Economic burden of maternal morbidity – A systematic review of cost-of-illness studies

Autoři: Patrick S. Moran aff001;  Francesca Wuytack aff001;  Michael Turner aff002;  Charles Normand aff003;  Stephanie Brown aff005;  Cecily Begley aff001;  Deirdre Daly aff001
Působiště autorů: School of Nursing and Midwifery, Trinity College, Dublin, Ireland aff001;  School Of Medicine, University College, Dublin, Ireland aff002;  Centre for Health Policy and Management, Trinity College, Dublin, Ireland aff003;  Cicely Saunders Institute, King’s College, London, United Kingdom aff004;  General Practice and Primary Health Care Academic Centre, University of Melbourne, Melbourne, Australia aff005;  Murdoch Children’s Research Institute, Melbourne, Australia aff006
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article



To estimate the economic burden of common health problems associated with pregnancy and childbirth, such as incontinence, mental health problems, or gestational diabetes, excluding acute complications of labour or birth, or severe acute adverse maternal outcomes.


Searches for relevant studies were carried out to November 2019 in Medline, Embase, CINAHL, PsycINFO and EconLit databases. After initial screening, all results were reviewed for inclusion by two authors. An adapted version of a previously developed checklist for cost-of-illness studies was used for quality appraisal. All costs were converted to 2018 Euro using national consumer price indices and purchasing power parity conversion factors.


Thirty-eight relevant studies were identified, some of which reported incremental costs for more than one health problem (16 gestational diabetes, 13 overweight/obesity, 8 mental health, 4 hypertensive disorders, 2 nausea and vomiting, 2 epilepsy, 1 intimate partner violence). A high level of heterogeneity was observed in both the methods used, and the incremental cost estimates obtained for each morbidity. Average incremental costs tended to be higher in studies that modelled a hypothetical cohort of women using data from a range of sources (compared to analyses of primary data), and in studies set in the United States. No studies that examined the economic burden of some common pregnancy-related morbidities, such as incontinence, pelvic girdle pain, or sexual health problems, were identified.


Our findings indicate that maternal morbidity is associated with significant costs to health systems and society, but large gaps remain in the evidence base for the economic burden of some common health problems associated with pregnancy and childbirth. More research is needed to examine the economic burden of a range of common maternal health problems, and future research should adopt consistent methodological approaches to ensure comparability of results.

Klíčová slova:

Birth – diabetes mellitus – Economics – Health economics – Hypertensive disorders in pregnancy – Morbidity – Obesity – Pregnancy


1. James SL, Abate D, Abate KH, Abay SM, Abbafati C, Abbasi N, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2018;392(10159):1789–858. doi: 10.1016/S0140-6736(18)32279-7 30496104

2. Gon G, Leite A, Calvert C, Woodd S, Graham WJ, Filippi V. The frequency of maternal morbidity: A systematic review of systematic reviews. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2018;141 Suppl 1:20–38. Epub 2018/06/01. doi: 10.1002/ijgo.12468 29851116; PubMed Central PMCID: PMC6001670.

3. Daly D, Clarke M, Begley C. Urinary incontinence in nulliparous women before and during pregnancy: prevalence, incidence, type, and risk factors. International urogynecology journal. 2018;29(3):353–62. Epub 2018/01/25. doi: 10.1007/s00192-018-3554-1 29362836.

4. O'Malley D, Higgins A, Begley C, Daly D, Smith V. Prevalence of and risk factors associated with sexual health issues in primiparous women at 6 and 12 months postpartum; a longitudinal prospective cohort study (the MAMMI study). BMC pregnancy and childbirth. 2018;18(1):196. Epub 2018/06/02. doi: 10.1186/s12884-018-1838-6 29855357; PubMed Central PMCID: PMC5984394.

