Changes in out-of-pocket charges associated with obstetric care provided under Medicare in Australia

Community-based doulas for migrant and refugee women: a mixed-method systematic review and narrative synthesis

BACKGROUND

Community-based doulas share the same cultural, linguistic, ethnic backgrounds or social experiences as the women they support. Community-based doulas may be able to bridge gaps for migrant and refugee women in maternity settings in high-income countries (HICs). The aim of this review was to explore key stakeholders' perceptions and experiences of community-based doula programmes for migrant and refugee women during labour and birth in HICs, and identify factors affecting implementation and sustainability of such programmes.

METHODS

We conducted a mixed-method systematic review, searching MEDLINE, CINAHL, Web of Science, Embase and grey literature databases from inception to 20th January 2022. Primary qualitative, quantitative and mixed-methods studies focusing on stakeholders' perspectives and experiences of community-based doula support during labour and birth in any HIC and any type of health facility were eligible for inclusion. We used a narrative synthesis approach to analysis and GRADE-CERQual approach to assess confidence in qualitative findings.

RESULTS

Twelve included studies were from four countries (USA, Sweden, England and Australia). There were 26 findings categorised under three domains: (1) community-based doulas' role in increasing capacity of existing maternity services; (2) impact on migrant and refugee women's experiences and health; and (3) factors associated with implementing and sustaining a community-based doula programme.

CONCLUSION

Community-based doula programmes can provide culturally-responsive care to migrant and refugee women in HICs. These findings can inform community-based doula organisations, maternity healthcare services and policymakers. Further exploration of the factors that impact programme implementation, sustainability, strategic partnership potential and possible wider-reaching benefits is needed.

Inequitable use of health services for Indigenous mothers who experience stillbirth in Australia

OBJECTIVES

The purpose of this study was to identify differences in health service expenditure on Indigenous and non-Indigenous women who experience a stillbirth, women's out-of-pocket costs, and health service use.

METHODS

The project used a whole-of-population linked data set called "Maternity1000," which includes all women who gave birth in Queensland, Australia, between July 1, 2012, and June 30, 2018 (n = 396 158). Multivariable analysis was undertaken to assess differences in mean health service expenditure; and number of health care services accessed between Indigenous and non-Indigenous women who had a stillbirth from birth to twelve months postpartum. Costs are presented in 2019/20 Australian dollars.

RESULTS

There was a total of 1864 babies stillborn to women in Queensland between July 1, 2012, and June 30, 2018, with 135 being born to Indigenous women and 1729 born to non-Indigenous women. There was significantly lower total expenditure per woman for Indigenous women compared with non-Indigenous women ($16 083 and $18 811, respectively). This was consistent across public hospital inpatient ($12 564 compared with $14 075), outpatient ($1127 compared with $1470), community-based services ($198 compared with $313), pharmaceuticals ($8 compared with $22), private hospital ($434 compared with $1265), and for individual out-of-pocket fees ($21 compared with $86). Mean expenditure on emergency department services per woman was higher for Indigenous women compared with non-Indigenous women ($947 compared with $643). Indigenous women who experienced a stillbirth accessed fewer general practitioners, allied health, specialist, obstetrics, and outpatient services, and fewer pathology and diagnostic test than their non-Indigenous counterparts.

CONCLUSIONS

Inequities in access to health services exist between Indigenous and non-Indigenous women who experience a stillbirth.

