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

Abstract

Introduction: Critical evaluation of the cost-effectiveness and clinical effectiveness of midwifery continuity models for women experiencing complex pregnancy is an important consideration in the review and reform of maternity services. Most studies either focus on women who experience healthy pregnancy or mixed risk samples. These results may not be generalised across the childbearing continuum to women with complexities. This review critically evaluates studies that measure the cost of care for women with complicated pregnancy, with a focus on method and quality.

Aim: To critically appraise and summarise the evidence relating to the combined cost-effectiveness, resource use and clinical effectiveness of midwifery continuity models for women who experience complex pregnancy and their babies in developed countries.

Method: A structured review using Medline, CINAHL, MIDIRS, DARE, EMBASE, OVID, PubMed, ProQuest, Informit, Science Direct, Cochrane Library, NHS Economic Evaluation Database (NHSEED) was undertaken 1994-2017.

Key Findings: Eight major themes were identified from the review: (1) cost and clinical effectiveness comparisons between midwife-led versus obstetric-led units; (2) economic effect of different modes of birth; (3) economic implications of place of birth; (4) cost of caseload midwifery and/or Team Midwifery compared to Standard Care; (5) cost-effectiveness of midwifery models for Australian Aboriginal women; (6) patterns of antenatal care for women of low obstetric risk and comparative provider cost; (7) cost of postnatal care midwifery models; (8) between-country and within-country cost-modelling for route of birth, interventions, and group prenatal care. Studies did not address cost-effectiveness across the continuum of antenatal, intrapartum and postpartum care for women with complexities, nor enable integrated analysis of clinical effectiveness and resource use among maternity models, including midwifery models.

Implications for practice and Policy: Studies that measure cost of care for women with complex pregnancy across the childbearing continuum are limited and apply inconsistent methods. The implementation of continuity of midwifery care is an important issue for women with pregnancy complications, clinicians and decision-makers. Robust cost-effectiveness evidence is essential to address current health inequities and sustainable systems change in maternity services.