Addendum to a review of the literature on Societal Costs of Severe Maternal and Infant Morbidity

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The SBSM Health Economics Team recently conducted a targeted reevaluation to quantify the societal economic burdens—both medical and non-medical—associated with maternal morbidity and adverse birth outcomes within a five-year postpartum period. This review builds upon our prior analysis as outlined in M25 Report #5, “Long-Term Postpartum Non-medical Costs Associated with Adverse Maternal and Child Outcomes from Preterm and Low Birth Weight Deliveries” (2022). In this analysis, we chronicle studies to assist us in quantifying precise estimates of short-term (Y0-1) and long-term (Y2-5) medical and non-medical cost metrics tied to severe maternal morbidity (SMM) and infant morbidity. The cost metrics identified will be utilized as foundational sources for formulating our calculations related to perinatal morbidity conditions, utilizing the SBSM dataset. Thus, this process requires a thorough and meticulous review of cost metrics found in selected studies.

With this framework, we used the screening protocols set in O’Neil et al. 2022 to maintain the focus of this review on three key findings: (1) the prevalence of outcomes associated with maternal or infant morbidity; (2) the likelihood of developing these outcomes given the morbidity condition; and (3) associated medical and nonmedical costs. When developing the search terms, we sought to capture the costs of maternal and infant morbidity in a fixed five-year postpartum period. We identified original articles published in peer-reviewed scientific journals via the National Library of Medicine, Cochrane Database of Systematic Reviews, and EconLit. We narrowed our focus to 56 empirical studies aligned with our search terms and the objectives of SBSM’s research initiatives. From these results, we reviewed titles, abstracts, and full text to determine estimates for our model using the following study criteria: (1) examined outcomes quantifiable in “per patient” monetary terms; (2) substantial methodological rigor and significance in cost findings; (2) examined medical costs in the United States with a concentration on similarly-situated areas to SBSM; (4) data from 2011 or later.

The synthesized screening narrowed down to 9 seminal studies, notably, O’Neil et al. 2021 (sponsored by Commonwealth Fund), Lakshmanan 2022, Trang 2017, Dukhovny 2013, and SBSM’s own 2021 Prenatal Cohort data (Group 1 and 2). These references, when analyzing SMM conditions and their significant impact on societal costs, primarily focused on gestational diabetes mellitus, preeclampsia, and hypertension. For specific conditions like gestational diabetes mellitus and preeclampsia, studies by Chen et al. (2009) and Stevens (2017) reveal considerable costs for mother-infant dyads, with a majority of these costs being borne by infants and public assistance programs like SNAP, TANF, and Medicaid.

The research conducted by O’Neil et al. (2021), however, expanded this scope to include maternal mental health conditions (MMHCs) in their evaluation of societal costs associated with SMM. Despite MMHCs not being classified as a traditional SMM condition, this study highlighted their relevance by revealing that MMHCs incurred the highest societal costs, amounting to $18.1 billion over a five-year postpartum period. This figure disproportionately surpassed the costs associated with all other high-cost SMM conditions in their review, such as hypertensive disorders at $7.5 billion, gestational diabetes mellitus at $4.8 billion, and hemorrhage at $1.8 billion. O’Neil et al. (2021) further emphasize that MMHCs are characterized by “chronic outcomes with ongoing costs” as their analysis, which showed that while all analyzed SMM conditions resulted in acute outcomes with short-term costs (Year 0-1), MMHCs consistently generated high costs. Notably, MMHCs maintained an average annual cost of $5,271.6 million over five years, underscoring their significant and enduring economic impact.

Numerous studies also underscored that adverse infant outcomes, notably hospitalizations and the developmental costs associated with preterm births and low birth weight infants, are key contributors to the societal costs of maternal morbidity. The research conducted by O’Neil et al. (2021) particularly underscores this, revealing that child outcomes constitute approximately 74% of their total estimated societal costs linked to SMM. Furthermore, analyses from O’Neil et al. (2021) also draw attention to the amplified societal costs when considering concurrent maternal and infant morbidity, compared to instances of singular morbidity as assessed by Lakshmanan (2022) and the array of supplemental studies.

The most pronounced consequences of SMM prominently feature substantial losses in productivity and earnings for mothers with spillover effects on their partners. Productivity loss, predominantly resulting from absenteeism (missing work) and presenteeism (working while ill), was particularly intensified in instances of concurrent maternal and infant morbidity. This dual burden significantly amplified the effect of morbidity on societal costs and individual household budgets. Additionally, in cases of infant morbidity, studies quantified a diverse range of out-of-pocket expenses arising particularly from the intensive care required for infant morbidity. These included transportation costs for frequent medical appointments, meal expenses, and lodging costs incurred due to infant hospitalization, particularly in cases involving extended stays in neonatal intensive care units (NICUs). Most notably, studies highlighted an increase in dependency on welfare programs, evident in the heightened utilization of special education and disability services for preterm infants (Roth 2003; Stevenson 1996; Chaikin 1991; Buck 2008).

A key limitation of our review is the age and quality of many studies that primarily provide cost metrics for adverse infant outcomes, like preterm births and low birth weights. These studies, often older and of lower evidence quality for these estimates, remain crucial due to the scarcity of literature on the long-term societal costs of infant and maternal morbidity. Despite these constraints, they offer valuable empirical insights at the per-patient level, or at least a basis for extrapolation, as we develop our calculations using the SBSM dataset. Importantly, these studies reinforce a central theme of our research: that SMM and infant morbidity extend beyond immediate acute costs, often representing chronic illnesses and disabilities that can have ongoing, compounded effects on social services, employers, and family members—shaping their workforce participation, nutrition, schooling, and other factors affecting the quality of life (Small et al 2012). These additional 23 studies are incorporated into our review in the “supplemental studies section,” providing a broader context for our analysis.

As we move forward, our findings clearly indicate the need for a dedicated review focusing specifically on MMHCs. As highlighted by O’Neil et al. (2021), while SMM conditions are critical near-death events and relatively rare, they typically do not have the chronic, long-term economic impacts associated with MMHCs. More crucially, research suggests that MMHCs can significantly influence the cost implications of SMM. For instance, a life-threatening perinatal condition can profoundly affect a mother’s mental health, leading to a cascade of societal impacts beyond just the medical sphere. This effect is even more pronounced in cases involving both SMM and infant morbidity.

A more thorough investigation into MMHCs would offer a deeper understanding of the extensive societal economic impact associated with morbidity in perinatal episodes. Such an examination is vital for enhancing our analyses and calculations using the SBSM dataset, thereby enriching our comprehension of the broader implications of these health conditions.