Download PDF
Am J Perinatol 2019; 36(07): 678-687
DOI: 10.1055/s-0038-1676495
SMFM Fellowship Series Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Cytomegalovirus Screening in Pregnancy: A Cost-Effectiveness and Threshold Analysis

Catherine M. Albright
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
,
Erika F. Werner
2   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Women and Infants Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
,
Brenna L. Hughes
3   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina
› Author Affiliations
Further Information

Publication History

28 June 2018

30 October 2018

Publication Date:
19 December 2018 (online)

   Permissions and Reprints

Abstract

Objective To determine threshold cytomegalovirus (CMV) infectious rates and treatment effectiveness to make universal prenatal CMV screening cost-effective.

Study Design Decision analysis comparing cost-effectiveness of two strategies for the prevention and treatment of congenital CMV: universal prenatal serum screening and routine, risk-based screening. The base case assumptions were a probability of primary CMV of 1% in seronegative women, hyperimmune globulin (HIG) effectiveness of 0%, and behavioral intervention effectiveness of 85%. Screen-positive women received monthly HIG and screen-negative women received behavioral counseling to decrease CMV seroconversion. The primary outcome was the cost per maternal quality-adjusted life year (QALY) gained with a willingness to pay of $100,000 per QALY.

Results In the base case, universal screening is cost-effective, costing $84,773 per maternal QALY gained. In sensitivity analyses, universal screening is cost-effective only at a primary CMV incidence of more than 0.89% and behavioral intervention effectiveness of more than 75%. If HIG is 30% effective, primary CMV incidence can be 0.82% for universal screening to be cost-effective.

Conclusion The cost-effectiveness of universal maternal screening for CMV is highly dependent on the incidence of primary CMV in pregnancy. If efficacious, HIG and behavioral counseling allow universal screening to be cost-effective at lower primary CMV rates.

Keywords

cytomegalovirus - cost-effectiveness - pregnancy - hyperimmune globulin - behavioral intervention

Note

This study was presented as a poster at the 2015 Society for Maternal-Fetal Medicine Annual Meeting, February 2–7, 2015, San Diego, CA.


 

