The principle of universality and value-based maternity care: a matched population-level study of costs and outcomes for obstetric-led continuity and multiprofessional non continuity models of care
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Objective
We aimed to compare health outcomes and costs in obstetric-led continuity versus multi-professional non-continuity models of care.
Design
Observational study with linked administrative data
Setting
Australian public and private maternity care
Population
867,334 births, coverall all births in three states of Australia between 2016 and 2019
Methods
We analysed outcomes from pregnancy onset to four weeks post-birth in a whole-of-population linked perinatal data asset. Tightly matched cohorts were generated, with bootstrapping of 50 re-matched datasets and sensitivity analyses.
Main outcome measures
Stillbirths or neonatal deaths; neonatal intensive care admissions; APGAR score <7 at 5 minutes; 3 rd or 4 th degree perineal tears; maternal haemorrhages; mean cost per pregnancy episode.
Results
Higher adverse outcomes in the multi-professional non-continuity model compared to the obstetric-led continuity model of care, including 786 more stillbirths or neonatal deaths (OR 2.0, 95% CI: 1.8 – 2.1), 2,780 more APGAR score <7 at 5 minutes (OR 2.0, 95% CI: 2.0 – 2.1), 3,327 more 3 rd or 4 th degree perineal tears (OR 2.9, 95% CI: 2.7 – 3.1) and 10,530 additional maternal haemorrhages (OR 2.7, 95% CI: 2.6 – 2.8). Obesity and mode of birth correlated with neonatal death. Mean cost in AUD per pregnancy episode was $5,888 higher in multi-professional non-continuity model versus obstetric-led continuity, equating to $1.77 billion in extra annual cost to government. Findings persisted across bootstrapping, sensitivity analyses and socioeconomic quintiles.
Conclusion
We have shown significant disparity and inequality in outcomes and costs, challenging universal value-based care, with lower adverse health outcomes and costs in the obstetric-led continuity model.
Funding
National Health and Medical Research Council (NHMRC).
