The Long-Term and Non-Medical Burden Associated with Adverse Maternal and Child Outcomes

For each reporting period, the SBSM Health Economics Team includes observations from an external literature review, to complement insights on the economics of high-risk pregnancies emerging from SBSM and helping position the program for operational and financial success well beyond the term of this 5-year effort. Four previous literature reviews have examined the economic burdens associated with complications during delivery, stays in neonatal intensive care units, and annual costs associated with preterm and low birth weight babies. This fifth literature review describes the long-term, non-medical economic burdens associated with adverse birth outcomes, with particular attention to the burdens borne by stakeholders beyond the healthcare sector (e.g., providers and/or payers).

To evaluate the long-term non-medical economic burdens of maternal and infant adverse outcomes, we examined studies on the burdens of surviving low birth weight infants with morbidity conditions. Most studies evaluate costs post-initial hospitalization to avoid coverage of medical costs, but some (e.g., Tommiska et al. 2007; Gennaro 1996; O’Neil et al. 2022) include non-medical costs such as travel costs and out-of-pocket (OOP) expenses not covered by medical insurance during NICU hospitalizations. Search terms primarily included (non-medical costs) OR (economic consequences) AND (medical economism), which were then combined with terms related to the condition of interest, i.e., (low-birth weight) OR (preterm) AND (morbidity). We first limited our geographical focus to the United States but quickly identified relevant studies conducted abroad (e.g., Finland and the UK). We sought to tailor our search to replicate the populations similar to the patients served by SBSM: maternal-infant pairs in predominantly urban, racially minority, and low-income communities. Our literature analysis found varying levels of rigor and precision across studies. Many studies (e.g., Tommiska et al., 2007; Lakshmanan et al.) reported approval by research ethics committees. We were particularly interested in a cost analysis over five years following birth, though the impacts within the education system become most apparent after age five (Chaikind and Corman 1991). The five-year mark is also likely to be most salient to policymakers (O’Neil et al. 2022). Table 1 below summarizes our key findings from the literature.

Adverse outcomes due to pregnancy and postpartum impose substantial economic tolls not only on the healthcare sector but also on all of society (Moran et al. 2020), including costs to patients and families, social services, education systems, and the economy at large. Past literature on the long-term non- medical economic costs of maternal and infant morbidity has primarily focused on two leading indicators of poor maternal and infant health: infants born either pre-term or low birth weight (LBW) due to inefficient maternal healthcare of susceptible patients (Martin 2008; Gilbert 2003; Schmitt 2006; McCormick 1993). For example, very low birth weight (VLBW; <1500g birth weight) infants represent only 1.5% of all live births in the United States (Martin 2008), but the cost of neonatal intensive care unit (NICU) hospitalizations for this group ranks them among the most expensive of all patients (Payne et al. 2008). In the short term, the economic burdens of LBW predominantly fall on the healthcare sector. Over time, the risk of long-term chronic illness, rehospitalization, and developmental delay can result in substantial non-medical costs. In the long term, this burden substantively falls on individuals and families, education, social services, and the economy at large. Recent literature has suggested that maternal mortality and morbidity are indicators of collaborative economic and social advancement, requiring active participation from all sectors of the economy.

While initial hospitalization medical costs represent the largest component of the economic burdens associated with adverse outcomes, studies of LBW infants have indicated that, depending on the type of disability incurred, non-medical costs to families from lost earnings, productivity loss, additional demands on the social safety net, and other indirect costs after the initial hospitalization can often account for more than half the total costs. The Institute of Medicine Committee puts this into perspective: the study estimated the annual societal economic burden associated with preterm birth in the United States at least $26.2 billion in 2005, or $51,600 per infant born preterm ($39.8 billion; $78,416 in 2023). Aside from medical costs, early developmental services amounted to $611 million in 2005 and $1,200 per infant ($928M; $1,823 in 2023), while special education services and total household productivity losses contributed over $5.7 billion and $11,200 per preterm infant ($8.6B; $17,020 in 2023). These estimates were noted as only a floor—a conservative minimum—given that many of the identified non-medical costs persist and accumulate over many years. As a result, the total economic burden of preterm disability is likely to increase substantially as the time horizon of estimation extends beyond the initial hospitalization period.

