NHMRC Fellowship - Associate Professor Emily Callander

Cutting costs and improving the journey to motherhood

After finding that expenses for obstetric services had soared by more than 1000 percent in Australia in just 25 years, a James Cook University health economics researcher is leading a major new study on the model of maternity care that delivers the “best bang for the buck” and gives women the best health outcomes.

Associate Professor Emily Callander, principal research fellow in health economics at the Australian Institute of Tropical Health and Medicine, has just been granted a $437,000 National Health and Medical Research Council (NHMRC) fellowship for the study. It involves researching the cost and outcomes of the pregnancy, obstetric and postnatal care of around 360,000 Queensland women who have given birth since 2012.

Callander says: “I think within Australia, there is a notable absence of economic-informed decision making around maternity care. It’s an area that has escaped a lot of research attention in terms of looking at the value of different models of care and that’s really what my fellowship aims to address.”

“The key part is that we actually are working directly with policy makers.” Callander says the initial findings are being used to “help executive directors of maternity services across Queensland build their business cases for changing the models of care that they're offering.” They are also working directly with health providers and policymakers so the research results can be used to change the way that maternity services are delivered.

As a health economist, Callander says she chose this field of research because she is a big believer in equity.. “I'm particularly interested in maternity care, in part having relatively recently had children myself. I had fabulous birthing experiences within the public system. I had a great time, but you hear so many women who don’t. And so, I think I'm quite passionate about ensuring that all women have the best access to care for their needs and that cost is not a barrier and that there's no institutional access barriers to them receiving the care that they would like and that they're entitled to. “

Callander is particularly concerned about ensuring equal access to good quality maternity care for people living in remote areas as well as Aboriginal and Torres Straight islander women.

She and her colleague Haylee Fox recently published the results of a study showing that out of pocket fees for obstetric services had increased by more than 1000 percent while the cost of in-hospital obstetric services had increased by 77 percent increase over 25 years.

“It’s a double whammy,” says Callander. “If you look overall at the different types of services covered by Medicare, obstetrics literally stand out as being some of the most expensive, but also the ones that have increased astronomically in that time period as well. So, there really is that anomaly. So, it’s not surprising, I think, that you're seeing a real decline in the number of women choosing to birth privately.”

In the new study, Callander and her team are looking at data for 186,000 Queensland women who gave birth between 2012 and 2015 and their 189,000 babies. They intend extending the research to another 186,000 odd women who delivered between 2015 and 2018.

“So for every woman having a baby in we want to see which model of maternity care gives the best health outcomes and is also the most cost effective.” The models are private obstetric-led care, private midwife-led care and public hospital obstetric or midwifery care. She says her team want to find whether the higher cost models are worth it in terms of the best outcome.

The public data the researchers are using covers the types of maternity services accessed by individual women. Callander says no identifying information is released and absolutely no personal details. The data includes details such as whether someone was triaged in emergency for obstetric reasons or whether women have had caesarian or vaginal births in particular hospitals. It also shows women who identify as Aboriginal and Torres Strait Islanders, so researchers can test whether results are consistent across all population groups or “whether perhaps for some groups different models might be more cost effective”.

Callander says delivering maternity healthcare that produces the best value for money and the best clinical outcomes in the most efficient manner seems like a ‘no-brainer”. The research will cover the costs and outcome of what she describes as “the whole care journey” of women from pregnancy through childbirth to two years afterwards.

The reason they are looking at such a long period is that the 1000 days after birth are vital for the baby and mother. “So, there is this whole postnatal journey that each woman has to go through. And particularly when you look at postnatal depression and follow-on mental health issues that have a longer time horizon, I think it’s quite important to go out that extra period of time, but also potentially for repeat pregnancies as well.”

For example, women who have had an initial caesarean section have a “remarkably high” risk of a follow-on caesarean. “The core of my fellowship is trying to get away from just looking at single activities and seeing the women’s experience in the health system as a continuum.”

Callander said they had found that in private Queensland facilities only 22 per cent of women were giving birth vaginally, with no induction or instruments used. In contrast in some public hospitals and health services 69 per cent of women were giving birth naturally.

Based on the results, Callander intends developing an online data base that will allow women in Queensland to find out the costs and make informed decisions about the type of maternity care they want.

On the data base she hopes to publish the costs plus the outcomes of each model of care. “So what is the relative risk of having a caesarean section if you choose this model of care and what is your risk of having a spontaneous natural vaginal birth if you choose this model of care as well. So, they can match up the outcomes and the costs so that they can make informed decisions.”

Callander adds: “I think this is exactly the sorts of things that patients need not just within maternity care even, but just across Australia, we really need with the public and private healthcare models that we have access to this type of transparent information.”