Finding value in birth : quality improvement, cost reduction, and trends in child and maternal health outcomes
Keywords: Medicine.
Health Policy.

My dissertation comprises three chapters on economic and policy issues related to maternal and child health in the United States. The first chapter -- co-authored with Sirina Keesara, Jill Krissberg, Elliott Main, and Jeremy Goldhaber-Fiebert -- evaluates the cost-effectiveness of California's statewide perinatal quality collaborative for reducing severe maternal morbidity (SMM) from hemorrhage. A decision-analytic model using open-source software (Amua version 0.30) compared outcomes and costs within a simulated cohort of 480,000 births to assess the annual effect in the state of California. We found the collaborative was cost effective, exhibiting strong dominance when compared to the baseline or standard of care. In a theoretical cohort of 480,000 births, collaborative implementation added 182 QALYs (0.000379/birth) by averting 913 cases of SMM, 28 emergency hysterectomies, and one maternal mortality. Additionally, it saved million ($17.78/birth) due to averted SMM costs. California's statewide perinatal quality collaborative initiative to reduce SMM from hemorrhage represents an inexpensive quality improvement initiative that reduces the incidence of maternal morbidity and mortality, and potentially provides cost savings to the majority of birthing hospitals. The second chapter -- co-authored with Maya Rossin-Slater, Jeremy Goldhaber-Fiebert, Michael Baiocchi -- examines whether nulliparous term singleton vertex (NTSV) deliveries during "business hours" is linked to an increase in medical procedures and complications and explore potential variations in these links based on hospital NTSV c-section rates and maternal race/ethnicity. This retrospective, population-based cohort study of all low-risk NTSV deliveries in California between 2008 and 2012 excluded women with planned c-sections, unbooked pregnancies (no prenatal care), fetal congenital anomalies, and high-risk maternal conditions. Delivery during "business hours" was defined as Monday -- Friday between 0700 -- 1900 and "non-business hours" otherwise. Our analysis of a large number of NTSV deliveries does not find a consistent relationship between greater use of procedures and higher risks of complications, helping to address concerns raised in previous studies that intervention levels for these births were too high and harming mothers and babies. However, for Hispanic and non-Hispanic Black mothers, some interventions and (for non-Hispanic Black mothers) complications may be unnecessarily more frequent during business hours. The third chapter -- coauthored with Maya Rossin-Slater and Jeremy Goldhaber-Fiebert -- evaluates the effect of delivery at a civilian hospital (off-base) vs. a military hospital (on-base) on types of medical interventions received and on maternal and infant health outcomes among active-duty family members; and to inform the debate regarding the value of expanding civilian health care services for military beneficiaries. The study used a quasi-experimental retrospective cohort design with linked birth and hospitalization records from 2005 to 2019 for 137,376 women with 2 singleton live births in military and/or civilian hospitals. We frame this empirical comparison by considering off-base civilian hospital care as the treatment, making those who give birth in military hospitals the untreated group. Our analysis sample included women who switched from delivering at a military hospital for their first birth to a civilian hospital for their second birth, and women who had the opposite switch between deliveries (civilian, then military). Since choice of hospital delivery is not random for most women, we leveraged the fact that moves in the military are randomly assigned, and therefore distance to the nearest military birthing hospital changes in a quasi-random way. Thus, we used an instrumental variables (IV) approach, in which we instrumented for delivery in a military hospital with an indicator for the mother's residence at the time of the second birth being within or outside of a 40-mile radius from such a hospital. Additionally, we evaluated heterogeneity of our results comparing birth outcomes pre- and post-2014 given the 2014 MHS review and subsequent efforts to improve quality, safety, and provider productivity; on the volume of births delivered at hospitals given documented relationships between quality of outcomes, care patterns, and resource availability based on hospital size and volume; and for subgroups of pregnant women whose sponsors were Black/African American, given prior evidence of a disproportionate burden of maternal and infant health complications borne by this group. We found delivering at a civilian hospital among active-duty family member dependents significantly reduced costs and complications compared to delivery at a military hospital even with higher procedure rates. Analyses stratified by race/ethnicity, hospital volume, and hospital rates of low birth weight and premature births demonstrated that these effects were generally consistent across subgroups. Despite efforts by the MHS to improve, our analysis of the stability of effects over time found the overall results remain largely robust and poorer outcomes remain an appreciable problem for deliveries at military hospitals. These findings provide evidence of health benefits and cost savings to support expanding civilian health care service use for military beneficiaries