INTRODUCTION:Nausea and vomiting in pregnancy is highly prevalent and can significantly impact pregnant women's quality of life. Despite this, access to effective pharmacotherapies can be constrained by stringent regulatory controls and socioeconomic barriers. The objective of this study was to examine the socioeconomic distribution of antiemetics (metoclopramide, ondansetron, and prochlorperazine) dispensed to pregnant women through Australia's publicly subsidized Pharmaceutical Benefits Scheme. MATERIAL AND METHODS:We used the Maternity1000 linked administrative dataset to characterize antiemetics dispensed during 297 630 pregnancies in Queensland, Australia (July 2013 to June 2018). Using a population-based historical cohort study design, we analyzed dispensing volume, prevalence, and government expenditure across socioeconomic quintiles, with socioeconomic disadvantage defined using the Australian Bureau of Statistics' Index of Relative Socioeconomic Disadvantage. Inequalities in medication access and public expenditure were assessed using concentration indices (C) and concentration curves. RESULTS:Off-label ondansetron dispensings for nausea and vomiting in pregnancy (i.e., use outside Therapeutic Goods Administration-approved indications and not subsidized under the Pharmaceutical Benefits Scheme) accounted for the largest share of public expenditure (53.5%), followed by metoclopramide (45.2%) and prochlorperazine (1.3%). Across all three antiemetics, prevalence was highest among women in the most socioeconomically disadvantaged quintiles and declined progressively across the two least disadvantaged groups. Small pro-poor inequalities in access (C < -0.10) and moderate pro-poor inequalities in public expenditure (C > -0.25) were observed across all antiemetics. (Medication access: Cmetoclopramide = -0.07, 95% CI (-0.080 to -0.068); Condansetron = -0.09, 95% CI (-0.114 to -0.075); Cprochlorperazine = -0.08, 95% CI (-0.109 to -0.045). Government expenditure: Cmetoclopramide = -0.30, 95% CI (-0.316 to -0.285); Condansetron = -0.25, 95% CI (-0.297 to -0.198); Cprochlorperazine = -0.28, 95% CI (-0.350 to -0.205)). CONCLUSIONS:Off-label ondansetron access accounted for the majority of public expenditure on antiemetics dispensed during pregnancy, revealing a disconnect between health policy, clinical practice, public expenditure, and pregnant women's needs. While pro-poor access and public subsidies for antiemetics align with the equity elements embedded in the design of the Pharmaceutical Benefits Scheme, they may also be reflective of inequitable access to other unsubsidized, guideline-recommended pharmacotherapies for nausea and vomiting in pregnancy.

INTRODUCTION:Medication use during pregnancy is common, and socioeconomic disparities in access may contribute to maternal and fetal health inequalities. This study examines socioeconomic disparities in access to and expenditure on medications dispensed through Australia's Pharmaceutical Benefits Scheme (PBS), evaluating its role in promoting equal access to medications for pregnant women. METHODS:We analysed the Maternity1000 linked administrative dataset, which includes data on 57 443 women who gave birth in Queensland, Australia, between 1 July 2017 and 30 June 2018. Socioeconomic quintiles were assigned using the Index of Relative Socioeconomic Disadvantage. Medication prevalence rates, usage proportions and costs (2022/2023 Australian dollar) were calculated, followed by concentration curves and indices to assess inequality. RESULTS:Medication prevalence was higher among more disadvantaged women (Q1 (most disadvantaged): 67% vs Q5 (least disadvantaged): 60%), who were also dispensed a higher average number of medications per pregnancy (Q1: 2.8 (95% CI 2.7 to 2.9) vs Q5: 2.4 (95% CI 2.3 to 2.5)). However, the total medication cost (patient contribution amount plus public subsidy) was, on average, lower for these women (Q1: $45 (95% CI 43 to 46) vs Q5: $52 (95% CI 50 to 54)), indicating potential disparities in access to newer, higher cost treatments. The unadjusted concentration index suggested mild pro-poor inequality in access (CI=-0.031; p<0.001), which was attenuated and statistically insignificant after adjusting for maternal demographic and clinical characteristics (CINA=-0.007; p=0.089). Government expenditure on medications showed no significant socioeconomic inequality (unadjusted CI=0.001; p=0.965). CONCLUSION:The PBS facilitates equitable access to publicly funded medications for pregnant women. However, the uniform distribution of public funds across socioeconomic groups suggests possible limitations in progressivity, as public subsidies are not disproportionately benefiting the most disadvantaged women overall. This may reflect missed opportunities to distribute public funds more effectively and efficiently, particularly if disadvantaged women are under-represented in access to newer, higher cost therapies, and warrants ongoing evaluation.

