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

ObjectiveWe aimed to compare health outcomes and costs in obstetric-led continuity versus multi-professional non-continuity models of care. DesignObservational study with linked administrative data SettingAustralian public and private maternity care Population867,334 births, coverall all births in three states of Australia between 2016 and 2019 MethodsWe 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 measuresStillbirths or neonatal deaths; neonatal intensive care admissions; APGAR score <7 at 5 minutes; 3rd or 4th degree perineal tears; maternal haemorrhages; mean cost per pregnancy episode. ResultsHigher 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 3rd or 4th 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. ConclusionWe 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. FundingNational Health and Medical Research Council (NHMRC).