Birthing in regional Australia: women's decision making surrounding birthplace

Objective Although there is some research on women's choice of birthplace, most of this research has been conducted overseas. This study explored factors influencing the decision to use public or private maternity services within regional Australia. Methods This cross-sectional study consisted of a community-based, anonymous, online questionnaire focused on factors influencing a woman's choice of birth location and included adult females who had given birth in the past 2 years within two regional areas. Descriptive statistics were used to analyse demographic characteristics and factors influencing decisions regarding birthplace. Pearson's Chi-squared test was used to compare public and private births for multiple variables. Binary logistic regression was used to determine the odds ratio for each potential factor based on whether participants with private health insurance (PHI) elected to birth in the public or private regional hospitals. Open coding was used to group responses to open ended questions into themes. Results Data from 510 questionnaires were analysed. The three most frequently reported factors influencing a woman's decision about birthplace were financial reasons, the ability to choose their doctor and not having PHI. Women with PHI who opted for birth in the public system were almost four-fold more likely to select access to intensive care services and 2.6-fold more likely to select a preference for a low-intervention birth as one of their top five most influential factors. The results highlight that women want access to midwifery continuity of care. Conclusion This study provides insights into the factors influencing a woman's complex decision about where and with whom to birth and how health insurance affects that decision, an area where there is a paucity of peer-reviewed literature. This research highlights the importance of being able to choose one's doctor and the desire for access to midwife-led models of care, and provides evidence to advocate for improved access to additional models of care in the private sector. What is already known? The viability of regional private maternity hospitals is in question because, once the birth rate goes below a certain threshold, providing private obstetric service becomes unviable. Closure of regional private hospitals means less choice in regional areas. Minimal information is available about the factors influencing a woman with PHI to give birth in the public system, and much of the evidence is anecdotal. What does this paper add? This study provides insight into how PHI status and other factors influence a woman's decision to birth in the public versus private sector, an area where there is a paucity of peer-reviewed literature. It also highlights a desire from women for access to midwifery continuity of care in the private system. What are the implications for practitioners? This research provides evidence to advocate for improved access to additional models of care, especially for midwifery-led care in the private sector.

Cost-effectiveness of public caseload midwifery compared to standard care in an Australian setting: a pragmatic analysis to inform service delivery

BACKGROUND

Decision-makers need quantifiable data on costs and outcomes to determine the optimal mix of antenatal models of care to offer. This study aimed to examine the cost utility of a publicly funded Midwifery Group Practice (MGP) caseload model of care compared to other models of care and demonstrate the feasibility of conducting such an analysis to inform service decision-making.

OBJECTIVE

To provide a methodological framework to determine the value of public midwifery in different settings.

METHODS

Incremental costs and incremental utility (health gains measured in quality-adjusted life years (QALYs)) of public MGP caseload were compared to other models of care currently offered at a large tertiary hospital in Australia. Patient Reported Outcomes Measurement Information System Global Short Form scores were converted into utility values by mapping to the EuroQol 5 dimensions and then converting to QALYs. Costs were assessed from a health system funder's point of view.

RESULTS

There were 85 women in the public MGP caseload care group and 72 received other models of care. Unadjusted total mean cost for mothers' and babies' health service use from study entry to 12 months post-partum was $27 618 for MGP caseload care and $33 608 for other models of care. After adjusting for clinical and demographic differences between groups, total costs were 22% higher (cost ratio: 1.218, P = 0.04) for other models of maternity care. When considering costs to all funders, public MGP caseload care cost $5208 less than other models of care. There was no significant difference in QALY between the two groups (difference: 0.010, 95% CI: -0.038, 0.018).

CONCLUSION

Public MGP caseload care costs 22% less than other models of care, after accounting for differences in baseline characteristics between groups. There were no significant differences in QALYs. Public MGP caseload care produced comparable health outcomes, with some indication that outcomes may be better for lower cost per woman.

Postnatal Major Depressive Disorder in Australia: Inequalities and Costs of Healthcare to Individuals, Governments and Insurers

BACKGROUND

Perinatal mental health has pervasive impacts on the wellbeing of both the mother and child, affecting quality of life, bonding and attachment and cognitive development.

OBJECTIVES

The aim of this study was to (i) quantify the costs to government healthcare funders, private health insurers and individuals through out-of-pocket fees, of women with postnatal major depressive disorder (MDD); and (ii) identify any socioeconomic inequalities in health service use and costs amongst these women.

