Table 5 Primary Articles Revieweda Study results
| Study | Major Cost Findings | Health Outcomes | Strengths / Limitations |
|---|---|---|---|
| 1. Gao, Y. et al. (2014) |
Cost saving AUS $ 703 / mother-infant episode for MGP cohort was not statistically significant (p=0.566) MGP (midwifery model): ↓birth cost -$ 411, p=0.049 ↓SCN cost – $ 1 767, p=0.144 ↑ AN cost + $ 272, p<0.001 ↑PN cost + $ 277, p<0.001 ↑infant readmission costs + $ 476, p=0.05 ↑travel cost = $ 115, p=0.001 |
Time horizon: Midwife cohort – all Aboriginal mothers who gave birth between Sept 2009 - June 2011 (and their infants) Baseline cohort – all Aboriginal mothers who gave birth between Jan 2004 – Dec 2006 (and their infants) Women who received midwife model had more antenatal care, more ultrasounds, were more likely to be admitted to hospital in antenatal period, had equivalent birth outcomes (i.e. mode of birth; pre-term birth; low birth weight) compared with baseline cohort. Babies in midwife model admitted to Special Care Nursery had significantly reduced length of stay |
Mixed risk; small sample Cost assumptions used for economic analysis – expert opinion not primary data Missing data (3.7% – 24.5%); 51% all cases = missing data; Time trend confounding; Hostel costs & transport costs not included |
| 2. Tracy, S.K. et al. (2013). | Median cost saving of $ 566 AUS / woman with Caseload / named midwife |
Time horizon: Dec 2008 – May 2011 Birth interventions reduced in midwifery model 30% > spontaneous onset of labor; ↓ analgesia; ↓elective caesarean; No significant difference for overall rate of caesarean between groups. Similar safe outcomes for mothers and babies between groups |
Registered Trial: ACTRN12609000349246 All pregnancy risk status No stratification of risk profile Defined eligibility, inclusion/exclusion criteria Study sufficiently powered (80%) and Type 1 error 5% Sample bias challenged external validity Cross-overs – did not receive assigned model of care Non-masking of group allocation from clinicians |
| 3. Jan S. et al. (2004). |
Net cost estimate AUS$1, 200 per client – calculated by subtracting cost savings to other centers Daruk Antenatal service saw 245 women for 339 pregnancies during study |
Time horizon: Women birthing between Oct 1990 – Dec 1996 No significant difference in service birth weights or perinatal survival Daruk Antenatal care = Gestational age @ 1’st visit lower; mean number AN visits higher; attendance for AN tests better Women strongly positive toward midwife model for relationship, trust, accessibility, flexibility, information, empowerment and family-centered care |
Mixed risk pregnancy Evaluation framework, both quant and qual methods Focused on antenatal care attendance and access; costs were broader than used in conventional economic analyses - included birth outcomes and antenatal attendance in a subsequent pregnancy Assumptions in sensitivity analyses / estimated downstream health costs |
| 4. Homer C.S. et al. (2001). |
Mean cost/woman: CMWC A$2 579 vs SHC A$3 483 Excluding neonatal costs: CMWC A$1 504 (1449–1559; 95%CI) v SHC A$1 643 (1563–1729 95%CI) Mean cost saving 9 areas SHC – CMCW: Antenatal +28.84 Day Assessment Unit -5.42 Antenatal inpatient +38.74 On-call cost -21.81 Labour / birth +68.83 Hospital Postnatal care 43.85 Domiciliary care -11.06 Special Care Nursery +2801.28 Total/woman +904.09 |
Time horizon: 1997 – 1998 (not specific) Caesarean rate: CMWM 13.3% vs SHC 17.8% (OR . 0.6, 95% CI 0.4±0.9, P = 0.02) No other significant differences were detected among women or babies for clinical outcomes or events during labour and birth between care models |
Cost analysis alongside RCT; 10 000 bootstrap replications Mixed risk sample; Costs included resource use, clinician travel, neonate care; No equipment, capital or program development costs; No transfer rates; Caseload/midwife key to cost saving; Not possible to determine optimal caseload numbers; unclear if data analyzed by intention to treat |
| 5. Rowley, M.J. et al. (1995). |
Mean cost ↓4.5% per birth: Team MW v Routine care A $3 324 vs A $3 475 |
Time horizon: May 1991 – June 1992 Included first AN visit to 6 weeks after birth Team MW women: higher AN class attendance OR 1.73; 95% CI:1.23-2.42 ↓ birth interventions 36% vs 24% OR; 1.73 (1.28 – 2.34); p<0.001 ↓ pethidine use 0.32 (0.22 – 0.46) ↓ newborn resuscitation 0.59 (0.41 – 0.86) Maternal satisfaction with team care was greater on 3 elements: information giving; participation in decision-making, and relationships with caregivers. Less cost than routine care and fewer adverse maternal and neonatal outcomes |
Cost study alongside RCT Included women of all pregnancy risk status Model was team midwifery care, not caseload continuity Costs based only on DRGs; i.e. top – down cost only / not detailed. Unable to compare with other economic evaluations |
| 6. Kenny, P. et al. (1994). |
Team Midwifery vs Standard Care: Avg costs AN cost/woman High risk $ 427 vs $ 456 Low risk $ 135 vs $ 133 Average additional cost per birth / woman $ 4.21 vs $ 9.36 PN cost/woman: Hospital stay $ 356.64 vs $ 397.26 (earlier discharge) Domiciliary $45.45 vs $45.80 |
Time horizon: Sept 1992 – July 1993 Significant differences: manipulative vaginal birth, episiotomy & perineal tears. Women in team midwife care reported higher levels of satisfaction over 3 periods of antenatal, birth and postnatal care with information, communication and midwife attitude and skill |
RCT Level 1 evidence; All risk pregnancy included; Discrete costs: AN, birth and PN Robust, bottom-up costing; Team midwife model, not caseload; Low risk of bias, although blinding not stated; Loss to follow up - 19 in TM vs 22 in SHC |