Elsevier

Early Human Development

Volume 82, Issue 2, February 2006, Pages 77-84
Early Human Development

Pushing the boundaries of viability: The economic impact of extreme preterm birth

https://doi.org/10.1016/j.earlhumdev.2006.01.002Get rights and content

Abstract

Background

Previous assessments of the economic impact of preterm birth focussed on short term health service costs across the broad spectrum of prematurity.

Objective

To estimate the societal costs of extreme preterm birth during the sixth year after birth.

Methods

Unit costs were applied to estimates of health, social and broader resource use made by 241 children born at 20 through 25 completed weeks of gestation in the United Kingdom and Republic of Ireland and a comparison group of 160 children born at full term. Societal costs per child during the sixth year after birth were estimated and subjected to a rigorous sensitivity analysis. The effects of gestational age at birth on annual societal costs were analysed, first in a simple linear regression and then in a multiple linear regression.

Results

Mean societal costs over the 12 month period were £9541 (standard deviation £11,678) for the extreme preterm group and £3883 (£1098) for the term group, generating a mean cost difference of £5658 (bootstrap 95% confidence interval: £4203, £7256) that was statistically significant (P < 0.001). After adjustment for clinical and sociodemographic covariates, sex-specific extreme preterm birth was a strong predictor of high societal costs.

Conclusion

The results of this study should facilitate the effective planning of services and may be used to inform the development of future economic evaluations of interventions aimed at preventing extreme preterm birth or alleviating its effects.

Introduction

The adverse sequelae resulting from preterm birth impose a considerable burden on finite healthcare resources. Preterm infants are at an increased risk of a range of adverse neonatal outcomes including chronic lung disease [1], severe brain injury [2], retinopathy of prematurity [3], necrotising enterocolitis [4], and neonatal sepsis [5]. In later life, preterm infants are at an increased risk of motor and sensory impairment [6], [7], learning difficulties [8], [9], [10], [11], [12], and behavioural problems [13], [14], [15], [16].

Assessments of the economic consequences of preterm birth could provide an invaluable resource for clinical decision-makers and budgetary or service planners, and might also provide a framework for identifying priorities in research and development. Previous economic assessments of preterm birth have focussed mainly on the neonatal sequelae. These studies revealed an inverse relationship between hospital costs during the neonatal period and gestational age at birth [17].

Relatively few studies have documented the economic costs of preterm birth or low birth weight following the infant's initial discharge from the neonatal unit. Brooten et al. [18] and McCormick et al. [19] report that preterm or low birth weight infants are significantly more likely to consume hospital and community health services during the early years of life than infants born at full term or at normal birth weight. Some studies have attached a monetary value to the additional health care resources consumed by infants following their discharge from the neonatal unit. However, they are of varying methodological quality and differ with regard to the nature of their comparison and control groups, duration of follow-up, and the measurement and classification of outcomes. Rogowski [20] limited her analysis to medical costs incurred during the first year after birth. She reported a 24-fold differential in costs between very low birth weight single live births (< 1500 g) in the state of California Medicaid programme between 1986 and 1987 and all US births in 1989. In contrast, Stevenson et al. [21] followed up a cohort of very low birth weight infants (< 1500 g) born in 1979–1981 and recorded their use of hospital and family practitioner services up to age 8–9 years. When compared to a group of controls, matched for age, sex and school class, it was found that the low birth weight children used hospital and family practitioner services more intensively throughout the follow-up period. Indeed, there was a five-fold differential in mean total costs per child between low birth weight infants without disability and the control infants they were matched to. This differential increased to 16-fold amongst the lowest birth weight group (< 1000 g). Amongst infants with disability, mean health service costs for the entire follow-up period were estimated at £14,510 for the lowest birth weight group (< 1000 g), £12,051 for the intermediate birth weight group (1000–1500 g) and £7178 for the highest birth weight group (> 1500 g) (1998 £ sterling).

Two recent cohort analyses explored the long term hospital service utilisation and costs attributable to preterm birth. The analyses were based on data extracted from the Oxford Record Linkage Study, a large collection of linked, anonymised birth registrations, death certificates and statistical abstracts of NHS hospital inpatient and day case admissions for part of southern England. A multivariate negative binomial regression performed on the 5-year hospital service utilisation profile of 239,694 infants born in Oxfordshire and West Berkshire during the period 1970–1993 revealed that the total duration of hospital admissions for infants born at < 28 and at 28–31 gestational weeks was, respectively, 85 and 16 times that for term infants, once duration of life had been taken into account [22]. A subsequent multi-level multiple regression model revealed that the adjusted effect of birth at < 28 gestational weeks on cumulative hospital inpatient admissions, days and costs over the first 10 years after birth was 2.30, 1.77 and 5.43, respectively, when compared to children born at term [23].

Relatively little is known about the economic impact of preterm birth outside of the health sector [17]. Moreover, there is no empirical evidence that focuses on the economic impact of extreme preterm birth, which is of increasing relevance in the modern perinatal care context. In this paper, we report the results of a comprehensive assessment of the economic impact of extreme preterm birth during the sixth year after birth. The specific hypothesis tested was that extreme preterm birth is associated with significantly increased health service and broader societal costs during mid-childhood.

