The costs to the NHS of maternity care: midwife-managed vs shared

Abstract

The objectives of this article are to compare the costs to the NHS of midwife-managed care and shared care. A randomized controlled trial was used. Women who were randomized to receive midwife-managed care but did not complete the care programme remained in the midwife-managed group for the purpose of analysis. The study took place in the Glasgow Royal Maternity Hospital, a major urban teaching hospital providing an integrated maternity service. A total of 1299 women experiencing normal healthy pregnancy took part in the study — 648 women were randomized to midwife-managed care and 651 to shared care. The main outcome measures were the costs to the NHS of providing the two alternative types of maternity care. Assuming a median caseload of 29 women per midwife in the midwife-managed group, there were no significant differences in the median costs of antenatal (midwife-managed=£287.60, shared care=£295.91, p=0.48) and intrapartum (midwife-managed=£240.90, shared care= £241.17, p=0.4) care. However, midwife-managed care was associated with significantly higher costs than shared care in the postnatal period (midwife-managed=£470.84, shared care=£352.03, p<0.001). When sensitivity analysis was performed to examine the effect of increased caseload on costs, shared care was associated with higher costs antenatally (midwife-managed=£274.94, shared care=£295.91, p=0.05). However, midwife-managed postnatal care remained significantly more expensive than shared care (midwife-managed=£404.17, shared care=£352.03, p<0.001). The costs of intrapartum care were not affected by this change in assumption. Differences in costs to the NHS largely reflected organizational differences between the two styles of care. Decisions concerning the provision of maternity services should not be based on costing information alone; information about clinical outcomes and women's satisfaction with care should also be considered. In the postnatal period, service providers would ultimately need to consider whether the increased costs of midwife-managed care were worth the enhanced levels of women's satisfaction measured in the randomized controlled trial.