Cost effectiveness of a controlled lifestyle intervention for pregnant women with obesity

Hanna Gyllensten, Karin Haby, Marie Berg, Åsa Premberg, Hanna Gyllensten, Karin Haby, Marie Berg, Åsa Premberg

Abstract

Background: The Mighty Mums antenatal lifestyle intervention is a person-centered behavioral intervention focusing on nutrition and physical activity for pregnant women with obesity (body mass index [BMI] ≥30). The aim of this study was to evaluate the costs and clinical outcomes of adding the Mighty Mums intervention to standard antenatal care.

Methods: Participants in the intervention group (n = 434) received motivational talks with their midwife and a selection of physical and/or nutritional activities in addition to antenatal care. Control participants (n = 867) from adjacent geographic areas received standard antenatal care. Costs for staff, unit costs for specific activities, and registered costs for specialized antenatal care were analyzed for associations with gestational weight gain and self-reported health. Results are reported for the intention-to-treat (ITT) population and a per protocol (PP) population identified by participation in the intervention. Analyses included bootstrapped linear regressions adjusted for background characteristics that differed significantly between groups.

Results: The average costs were SEK 9727 higher (95% confidence interval [CI]: 6677 to 12,777) among participants in the intervention group than in the control ITT population and SEK 8655 (95% CI 4586 to 12,724) higher than in the PP population. The cost increase per 1 kg reduction in gestational weight gain was SEK 12,369 in the ITT population and SEK 7209 for the PP population.

Conclusion: Participation in the Mighty Mums intervention was associated with higher costs, but also reduced gestational weight gain. The cost per kilogram reduction in gestational weight gain was low, particularly in the PP population. A future decision to implement this behavioral intervention in standard care should take into account society's willingness to pay per unit reduction in gestational weight gain.

Trial registration: The study is registered at ClinicalTrials.gov , Identifier: NCT03147079 .

Keywords: And nutrition; Diet; Economic evaluation; Food; Gestational weight gain; Maternal health services; Obesity; Physical activity; Pregnancy.

Conflict of interest statement

The authors state they have no conflicts of interest.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Incremental cost-effectiveness plane of the Mighty Mums intervention (adjusted analyses). ITT = intention to treat; PP = per protocol; SEK = Swedish krona. The x-axis is inverted to ensure an assumed positive health outcome (i.e., reduced gestational weight gain) is shown to the right in the figure
Fig. 2
Fig. 2
Univariate analysis of the distribution of mean costs (excluding interpreter services) by health outcomes and background characteristics of participants in the Mighty Mums intervention group. BMI = body mass index; SEK = Swedish krona. Categories indicated by lower mean v. higher mean: * No v. yes. ** BMI 30–35 v. BMI ≥ 40. *** Other v. paid work. **** Sweden v. other
Fig. 3
Fig. 3
Univariate analysis on the distribution of mean gestational weight gain by health outcomes and background characteristics of participants in the Mighty Mums intervention group. BMI = body mass index; kg = kilograms. Categories indicated by lower mean v. higher mean: * BMI ≥ 40 v. BMI 