IntroductionCaseload 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.MethodsA 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.ResultsFor 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.ConclusionCaseload 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.

BACKGROUND AND OBJECTIVE:Medication use is increasing to treat both pre-existing and pregnancy-related medical conditions or complications. This study aims to investigate factors associated with multiple medication use during pregnancy, as well as any increased risk of pregnancy complications for women taking multiple medications. METHODS:A retrospective analysis of routinely collected medical records of singleton pregnant women was conducted in Southeast Melbourne, Australia, between 2016 and 2021. Self-reported medication use was recorded as part of routine medical care, starting from the first antenatal booking appointment and continuing for every subsequent antenatal appointment until birth. Multimorbidity was defined as having two or more medical conditions. Logistic regression was used to assess factors influencing multiple medication use (defined as taking two or more non-supplemental medications at any stage of pregnancy) and associations with pregnancy complications. RESULTS:Of 48,502 participants, 34.9% used one medication, while 11.7% used multiple medications. Women of older age (30-34, 35-39, and ≥  40 years), higher body mass index (25.0-29.9 kg/m2 and ≥  30 kg/m2), born in Australasia and Oceania, higher socioeconomic status, and multimorbidity were more likely to use multiple medications during pregnancy. Women taking multiple medications had a higher risk of preterm and caesarean deliveries, fetal death, and neonatal admissions to intensive care. Sensitivity analyses exploring different morbidity categories produced no changes to findings. CONCLUSIONS:Medication use during pregnancy is prevalent, with many pregnant mothers taking multiple medications. Given the rising maternal age, body mass index, and morbidities in pregnancy, the use of medications during pregnancy is increasing. Such use correlates with an increased chance of adverse pregnancy outcomes. In the context of limited trials on the safety and efficacy of medications in pregnancy, timely harnessing of the information available within routine medical records for post-marketing surveillance is important.

Structural factors that contribute to health disparities (e.g., population-level policies, cultural norms) impact the distribution of resources in society and can affect medication accessibility; even in high-income countries like Australia. Industry practices and regulatory approaches (e.g., a conservative approach to testing medicines in pregnant women) influence the availability of safety and efficacy data necessary for the licencing and funding of prescription medications used during pregnancy. Consequently, pregnant women may be prescribed medications outside of regulatory or funder-approved indications, posing risks for both prescribers and pregnant women and potentially compromising equitable access to medications. This review examines the regulatory and legislative structural factors that contribute to health disparities and perpetuate the deeply ingrained social norm that we should be protecting pregnant women from clinical research rather than safeguarding them through such research. Addressing these challenges requires a renewed commitment to integrated, woman-centred maternal healthcare and strengthened collaboration across all sectors.

Objective: To describe the pharmacoepidemiology and costs associated with medications dispensed during pregnancy. Design: Pharmacoepidemiological study and cost analysis. Setting: Queensland, Australia. Population: All women who gave birth in Queensland between January 2013 and June 2018. Methods: We used a whole-of-population linked administrative dataset, Maternity 1000, to describe medications approved for public subsidy that were dispensed to 255 408 pregnant women. We describe the volume of medications dispensed and their associated costs from a Government and patient perspective. Main outcome measures: Prevalence of medication use; proportion of total dispensings; total medication costs in AUD 2020/21 ($1AUD = $0.67USD/0.55GBP pound in December 2022). Results: During pregnancy, 61% (95% CI 60.96-61.29%) of women were dispensed at least one medication approved for public subsidy. The mean number of items dispensed per pregnancy increased from 2.14 (95% CI 2.11-2.17) in 2013 to 2.47 (95% CI 2.44-2.51) in 2017; an increase of 15%. Furthermore, mean Government cost per dispensing increased by 41% from $21.60 (95% CI $20.99-$22.20) in 2013 to $30.44 (95% CI $29.38-$31.49) in 2017. These factors influenced the 53% increase in total Government expenditure observed for medication use during pregnancy between 2013 and 2017 ($2,834,227 versus $4,324,377); a disproportionate rise compared with the 17% rise in women's total out-of-pocket expenses observed over the same timeframe ($1,880,961 versus $2,204,415). Conclusions: Prevalence of medication use in pregnancy is rising and is associated with disproportionate and rapidly escalating cost implications for the Government.

