Research Articles
Costs of maternal conditions attributable to smoking during pregnancy

https://doi.org/10.1016/S0749-3797(98)00049-XGet rights and content

Abstract

Context: Despite known adverse health effects, many women continue to smoke during pregnancy. Public attention has now focused on the economic as well as health effects of this behavior.

Objective: To estimate health care costs associated with smoking-attributable cases of placenta previa, abruptio placenta, ectopic pregnancy, preterm premature rupture of the membrane (PPROM), pre-eclampsia, and spontaneous abortion.

Design: Pooled odds ratios were used with data on total cases to estimate smoking-attributable cases. Estimated average costs for cases of ectopic pregnancy and spontaneous abortion were used to estimate smoking-attributable health care costs for these conditions. Incremental costs, or costs above those for a “normal” delivery, were used to estimate smoking-attributable costs of placenta previa, abruptio placenta, PPROM, and pre-eclampsia associated with delivery.

Setting: National estimates for 1993.

Participants: Data from the National Hospital Discharge Survey (NHDS) and claims data from a sample of large, self-insured employers across the country.

Results: Smoking-attributable costs ranged from $1.3 million for PPROM to $86 million for ectopic pregnancy. Smoking during pregnancy apparently protects against pre-eclampsia and saves between $36 and $49 million, depending on smoking prevalence. Over all conditions smoking-attributable costs ranged from $135 to $167 million.

Conclusions: Smoking during pregnancy is a preventable cause of higher health care costs for the conditions studied. While smoking during pregnancy was found to be protective against pre-eclampsia and, hence, saves costs, the net costs were still positive and significant. Effective smoking-cessation programs can reduce health care costs but clinicians will perhaps need to manage increased cases of pre-eclampsia in a cost-effective manner.

Introduction

Concern with increasing health care costs and the movement to make tobacco companies financially accountable for the ill effects of smoking have provided the impetus for researchers to focus on measuring the economic costs related to smoking. Most efforts at estimating the costs of smoking have focused on the general population,1, 2, 3, 4 although one included an estimate of the value of lost lives through infant mortality due to maternal smoking.4

In general, these studies have estimated the excess costs of health care for smokers and the economic value of lost productivity. More recently, researchers estimated the internal (paid by the individual) and external (paid by society at large) costs of health care services attributable to smoking at $50.0 billion in 1993 dollars or $2.06 per pack.3 Important for this study, these earlier efforts omitted the costs for maternal conditions affected by smoking during pregnancy.

In this study we are interested specifically in these costs. Pregnant women constitute a group of health care users whose health costs can often be better managed. Managed care organizations are interested in serving them in a less costly manner as they assume financial risk under capitated arrangements, and Medicaid programs, now serving a much expanded number of pregnant women, are also interested in achieving efficiency. It will be important as these entities seek to curb costs related to smoking during pregnancy that they understand the maternal conditions affected, their relative costs, and the potential for an increase in some conditions—pre-eclampsia—as pregnant women are encouraged to quit smoking.

The results in this paper are part of a broader effort at the Centers for Disease Control and Prevention (CDC) to summarize the literature on smoking and reproductive health for the 1997 Surgeon General’s Report on Smoking and Women’s Health and within the CDC, to determine the direct and indirect costs of smoking. In the analysis presented here we have used information from the epidemiologic and clinical literature on the relative risks of reproductive outcomes related to smoking, and independent measures of health care costs to assess the magnitude of costs of maternal conditions affected by smoking.

Specifically, we have estimated the national smoking-attributable costs of ectopic pregnancy, placenta previa, abruptio placenta, preterm premature rupture of the membrane (PPROM), pre-eclampsia, and spontaneous abortion. These conditions were selected after an extensive review of the literature and in coordination with authors of the Surgeon General’s report. Our review indicates that they fully represent the costly maternal conditions associated with smoking during pregnancy.

The remainder of this paper is organized into five major sections. The first provides background on smoking during pregnancy and its adverse health effects. The next section describes our data and methods used; detail is provided on each of the maternal conditions studied. The third section presents the results on the average, incremental, and total costs related to conditions affected by smoking during pregnancy. A fourth section discusses the study limitations. The fifth and final section provides a brief discussion of the findings.

Section snippets

Background

An estimated 26% of women of reproductive age (18 to 44 years) smoked in 1993.5 The chronic effects of smoking for women are well documented, and each year smoking causes more than 140,000 deaths among U.S. women.5 The adverse health effects of smoking during pregnancy on the fetus and neonate are also well documented: tobacco use is related to intrauterine growth retardation, small for gestational age, low birthweight, perinatal mortality, and sudden infant death syndrome.6, 7, 8, 9 Yet, 19%

Methods

To derive our cost estimates, we used data from published studies on odds ratios for smokers versus non-smokers and two national databases as described below. We then followed a series of calculations to estimate the costs of certain maternal conditions attributable to smoking. For each maternal condition, we used the pooled odds ratio (R) from published studies and an estimate of the percentage of women who smoke during pregnancy (p) to calculate the proportion of national cases attributable

Average and incremental costs

The average cost of each maternal condition is presented in Table 2. For placental complications, PPROM, and pre-eclampsia, the incremental costs, or those in excess of the costs of a “normal” delivery ($4,518), are also provided.

The average costs for cases of ectopic pregnancy with an inpatient stay was estimated at $8,382, as shown in Table 2. This includes an average cost incurred in an outpatient setting for these women of $1,088. For those women with only outpatient claims for ectopic

Study limitations

This study combined epidemiologic and economic techniques to provide information on the smoking-attributable costs of maternal conditions affected by smoking. While we used the traditional epidemiologic approach to estimate the number of cases nationally, we were hampered in several instances by lack of reliable surveillance data. For example, the number of cases of ectopic pregnancy may be underestimated because the CDC estimates are based only on inpatient and outpatient hospital data. Of the

Discussion

Despite these limitations our dollar estimates provide data previously unavailable on the magnitude of the health care costs incurred by the increased prevalence of maternal conditions due to smoking during pregnancy. They also provide important information on the relative magnitude of costs across the conditions studied, one of which has a lower risk among smokers. We stress that these are only a portion of the total costs of smoking during pregnancy in that they omit the costs due to adverse

Acknowledgements

This research was supported in part by the Associations of Schools of Public Health Cooperative Agreement no. S127.

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