  • References

  • 1 Cannon MJ. Congenital cytomegalovirus (CMV) epidemiology and awareness. J Clin Virol 2009; 46 (Suppl 4): S6-S10
    PubMedGoogle Scholar
  • 2 Boppana SB, Ross SA, Fowler KB. Congenital cytomegalovirus infection: clinical outcome. Clin Infect Dis 2013; 57 (Suppl 4): S178-S181
    CrossrefPubMedGoogle Scholar
  • 3 Britt W. Cytomegalovirus A2. In: Remington JS, Klein JO, Wilson CB, Nizet V, Maldonado YA, eds. Infectious Diseases of the Fetus and Newborn, 7th edition. Chap 23. Philadelphia: W.B. Saunders; 2011:706–755
  • 4 Hyde TB, Schmid DS, Cannon MJ. Cytomegalovirus seroconversion rates and risk factors: implications for congenital CMV. Rev Med Virol 2010; 20 (05) 311-326
    CrossrefPubMedGoogle Scholar
  • 5 Revello MG, Gerna G. Diagnosis and management of human cytomegalovirus infection in the mother, fetus, and newborn infant. Clin Microbiol Rev 2002; 15 (04) 680-715
    CrossrefPubMedGoogle Scholar
  • 6 Revello MG, Tibaldi C, Masuelli G. , et al; CCPE Study Group Prevention of primary cytomegalovirus infection in pregnancy. EBioMedicine 2015; 2 (09) 1205-1210
    CrossrefPubMedGoogle Scholar
  • 7 American College of Obstetricians and Gynecologists Practice bulletin no. 151: Cytomegalovirus, parvovirus B19, varicella zoster, and toxoplasmosis in pregnancy. Obstet Gynecol 2015; 125 (06) 1510-1525
    CrossrefPubMedGoogle Scholar
  • 8 Hughes BL, Gyamfi-Bannerman C. ; Society for Maternal-Fetal Medicine (SMFM). Diagnosis and antenatal management of congenital cytomegalovirus infection. Am J Obstet Gynecol 2016; 214 (06) B5-B11
    CrossrefPubMedGoogle Scholar
  • 9 Revello MG, Campanini G, Piralla A. , et al. Molecular epidemiology of primary human cytomegalovirus infection in pregnant women and their families. J Med Virol 2008; 80 (08) 1415-1425
    CrossrefPubMedGoogle Scholar
  • 10 Staras SA, Flanders WD, Dollard SC, Pass RF, McGowan Jr JE, Cannon MJ. Cytomegalovirus seroprevalence and childhood sources of infection: a population-based study among pre-adolescents in the United States. J Clin Virol 2008; 43 (03) 266-271
    CrossrefPubMedGoogle Scholar
  • 11 Adler SP, Finney JW, Manganello AM, Best AM. Prevention of child-to-mother transmission of cytomegalovirus by changing behaviors: a randomized controlled trial. Pediatr Infect Dis J 1996; 15 (03) 240-246
    CrossrefPubMedGoogle Scholar
  • 12 Harvey J, Dennis C-L. Hygiene interventions for prevention of cytomegalovirus infection among childbearing women: systematic review. J Adv Nurs 2008; 63 (05) 440-450
    CrossrefPubMedGoogle Scholar
  • 13 Cannon MJ, Westbrook K, Levis D, Schleiss MR, Thackeray R, Pass RF. Awareness of and behaviors related to child-to-mother transmission of cytomegalovirus. Prev Med 2012; 54 (05) 351-357
    CrossrefPubMedGoogle Scholar
  • 14 Adler SP, Finney JW, Manganello AM, Best AM. Prevention of child-to-mother transmission of cytomegalovirus among pregnant women. J Pediatr 2004; 145 (04) 485-491
    CrossrefPubMedGoogle Scholar
  • 15 Vauloup-Fellous C, Picone O, Cordier A-G. , et al. Does hygiene counseling have an impact on the rate of CMV primary infection during pregnancy? Results of a 3-year prospective study in a French hospital. J Clin Virol 2009; 46 (Suppl 4): S49-S53
    PubMedGoogle Scholar
  • 16 Centers for Disease Control and Prevention (CDC). Knowledge and practices of obstetricians and gynecologists regarding cytomegalovirus infection during pregnancy--United States, 2007. Morb Mortal Wkly Rep 2008; 57 (03) 65-68
    PubMedGoogle Scholar
  • 17 Korver AM, de Vries JJ, de Jong JW, Dekker FW, Vossen AC, Oudesluys-Murphy AM. Awareness of congenital cytomegalovirus among doctors in the Netherlands. J Clin Virol 2009; 46 (Suppl 4): S11-S15
    PubMedGoogle Scholar
  • 18 Hughes BL, Gans KM, Raker C, Hipolito ER, Rouse DJ. A brief prenatal intervention of behavioral change to reduce the risk of maternal cytomegalovirus: a randomized controlled trial. Obstet Gynecol 2017; 130 (04) 726-734