Many autistic children access some form of early intervention, but little is known about the value for money of different programs. We completed a scoping review of full economic evaluations of early interventions for autistic children and/or their families. We identified nine studies and reviewed their methods and quality. Most studies involved behavioral interventions. Two were trial-based, and the others used various modelling methods. Clinical measures were often used to infer dependency levels and quality-adjusted life-years. No family-based or negative outcomes were included. Authors acknowledged uncertain treatment effects. We conclude that economic evaluations in this field are sparse, methods vary, and quality is sometimes poor. Economic research is needed alongside longer-term clinical trials, and outcome measurement in this population requires further exploration.

Background A large proportion of the burden of disease is preventable, yet investment in health promotion and disease prevention programmes remains a small share of the total health budget in many countries. The perception that there is paucity of evidence on the cost-effectiveness of public health programmes is seen as a barrier to policy change. The aim of this scoping review is to conduct a census of economic evaluations in primary prevention in order to identify and map the existing evidence. Methods This review is an update of a prior census and will include full economic evaluations of primary prevention programmes conducted in a community-based setting that were published between 2014 and 2019. The search of electronic databases (MEDLINE and Embase, and NHS-EED for 2014) will be supplemented by a search for grey literature in OpenGrey and a search of the reference lists of reviews of economic evaluations identified in our searches. Retrieved citations will be imported into Covidence® and independently screened in a two-stage process by two reviewers (abstracts and full papers). Any disagreements on the eligibility of a citation will be resolved by discussion with a third reviewer. Included studies will then be categorised by one independent reviewer according to a four-part typology covering the type of health promotion intervention, the risk factor being tackled, the setting in which the intervention took place and the population most affected by the intervention. New to this version of the census, we will also document whether or not the intervention sets out specifically to address inequalities in health. Discussion This review will produce an annotated bibliography of all economic evaluations plus a report summarising the current scope and content of the economic evidence (highlighting where it is plentiful and where it is lacking) and describing any changes in the type of economic evidence available for the various categories of disease prevention programmes since the last census. This will allow us to identify where future evaluative efforts should be focused to enhance the economic evidence base regarding primary prevention interventions. Systematic review registration Registration is being sought concurrently.

ISSUE ADDRESSED How much Australia spends on prevention, how this compares with other OECD countries and how do we know if Australia spends enough. METHODS Document review and integrative literature review. RESULTS Australia spends $89 per person on prevention or 1.34% of all health spending and 0.13% of gross domestic product (GDP). In comparison with other OECD countries, Australia is distinctly "mid-table," 16th (of 31 countries) in terms of per capita spending, 19th in terms of share of GDP and 20th in terms of share of health spending. However, the argument that Australia should spend more based on such comparisons is easy to undermine. With the exception of Aboriginal and Torres Strait Islander people, the health of Australians is as good if not better than the health of people in countries spending considerably more on prevention. Instead, we need to look at the value gained from any incremental increase in spending and compare this to the value lost because of cuts made elsewhere to accommodate the change. Evidence on the relative cost-effectiveness of prevention points to the benefits of increasing spending from current levels. CONCLUSIONS Arguments about how much Australia should spend on prevention would be better couched in terms of the value gained from any increase in spending, not from comparisons of spending with other countries. SO WHAT?: Arguments that Australia needs to spend more on prevention would be better with evidence on the opportunity costs and health gains to be realised from specific interventions.