Effects of different payment methods on perinatal care outcomes: a systematic review

Abstract

Background

Respectful maternity care in healthcare facilities during childbirth is a growing concern around the world. It is more than just an important component of care quality; it is also a human right. The aim of this study was to develop and validate a tool to assess respectful maternity care practices among healthcare providers in Nepal.

Methods

We systematically searched primary studies published until May 2023, adhering to PRISMA guidelines. Studies evaluating causal effects of payment methods on perinatal outcomes were included. Quality was assessed using the JBI-MAStARI tools. Due to heterogeneity in the studies, a meta-analysis was not feasible; findings were summarized narratively and presented in tables/ figures.

Results

Fifty-three studies were included, focusing on prenatal care (62%), childbirth (28%), and NICU care (10%). Pay-for-performance (P4P) methods improved institutional deliveries and reduced costs but had minimal effects on prenatal care quality. Diagnosis-Related Groups (DRGs) methods reduced cesarean rates but increased complications compared to Fee-For-Service (FFS). Bundled payments lowered cesarean rates and costs, while blended methods also reduced rates but increased postpartum hemorrhage. In NICU care, DRG methods increased the length of stay (LoS) and costs, primarily due to upcoding.

Conclusion

The effectiveness of payment methods depends heavily on their design, implementation, and context. Poorly designed programs, despite their potential, can lead to adverse outcomes. Further research is needed to develop effective and equitable payment models that sustainably enhance maternal and neonatal health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13160-3.

Introduction

Reducing the infant mortality rate (IMR) to no more than 12 deaths per 1,000 live births by 2023 is a key target of the Sustainable Development Goals (SDGs) [1]. Although the global IMR has declined significantly from 36.6 deaths per 1,000 live births in 1990 to 17.5 deaths per 1,000 live births, infants, particularly in developing countries, continue to face severe health challenges [2]. The leading causes of neonatal mortality include complications during birth and asphyxia, low birth weight (LBW) and prematurity, and infections [3]. Notably, over half of neonatal deaths in low- and middle-income countries (LMICs) can be prevented through affordable and effective interventions [3].

Improving infant health remains a critical global health priority [4–7]. Interventions during the prenatal, child birth, and postnatal periods are essential for improving long-term health outcomes and fostering human capital development [8]. Research shows that financial support for economically disadvantaged pregnant women, provided either during pregnancy or before conception, significantly improves birth outcomes [8, 9]. These interventions not only reduce the incidence of LBW by prolonging gestation and enhancing fetal growth in the short term, but also lower the risk of metabolic disorders in the long term [8].

The method of payment during pregnancy and delivery plays a crucial role in shaping maternal and neonatal health outcomes [10–12]. Both the type of payment model and the reimbursement amount significantly impact provider behavior. Fee for service (FFS) models, for instance, often deviate from optimal care practices and can promote overtreatment [13, 14]. In the context of perinatal care, such models may hinder multidisciplinary collaboration among providers, potentially resulting in adverse maternal and child health outcomes [15]. Alternative payment models (APMS), on the other hand, aim to shift financial responsibility from payers to providers, thereby enhancing health outcomes and reducing costs by curbing the over-provision of services [12]. For instance, performance-based payment methods have been shown to improve gestational age and birth weight by increasing the frequency of prenatal visits [16]. The payment model used in neonatal intensive care units (NICUs) also significantly influences provider behavior, often creating induced demand due to providers’ greater access to patient and insurer information [17].Similarly, reimbursement rates for providers can affect both the quantity and quality of prenatal and postnatal care visits. Quality care during pregnancy can improve birth weight and reduce the likelihood of long-term hospitalization for newborns [10]. However, higher payment rates for childbirth, particularly for cesarean sections (CS) performed without medical necessity and indications, may lead to increased risks for both mothers and newborns. Mothers are at higher risk of surgical site infections, while newborns may experience respiratory distress, necessitating NICUs care and raising overall healthcare costs [18, 19]. Therefore, understanding how different payment methods influence provider behavior and outcomes in prenatal, child birth, and NICUs care is critical for designing effective policies. This study aims to identify the range of payment methods used during these stages of care and to examine their relationship with provider behavior. Additionally, we explore how these payment methods ultimately affect the health of mothers and their newborns.