METHODS

A whole-of-population linked administrative dataset containing the clinical records and health service use for all births in the state of Queensland, Australia between 01 July 2012 and 30 June 2015 was used (n = 189,081). Postnatal MDD was classified according to ICD-10 code, with women hospitalised for MDD in the 12 months after birth classified as having 'postnatal MDD' (n = 728). Health service use and costs from birth to 12 months post-birth were included. Total costs included cost to government funders and private health insurers and out-of-pocket fees. Total costs and costs to different funders were compared for women with postnatal MDD and for women without an inpatient event for postnatal MDD, with unadjusted means presented. A generalised linear model was used to compare the difference in total costs, adjusting for key confounders. Costs to different funders and number of different services accessed were then compared for women with postnatal MDD by socioeconomic status, with unadjusted means presented.

RESULTS

The total costs from birth to 12 months post-birth were 636% higher for women with postnatal MDD than women without an inpatient event for postnatal MDD, after accounting for differences in private hospital use, mode of birth, clinical characteristics and socioeconomic status. Amongst women with postnatal MDD, the cost of all services accessed was higher for women of highest socioeconomic status than for women of lowest socioeconomic status (A$15,787.66 vs A$11,916.94). The cost of services for women of highest socioeconomic status was higher for private health insurers (A$8941.25 vs A$2555.26), but lower for public hospital funders (A$2423.39 vs A$6582.09) relative to women of lowest socioeconomic status. Outside of public hospitals, costs to government funders was higher for women of highest socioeconomic status (A$2766.80 vs A$1952.00). Women of highest socioeconomic status accessed more inpatient (8.2 vs 3.1) and specialist services (13.4 vs 5.5) and a higher proportion had access to psychiatric specialist care (39.7% vs 13.6%) and antidepressants (97.6% vs 93.8%).

CONCLUSION

MDD is costly to all funders of healthcare. Amongst women with MDD, there are large differences in the types of services accessed and costs to different funders based on socioeconomic status. There may be significant financial and structural barriers preventing equal access to care for women with postnatal MDD.

Differential access to continuity of midwifery care in Queensland, Australia

ObjectiveTo determine maternal access to continuity of midwifery care in public maternity hospitals across the state of Queensland, Australia. MethodsMaternal access to continuity of midwifery care in Queensland was modelled by considering the proportion of midwives publicly employed to provide continuity of midwifery care alongside 2017 birth data for Queensland Hospital and Health Services. The model assumed an average caseload per full-time equivalent midwife working in continuity of care with 35 women per annum, based on state Nursing and Midwifery Award conditions. Hospitals were grouped into five clusters using standard Australian hospital classifications. ResultsTwenty-seven facilities (out of 39, 69%) across all 15 hospital and health services in Queensland providing a maternity service offered continuity of midwifery care in 2017 (birthing onsite). Modelling applying the assumed caseload of 35 women per full-time equivalent midwife found wide variations in the percentage of women able to access continuity of midwifery care, with access available for an estimated 18% of childbearing women across the state. Hospital classifications with higher clinical services capability and birth volume did not equate with higher access to continuity of midwifery care in metropolitan areas. Regional health services with level 3 district hospitals assisting with <500 births showed higher levels of access, potentially due to additional challenges to meet local population needs to those of a metropolitan service. Access to full continuity of midwifery care in level 3 remote hospitals (<500 births) was artificially inflated due to planned pre-labour transfers for women requiring specialised intrapartum care and women who planned to birth at other hospitals. ConclusionsDespite strong evidence that continuity of midwifery care offers optimal care for women and their babies, there was significant variation in implementation and scale-up of these models across hospital jurisdictions. What is known about the topic?Access to continuity of midwifery care for pregnant women within the public health system varies widely; however, access variation among different hospital classification groups in Australian states and territories has not been systematically mapped. What does this paper add?This paper identified differential access to continuity of midwifery care among hospital classifications grouped for clinical services capability and birth volume in one state, Queensland. It shows that higher clinical services capability and birth volume did not equate with higher access to continuity of midwifery care in metropolitan areas. What are the implications for practitionersScaling up continuity of midwifery care among all hospital classification groups in Queensland remains an important public health strategy to address equitable service access.

