Given the increased interest among policy makers to expand midwifery-led care in
Ireland (Condon 2015; Culliton 2014; DOH 2015; KPMG 2008), this research aims
to provide timely, evidence-based data on the worthwhileness of midwifery-led care
in Ireland. In particular, this research examines women’s preferences for maternity
care, and examines whether women would utilise midwifery-led care when presented
this option. This research addresses the question of efficiency with respect to the two
major models of maternity care: consultant- and midwifery-led care. The specific
methodology employed to investigate maternal preferences in this thesis is stated
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analysis (CBA), which provides a comprehensive framework for decision making on
the relative efficiency of competing alternatives. These methodologies present an
interesting opportunity to investigate demand and evaluate the worthwhileness of
consultant- and midwifery-led care in Ireland.
The basis for CBA stems from welfare analysis, which seeks to obtain a social ordering
of alternative states of the world (Broadway and Bruce 1984). It assumes that
individuals behave in a way that is utility maximising, and these utilities can be used
to describe social welfare when aggregated across all individuals. When deciding on
an allocation of resources, the role of government or policy makers is to maximise
social welfare (McGuire 2001). CBA provides a comprehensive framework for
decision making on socially desirable uses of resources (Mishan 1971).
In health care, CBA can be used to guide decision making on competing uses of
resources. For instance, it can be used to determine the worthwhileness of a new
cardiac or maternity unit, or a new drug. However, price and quantity signals are often
unobservable in health care due to market failure, which characteristically arises from
risk and uncertainty regarding illness, externalities, information asymmetries between
the health care provider and patient, and oligopolies (Donaldson and Gerard 1993).
The presence of market failure in health care often requires government intervention.
As a consequence, the conditions required to observe price and quantity signals are
absent when health care is provided through collectively funded health care systems
(McIntosh 2010b). This lack of data, referred to as revealed preference (RP) data,
restricts the approach to alternative measures, including the SP method, travel cost
method, and hedonic approach. Despite its advantages relative to other economic
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Williams 2001), CBA remains under-utilised in the health economics literature. The
difficulty of the approach lies in applying a valid and reliable monetary valuation to
health and health care (McGuire 2001).
SP methodology is widely used to elicit monetary valuations of health and health care,
although the literature rarely progresses to compare these valuations against costs in a
formal CBA (McIntosh 2010b). Two SP techniques are commonly used to value
health and health care: a discrete choice experiment (DCE) and contingent valuation
method (CVM). A DCE is a survey-based measure which examines expected
behaviour (Lancsar and Louviere 2008). Respondents are presented with a set of
hypothetical alternatives and asked to select their preferred scenario. The alternatives
are described and compared using attributes, which are characteristic of the goods or
services on offer (Amaya-Amaya et al 2008; Lancsar and Louviere 2008). Value is
captured in a DCE through the inclusion of a cost attribute, also referred to as a
willingness to pay (WTP) attribute. The CVM is also a survey-based SP technique
which examines expected behaviour (McIntosh 2010b). In a contingent valuation
study, respondents are presented with an alternative and asked to infer how much they
would be willing to pay to experience that particular good or service, for example. The
CVM approach differs to the DCE in that it measures value holistically.
This thesis employs both techniques to assess the performance of the different
methodology to inform benefit valuations within CBA. First, qualitative research is
undertaken to identify the features of maternity care that influence women’s decision- making when choosing between consultant- and midwifery-led care. These data are
used to inform attribute development for the DCE and CVM. Given the flexibility of
13
strengths of preferences for consultant- and midwifery-led care and model potential
market uptake for the different models of care. The data obtained from the CVM are
incorporated into a formal CBA that examines the costs and benefits of care in a CLU
and MLU for a low risk woman availing of maternity care.
The data presented throughout this thesis derive from primary data collection. As the
SP methodology is survey-based, pregnant women are invited to participate in the
DCE and CVM, while the qualitative research also relies on the views of pregnant
women to inform attribute development. The qualitative research invites 196 women
to participate in the study from one maternity unit. The DCE and CVM are distributed
across a number of maternity units in Ireland to provide an all-encompassing view of
preferences. Four hundred surveys containing the DCE are distributed across two
maternity units, and 1,150 surveys containing the CVM are distributed across five
maternity units. The surveys are designed as self-completion postal questionnaires,
and women receiving antenatal care are invited at random to participate in the studies.
A cost analysis of consultant- and midwifery-led care is undertaken to inform cost
estimates for use in the CBA, where the data derive from primary data collection.
The specific research aims and objectives of this thesis are outlined below, in section