poor mental health on health care costs in the perinatal period.

The perinatal period is a critical time for mental health and is also associated with high health care expenditure. Our previous work has identified a history of poor mental health as the strongest predictor of poor perinatal mental health. This study aims to examine the impact of a history of poor mental health on health care costs during the perinatal period. Data from the 1973-1978 cohort of the Australian Longitudinal Study on Women's Health (ALSWH) were linked with a number of administrative datasets including the NSW Admitted Patient Data Collection and Perinatal Data Collection, the Medicare Benefits Scheme and the Pharmaceuticals Benefits Scheme between 2002 and 2011. Even when taking birth type and private health insurance status into account, a history of poor mental health resulted in an average increase of over 11% per birth across the perinatal period. These findings indicate that an investment in prevention and early treatment of poor mental health prior to child bearing may result in a cost saving in the perinatal period and a reduction of the incidence of women experiencing poor perinatal mental health.

Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California, 2009-2011.

OBJECTIVE: To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight. STUDY DESIGN: We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean diagnosis related group-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1 265 212. RESULTS: The mean maternal costs for all in-hospital deliveries was $8204, increasing to $13 154 for late preterm (32-36 weeks) and $22 702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6389: $2433 for term infants, $22 102 for late preterm, $223 931 for very preterm infants, and $317 982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants, these shares were 1.0% and 36.5%, and 0.4% and 20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization. CONCLUSIONS: Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs and these costs have increased over time.

Implementation of a labour companionship model in three public hospitals in Arab middle-income countries.

AIM: To assess the feasibility, acceptability, effectiveness and cost of the integration of a tailored labour companionship model in three public hospitals in Egypt, Lebanon and Syria. METHODS: Phased implementation research using mixed methods. Implementation strategies consisted of steering committees in hospitals, seminars for healthcare providers, information, education and communication materials, and adjustments in labour rooms. The labour companionship model consisted of (i) identification of a female relative as labour companion by women; (ii) provision of information, education and communication materials to women and companions; and (iii) allowing companions to accompany women throughout the first stage of labour. Semi-structured interviews with women, labour companions and healthcare providers were used to assess feasibility and acceptability of the model. Effectiveness was assessed through structured interviews with women, information abstracted from medical records and cost data. The comparison was made between the pre-implementation and the implementation phases. RESULTS: This model was found to be feasible, acceptable, effective and cost-beneficial. Women's satisfaction and perception of control improved and caesarean section rates were reduced significantly. CONCLUSION: This model can be adopted for these countries and elsewhere with comparable health systems. It enhances the quality of care and the provision of equitable and respectful maternity services.

The Indigenous Birthing in an Urban Setting study: the IBUS study : A prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland, Australia.

BACKGROUND: With persisting maternal and infant health disparities, new models of maternity care are needed to meet the needs of Aboriginal and Torres Strait Islander people in Australia. To date, there is limited evidence of successful and sustainable programs. Birthing on Country is a term used to describe an emerging evidence-based and community-led model of maternity care for Indigenous families; its impact requires evaluation. METHODS: Mixed-methods prospective birth cohort study comparing different models of care for women having Aboriginal and Torres Strait Islander babies at two major maternity hospitals in urban South East Queensland (2015-2019). Includes women's surveys (approximately 20 weeks gestation, 36 weeks gestation, two and six months postnatal) and infant assessments (six months postnatal), clinical outcomes and cost comparison, and qualitative interviews with women and staff. DISCUSSION: This study aims to evaluate the feasibility, acceptability, sustainability, clinical and cost-effectiveness of a Birthing on Country model of care for Aboriginal and Torres Strait Islander families in an urban setting. If successful, findings will inform implementation of the model with similar communities. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry # ACTRN12618001365257 . Registered 14 August 2018 (retrospectively registered).