Horizontal inequity in the utilisation of healthcare services in Australia

The Australian universal healthcare system aims to ensure affordable and equitable use of healthcare services based on individual health needs. This paper presents empirical evidence on the extent of horizontal inequity (HI) in healthcare services (unequal utilisation by income for equal need) in Australia during the period of promoting reliance on private healthcare financing. Using data from the most recent Australian National Health Survey of 2011-12 and 2014-15, we examined and measured the extent of HI in eight indicators of out-of-hospital services and hospital-related care. Contrary to earlier studies, our results show a small but pro-rich inequity in the probability of general practitioner visits. Inequity in the distribution of specialist and dentist visits was in favour of richer people, a result that is commonly found in other developed countries and is also consistent with existing Australian evidence. Hospital-related care was equitably distributed compared to the pro-poor pattern found in earlier studies. Despite the universal health insurance system in Australia, there was inequity in the utilisation of needed healthcare services. Our evidence is relevant to similar health systems as governments move to higher out-of-pocket payments and other private sources to reduce pressure on public healthcare expenditure.

Out-of-pocket expenditure on health care by Australian mothers: Lessons for maternal universal health coverage from a long-established system

BACKGROUND

Designing effective universal health care systems has challenges, including the use of patient co-payments and the role of the public and private systems. This study sought to quantify the total amount of out-of-pocket fees incurred by women who gave birth in private and public hospitals within Australia-a country with universal health coverage-and assess the impact that variation in birth type has on out-of-pocket fees.

METHODS

Data came from a linked administrative data set of all women who gave birth in the Australian state Queensland between July 1, 2012, and June 30, 2015, plus their resultant children. Propensity score matching was used to create two similar cohorts of women who gave birth in private and public hospitals.

RESULTS

The mean total out-of-pocket fees for care from conception to the child's first birthday was $2813 (±2683 standard deviation) and $623 (±1202) for women who gave birth in private and public hospitals, respectively. Total fees were higher in both public and private hospitals for women who had a cesarean birth ($716 [±1419] and $3010 [±2988]) than for women who had a vaginal birth without instruments ($556 [±1044] and $2560 [±2284]).

DISCUSSION

Australia's strong policy incentives for women to take out private health insurance are leaving women with large out-of-pocket costs. This should hold important lessons for other countries implementing a universal health care system, to ensure that using a combination of public and private practitioners does not undermine the intention of universal care.

Recent estimates of the out-of-pocket expenditure on health care in Australia

Objective The aims of this study were to estimate the average annual out-of-pocket (OOP) expenditure on health care by households in Australia in 2015–16, and to compare this with the estimate for 2009–10. Methods Data from the most recent Household Expenditure Survey (HES) conducted by the Australian Bureau of Statistics were used. Various statistical methods were used to estimate the annual OOP expenditures at the household and national levels. Results The average annual OOP expenditure was A$4290 per household, representing 5.8% of the amount spent on all goods and services. Private health insurance (PHI) premiums, although not a direct expenditure on health care, were 40.6% of the total OOP expenses. Of the remaining 59.4%, nearly half was spent on doctors and other health professionals, and approximately one-third was spent on medicines. Dental treatments and specialist consultations were the most expensive, whereas visits to general practitioners incurred the least OOP expenditure. Households with PHI (58.6%) spent fourfold more on health care than those not insured. Compared with the 2009–10 survey, the biggest increases were in the cost of PHI (50.7%) and copayments to specialists (34.8%) and other health professionals (42.0%). Conclusions OOP expenditure on health care as a proportion of the total household expenditure on all goods and services has increased by more than 25% between 2009–10 and 2015–16. What is known about the topic? Australian households incur OOP expenses for health care in Australia for a wide range of goods and services, such as copayments to doctors and other health professionals beyond the Medicare rebates, the cost of medicines and other pharmaceutical goods not covered entirely by the Pharmaceutical Benefits Scheme and PHI premiums. Although other estimates of OOP expenditure are available in official reports of the Australian Institute of Health and Welfare, they are based on administrative records rather than consumer reports, and cannot be disaggregated by item or the characteristics of households. What does this paper add? This paper provides detailed information on OOP expenditure on health care as reported by a probability sample of households interviewed for the HES conducted by the ABS during 2015–16. These estimates of OOP expenditure, based on consumer reports, add a further dimension to the information available from administrative records only. What are the implications for practitioners? Practitioners should take account of the effect of increasing copayments for their services, especially on patients belonging to the lower socioeconomic categories. Increasing copayments may lead to people foregoing medical care. Health planners and politicians should note the steady upward drift in OOP expenses and factor these into their policies for future funding of health care.

