Substantial out-of-pocket expenditure on maternity care practitioner consultations and treatments during pregnancy: estimates from a nationally-representative sample of pregnant women in Australia

This study highlights a substantive annual out-of-pocket expenditure by Australian women for pregnancy-related health treatments and services. This finding may be related to high rates of private obstetrics services being accessed by women [7], which may be linked to increased public uptake of private health cover [6] in line with the health insurance legislative changes in recent years [19]. Our findings confirm that women with private health insurance have much greater pregnancy-related out-of-pocket expenses from consultations with a conventional maternity care provider. Likewise, women who birth in a private hospital or the community are also more likely to have high out-of-pocket maternity care expenses. These findings create an interesting juxtaposition in that the obstetrician-led model of care women would have access to in a private hospital is vastly different to the midwife-led continuity of care model most common in home births [1, 20, 21].

There are also links in the findings between women’s out-of-pocket maternity care expenses and their maternity care provider which adds complexity to the interpretation: women are more likely to have high out-of-pocket expenses if they consult with an obstetrician but to have low out-of-pocket expenses if they consult a midwife. The seeming conflict between the findings associated with birth setting and maternity care providers may be explained by the models of care supported by government health funding in Australia [1]. The most common maternity care services accessed by Australian women are offered through public hospitals where, alongside obstetricians, midwives play a fundamental role in the service delivery [2]. In some circumstances, these services include midwife-led continuity of care models offered through a birth centre within the hospital [2]. These services are all fully government funded and result in no out-of-pocket expenses for women. In contrast, women accessing obstetrician-led maternity care in a private hospital will be commonly accessing private health insurance to reduce their costs; but while a health insurer covers 88% of their obstetric costs, 12% are out-of-pocket expenses [8]. In this context, it is important to note that the figure identified in our study does not include insurance premiums outlaid by women and as such our calculations may underestimate the true out-of-pocket expenses which individuals contribute to their maternity care. Meanwhile, there is a growing body of evidence of safety and effectiveness and a lower overall cost of care per birth associated with the midwife-led care for pregnant women at all levels of risk [17]. Despite this, it is worth noting that women who give birth in the community have a much greater likelihood of having high out-of-pocket expenses compared to women birthing in a private hospital. This finding is best explained by the low level of government funding for home birth programs in Australia [22] and inadequate provision for private health insurance rebates for women who birth at home.

Another important finding from our analysis is the significant out-of-pocket expense women are committing for CAM treatments and practitioners. Previous work estimates CAM expenditure in the Australian general population as AUD$4.13 billion [9] with mid-age women spending AUD$349 annually per capita on self-prescribed CAM [23]. Recent research has identified high CAM use by Australian women for pregnancy-related health conditions [3, 24] including the high rate of self-prescription of herbal medicine [12]. Our data provides the first differential breakdown of expenditure on both CAM products and practitioners and as such adds context to our understanding of CAM use in Australia and its perceived importance and value amongst the Australian population.

It is also interesting to observe that our study found a higher degree of spending on CAM products by women who were more likely to consult with a GP or obstetrician for their maternity care. Previous research has identified antipathy toward CAM by medical doctors [25]. As such, the relationship between greater spending on CAM by women consulting with a physician for pregnancy-related health is unexpected and is possibly driven by women rather than under the guidance of the practitioner. Given the reportedly low rates of disclosure of the use of CAM to obstetricians [26], this finding emphasises the need for medical doctors to inquire about CAM use when providing care to pregnant women.

The findings from this analysis may be affected by recall bias as the survey was prospective and self-administered. Previous maternity care research has examined the effects of recall bias and has identified that the more general aspects of health and care provision are less affected than recall of pregnancy-related health conditions [27, 28]. As such, recall bias for this analysis is not expected to be substantive. Furthermore, as any errors generated by the recall bias would occur equally across all subcategories of the study population the effect would be considered non-differential and the reported odds ratios are likely to be an under-estimate if they deviate from the true effect [29]. In addition, not all women who were eligible to complete the survey chose to do so and as such may expose the study to risk of sampling bias, whereby the sample is not representative of the whole population [29]. Fortunately, the size of this study and previous verification of the ALSWH study as nationally representative [30] offsets the potential impact of any actual sampling bias. Another possible limitation of this analysis may be linked to the age restrictions of the cohort which may have resulted in selection bias. While the average age of birthing women in Australia in 2009 was 30.0 years [2], which is within the range of women included in the study, it is acknowledged that not all Australian women who give birth are represented in the age group of the cohort. In light of these limitations, the expenditure figures presented should be viewed as estimates only. A comprehensive economic evaluation of Australian maternity care, which includes all elements of pregnancy-related health spending is needed, and this data provides insights which can inform such work.