Management of Care for Low-Risk Pregnancies By Midwives Vs. Obstetricians: A Decision Analysis
Published in 40th Annual North American Meeting of the Society for Medical Decision Making, 2018
Purpose
Childbirth is the most common and most costly reason for hospitalization in the US. Low-risk pregnant women who are cared for by midwives have similar birth outcomes as women cared for by physicians, while experiencing fewer unnecessary medical procedures and lower rates of preterm birth. We compared the costs and resource utilization of midwife-led care for low-risk pregnancies vs. obstetrician-led care using a decision-analytic approach.
Methods
We developed a decision-analytic model of the potential costs and use of medical procedures during childbirth (epidural analgesia, labor induction, cesarean delivery, episiotomy, etc.) as well as outcomes of care (preterm birth) that may differ with midwife-led vs. obstetrician-led care. Specifically, we compared two different strategies of care for low-risk pregnancies: 1) obstetrician-led care (usual care), and 2) midwife-led. To incorporate the difference in the probability of medical procedure use and preterm birth in both models of care, we used multivariate logistic and multinomial logistic regressions using midwife-led care as the main predictor. Data were obtained from the Listening to Mothers III (LTM 3) survey, a nationally-representative sample of women who gave birth to a singleton infant in a U.S. hospital between July 1, 2011 and June 30, 2012 (N=2,400). Costs were considered separately for Medicaid and private insurance plans. To quantify the uncertainty of the model’s results to specific parameters’ uncertainty, we conducted a probabilistic sensitivity analysis.
Results
Births to low-risk women who were cared for by midwives during pregnancy cost, $26,217, on average, $2,262 less than births to low-risk women cared for by obstetricians (Figure). These cost differences derive from lower measured rates of preterm birth and episiotomy among women with midwife-led care, compared with obstetrician-led care. Across the population of US women with low-risk births each year (approximately 2.6 million), the model predicted substantially fewer preterm births (167,259 vs. 219,427 for midwife-led vs obstetrician-led care) and fewer episiotomies (170,504 vs. 415,686, for midwife-led vs obstetrician-led care).
Conclusions
A shift from obstetrician-led care to midwife-led care for low-risk pregnancies could be cost-saving for public and private payers.