5. Wuytack F, Curtis E, Begley C. The health-seeking behaviours of first-time mothers with persistent pelvic girdle pain after childbirth in Ireland: A descriptive qualitative study. Midwifery. 2015;31(11):1104–9. Epub 2015/08/15. doi: 10.1016/j.midw.2015.07.009 26272749.

6. Wuytack F, Curtis E, Begley C. Experiences of First-Time Mothers With Persistent Pelvic Girdle Pain After Childbirth: Descriptive Qualitative Study. Physical therapy. 2015;95(10):1354–64. Epub 2015/05/02. doi: 10.2522/ptj.20150088 25929535.

7. Wilkinson A, Anderson S, Wheeler SB. Screening for and Treating Postpartum Depression and Psychosis: A Cost-Effectiveness Analysis. Maternal and child health journal. 2017;21(4):903–14. doi: 10.1007/s10995-016-2192-9 27832444.

8. Cheng C-Y, Li Q. Integrative Review of Research on General Health Status and Prevalence of Common Physical Health Conditions of Women After Childbirth. Women's Health Issues. 2008;18(4):267–80. doi: 10.1016/j.whi.2008.02.004 18468922

9. Brown S, Gartland D, Perlen S, McDonald E, MacArthur C. Consultation about urinary and faecal incontinence in the year after childbirth: a cohort study. BJOG: an international journal of obstetrics and gynaecology. 2015;122(7):954–62. Epub 2014/07/22. doi: 10.1111/1471-0528.12963 25039427.

10. Brown SJ, Lumley JM, McDonald EA, Krastev AH, Maternal Health Study collaborative g. Maternal health study: a prospective cohort study of nulliparous women recruited in early pregnancy. BMC pregnancy and childbirth. 2006;6:12-. doi: 10.1186/1471-2393-6-6 16529649.

11. Schmied V, Johnson M, Naidoo N, Austin M-P, Matthey S, Kemp L, et al. Maternal mental health in Australia and New Zealand: A review of longitudinal studies. Women and Birth. 2013;26(3):167–78. doi: 10.1016/j.wombi.2013.02.006 23583667

12. Panda S, Begley PC, Daly DD. Readmission following caesarean section: Outcomes for women in an Irish maternity hospital. British Journal of Midwifery. 2016;24(5):322–8. doi: 10.12968/bjom.2016.24.5.322

13. Carroll M, Daly D, Begley CM. The prevalence of women's emotional and physical health problems following a postpartum haemorrhage: a systematic review. BMC pregnancy and childbirth. 2016;16:261. Epub 2016/09/07. doi: 10.1186/s12884-016-1054-1 27596720; PubMed Central PMCID: PMC5011962.

14. Woolhouse H, Perlen S, Gartland D, Brown SJ. Physical health and recovery in the first 18 months postpartum: does cesarean section reduce long-term morbidity? Birth (Berkeley, Calif). 2012;39(3):221–9. Epub 2013/01/04. doi: 10.1111/j.1523-536X.2012.00551.x 23281904.

15. Byford S, Torgerson DJ, Raftery J. Cost of illness studies. BMJ. 2000;320(7245):1335. doi: 10.1136/bmj.320.7245.1335 10807635

16. Tarricone R. Cost-of-illness analysis. What room in health economics? Health policy (Amsterdam, Netherlands). 2006;77(1):51–63. Epub 2005/09/06. doi: 10.1016/j.healthpol.2005.07.016 16139925.

17. Drummond M. Cost-of-Illness Studies. PharmacoEconomics. 1992;2(1):1–4. doi: 10.2165/00019053-199202010-00001 10146974

18. Public Health Wales Observatory Evidence Service. Questions to assist with the critical appraisal of a Cost of Illness/ Risk factor Analysis Wales: Public Health Wales, 2014.