Section snippets

Study population

EPICure is a national cohort study of all infants born at 20 through 25 completed weeks of gestation in all 276 maternity units in the United Kingdom and Republic of Ireland from March through December 1995. A full description of the study population, recruitment methods and assessment procedures is available elsewhere [24], [25]. In brief, of 308 surviving children, 241 (78.2%) were assessed at a median age of six years and four months (range: five years and two months to seven years and three

Results

The clinical and sociodemographic characteristics of the 241 extreme preterm and 160 term children who participated in the six year follow-up study are reported in detail elsewhere [25].

Table 1 presents the mean cost per child over a 12 month period according to cost category for the extreme preterm and term study groups. Mean societal costs over the 12 month period were £11,982 (standard deviation: £13,660) among children born at ≤ 23 completed weeks, £11,308 (£13,334) among children born at 24+

Discussion

A previous review of the published and unpublished medical and health economics literature revealed that relatively few studies have estimated the long-term economic impact of preterm birth [17]. The vast majority of those studies adopted a narrow health service perspective and, therefore, overlooked the broader societal impacts of the condition. Moreover, none focussed on the economic impact of birth at borderline viability, which is of increasing relevance in the modern perinatal care context.

Acknowledgements

We would like to thank the children who participated in EPICure Study and the parents who completed the relevant research instruments. The six year follow-up study was supported by BLISS, the premature baby charity; the Health Foundation; and Well-Being of Women. The views contained in this paper are those of the authors and, not necessarily, of the funding bodies.

References (43)

  • D. Wolke et al.

    Cognitive status, language attainment and pre-reading skills of 6 year-old very preterm children and their peers: the Bavarian longitudinal study

    Dev Med Child Neurol

    (1999)
  • N. Botting et al.

    Cognitive and educational outcome of very low birthweight children in early adolescence

    Dev Med Child Neurol

    (1998)
  • A. Hall et al.

    School attainment, cognitive ability and motor function in a total Scottish very low birthweight population at 8 years—a controlled study

    Dev Med Child Neurol

    (1995)
  • L.J. Horwood et al.

    Cognitive, educational and behavioural outcomes at 7–8 years in a national very low birthweight cohort

    Arch Dis Child Fetal Neonatal Ed

    (1998)
  • N. Botting et al.

    Attention deficit hyperactivity disorders and other psychiatric outcomes in very low birthweight children at age 12 years

    J Child Psychol Psychiat

    (1997)
  • D. Wolke

    The psychological development of prematurely born children

    Arch Dis Child

    (1998)
  • P.O.D. Pharoah et al.

    Prevalence of behaviour disorders in low birthweight infants

    Arch Dis Child

    (1994)
  • D. Brooten et al.

    A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth-weight infants

    N Engl J Med

    (1986)
  • M.C. McCormick et al.

    Costs incurred by parents of very low birth weight infants after the initial neonatal hospitalization

    Pediatrics

    (1991)
  • J. Rogowski

    Cost-effectiveness of care for very low birth weight infants

    Pediatrics

    (1998)
  • R.C. Stevenson et al.

    Cost of care for a geographically determined population of low birthweight infants to age 8–9 years: I. Children without disability

    Arch Dis Child Fetal Neonatal Ed

    (1996)
  • Cited by (49)

    • Perinatal care for the extremely preterm infant

      2022, Seminars in Fetal and Neonatal Medicine
      Citation Excerpt :

      As demonstrated by the Epipage Study, survival amongst extremely preterm infants is strongly impacted by gestational age at delivery [23]. Given the very high relative risk of these infants developing serious PTB complications, the resource implications of caring for extremely preterm/ELBW infants are significant [24]; relative to an uncomplicated term-delivery, a single extremely preterm delivery is estimated to consume an additional $US146,847.00 in direct (i.e. to discharge) healthcare expenditure [25]. The gestational age at which an extremely preterm infant is considered to have the potential to survive has undergone a left-hand shift over the past several decades [26].

    • The financial burden on families of infants requiring neonatal intensive care

      2021, Seminars in Perinatology
      Citation Excerpt :

      Leader et al. determined overall direct non-medical OOP costs during a rehospitalization for respiratory syncytial virus to be on average $643 (USD 2001).23 Petrou et al. explored the societal costs during the sixth year of life in former extremely preterm infants and estimated £573 (GBP 2003) of additional non-medical OOP costs, compared to £120 in term controls.24 Lindly et al. reported responses from the National Survey of Child Health in the United States, which found that 14% of families of infants born VLBW had more than $1,000 (USD 2017) in annual direct non-medical OOP costs up to age 5.25

    • Harnessing the potential of artificial neural networks for pediatric patient management

      2020, Artificial Intelligence in Medicine: Technical Basis and Clinical Applications
    • Maternal pre-pregnancy infection with hepatitis B virus and the risk of preterm birth: a population-based cohort study

      2017, The Lancet Global Health
      Citation Excerpt :

      In low-income and many middle-income settings, preterm babies do not have even basic care, and such babies account for most preterm deaths worldwide.2 There is only a 50% chance of survival for infants born before 34 weeks in low-income and middle-income countries.2,36 From a public health perspective and with respect to policy and planning, prevention of preterm births is important, especially for early preterm births.

    • Effects of erythropoietin on neonatal hypoxia–ischemia brain injury in rat model

      2017, Physiology and Behavior
      Citation Excerpt :

      The neurological deficits seen in the majority of surviving premature infants may be the result of cerebral white matter injury. The resulting cognitive and behavioral problems became a huge burden for both the family and society [3,4]. Although there is no established intervention that fully treat HI induced perinatal brain injury, many potential therapies that may prevent injury progression and enhance repair are under investigation [5].

    View all citing articles on Scopus
    View full text