Materials and methods

Search strategy for identifying studies

The search strategy was developed to identify both published and unpublished primary studies (grey literature) up to May 2023, with guidance from a medical librarian. Combinations of the following search terms were employed to retrieve relevant records: “perinatal service”, “antenatal care”, “neonatal care”, “intensive care unit, neonatal”, “reimbursement mechanism”, “prospective payment”, “retrospective payment”, “alternative payment”. The search strategy was conducted in three stages. First, a preliminary search was performed in the PubMed and Web of Science databases to identify relevant studies. Second, the text words in the titles and abstracts of the retrieved articles were analyzed to refine the search terms and improve the search strategy. Finally, the reference lists of all identified reports and articles were screened to uncover additional relevant studies.

International and specialized databases, including PubMed, Embase, Web of Science, Scopus, ProQuest, the World Health Organization website, the World Bank website, Open Grey, and the Cochrane Central Register of Controlled Trials (CENTRAL), were searched. However, the systematic review was not registered in any systematic review registry.

Study selection

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Titles and abstracts were screened based on the study population (providers of prenatal, childbirth, and NICUs care), intervention (payment models for perinatal care and neonatal hospitalization), and outcomes of interest. Key outcomes were categorized into four domains: quality, satisfaction, clinical outcomes, and costs. Quality included institutional delivery, vaccination, prenatal care, and availability of medications and medical supplies. Satisfaction encompassed both provider and patient satisfaction, reflecting perceived quality and expectations. Clinical outcomes encompassed negative pregnancy outcomes, premature birth, LBW, CS rates, and other health indicators. Costs included out-of-pocket payments and overall healthcare expenditures. These outcomes were deemed essential for evaluating the effects of different payment methods on maternal and neonatal health during the perinatal period. However, it is acknowledged that other potentially relevant outcomes might not have been included. Studies with robust methodologies that could explain causal relationships between payment methods and provider behavior outcomes were included. In the final screening stage, all full texts that were available were reviewed. Conference articles, letters to the editor, review studies, systematic reviews, guidelines, and studies that required emailing the authors for clarification but did not receive a response were excluded.

Data extraction and quality assessment

Two reviewers (ZO and MNM) collaboratively developed a data extraction form aligned with the study objectives. The extracted data included general information about the study, details about participants and the study location, the study method, the type of payment method (intervention), and the reported outcomes. The methodological quality of the included studies was independently assessed by the two reviewers using standardized critical appraisal instruments from the Joanna Briggs Institute’s Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) [20]. Any disagreements between the reviewers were resolved through discussion with a third reviewer (VYF).

Data synthesis and analysis

Due to the high heterogeneity among the included studies, a meta-analysis was not feasible. Instead, a narrative synthesis approach was adopted. Key information from each study was extracted and categorized into four main areas: quality, satisfaction, clinical outcomes, and costs. These findings were then organized into tables summarizing the relationships and outcomes associated with each payment model. To enhance clarity and facilitate interpretation, the tabulated data were visualized using a color-coding scheme, providing a comprehensive overview of the diverse findings without relying on statistical aggregation.

Results

Database search results

The literature search identified a total of 4,623 potentially eligible articles up to May 2023. After screening the titles and abstracts, 197 articles were selected for full-text reading. Of these, 144 full-text studies were excluded for various reasons, and 53 studies were ultimately included in this review (Fig. 1).

Fig. 1.

PRISMA Flow Diagram of Payment methods for perinatal care

Quality assessment results

The quality of all studies that met the inclusion criteria was assessed. Most studies were quasi-experimental, clinical trials, or observational studies, with many lacking a control group or randomization. Two studies were excluded due to a high risk of bias [21, 22], three had a moderate risk of bias [23–25], and the rest had a lower risk of bias. Selection bias was high in these studies due to the absence of randomization. Additionally, there was a risk of regression to the mean, recall errors, and confounding factors due to short study periods and the nature of data collection methods. Clinical trial studies showed a low risk of bias.