    CrossrefPubMedGoogle Scholar
  • 19 Nigro G, Adler SP, La Torre R, Best AM. ; Congenital Cytomegalovirus Collaborating Group. Passive immunization during pregnancy for congenital cytomegalovirus infection. N Engl J Med 2005; 353 (13) 1350-1362
    CrossrefPubMedGoogle Scholar
  • 20 Revello MG, Lazzarotto T, Guerra B. , et al; CHIP Study Group. A randomized trial of hyperimmune globulin to prevent congenital cytomegalovirus. N Engl J Med 2014; 370 (14) 1316-1326
    CrossrefPubMedGoogle Scholar
  • 21 Cahill AG, Odibo AO, Stamilio DM, Macones GA. Screening and treating for primary cytomegalovirus infection in pregnancy: where do we stand? A decision-analytic and economic analysis. Am J Obstet Gynecol 2009; 201 (05) 466.e1-466.e7
    CrossrefPubMedGoogle Scholar
  • 22 Guerra B, Simonazzi G, Puccetti C. , et al. Ultrasound prediction of symptomatic congenital cytomegalovirus infection. Am J Obstet Gynecol 2008; 198 (04) 380.e1-380.e7
    CrossrefPubMedGoogle Scholar
  • 23 Pryde PG, Drugan A, Johnson MP, Isada NB, Evans MI. Prenatal diagnosis: choices women make about pursuing testing and acting on abnormal results. Clin Obstet Gynecol 1993; 36 (03) 496-509
    CrossrefPubMedGoogle Scholar
  • 24 Revello MG, Fabbri E, Furione M. , et al. Role of prenatal diagnosis and counseling in the management of 735 pregnancies complicated by primary human cytomegalovirus infection: a 20-year experience. J Clin Virol 2011; 50 (04) 303-307
    CrossrefPubMedGoogle Scholar
  • 25 Visentin S, Manara R, Milanese L. , et al. Early primary cytomegalovirus infection in pregnancy: maternal hyperimmunoglobulin therapy improves outcomes among infants at 1 year of age. Clin Infect Dis 2012; 55 (04) 497-503
    CrossrefPubMedGoogle Scholar
  • 26 LeFevre ML, Bain RP, Ewigman BG, Frigoletto FD, Crane JP, McNellis D. ; RADIUS (Routine Antenatal Diagnostic Imaging with Ultrasound) Study Group. A randomized trial of prenatal ultrasonographic screening: impact on maternal management and outcome. Am J Obstet Gynecol 1993; 169 (03) 483-489
    CrossrefPubMedGoogle Scholar
  • 27 Pham CT, Crowther CA. Birth outcomes: utility values that postnatal women, midwives and medical staff express. BJOG 2003; 110 (02) 121-127
    CrossrefPubMedGoogle Scholar
  • 28 Vandenbussche FP, De Jong-Potjer LC, Stiggelbout AM, Le Cessie S, Keirse MJ. Differences in the valuation of birth outcomes among pregnant women, mothers, and obstetricians. Birth 1999; 26 (03) 178-183
    CrossrefPubMedGoogle Scholar
  • 29 Kaimal AJ, Norton ME, Kuppermann M. Prenatal testing in the genomic age: clinical outcomes, quality of life, and costs. Obstet Gynecol 2015; 126 (04) 737-746
    CrossrefPubMedGoogle Scholar
  • 30 Kuppermann M, Norton ME, Thao K. , et al. Preferences regarding contemporary prenatal genetic tests among women desiring testing: implications for optimal testing strategies. Prenat Diagn 2016; 36 (05) 469-475
    CrossrefPubMedGoogle Scholar
  • 31 Kuppermann M, Nease RF, Learman LA, Gates E, Blumberg B, Washington AE. Procedure-related miscarriages and Down syndrome-affected births: implications for prenatal testing based on women's preferences. Obstet Gynecol 2000; 96 (04) 511-516
    PubMedGoogle Scholar
  • 32 Sonnenberg FA, Burkman RT, Hagerty CG, Speroff L, Speroff T. Costs and net health effects of contraceptive methods. Contraception 2004; 69 (06) 447-459
    CrossrefPubMedGoogle Scholar
  • 33 Carroll AE, Downs SM. Improving decision analyses: parent preferences (utility values) for pediatric health outcomes. J Pediatr 2009; 155 (01) 21-25
    CrossrefPubMedGoogle Scholar
  • 34 Tengs TO, Wallace A. One thousand health-related quality-of-life estimates. Med Care 2000; 38 (06) 583-637
    CrossrefPubMedGoogle Scholar
  • 35 Institute of Medicine (US) Committee to Study Priorities for Vaccine Development; Stratton KR, Durch JS, Lawrence RS. Cytomegalovirus. Washington, DC: National Academies Press (US); 2000