References

    1. Galliano D, Bellver J. Female obesity: short- and long-term consequences on the offspring. Gynecol Endocrinol. 2013;29(7):626–631. doi: 10.3109/09513590.2013.777420.
    1. 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. 2014;121(1):72–81. doi: 10.1111/1471-0528.12443.
    1. 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:e003983–2013–003983. doi: 10.1136/bmjopen-2013-003983.
    1. Marchi J, Berg M, Dencker A, Olander EK, Begley C. Risks associated with obesity in pregnancy, for the mother and baby: a systematic review of reviews. Obes Rev. 2015;16(8):621–638. doi: 10.1111/obr.12288.
    1. Moran PS, Wuytack F, Turner M, Normand C, Brown S, Begley C, et al. Economic burden of maternal morbidity - a systematic review of cost-of-illness studies. PLoS One. 2020;15(1):e0227377. doi: 10.1371/journal.pone.0227377.
    1. Cameron CM, Shibl R, McClure RJ, Ng SK, Hills AP. Maternal pregravid body mass index and child hospital admissions in the first 5 years of life: results from an Australian birth cohort. Int J Obes (Lond) 2014;38(10):1268–1274. doi: 10.1038/ijo.2014.148.
    1. Ahrens W, Pigeot I, Pohlabeln H, De Henauw S, Lissner L, Molnar D, et al. Prevalence of overweight and obesity in European children below the age of 10. Int J Obes (Lond) 2014;38(Suppl 2):S99–107. doi: 10.1038/ijo.2014.140.
    1. Campbell MK. Biological, environmental, and social influences on childhood obesity. Pediatr Res. 2015;79:205–211. doi: 10.1038/pr.2015.208.
    1. Bammann K, Gwozdz W, Lanfer A, Barba G, De Henauw S, Eiben G, et al. Socioeconomic factors and childhood overweight in Europe: results from the multi-Centre IDEFICS study. Pediatr Obes. 2013;8(1):1–12. doi: 10.1111/j.2047-6310.2012.00075.x.
    1. Bammann K, Peplies J, De Henauw S, Hunsberger M, Molnar D, Moreno LA, et al. Early life course risk factors for childhood obesity: the IDEFICS case-control study. PLoS One. 2014;9(2):e86914. doi: 10.1371/journal.pone.0086914.
    1. 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. 2015;23(11):2299–2308. doi: 10.1002/oby.21222.
    1. Arabin B, Stupin JH. Overweight and obesity before, during and after pregnancy: part 2: evidence-based risk factors and interventions. Geburtshilfe Frauenheilkd. 2014;74(7):646–655. doi: 10.1055/s-0034-1368462.
    1. Yi XY, Li QF, Zhang J, Wang ZH. A meta-analysis of maternal and fetal outcomes of pregnancy after bariatric surgery. Int J Gynaecol Obstet. 2015;130:3–9. doi: 10.1016/j.ijgo.2015.01.011.
    1. Nascimento S, Surita F, Parpinelli M, Siani S, Pinto e Silva J. The effect of an antenatal physical exercise programme on maternal/perinatal outcomes and quality of life in overweight and obese pregnant women: a randomised clinical trial. BJOG. 2011;118(12):1455–1463. doi: 10.1111/j.1471-0528.2011.03084.x.
    1. Thangaratinam S, Rogozinska E, Jolly K, Glinkowski S, Roseboom T, Tomlinson JW, et al. Effects of interventions in pregnancy on maternal weight and obstetric outcomes: meta-analysis of randomised evidence. BMJ. 2012;344(may16 4):e2088. doi: 10.1136/bmj.e2088.
    1. International Weight Management in Pregnancy (i-WIP) Collaborative Group Effect of diet and physical activity based interventions in pregnancy on gestational weight gain and pregnancy outcomes: meta-analysis of individual participant data from randomised trials. BMJ. 2017;358:j3119. doi: 10.1136/bmj.j3119.
    1. Tanentsapf I, Heitmann BL, Adegboye AR. Systematic review of clinical trials on dietary interventions to prevent excessive weight gain during pregnancy among normal weight, overweight and obese women. BMC Pregnancy Childbirth. 2011;11(1):81. doi: 10.1186/1471-2393-11-81.
    1. Agha M, Agha RA, Sandall J. Interventions to reduce and prevent obesity in pre-conceptual and pregnant women: a systematic review and meta-analysis. PLoS One. 2014;9(5):e95132. doi: 10.1371/journal.pone.0095132.
    1. Caldas MC, Serrette JM, Jain SK, Makhlouf M, Olson GL, McCormick DP. Maternal morbid obesity: financial implications of weight management. Clin Obes. 2015;5(6):333–341. doi: 10.1111/cob.12116.
    1. Haby K, Berg M, Gyllensten H, Hanås R, Premberg Å. Mighty mums - a lifestyle intervention at primary care level reduces gestational weight gain in women with obesity. BMC Obes. 2018;5(1):16. doi: 10.1186/s40608-018-0194-4.
    1. Ekman I, Swedberg K, Taft C, Lindseth A, Norberg A, Brink E, et al. Person-centered care--ready for prime time. Eur J Cardiovasc Nurs. 2011;10(4):248–251. doi: 10.1016/j.ejcnurse.2011.06.008.
    1. O’Reilly D, Gaebel K, Xie F, Tarride J-E, Goeree R. Health economic evaluations help inform payers of the best use of scarce health care resources. Int J Circumpolar Health. 2011;70(4):417–427. doi: 10.3402/ijch.v70i4.17843.
    1. Haby K, Glantz A, Hanås R, Premberg Å. Mighty mums - an antenatal health care intervention can reduce gestational weight gain in women with obesity. Midwifery. 2015;31(7):685–692. doi: 10.1016/j.midw.2015.03.014.
    1. Petersson K, Persson M, Lindkvist M, Hammarstrom M, Nilses C, Haglund I, et al. Internal validity of the Swedish maternal health care register. BMC Health Serv Res. 2014;14(1):364. doi: 10.1186/1472-6963-14-364.
    1. Basprogram för graviditetsövervakning / hälsovård för gravida i Göteborg [Basic program for pregnancy monitoring / health care for pregnant women in Gothenburg]. Gothenburg: Region Västra Götaland: Centrala mödrahälsovårdsteamet Göteborg, Region Västra Götaland [Central Maternal Health Care Team, Gothenburg, Region Västra Götaland]; 2012.