19. OECD. Purchasing power parities (PPP): Organisation for Economic Co-operation and Development (OECD); 2018 [cited 2019 02/04]. Available from:

20. Ammerman RT, Chen J, Mallow PJ, Rizzo JA, Folger AT, Van Ginkel JB. Annual direct health care expenditures and employee absenteeism costs in high-risk, low-income mothers with major depression. Journal of Affective Disorders. 2016;190:386–94. doi: 10.1016/j.jad.2015.10.025 26546774. Language: English. Entry Date: 20160507. Revision Date: 20170902. Publication Type: journal article. Journal Subset: Biomedical.

21. Bauer A, Knapp M, Parsonage M. Lifetime costs of perinatal anxiety and depression. J Affect Disord. 2016;192:83–90. Epub 2015/12/29. doi: 10.1016/j.jad.2015.12.005 26707352.

22. Bauer A, Pawlby S, Plant DT, King D, Pariante CM, Knapp M. Perinatal depression and child development: exploring the economic consequences from a South London cohort. Psychological medicine. 2015;45(1):51–61. Epub 2014/07/30. doi: 10.1017/S0033291714001044 25066467; PubMed Central PMCID: PMC4341975.

23. Dall TM, Yang W, Halder P, Pang B, Massoudi M, Wintfeld N, et al. The economic burden of elevated blood glucose levels in 2012: diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes. Diabetes care. 2014;37(12):3172–9. Epub 2014/11/22. doi: 10.2337/dc14-1036 25414388.

24. Piwko C, Ungar WJ, Einarson TR, Wolpin J, Koren G. The weekly cost of nausea and vomiting of pregnancy for women calling the Toronto Motherisk Program. Current medical research and opinion. 2007;23(4):833–40. Epub 2007/04/05. doi: 10.1185/030079907x178739 17407640.

25. Fox A, McHugh S, Browne J, Kenny LC, Fitzgerald A, Khashan AS, et al. Estimating the Cost of Preeclampsia in the Healthcare System: Cross-Sectional Study Using Data From SCOPE Study (Screening for Pregnancy End Points). Hypertension (Dallas, Tex: 1979). 2017;70(6):1243–9. Epub 2017/11/01. doi: 10.1161/hypertensionaha.117.09499 29084880.

26. Solmi F, Morris S. Overweight and obese pre-pregnancy BMI is associated with higher hospital costs of childbirth in England. BMC pregnancy and childbirth. 2018;18(1):253. Epub 2018/06/22. doi: 10.1186/s12884-018-1893-z 29925340; PubMed Central PMCID: PMC6011257.

27. Xu T, Dainelli L, Yu K, Ma L, Silva Zolezzi I, Detzel P, et al. The short-term health and economic burden of gestational diabetes mellitus in China: a modelling study. BMJ open. 2017;7(12):e018893. Epub 2017/12/06. doi: 10.1136/bmjopen-2017-018893 29203507; PubMed Central PMCID: PMC5736026.

28. Petrou S, Cooper P, Murray L, Davidson LL. Economic costs of post-natal depression in a high-risk British cohort. The British journal of psychiatry: the journal of mental science. 2002;181:505–12. Epub 2002/11/29. doi: 10.1192/bjp.181.6.505 12456521.

29. Mogos MF, Araya WN, Masho SW, Salemi JL, Shieh C, Salihu HM. The Feto-Maternal Health Cost of Intimate Partner Violence Among Delivery-Related Discharges in the United States, 2002–2009. Journal of interpersonal violence. 2016;31(3):444–64. Epub 2014/11/14. doi: 10.1177/0886260514555869 25392375.

30. Law A, McCoy M, Lynen R, Curkendall SM, Gatwood J, Juneau PL, et al. The prevalence of complications and healthcare costs during pregnancy. Journal of medical economics. 2015;18(7):533–41. Epub 2015/02/26. doi: 10.3111/13696998.2015.1016229 25714263.