  • 36 Moster D, Lie RT, Markestad T. Long-term medical and social consequences of preterm birth. N Engl J Med 2008; 359 (03) 262-273
    CrossrefPubMedGoogle Scholar
  • 37 Hamilton BE, Martin JA, Osterman MJ, Curtin SC, Matthews TJ. Births: final data for 2014. Natl Vital Stat Rep 2015; 64 (12) 1-64
    PubMedGoogle Scholar
  • 38 Kochanek KD, Murphy SL, Xu J, Tejada-Vera B. Deaths: final data for 2014. Natl Vital Stat Rep 2016; 65 (04) 1-122
    PubMedGoogle Scholar
  • 39 Hirth RA, Chernew ME, Miller E, Fendrick AM, Weissert WG. Willingness to pay for a quality-adjusted life year: in search of a standard. Med Decis Making 2000; 20 (03) 332-342
    CrossrefPubMedGoogle Scholar
  • 40 Kaplan RM, Bush JW. Health-related quality of life measurement for evaluation research and policy analysis. Health Psychol 1982; 1 (01) 61-80
    CrossrefPubMedGoogle Scholar
  • 41 Werner EF, Wheeler S, Burd I. Creating decision trees to assess cost-effectiveness in clinical research. J Biom Biostat 2012;S7:004. Doi: 10.4172/2155-6180.S7-004
    PubMedGoogle Scholar
  • 42 Gantt S, Dionne F, Kozak FK. , et al. Cost-effectiveness of universal and targeted newborn screening for congenital cytomegalovirus infection. JAMA Pediatr 2016; 170 (12) 1173-1180
    CrossrefPubMedGoogle Scholar
  • 43 Kenneson A, Cannon MJ. Review and meta-analysis of the epidemiology of congenital cytomegalovirus (CMV) infection. Rev Med Virol 2007; 17 (04) 253-276
    CrossrefPubMedGoogle Scholar
  • 44 Dollard SC, Grosse SD, Ross DS. New estimates of the prevalence of neurological and sensory sequelae and mortality associated with congenital cytomegalovirus infection. Rev Med Virol 2007; 17 (05) 355-363
    CrossrefPubMedGoogle Scholar
  • 45 Wang C, Zhang X, Bialek S, Cannon MJ. Attribution of congenital cytomegalovirus infection to primary versus non-primary maternal infection. Clin Infect Dis 2011; 52 (02) e11-e13
    CrossrefPubMedGoogle Scholar
  • 46 Bate SL, Dollard SC, Cannon MJ. Cytomegalovirus seroprevalence in the United States: the national health and nutrition examination surveys, 1988-2004. Clin Infect Dis 2010; 50 (11) 1439-1447
    CrossrefPubMedGoogle Scholar
  • 47 Cannon MJ, Schmid DS, Hyde TB. Review of cytomegalovirus seroprevalence and demographic characteristics associated with infection. Rev Med Virol 2010; 20 (04) 202-213
    CrossrefPubMedGoogle Scholar
  • 48 Lazzarotto T, Spezzacatena P, Varani S. , et al. Anticytomegalovirus (anti-CMV) immunoglobulin G avidity in identification of pregnant women at risk of transmitting congenital CMV infection. Clin Diagn Lab Immunol 1999; 6 (01) 127-129
    CrossrefPubMedGoogle Scholar
  • 49 Lazzarotto T, Gabrielli L, Lanari M. , et al. Congenital cytomegalovirus infection: recent advances in the diagnosis of maternal infection. Hum Immunol 2004; 65 (05) 410-415
    CrossrefPubMedGoogle Scholar
  • 50 Macé M, Sissoeff L, Rudent A, Grangeot-Keros L. A serological testing algorithm for the diagnosis of primary CMV infection in pregnant women. Prenat Diagn 2004; 24 (11) 861-863
    CrossrefPubMedGoogle Scholar
  • 51 Goegebuer T, Van Meensel B, Beuselinck K. , et al. Clinical predictive value of real-time PCR quantification of human cytomegalovirus DNA in amniotic fluid samples. J Clin Microbiol 2009; 47 (03) 660-665
    CrossrefPubMedGoogle Scholar
  • 52 Liesnard C, Donner C, Brancart F, Gosselin F, Delforge ML, Rodesch F. Prenatal diagnosis of congenital cytomegalovirus infection: prospective study of 237 pregnancies at risk. Obstet Gynecol 2000; 95 (6 Pt 1) 881-888
    PubMedGoogle Scholar
  • 53 Azam AZ, Vial Y, Fawer CL, Zufferey J, Hohlfeld P. Prenatal diagnosis of congenital cytomegalovirus infection. Obstet Gynecol 2001; 97 (03) 443-448
    PubMedGoogle Scholar
  • 54 Enders M, Daiminger A, Exler S, Ertan K, Enders G, Bald R. Prenatal diagnosis of congenital cytomegalovirus infection in 115 cases: a 5 years' single center experience. Prenat Diagn 2017; 37 (04) 389-398