    1. Stephansson O, Petersson K, Björk C, Conner P, Wikström A-K. The Swedish pregnancy register – for quality of care improvement and research. Acta Obstet Gynecol Scand. 2018;97(4):466–476. doi: 10.1111/aogs.13266.
    1. Anell A, Glenngård AH, Merkur S. Sweden: health system review. Health Syst Transit. 2012;14:1–159.
    1. Emmons KM, Rollnick S. Motivational interviewing in health care settings. Opportunities and limitations. Am J Prev Med. 2001;20:68–74. doi: 10.1016/S0749-3797(00)00254-3.
    1. World Health Organization . Robson classification: implementation manual. Geneva: World Health Organization; 2017.
    1. Angerås U, Kjellström A, Ladfors L. Förlossningsvården i Västra Götalandsregionen 2002–2013 - med fokus på fullgångna förstföderskor [Childbirth care in the Västra Götaland region 2002–2013—Focusing on full-time firstborns]. Hälso- och sjukvårdsavdelningen, Västra Götalandsregionen [Department of Health, Västra Götaland Region]; 2015.
    1. Landstingens faktiska kostnader för Försäkringskassans beställningar . The county Council’s actual costs for the social insurance Agency’s orders. Stockholm: Socialstyrelsen: Socialstyrelsen; 2014.
    1. Holm M. Löne- och prisförändringar för regioner 2018–2019 [wage and price developments in the regions] 2020.
    1. Johansson K, Hutcheon JA, Stephansson O, Cnattingius S. Pregnancy weight gain by gestational age and BMI in Sweden: a population-based cohort study. Am J Clin Nutr. 2016;103(5):1278–1284. doi: 10.3945/ajcn.115.110197.
    1. Ranganathan P, Pramesh CS, Aggarwal R. Common pitfalls in statistical analysis: intention-to-treat versus per-protocol analysis. Perspect Clin Res. 2016;7(3):144–146. doi: 10.4103/2229-3485.184823.
    1. Barber JA, Thompson SG. Analysis of cost data in randomized trials: an application of the non-parametric bootstrap. Stat Med. 2000;19:3219–3236. doi: 10.1002/1097-0258(20001215)19:23<3219::AID-SIM623>;2-P.
    1. Gallacher D. HEABS: Stata module to calculate the ICER and net benefit for up to two datasets. 2020.
    1. OECD. Conversion rates - Purchasing power parities (PPP). Organization for Economic Co-operation and Development. 2020. . Accessed 5 Jun 2020.
    1. Wahlberg A, Rööst M, Haglund B, Högberg U, Essén B. Increased risk of severe maternal morbidity (near-miss) among immigrant women in Sweden: a population register-based study. BJOG. 2013;120(13):1605–1611. doi: 10.1111/1471-0528.12326.
    1. Leppälä S, Lamminpää R, Gissler M, Vehviläinen-Julkunen K. Humanitarian migrant women’s experiences of maternity care in Nordic countries: a systematic integrative review of qualitative research. Midwifery. 2020;80:102572. doi: 10.1016/j.midw.2019.102572.
    1. Tanvig M. Offspring body size and metabolic profile - effects of lifestyle intervention in obese pregnant women. Dan Med J. 2014;61:B4893.
    1. Briggs A. Economic evaluation and clinical trials: size matters. BMJ. 2000;321(7273):1362–1363. doi: 10.1136/bmj.321.7273.1362.
    1. Rogozinska E, Marlin N, Jackson L, Rayanagoudar G, Ruifrok AE, Dodds J, et al. Effects of antenatal diet and physical activity on maternal and fetal outcomes: individual patient data meta-analysis and health economic evaluation. Health Technol Assess. 2017;21(41):1–158. doi: 10.3310/hta21410.
    1. Shepherd E, Gomersall JC, Tieu J, Han S, Crowther CA, Middleton P. Combined diet and exercise interventions for preventing gestational diabetes mellitus. Cochrane Database Syst Rev. 2017;11:CD010443. doi: 10.1002/14651858.CD010443.pub3.
    1. Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excessive weight gain in pregnancy. Cochrane Database Syst Rev. 2015:(6):CD007145. 10.1002/14651858.CD007145.pub3.
    1. Walker R, Bennett C, Blumfield M, Gwini S, Ma J, Wang F, et al. Attenuating pregnancy weight gain-what works and why: a systematic review and meta-analysis. Nutrients. 2018;10. 10.3390/nu10070944.
    1. Schembre SM, Liao Y, Robertson MC, Dunton GF, Kerr J, Haffey ME, et al. Just-in-time feedback in diet and physical activity interventions: systematic review and practical design framework. J Med Int Res. 2018;20(3):e106. doi: 10.2196/jmir.8701.
    1. Hoomans T, Severens JL. Economic evaluation of implementation strategies in health care. Implement Sci. 2014;9(1):168. doi: 10.1186/s13012-014-0168-y.
    1. Personcentrerad vård i Sverige [Person-centred care in Sweden]. Gothenburg: University of Gothenburg: Swedish Association of Local Authorities and Regions; 2018.
    1. Broekhuizen K, Simmons D, Devlieger R, van Assche A, Jans G, Galjaard S, et al. Cost-effectiveness of healthy eating and/or physical activity promotion in pregnant women at increased risk of gestational diabetes mellitus: economic evaluation alongside the DALI study, a European multicenter randomized controlled trial. Int J Behav Nutr Phys Act. 2018;15:23–018-0643-y. doi: 10.1186/s12966-018-0643-y.
    1. Bailey C, Skouteris H, Harrison CL, Boyle J, Bartlett R, Hill B, et al. Cost effectiveness of antenatal lifestyle interventions for preventing gestational diabetes and hypertensive disease in pregnancy. Pharmacoecon Open. 2020;4(3):499-510. 10.1007/s41669-020-00197-9.

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