Characteristics of included studies

The studies were grouped into three categories: payments for pregnancy (62%) [12, 26–57], childbirth (28%) [18, 23–25, 58–68], and NICUs care (10%) [17, 23, 69–72] (Fig. 2). One study [23] examined both childbirth and NICUs payments. Most studies were quasi-experimental studies on prenatal care published between 2012 and 2022, primarily from Africa (Fig. 3). The number of studies that investigating variable payment methods (63%) exceeded those examining fixed payment methods (37%) (Fig. 2).

Fig. 2.

Types of payment methods examined in the studies and publication years of articles related to the payment methods for perinatal care

Fig. 3.

Geographical distribution of the studies

Payment methods in prenatal care

A total of 33 studies met the inclusion criteria for prenatal care (Supplementary Table 1). These studies were categorized into five main payment models: P4P vs. non-P4P; P4P vs. FFS and fixed payment; P4P vs. capitation; episode-based payment vs. FFS, and blended (FFS + incentive) vs. FFS; blended (1/2 capitation + 2/3 FFS) vs. capitation. The results of the studies were extracted and organized into a table (Supplementary Table 2), detailing the relationships between the variables of interest. To enhance clarity, these data were visualized as a color-coded figure (Table 1).

Table 1.

Summary of results related to prenatal care payment methods

P4P vs. non-P4P

The implementation of P4P was associated with several positive effects on quality, costs, and clinical outcomes. It was linked to significant improvements in institutional deliveries and access to medicines and medical supplies, with 86.7% (13 out of 15) of studies reporting improvements in institutional deliveries. Additionally, 50% (5 out of 10) showed increased vaccination rates among pregnant women. Regarding prenatal care, 53.3% (8 out of 15) of studies found no effect of P4P. Several studies reported reductions in out-of-pocket payments and total medical costs. Notably, no negative outcomes were observed in the studies that examined them. Overall, these findings suggest that P4P is positively associated with improvements in quality and reductions in medical costs without causing negative outcomes.

P4P vs. FFS and fixed payment

The P4P payment method significantly improved the quality of care in terms of institutional deliveries compared to FFS model. However, no notable effect was observed when P4P was compared to fixed payments. Provider and patient satisfaction remained unchanged in the fixed payment comparison. Nevertheless, P4P resulted in reduced costs with no effect on health outcomes (Table 1).

P4P vs. capitation

Prenatal care was either similar or started earlier in the capitation system compared to FFS. The length of stay (LoS) and likelihood of readmission were greater in the FFS model, but no significant relationship was found for adverse outcomes during hospitalization. Capitation had a negative impact on birth outcomes, particularly among younger women, compared to FFS (Table 1).

Episode-based payment vs. FFS, and blended (FFS + incentive) vs. FFS

Episode-based payment was associated with reduced costs but demonstrated limited improvements in quality of care compared to FFS, with no negative health effects. Combined FFS and bonus incentives did not significantly enhance prenatal care compared to FFS, and there were no significant differences in gestational age or birth weight. However, the proportion of very LBW infants increased slightly within the study population (Table 1).

Blended (1/2 capitation + 2/3 FFS) vs. capitation

The probability of premature birth was 1.9% higher for newborns to women under the capitation payment method compared to those under the blended payment method. Furthermore, newborns in the capitation payment system had 1.3% lower birth weights than those in the blended payment method (Table 1).

Payment methods in childbirth

Fifteen studies met the inclusion criteria for childbirth (Supplementary Table 3). After summarizing the results (Supplementary Table 4), we classified them into five main categories: DRGs and DRG vs. FFS; salary, prospective FFS, bundled and blended vs. retrospective FFS; global budget; and case payment. Most studies examined the effect of payment methods on caesarean section rates.

