A Value-Based Health Care Maternity Program and Perinatal Outcomes in Brazil.

Abstract

The Brazilian private health sector is characterized by cesarean delivery rates approaching 88% and fragmented maternity care models, contributing to preventable perinatal complications and high health care costs. Value-based health care (VBHC) frameworks offer a structured approach to aligning care delivery with outcomes that matter to patients. The authors conducted a propensity score-matched cohort study using data from 5477 consecutive pregnancies delivered between January 2022 and March 2026 at Hospital and Maternity São Joaquim, Franca, São Paulo, Brazil. The matched analysis was restricted to 2022-2024 (N=3791), the period in which balanced 1:1 matching was achievable; later years are reported descriptively. To reduce selection bias, propensity score matching incorporated maternal age, multiple gestation, prior cesarean delivery, gestational age at first prenatal visit, gestational comorbidities, and year of delivery (area under the curve=0.770). Program participants were matched 1:1 to nonparticipants using nearest-neighbor matching with a caliper of 0.2 standard deviations of the logit of the propensity score, yielding 678 matched pairs. Primary outcomes included preterm birth rate (<37 weeks), early-term birth rate (37 0 days to 38 weeks 6 days), full-term delivery rate (≥39 weeks), and maternal ICU and NICU admissions. Secondary outcomes included mode of delivery, ED utilization, and direct medical costs. Reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. After matching, participants demonstrated significantly lower rates of preterm birth (6.0% vs. 12.4%; odds ratio 0.46, 95% confidence interval [CI], 0.31 to 0.68; P<0.001), higher rates of full-term delivery (58.8% vs. 52.2%; odds ratio 1.31, 95% CI, 1.06 to 1.63; P=0.016), and lower NICU admission rates (2.8% vs. 7.2%; odds ratio 0.37, 95% CI, 0.22 to 0.64; P<0.001). Maternal ICU admissions were also significantly reduced (0.3% vs. 2.2%; odds ratio 0.13, 95% CI, 0.03 to 0.58; P=0.004). Early-term births accounted for approximately 35% of deliveries in both groups (35.1% vs. 35.4%), unchanged by participation. The overall cesarean delivery rate remained high (82.4% vs. 87.6%; odds ratio 0.67, 95% CI, 0.49 to 0.90; P=0.010), with no significant difference in ED utilization after matching (P=0.097). Findings for preterm birth, full-term delivery, and both ICU outcomes were reproduced under inverse probability of treatment weighting. Across the 2023-2024 program period, mean direct cost per birth episode differed by R$2879 between participants (R$11,834) and nonparticipants (R$14,713), corresponding to an estimated total direct cost difference of R$4,764,830 across the 1655 participants delivering in that period; however, that population-level comparison is unadjusted and its difference was not demonstrable within matched pairs, where median per-episode costs were comparable. Notably, the study shows that participation in a coordinated, VBHC-oriented maternity program was independently associated with improved perinatal outcomes and reduced high-acuity health care utilization, even after accounting for selection bias. Strategies specifically targeting delivery mode decisions, intrapartum care organization, and early-term delivery remain essential for comprehensive VBHC implementation.