title: Systematic literature review of the costs of pregnancy in the US.
abstract: BACKGROUND
  The cost of pregnancy is increasing over time despite the decline in pregnancy rates.
  
  
  OBJECTIVE
  To fully elucidate and evaluate the cost drivers of pregnancy in the US for payers, a systematic review was conducted to understand the main cost components and primary factors that contribute to the direct costs of pregnancy, pregnancy-related complications and unintended pregnancy among women of childbearing age (15-44 years).
  
  
  METHODS
  We performed electronic searches in the PubMed database from January 2000 to December 2012, and major women's health and pharmacoeconomics conference proceedings from 2011 to 2012.
  
  
  METHODS
  The systematic review is comprised of studies that reported pregnancy, pregnancy-related complications, unplanned pregnancy, and pregnancy-induced monetary costs. The review excluded narrative reports, systematic reviews, model-derived cost of pregnancy papers, non-US-based studies, and reports based solely on expert opinions.
  
  
  METHODS
  Two reviewers independently applied the inclusion criteria and assessed the quality of the data collected. Disagreements between reviewers were resolved by consensus or by arbitration through a third party, with reference to the original sources. We collected information on the study design and outcomes for each included study. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines in designing, performing, and reporting of the systematic review.
  
  
  RESULTS
  We identified 40 studies from electronic and handsearching methods. We classified studies based on the primary research topic focusing on the overall cost of pregnancy (N = 10), cost of pregnancy-related complications (N = 26), cost of unintended pregnancy (N = 2), cost of planned pregnancy (N = 1), or cost of pregnancy by facilities (N = 1). In the quality assessment, randomized, non-randomized, and retrospective database studies had low to moderate risk of bias. We determined primary cost drivers based on the highest cost reported in each study. The identified cost drivers were inpatient care, pregnancy delivery, multiple births, complicated cesarean sections, high-risk pregnancy, preterm birth, low birth weight, complications due to conditions such as hypertension, diabetes, anemia, and cancer, and in vitro fertilization. In 2008, the overall mean cost per hospital stay for pregnancy-related incidence ranged from $3,306 to $9,234 in 2012 dollars. The mean cost of pregnancy-related complications that led to preterm birth was as high as $326,953 for an infant born at 25 weeks. It is estimated that over 50 % of live births were unintended in the US. The difference in the cost of unintended pregnancy and intended pregnancy was approximately $536 million.
  
  
  CONCLUSIONS
  One limitation of the systematic review was the exclusion of model-based cost studies which were excluded because of the high level of variation and heterogeneity across sources of reported cost. Another limitation of the review is that the cost of pregnancy perspective is restricted to the US.
  
  
  CONCLUSIONS
  Preventing pregnancy-related complications and reducing unintended pregnancies may lower the overall economic burden of pregnancy on the US health care system.
authors.affiliation: Analysis Group, Inc., 111 Huntington Avenue, Tenth Floor, Boston, MA, 02199, USA.
authors.forename: Lynn
authors.initials: L
authors.lastname: Huynh
authors.forename: Mark
authors.initials: M
authors.lastname: McCoy
authors.forename: Amy
authors.initials: A
authors.lastname: Law
authors.forename: Kevin N
authors.initials: KN
authors.lastname: Tran
authors.forename: Senta
authors.initials: S
authors.lastname: Knuth
authors.forename: Patrick
authors.initials: P
authors.lastname: Lefebvre
authors.forename: Sean
authors.initials: S
authors.lastname: Sullivan
authors.forename: Mei Sheng
authors.initials: MS
authors.lastname: Duh
mesh_terms: D000293:Adolescent; D000328:Adult; D003695:Delivery of Health Care / Q000191:economics; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D018803:Models, Economic; D011247:Pregnancy; D011248:Pregnancy Complications / Q000191:economics* / Q000453:epidemiology / Q000517:prevention & control; D049168:Pregnancy, Unplanned; D014481:United States; D055815:Young Adult