DRGs and DRG vs. FFS

The DRGs payment method has demonstrated significant impacts on clinical outcomes. Fee equalization under the DRGs system resulted in a 2.6% reduction in the CS rate [67]. Additionally, the odds ratio (OR) for cesarean delivery was 0.997 (95% CI: 0.996–0.998), indicating a statistically significant decrease [60]. Another study found a 3.24% reduction in the CS rate under the DRGs system [62]. However, complications during vaginal and cesarean deliveries remained a concern, as these procedures were associated with higher complication [61]. When DRGs replaced FFS, the CS rate increased from 18.9 to 21.5%, and complications saw a six-fold increase [23].

Salary, prospective FFS, Bundled and blended vs. FFS

Replacing salary with FFS was associated with a 5.8% increase in the caesarean section rate, although no significant difference in adverse outcomes was found [65]. Compared to FFS, the prospective payment method of FFS led to increased direct medical costs regardless of the type of delivery and level of care [66]. When bundled payment method replaced FFS, there was a 33.9% reduction in the caesarean section rate and total admission costs, with no evidence of increased readmission rates [68]. The blended payment method, which applied to both providers and facilities, appeared to be associated with reductions in cesarean rates and hospitalization costs [18, 63], although postpartum bleeding increased among women in areas where the blended payment policy was implemented [18].

Global budget

This payment method was associated with an increase in caesarean section rates among older individuals, while it significantly reduced caesarean sections in the younger population [59]. Fee equalization for vaginal and caesarean deliveries did no significantly impact caesarean section rates or lead to a decrease in caesarean Sect. [58].

Case payment

This method was linked to an increase in caesarean section rates, LoS, and medical expenses for both caesarean section and natural deliveries [64].

Payment methods in NICU

Six studies [17, 23, 69–72] that met the inclusion criteria NICUs were included, all of which examined the DRGs payment method (Supplementary Table 5).

DRGs

China’s DRGs payment method (C-DRGs), which uses “bundled” payments based on fixed rates for both insurance reimbursement and patient out-of-pocket payments, was not was not significantly associated with a reduced LoS [71]. In Germany, the DRGs system, based on weight, resulted in longer stays for infants weighing below the corresponding threshold [70]. Japan’s Diagnosis Procedure Combination (DPC) payment method, which aims to shorten hospital stays and is based on infant birth weight, was associated with increased LoS for infants [17].

The introduction of DRGs payment system may have led to upcoding of infant birth weight, where infants were recorded as having more complex or costly conditions than they actually did. This resulted in higher payments for unnecessary or unprovided services [73]. Since the introduction of DRGs in Japan and Germany, there has been a noticeable increase in the reporting of birth weights under 1000 and 1500 g [17, 69, 70]. Results from the South Carolina studies further illustrate this trend: the rate of infant complications increased from 8.6 to 27.9%, and the frequency of coding for major or complex conditions tripled under DRGs. This led to a 66.6% rise in the case mix index for infants, contributing to a 5.5% increase in total Medicaid hospital spending. These increases were largely attributed to changes in hospital administrative policies on coding diagnoses [23].

While DRGs were associated with a reduction in total costs and out-of-pocket payments [71], hospitals admitting significant numbers of very LBW newborns found the costs far exceeded their expected reimbursements [72].

DRG vs. FFS

Complication rates among infants were notably higher under DRGs. The frequency of coding for major or complex conditions more than tripled, resulting in an increase in total Medicaid hospital spending by 5.5% [23].

Discussion

To the best of our knowledge, this study is the first to comprehensively examine payment methods over three distinct periods of maternal care and childbirth. We reviewed 53 studies of various types and designs, exploring diverse payment methods for perinatal care, including P4P, FFS, blended models, DRGs, and fixed payment methods such as episode-based, global budget, and salary capitation, across different countries and health systems. Our findings reveal that these payment methods have varying effects on clinical outcomes in perinatal care. Specifically, for pregnancy, P4P models generally had no effect on clinical outcomes, or no negative outcomes were reported. Similarly, episode based payment (EBP) and per capita models also did not result in negative outcomes. During labor, bundled and blended payment models tended to reduce cesarean rates, whereas FFS and DRGs payments were associated with higher cesarean rates and complications. In the NICUs, DRGs payment methods were linked to longer LoS and potential up-coding, leading to higher costs.

