Multiple Birth Pregnancies Can Cost Nearly 20 Times More Than Singleton Pregnancies

Strategies to minimize multiple embryo transfer should be considered, say researchers in the American Journal of Obstetrics & Gynecology

Multiple pregnancies are a major public health concern in the United States and the rest of the world due to the significantly higher health risks for both mothers and infants, as well as the impact on healthcare costs. Investigators analyzed and compared the cost of multiple versus single-birth pregnancies and found that pregnancies with delivery of twins cost about five times more than singletons, and pregnancies with delivery of triplets or more cost nearly 20 times as much. They call for strategies to reduce this burden. Their findings are published in the American Journal of Obstetrics & Gynecology.

Multiple pregnancies are increasing worldwide in parallel with increased use of reproductive technologies such as ovulation induction and in vitro fertilization (IVF). According to the Centers for Disease Control and Prevention (CDC), 3% of all infants born in the United States in 2010 were multiple deliveries. The twin birth rate was 33 per 1,000 total births, and the rate of triplets and more was 1.4 per 1,000 births. Experts generally agree that while less than half (about 40%) of twin births result from assisted reproductive technologies, this increases to around 80% of births of triplets or more.

The current study documents and compares costs associated with multiple pregnancies versus singletons in the United States, using the Truven Health MarketScan Commercial Claims and Encounters Database. The study population included all women aged 19-45 years who delivered at least one live born infant between January 2005 and September 2010. Investigators identified 437,924 eligible delivery events during the study period. Of these, about 97% (424,880) were singletons, 2.85% (12,482) were twins, and 0.13% (562) were triplets or more.

For mothers, the cost included medical expenses during the 27 weeks before and up to 30 days after the delivery date. For infants, costs contained all medical expenses up to their first birthday. This is the first study taking into account a comprehensive assessment of the incremental cost associated with multiple pregnancies by estimating all-cause medical expenses over this timeframe.

"By taking a broad approach, we have shown that medical expenses attributable to mothers and infants varied according to birth multiplicity," comments lead investigator Dongmu Zhang, PhD, Global Health Outcomes, Merck & Co. "For singleton pregnancy, maternal expenses accounted for about 60% of overall cost. whereas for twins or higher-order multiple births, expenses for infant care accounted for about 70% and 85% of total expenses, respectively."

The adjusted total all-cause healthcare cost was around $21,000 per delivery with singletons, $105,000 with twins, and over $400,000 with triplets or more.

The investigators took into account co-existing conditions, which they categorized into systemic conditions such as hypertension, cardiovascular disease, diabetes, edema/renal disease, genitourinary infection, thyroid disease, and anemia, and conditions in the reproductive tract. Women with twins or more had significantly higher co-existing conditions in each category than women who delivered singletons. Mothers with twins or triplets or more also had longer hospital stays for delivery and higher mortality.

"On average, combined all-cause healthcare expenses for mothers with twins or higher-order multiple births were about five and 20 times more expensive, respectively, than singleton delivery. The greater expenses were likely to have been due to increased maternal morbidities, significantly increased use of cesarean section and longer hospital stay for the deliveries in women with multiple pregnancies, and increased admission and longer stay in NICU for neonates of multiple gestations. We also demonstrated increased mortality for both mothers and infants associated with multiple pregnancies, although the absolute rates were small," Dr. Zhang adds.

To the researchers' knowledge, this is the first study that reports increased medical expenses for both maternal and infant care associated with IVF-assisted pregnancy. The researchers comment that for women undergoing IVF, the risk of multiple pregnancies is due nearly entirely to multiple embryo transfer, and recommend that strategies aiming at minimizing multiple embryo transfer should be considered to reduce the burden associated with multiple pregnancies.

# # #

Notes for editors
"Healthcare Expenses Associated with Multiple Pregnancies versus Singletons in the United States," by Elkin V. Lemos, MD, PhD, Dongmu Zhang, PhD, Bradley J. Van Voorhis, MD, X. Henry Hu, MD, MPH, PhD (DOI: http://dx.doi.org/10.1016/j.ajog.2013.10.005), American Journal of Obstetrics & Gynecology, Volume 209, Issue 6 (December 2013), published by Elsevier.

Full text of the article is available to credentialed journalists upon request. Contact Eileen Leahy at +1 732 238 3628or ajogmedia@elsevier.com to obtain a copy. Journalists wishing to schedule interviews with the authors should contact Dongmu Zhang, PhD, at +1 215 652 6097 or dongmu.zhang@merck.com.

Authors
Elkin V. Lemos, MD, PhD, Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, PA, USA, and Global Health Outcomes, Merck & Co., Inc., West Point, PA, USA
Dongmu Zhang, PhD, Global Health Outcomes, Merck & Co., Inc., West Point, PA, USA
Bradley J. Van Voorhis, MD, College of Medicine, University of Iowa, Iowa City, IA, USA
X. Henry Hu, MD, MPH, PhD, Global Health Outcomes, Merck & Co., Inc., West Point, PA, USA

About the American Journal of Obstetrics & Gynecology
The American Journal of Obstetrics & Gynecology (www.AJOG.org), known as "The Gray Journal," presents coverage of the entire spectrum of the field, from the newest diagnostic procedures to leading-edge research. The Journal provides comprehensive coverage of the specialty, including maternal-fetal medicine, reproductive endocrinology/infertility, and gynecologic oncology. It also publishes the annual meeting papers of several of its 7 sponsoring societies, including the Society for Maternal-Fetal Medicine and the Society of Gynecologic Surgeons.

The American Journal of Obstetrics & Gynecology's 2012 Impact Factor is 3.877. The journal now ranks second in Eigenfactor score, and continues to be first in total citations and the number 6 journal in the Obstetrics & Gynecology category according to the 2012 Journal Citation Reports®, published by Thomson Reuters.

The Journal's standard of excellence and continued success can be attributed to the strong leadership of Editors-in-Chief Thomas J. Garite, MD, and Moon H. Kim, MD, and their outstanding nationally and internationally recognized editorial board and reviewers. The journal has also been recognized as one of the 100 most influential journals in Biology & Medicine over the last 100 years, as determined by the BioMedical & Life Sciences Division of the Special Libraries Association (2009).

About Elsevier
Elsevier is a global information analytics company that helps institutions and professionals progress science, advance healthcare and improve performance for the benefit of humanity. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, more than 35,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX Group, a global provider of information and analytics for professionals and business customers across industries. www.elsevier.com

Media contact
Eileen Leahy
Elsevier
+1 732 238 3628
ajogmedia@elsevier.com