The principle of universality and value-based maternity care: a population-level matched study of costs and outcomes for private obstetric and public models of care

Background

Public maternity models of care in high income countries are usually multi-professional with non-continuity. Private care usually involves obstetric-led continuity models. The comparative outcomes across these models, is not known. We aimed to compare value across health outcomes and costs of care in public hospital birth/model of care and private hospital birth/ model of care.

Methods

We analysed maternal and neonatal outcomes from pregnancy onset to four weeks post-birth in unique whole-of-population linked perinatal data assets, Maternity2000 (covering three states and 78% of Australian births, n= 867,334, 2016 to 2019) for health outcomes and Maternity1000 (one State, 21% births, n= 148,466, 2016 to 2018) for cost and outcome analyses. Tightly matched cohorts were generated, analysed and reinforced with bootstrapping of 50 re-matched datasets and sensitivity analyses.

Results

Matching generated 184,146 births per model of care. Higher adverse outcomes in the public compared to the private obstetric model of care, including 786 more stillbirths or neonatal deaths (OR 2.0, 95% CI: 1.8 – 2.1), 2,251 more neonatal intensive care admissions (OR 2.9, 95% CI: 2.7 – 3.0), 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 public versus private care ($28,645, 95% CI: 28,417 – 28,874 versus $22,757, 95% CI: 22,624 – 22,890), equating to $1.77 billion in extra annual cost to government if all care was provided in the public model of care. Findings persisted across bootstrapping, sensitivity analyses and socioeconomic quintiles.

Conclusions

Maternity healthcare has been transformational historically in improving outcomes, yet we have shown significant disparity and inequality in outcomes and costs, challenging universal value-based care, with higher adverse health outcomes and costs in the public compared to the private model of care. To identify and address drivers of observed disparities, actions could include an independent inquiry, further research including timely transparent data use.

Key Messages

• More frequent adverse outcomes in the public model of care included stillbirth/ neonatal death; intensive care admission; perineal damage; haemorrhage, versus the private obstetric model of care.

• There were higher costs in the public model of care.

• There is significant inequality across health outcomes and costs in maternity care, contextualised by differences in continuity, provider, mode of birth and setting.