A review of the impact of financing mechanisms on maternal health care in Australia

BACKGROUND

The World Health Organization states there are three interrelated domains that are fundamental to achieving and maintaining universal access to care - raising sufficient funds for health care, reducing financial barriers to access by pooling funds in a way that prevents out-of-pocket costs, and allocating funds in a way that promotes quality, efficiency and equity. In Australia, a comprehensive account of the mechanisms for financing the health system have not been synthesised elsewhere. Therefore, to understand how the maternal health system is financed, this review aims to examine the mechanisms for funding, pooling and purchasing maternal health care and the influence these financing mechanisms have on the delivery of maternal health services in Australia.

METHODS

We conducted a scoping review and interpretative synthesis of the financing mechanisms and their impact on Australia's maternal health system. Due to the nature of the study question, the review had a major focus on grey literature. The search was undertaken in three stages including; searching (1) Google search engine (2) targeted websites and (3) academic databases. Executive summaries and table of contents were screened for grey literature documents and Titles and Abstracts were screened for journal articles. Screening of publications' full-text followed. Data relating to either funding, pooling, or purchasing of maternal health care were extracted for synthesis.

RESULTS

A total of 69 manuscripts were included in the synthesis, with 52 of those from the Google search engine and targeted website (grey literature) search. A total of 17 articles we included in the synthesis from the database search.

CONCLUSION

Our study provides a critical review of the mechanisms by which revenues are raised, funds are pooled and their impact on the way health care services are purchased for mothers and babies in Australia. Australia's maternal health system is financed via both public and private sources, which consequentially creates a two-tiered system. Mothers who can afford private health insurance - typically wealthier, urban and non-First Nations women - therefore receive additional benefits of private care, which further exacerbates inequity between these groups of mothers and babies. The increasing out of pocket costs associated with obstetric care may create a financial burden for women to access necessary care or it may cause them to skip care altogether if the costs are too great.

Comparing public and private emergency departments in China: Early evidence from a national healthcare quality survey

The number of private healthcare facilities has rapidly increased since the progressive open market policies, which began in the 1980s; however, little is known about the development of private emergency departments (EDs). This cross-sectional study was part of the National Control Information System (NCIS) project, which collects data annually from hospitals across China. Emergency services data were extracted and included location, infrastructure, human resources, beds, and number of patients; 4529 hospitals across 31 provinces in mainland China were eventually included, consisting of 988 private and 3541 public EDs. Evidence shows that most private EDs are located in central China, where local economies are relatively developed. Most private EDs (91.6%) are found in secondary hospitals but have significantly fewer beds and smaller workforces compared with public EDs. An imbalance of emergency medical resources was observed across China, and this disparity becomes even more profound in rural hospitals. These findings may initiate collaborative, public-private partnerships in emergency health services provision and suggest there is a need to offer tax breaks to incentivize investors, but further research is required. We may also need to rethink health insurance policies, which could enable more equitable access to private emergency care. Future planning and health policies must be based upon the strongest available evidence, if we are to address imbalanced health services distribution and growing demand.