The studies in this report demonstrate the impact on stakeholders beyond the health system and beyond the initial period following the premature or low-weight birth of a baby, while difficult to measure precisely, are potentially wide-reaching and substantial in magnitude. More work is needed to refine and tailor the evidence to support community-wide efforts toward maternal-child health initiatives. The consideration of burdens and benefits beyond the health system, and beyond the baby’s first year will establish parameters and justification for investments from policymakers, leaders in education, and social services, as well as stewards of the local economy to invest and actively collaborate with health care providers and payers in addressing the burden of poor maternal and childbirth outcomes. The Health Economics team will continue to highlight findings from existing research as identified by our team in partnership with the clinical and administrative leads on the SBSM program.

Bibliography- Primary Sources:

Buck GM, Msall ME, Schisterman EF, et al. 2000. Extreme prematurity and school outcomes: Social and biomedical risks. Paediatric and Perinatal Epidemiology 14:324–31.

Chaikind, S. & Corman, H. (1991) The impact of low birthweight on special education costs. Journal of Health Economics, 10, 291–311. https://pubmed.ncbi.nlm.nih.gov/10170854/

Gennaro S: “Leave and employment in families of preterm low birthweight infants.” Image J Nurs Sch 1996, 28:193-8. https://www.jstor.org/stable/pdf/44953583.pdf.

White, Robert S, et al. “Economic Burden of Maternal Mortality in the USA, 2018–2020.” Journal of Comparative Effectiveness Research, vol. 11, no. 13, Sept. 2022, pp. 927–933, 10.2217/cer-2022-

0056. https://www.futuremedicine.com/doi/10.2217/cer–2022-0056.

Lakshmanan, A., Song, A.Y., Belfort, M.B. et al. The financial burden experienced by families of preterm infants after NICU discharge. J Perinatol 42, 223–230 (2022). https://doi.org/10.1038/s41372-021- 01213-4

McLoughlin A, Hillier VF, Robinson MJ: Parental costs of neonatal visiting. Arch Dis Child 1997,68(5):597–9. https://adc.bmj.com/content/68/5_Spec_No/597.short

Tommiska V, Tuominen R, Fellman V: “Economic costs of care in extremely low birthweight infants during the first 2 years of life”. Pediatr Crit Care Med 2003, 4:157-3.

https://journals.lww.com/pccmjournal/Fulltext/2003/04000/Economic_costs_of_care_in_extremely_l ow.1.aspx.

Walker, D. J., Feldman, A., Vohr, B. R. & Oh, W. (1984) Cost-benefit analysis of neonatal intensive care for infants weighing less than grams at birth. Pediatrics, 31 ,188–205.

Walker, D. J., Vohr, B. R. & Oh, W. (1985) Economic analysis of regionalized neonatal care for very low- birth-weight infants in the state of Rhode Island. Pediatrics, 76, 69–74.

Secondary sources:

Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes; Behrman RE, Butler AS, editors. Preterm Birth: Causes, Consequences, and Prevention. Washington (DC): National Academies Press (US); 2007. Doi: 10.17226/11622. https://www.ncbi.nlm.nih.gov/books/NBK11362/

Consumer price index for hospital services: 2009. 2010.

Gilbert WM, Nesbitt TS, Danielsen B. The cost of prematurity: Quantification by gestational age and birth weight. Obstet Gynecol. 2003 Sep;102(3):488–92.

Killien, M. (1993). Returning to work after childbirth: Considerations for health policy. Nursing Outlook, 41,73-78.

Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Mathews TJ, Osterman MJK. Births: Final data for 2008. Natl Vital Stat Rep. 2010 Dec 8;59(1):1–72.

McCormick MC, Bernbaum JC, Eisenberg JM, Kustra S, Finnegan E: Costs incurred by parents of very low birth weight infants after the initial neonatal hospitalization. Pediatrics 1993, 88: 533–41

Moran PS, Wuytack F, Turner M, Normand C, Brown S, Begley C, et al. Economic burden of maternal morbidity—A systematic review of cost-of-illness studies. PLOS ONE. 2020;15: e0227377. doi:10.1371/journal.pone.0227377

Schmitt SK, Sneed L, Phibbs CS. Costs of newborn care in California: A population-based study. Pediatrics. 2006;117(1):154–60.

Payne NR, Carpenter JH, Badger GJ, Horbar JD, Rogowski J. Marginal increase in cost and excess length of stay associated with nosocomial bloodstream infections in surviving very low birth weight infants. Pediatrics. 2004;114(2):348–55.

Schmidt B, Asztalos EV, Roberts RS, Robertson CM, Sauve RS, Whitfield MF, et al. “Impact of bronchopulmonary dysplasia, brain injury, and severe retinopathy on the outcome of extremely low- birth-weight infants at 18 months: Results from the trial of indomethacin prophylaxis in preterms.” JAMA. 2003;289(9):1124–9.