31. Denison FC, Norwood P, Bhattacharya S, Duffy A, Mahmood T, Morris C, et al. Association between maternal body mass index during pregnancy, short-term morbidity, and increased health service costs: a population-based study. BJOG: an international journal of obstetrics and gynaecology. 2014;121(1):72–81; discussion 2. Epub 2013/10/10. doi: 10.1111/1471-0528.12443 24102880.

32. Lenoir-Wijnkoop I, van der Beek EM, Garssen J, Nuijten MJ, Uauy RD. Health economic modeling to assess short-term costs of maternal overweight, gestational diabetes, and related macrosomia—a pilot evaluation. Frontiers in Pharmacology. 2015;6(MAY). doi: 10.3389/fphar.2015.00103 26042038

33. Meregaglia M, Dainelli L, Banks H, Benedetto C, Detzel P, Fattore G. The short-term economic burden of gestational diabetes mellitus in Italy. BMC pregnancy and childbirth. 2018;18(1):58. Epub 2018/02/24. doi: 10.1186/s12884-018-1689-1 29471802; PubMed Central PMCID: PMC5824573.

34. Gillespie P, Cullinan J, O'Neill C, et al. Modeling the independent effects of gestational diabetes mellitus on maternity care and costs. 2013;36(5):1111–6.

35. Moore Simas TA, Huang MY, Packnett ER, Zimmerman NM, Moynihan M, Eldar-Lissai A. Matched cohort study of healthcare resource utilization and costs in young children of mothers with postpartum depression in the United States. Journal of medical economics. 2019. doi: 10.1080/13696998.2019.1679157 31597499

36. Son KH, Lim NK, Lee JW, Cho MC, Park HY. Comparison of maternal morbidity and medical costs during pregnancy and delivery between patients with gestational diabetes and patients with pre-existing diabetes. Diabetic medicine: a journal of the British Diabetic Association. 2015;32(4):477–86. Epub 2014/12/05. doi: 10.1111/dme.12656 25472691; PubMed Central PMCID: PMC4407911.

37. Law A, McCoy M, Lynen R, Curkendall SM, Gatwood J, Juneau PL, et al. Costs of Newborn Care Following Complications During Pregnancy and Delivery. Maternal and child health journal. 2015;19(9):2081–8. Epub 2015/02/25. doi: 10.1007/s10995-015-1721-2 25707488.

38. Whiteman VE, Salemi JL, Mejia De Grubb MC, Ashley Cain M, Mogos MF, Zoorob RJ, et al. Additive effects of Pre-pregnancy body mass index and gestational diabetes on health outcomes and costs. Obesity (Silver Spring, Md). 2015;23(11):2299–308. Epub 2015/09/24. doi: 10.1002/oby.21222 26390841.

39. Jovanovic L, Liang Y, Weng W, Hamilton M, Chen L, Wintfeld N. Trends in the incidence of diabetes, its clinical sequelae, and associated costs in pregnancy. Diabetes/metabolism research and reviews. 2015;31(7):707–16. Epub 2015/04/23. doi: 10.1002/dmrr.2656 25899622; PubMed Central PMCID: PMC4676929.

40. Danyliv A, Gillespie P, O'Neill C, Noctor E, O'Dea A, Tierney M, et al. Short- and long-term effects of gestational diabetes mellitus on healthcare cost: a cross-sectional comparative study in the ATLANTIC DIP cohort. Diabetic medicine: a journal of the British Diabetic Association. 2015;32(4):467–76. Epub 2014/12/23. doi: 10.1111/dme.12678 25529506.

41. Cavassini AC, Lima SA, Calderon IM, Rudge MV. Care cost for pregnant and parturient women with diabetes and mild hyperglycemia. Revista de saude publica. 2012;46(2):334–43. Epub 2012/02/09. doi: 10.1590/s0034-89102012005000009 22310650.

42. Kolu P, Raitanen J, Rissanen P, Luoto R. Health care costs associated with gestational diabetes mellitus among high-risk women—results from a randomised trial. BMC pregnancy and childbirth. 2012;12:71. Epub 2012/07/26. doi: 10.1186/1471-2393-12-71 22827919; PubMed Central PMCID: PMC3565864.

