title: A Cost-Effectiveness Analysis of Low-Risk Deliveries: A Comparison of Midwives, Family Physicians and Obstetricians.
abstract: OBJECTIVE
  To investigate the cost-effectiveness of in-hospital obstetrical care by obstetricians (OBs), family physicians (FPs) and midwives (MWs) for delivery of low-risk obstetrical patients.
  
  
  METHODS
  Cost-effectiveness analysis from the Ministry of Health perspective using a retrospective cohort study. The time horizon was from hospital admission of a low-risk pregnant patient to the discharge of the mother and infant. Costing data included human resource, intervention and hospital case-mix costs. Interventions measured were induction or augmentation of labour with oxytocin, epidural use, forceps or vacuum delivery and caesarean section. The outcome measured was avoidance of transfer to a neonatal intensive care unit (NICU). Model results were tested using various types of sensitivity analyses.
  
  
  RESULTS
  The mean maternal age by provider groups was 29.7 for OBs, 29.8 for FPs and 31.2 for MWs - a statistically higher mean for the MW group. The MW deliveries had lower costs and better outcomes than FPs and OBs. FPs also dominated OB.s The differences in cost per delivery were small, but slightly lower in MW ($5,102) and FP ($5,116) than in OB ($5,188). Avoidance of transfer to an NICU was highest for MW at 94.0% (95% CI: 91.0-97.0), compared with 90.2% for FP (95% CI: 88.2-92.2) and 89.6% for OB (95% CI: 88.6-90.6). The cost-effectiveness of the MW group is diminished by increases in compensation, and the cost-effectiveness of the FP group is sensitive to changes in intervention rates and costs.
  
  
  CONCLUSIONS
  The MW strategy was the most cost-effective in this hospital setting. Given data limitations to further examine patient characteristics between groups, the overall conservative findings of this study support investments and better integration for MWs in the current system.
authors.affiliation: Student Fellow, Canadian Centre for Health Economics, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.
authors.forename: Dylan
authors.initials: D
authors.lastname: Walters
authors.affiliation: Family Physician, Department of Family Medicine, Brampton Civic Hospital, Brampton, ON.
authors.forename: Archna
authors.initials: A
authors.lastname: Gupta
authors.affiliation: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.
authors.forename: Austin E
authors.initials: AE
authors.lastname: Nam
authors.affiliation: Assistant Professor, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Lake
authors.affiliation: Chief of Family Medicine, William Osler Health System, Brampton, ON.
authors.forename: Frank
authors.initials: F
authors.lastname: Martino
authors.affiliation: Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON.
authors.forename: Peter C
authors.initials: PC
authors.lastname: Coyte
mesh_terms: D000328:Adult; D002170:Canada / Q000453:epidemiology; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D036861:Delivery, Obstetric / Q000191:economics* / Q000379:methods; D005260:Female; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008423:Maternal Age; D008880:Midwifery / Q000191:economics* / Q000379:methods; D009774:Obstetrics / Q000191:economics*; D010821:Physicians, Family / Q000191:economics*; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000191:economics* / Q000453:epidemiology; D012189:Retrospective Studies; D012306:Risk