Continuity of care by a primary midwife (caseload midwifery): a cost analysis using results from the COSMOS randomised controlled trial

Introduction: Caseload midwifery (continuity of midwifery carer) offers benefits including lower caesarean section rates, lower risks of preterm birth and stillbirth, and improved maternal satisfaction of care. Despite these advantages, concerns about additional costs hinder widespread implementation. This study examines the cost of caseload midwifery compared with standard maternity care from the perspective of both public hospitals and public funders.Methods: A cost analysis was conducted using data from a randomised controlled trial of 2314 low-risk pregnant women in Melbourne, Australia. Women randomised to caseload care received antenatal, intrapartum and postpartum care from a primary midwife, with some care provided by a ‘back-up’ midwife. Women in standard care received midwifery-led care with varying levels of continuity, junior obstetric care or community-based medical care. The cost analysis compared differences in mean costs of health resources to public hospitals and to public funders. Additionally, a budget impact analysis estimated total costs to the health system between 2023 and 2027.Results: For public hospitals, there was no significant difference in overall costs between women receiving caseload midwifery (n=1146) versus standard care (n=1151) ($A12 363 (SD: $A4967) vs $A12 323 (SD: $A7404); p=0.85). Conversely, public funders incurred lower expenditures for women receiving caseload midwifery ($A20 330 (SD: $A8312)) versus standard care ($A21 637 (SD: $A11 818); p <0.001). The budget impact analysis estimated savings of $A625 million to the health system over the next 5 years with expanded access to caseload midwifery in Australia.Conclusion: Caseload midwifery in low-risk women is cost-neutral to public hospitals and cost-saving to public funders.Tweetable abstractContinuity of midwifery for low-risk women reduces costs to public funders, with no additional costs to hospitals.