43. Anderberg E, Carlsson KS, Berntorp K. Use of healthcare resources after gestational diabetes mellitus: a longitudinal case-control analysis. Scandinavian journal of public health. 2012;40(4):385–90. Epub 2012/07/13. doi: 10.1177/1403494812449923 22786924.

44. Kolu P, Raitanen J, Luoto R. Cost of gestational diabetes-related antenatal visits in health care based on the Finnish Medical Birth Register. Primary care diabetes. 2011;5(2):139–41. Epub 2011/02/05. doi: 10.1016/j.pcd.2011.01.001 21292576.

45. Chen Y, Quick WW, Yang W, Zhang Y, Baldwin A, Moran J, et al. Cost of gestational diabetes mellitus in the United States in 2007. Population health management. 2009;12(3):165–74. Epub 2009/06/19. doi: 10.1089/pop.2009.12303 19534581.

46. Kuhle S, Muir A, Woolcott CG, Brown MM, McDonald SD, Abdolell M, et al. Maternal pre-pregnancy obesity and health care utilization and costs in the offspring. International Journal of Obesity. 2018:1–9. doi: 10.1038/s41366-018-0149-3 30006584

47. Morgan KL, Rahman MA, Hill RA, Khanom A, Lyons RA, Brophy ST. Obesity in pregnancy: infant health service utilisation and costs on the NHS. BMJ open. 2015;5(11):e008357. Epub 2015/11/28. doi: 10.1136/bmjopen-2015-008357 26610756; PubMed Central PMCID: PMC4663437.

48. Caldas MC, Serrette JM, Jain SK, Makhlouf M, Olson GL, McCormick DP. Maternal morbid obesity: financial implications of weight management. Clinical obesity. 2015;5(6):333–41. Epub 2015/10/06. doi: 10.1111/cob.12116 26434773.

49. Morgan KL, Rahman MA, Macey S, Atkinson MD, Hill RA, Khanom A, et al. Obesity in pregnancy: a retrospective prevalence-based study on health service utilisation and costs on the NHS. BMJ open. 2014;4(2):e003983. Epub 2014/03/01. doi: 10.1136/bmjopen-2013-003983 24578535; PubMed Central PMCID: PMC3939655.

50. Watson M, Howell S, Johnston T, Callaway L, Khor SL, Cornes S. Pre-pregnancy BMI: costs associated with maternal underweight and obesity in Queensland. The Australian & New Zealand journal of obstetrics & gynaecology. 2013;53(3):243–9. Epub 2013/01/16. doi: 10.1111/ajo.12031 23316881.

51. Trasande L, Lee M, Liu Y, Weitzman M, Savitz D. Incremental charges, costs, and length of stay associated with obesity as a secondary diagnosis among pregnant women. Medical care. 2009;47(10):1046–52. Epub 2009/10/13. doi: 10.1097/MLR.0b013e31819c94b8 19820612.

52. Denison FC, Norrie G, Graham B, Lynch J, Harper N, Reynolds RM. Increased maternal BMI is associated with an increased risk of minor complications during pregnancy with consequent cost implications. BJOG: an international journal of obstetrics and gynaecology. 2009;116(11):1467–72. Epub 2009/06/06. doi: 10.1111/j.1471-0528.2009.02222.x 19496775.

53. Roberts J, Sword W, Watt S, Gafni A, Krueger P, Sheehan D, et al. Costs of postpartum care: examining associations from the Ontario mother and infant survey. The Canadian journal of nursing research = Revue canadienne de recherche en sciences infirmieres. 2001;33(1):19–34. Epub 2002/04/04. 11928152.