    CrossrefPubMedGoogle Scholar
  • 55 Bilavsky E, Pardo J, Attias J. , et al. Clinical implications for children born with congenital cytomegalovirus infection following a negative amniocentesis. Clin Infect Dis 2016; 63 (01) 33-38
    CrossrefPubMedGoogle Scholar
  • 56 Guerra B, Simonazzi G, Banfi A. , et al. Impact of diagnostic and confirmatory tests and prenatal counseling on the rate of pregnancy termination among women with positive cytomegalovirus immunoglobulin M antibody titers. Am J Obstet Gynecol 2007; 196 (03) 221.e1-221.e6
    CrossrefPubMedGoogle Scholar
  • 57 Crane JP, LeFevre ML, Winborn RC. , et al; The RADIUS Study Group A randomized trial of prenatal ultrasonographic screening: impact on the detection, management, and outcome of anomalous fetuses. Am J Obstet Gynecol 1994; 171 (02) 392-399
    CrossrefPubMedGoogle Scholar
  • 58 Beke A, Latkóczy K, Nagy GR. , et al. Comparison of prevalence of toxoplasma and cytomegalovirus infection in cases with fetal ultrasound markers in the second trimester of pregnancy. Prenat Diagn 2011; 31 (10) 945-948
    CrossrefPubMedGoogle Scholar
  • 59 Polilli E, Parruti G, D'Arcangelo F. , et al. Preliminary evaluation of the safety and efficacy of standard intravenous immunoglobulins in pregnant women with primary cytomegalovirus infection. Clin Vaccine Immunol 2012; 19 (12) 1991-1993
    CrossrefPubMedGoogle Scholar
  • 60 Centers for Disease Control and Prevention (CDC) Renal insufficiency and failure associated with immune globulin intravenous therapy--United States, 1985-1998. Morb Mortal Wkly Rep 1999; 48 (24) 518-521
    PubMedGoogle Scholar
  • 61 Odibo AO, Gray DL, Dicke JM, Stamilio DM, Macones GA, Crane JP. Revisiting the fetal loss rate after second-trimester genetic amniocentesis: a single center's 16-year experience. Obstet Gynecol 2008; 111 (03) 589-595
    CrossrefPubMedGoogle Scholar
  • 62 Eddleman KA, Malone FD, Sullivan L. , et al. Pregnancy loss rates after midtrimester amniocentesis. Obstet Gynecol 2006; 108 (05) 1067-1072
    CrossrefPubMedGoogle Scholar
  • 63 Mujezinovic F, Alfirevic Z. Procedure-related complications of amniocentesis and chorionic villous sampling: a systematic review. Obstet Gynecol 2007; 110 (03) 687-694
    CrossrefPubMedGoogle Scholar
  • 64 Akolekar R, Beta J, Picciarelli G, Ogilvie C, D'Antonio F. Procedure-related risk of miscarriage following amniocentesis and chorionic villus sampling: a systematic review and meta-analysis. Ultrasound Obstet Gynecol 2015; 45 (01) 16-26
    CrossrefPubMedGoogle Scholar
  • 65 Enders G, Bäder U, Lindemann L, Schalasta G, Daiminger A. Prenatal diagnosis of congenital cytomegalovirus infection in 189 pregnancies with known outcome. Prenat Diagn 2001; 21 (05) 362-377
    CrossrefPubMedGoogle Scholar
  • 66 Stagno S, Whitley RJ. Herpesvirus infections of pregnancy. Part I: cytomegalovirus and Epstein-Barr virus infections. N Engl J Med 1985; 313 (20) 1270-1274
    CrossrefPubMedGoogle Scholar
  • 67 Stagno S, Pass RF, Cloud G. , et al. Primary cytomegalovirus infection in pregnancy. Incidence, transmission to fetus, and clinical outcome. JAMA 1986; 256 (14) 1904-1908
    CrossrefPubMedGoogle Scholar
  • 68 Fowler KB, Stagno S, Pass RF, Britt WJ, Boll TJ, Alford CA. The outcome of congenital cytomegalovirus infection in relation to maternal antibody status. N Engl J Med 1992; 326 (10) 663-667
    CrossrefPubMedGoogle Scholar
  • 69 Fetal and Perinatal Mortality. United States, 2006. 2012. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_08.pdf . Accessed August 6, 2018
    PubMed
  • 70 Clements KM, Barfield WD, Ayadi MF, Wilber N. Preterm birth-associated cost of early intervention services: an analysis by gestational age. Pediatrics 2007; 119 (04) e866-e874
    CrossrefPubMedGoogle Scholar