54. Chojenta C, William J, Martin MA, Byles J, Loxton D. The impact of a history of poor mental health on health care costs in the perinatal period. Archives of Women's Mental Health. 2018. doi: 10.1007/s00737-018-0912-4 30251209

55. Dagher RK, McGovern PM, Dowd BE, Gjerdingen DK. Postpartum depression and health services expenditures among employed women. Journal of occupational and environmental medicine. 2012;54(2):210–5. Epub 2012/01/24. doi: 10.1097/JOM.0b013e31823fdf85 22267187.

56. Hao J, Hassen D, Hao Q, Graham J, Paglia MJ, Brown J, et al. Maternal and Infant Health Care Costs Related to Preeclampsia. Obstetrics and gynecology. 2019. doi: 10.1097/AOG.0000000000003581

57. Piwko C, Koren G, Babashov V, Vicente C, Einarson TR. Economic burden of nausea and vomiting of pregnancy in the USA. Journal of population therapeutics and clinical pharmacology = Journal de la therapeutique des populations et de la pharamcologie clinique. 2013;20(2):e149–60. Epub 2013/08/06. 23913638.

58. O'Brien L, Laporte A, Koren G, O'Brien L, Laporte A, Koren G. Estimating the economic costs of antidepressant discontinuation during pregnancy. Canadian Journal of Psychiatry. 2009;54(6):399–408. doi: 10.1177/070674370905400607 19527560. Language: English. Entry Date: 20090828. Revision Date: 20170228. Publication Type: journal article.

59. Ramos E, Ofori B, Oraichi D, Berard A. Antidepressant therapy during pregnancy: an insight on its potential healthcare costs. The Canadian journal of clinical pharmacology = Journal canadien de pharmacologie clinique. 2008;15(3):e398–410. Epub 2008/10/28. 18953084.

60. Powell-Jackson T, Hoque ME. Economic consequences of maternal illness in rural Bangladesh. Health economics. 2012;21(7):796–810. Epub 2011/05/11. doi: 10.1002/hec.1749 21557382.

61. Iyengar K, Yadav R, Sen S. Consequences of maternal complications in women's lives in the first postpartum year: a prospective cohort study. J Health Popul Nutr. 2012;30(2):226–40. Epub 2012/07/31. doi: 10.3329/jhpn.v30i2.11318 22838164; PubMed Central PMCID: PMC3397333.

62. Storeng KT, Baggaley RF, Ganaba R, et al. Paying the price: The cost and consequences of emergency obstetric care in Burkina Faso. 2008;66(3):545–57.

63. Hoque ME, Powell-Jackson T, Dasgupta SK, Chowdhury ME, Koblinsky M. Costs of maternal health-related complications in Bangladesh. J Health Popul Nutr. 2012;30(2):205–12. Epub 2012/07/31. doi: 10.3329/jhpn.v30i2.11315 22838162; PubMed Central PMCID: PMC3397331.

64. Hoque ME, Dasgupta SK, Naznin E, Al Mamun A. Household coping strategies for delivery and related healthcare cost: findings from rural Bangladesh. Tropical medicine & international health: TM & IH. 2015;20(10):1368–75. Epub 2015/05/20. doi: 10.1111/tmi.12546 25982905.

65. Saha S, Gerdtham UG. Cost of illness studies on reproductive, maternal, newborn, and child health: A systematic literature review. Health Economics Review. 2013;3(1):1–12. doi: 10.1186/2191-1991-3-1

66. Islam MK, Gerdtham U-G. The costs of maternal–newborn illness and mortality. World Health Organization (WHO), 2006.

67. Huynh L, McCoy M, Law A, Tran KN, Knuth S, Lefebvre P, et al. Systematic literature review of the costs of pregnancy in the US. Pharmacoeconomics. 2013;31(11):1005–30. Epub 2013/10/26. doi: 10.1007/s40273-013-0096-8 24158771.

Článek vyšel v časopise


2020 Číslo 1
Nejčtenější tento týden