  • 71 Phibbs CS, Schmitt SK. Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants. Early Hum Dev 2006; 82 (02) 85-95
    CrossrefPubMedGoogle Scholar
  • 72 McIntire DD, Bloom SL, Casey BM, Leveno KJ. Birth weight in relation to morbidity and mortality among newborn infants. N Engl J Med 1999; 340 (16) 1234-1238
    CrossrefPubMedGoogle Scholar
  • 73 Smith GC. Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies. Am J Obstet Gynecol 2001; 184 (03) 489-496
    CrossrefPubMedGoogle Scholar
  • 74 Luan FL, Kommareddi M, Ojo AO. Universal prophylaxis is cost effective in cytomegalovirus serology-positive kidney transplant patients. Transplantation 2011; 91 (02) 237-244
    CrossrefPubMedGoogle Scholar
  • 75 Harris RA, Washington AE, Nease Jr RF, Kuppermann M. Cost utility of prenatal diagnosis and the risk-based threshold. Lancet 2004; 363 (9405) 276-282
    CrossrefPubMedGoogle Scholar
  • 76 Odibo AO, Stamilio DM, Nelson DB, Sehdev HM, Macones GA. A cost-effectiveness analysis of prenatal screening strategies for Down syndrome. Obstet Gynecol 2005; 106 (03) 562-568
    CrossrefPubMedGoogle Scholar
  • 77 Physician Fee Schedule Search.. Available at: https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx . Accessed August 6, 2018
    PubMed
  • 78 Hawk AF, Chang EY, Shields SM, Simpson KN. Costs and clinical outcomes of noninvasive fetal RhD typing for targeted prophylaxis. Obstet Gynecol 2013; 122 (03) 579-585
    CrossrefPubMedGoogle Scholar
  • 79 Duff P. Diagnosis and Management of CMV Infection in Pregnancy. 2010. Available at: http://www.perinatology.com//perinatology/Volume1-Issue1/Cytomegalovirusprint.htm . Accessed August 6, 2018
    PubMed
  • 80 Jordan S, Cunningham-Rundles C, McEwan R. Utility of intravenous immune globulin in kidney transplantation: efficacy, safety, and cost implications. Am J Transplant 2003; 3 (06) 653-664
    CrossrefPubMedGoogle Scholar
  • 81 Drug Result Page - MICROMEDEX®. Available at: http://www.micromedexsolutions.com/micromedex2/librarian/CS/19417E/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/8BB230/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.GoToDashboard?docId=153000&contentSetId=100&title=Cytomegalovirus+Immune+Globulin%2C+Human&servicesTitle=Cytomegalovirus+Immune+Globulin%2C+Human&brandName=Cytogam# . Accessed August 6, 2018
    PubMed
  • 82 Bivins Jr HA, McCallum OJ, Roegge DD. The Mother's House: a new concept in antepartum care. Am J Obstet Gynecol 2007; 197 (02) 201.e1-201.e3
    CrossrefPubMedGoogle Scholar
  • 83 Caughey AB, Kuppermann M, Norton ME, Washington AE. Nuchal translucency and first trimester biochemical markers for down syndrome screening: a cost-effectiveness analysis. Am J Obstet Gynecol 2002; 187 (05) 1239-1245
    CrossrefPubMedGoogle Scholar
  • 84 Gold KJ, Sen A, Xu X. Hospital costs associated with stillbirth delivery. Matern Child Health J 2013; 17 (10) 1835-1841
    CrossrefPubMedGoogle Scholar
  • 85 Gilbert WM, Nesbitt TS, Danielsen B. The cost of prematurity: quantification by gestational age and birth weight. Obstet Gynecol 2003; 102 (03) 488-492
    PubMedGoogle Scholar
  • 86 Waitzman NJ, Romano PS, Scheffler RM. Estimates of the economic costs of birth defects. Inquiry 1994; 31 (02) 188-205
    PubMedGoogle Scholar
  • 87 Mohr PE, Feldman JJ, Dunbar JL. , et al. The societal costs of severe to profound hearing loss in the United States. Int J Technol Assess Health Care 2000; 16 (04) 1120-1135
    CrossrefPubMedGoogle Scholar
  • 88 Keren R, Helfand M, Homer C, McPhillips H, Lieu TA. Projected cost-effectiveness of statewide universal newborn hearing screening. Pediatrics 2002; 110 (05) 855-864
    CrossrefPubMedGoogle Scholar
  • 89 Dempsey JC, Sorensen TK, Williams MA. , et al. Prospective study of gestational diabetes mellitus risk in relation to maternal recreational physical activity before and during pregnancy. Am J Epidemiol 2004; 159 (07) 663-670
    CrossrefPubMedGoogle Scholar