Prenatal payment methods

Our study shows a direct positive effect of P4P on antenatal care outcomes, suggesting that P4P payments may increase institutional deliveries and enhance the quality of antenatal care by offering financial incentives to high-quality care providers and encouraging women to use institutional services. Notably, no increase in negative clinical outcomes was reported. Other studies examining the effect of P4P on maternal and child health (MCH) quality have primarily shown positive effects on the MCH process [74, 75], but its effect on delivery, postpartum care, maternal and newborn health outcomes, and out-of-pocket payments remains inadequately assessed [74].

P4P may also empower providers, reducing their reliance on patient behavior and organizational factors [29, 44]. It is believed to strengthen a facility’s professional norms, culture and teamwork [31]. However, the reviewed studies reported no effect on provider satisfaction, possibly due to unintended consequences of P4P, such as increased workload and decreased provider autonomy and morale [75]. Despite these concerns, P4P is likely to reduce costs and out-of-pocket expenditures for patients without negatively affecting service quality, such as the completeness of services and recommendations provided during pregnancy [42].

Our study found that EBP reduces costs but shows limited improvements in quality compared to FFS, without negatively affecting health outcomes. EBP also decreased CS rates and total admission costs, while not increasing readmission rates. However, the Chinese C-DRGs payment method did not significantly reduce the LoS in the NICUs. These findings align with existing literature suggesting that EBP can effectively reduce the utilization of acute services by improving ambulatory care processes. This payment model can also influence physician management practices, leading to cost reductions in hospital care [12, 49]. However, unintended consequences, such as shifting care outside the perinatal period, altering diagnostic coding practices, or encouraging patients to seek care in the emergency department, have been observed [49].

A scoping review of bundled payments in perinatal care also reported a reduced likelihood of emergency department (ED) visits during pregnancy, alongside increased rates of screenings for HIV, chlamydia, and group B strep tests compared to the control group. However, predelivery and postpartum hospitalizations were higher relative to the comparison group [76].

Payment methods in childbirth

Our study found that DRGs payment methods can reduce CS rates, but when DRGs replaced FFS, complications increased. Bundled payment methods led to significant reductions in CS rates and total admission costs without increasing readmission rates. Blended payment methods likely reduced CS rates and hospitalization costs, although they were associated with increased postpartum hemorrhage in some regions. Conversely, replacing salary-based payments with FFS led to an increase in CS rates, and the global budget payment method showed mixed results, with variations depending on age group. In contrast, a scoping review revealed that DRGs payment systems had mixed outcomes, with some studies reporting no significant difference in CS rates compared to FFS [77]. Similarly, global budget payment systems had little or no effect on CS rates [77].

The DRGs payment method, which sets a fixed price for each diagnosis or procedure, can influence CS rates, though its effect varies by country. For instance, in Korea, where DRGs was introduced to reduce high CS rates, studies reported a significant decrease in CS rates compared to FFS. This reduction is likely due to lower reimbursement rates and penalties for exceeding target rates [60, 62]. In Italy, however, where DRGs was implemented to contain healthcare costs, increased DRGs tariffs led to higher probabilities of CS with complications and vaginal births with complications [61]. In a Chinese village, where case payments replaced the DRGs method, CS rates remained high. This could be due to higher compensation for CS compared to vaginal delivery and patient factors, such as obesity among rural women [64]. Additionally, hospitals may have selected more complex and costly DRGs or induced complications to increase reimbursement. These findings suggest that the effectiveness of the DRGs payment method on CS rates depends largely on its design and implemented in different settings.

Payment method in NICU

In Germany, the DRGs system led to longer stays for infants with lower birth weights, while Japan’s DPC method was associated with increased LoS for infants. The introduction of the DRGs system in these countries also resulted in upcoding of infant birth weights, leading to higher payments for unnecessary or unprovided services. Additionally, the case mix index for infants increased, contributing to higher hospital spending. Our study raises concerns about these administrative practices and their potential effect on clinical outcomes.

In contrast, a meta-analysis of DRGs-based payment systems in patient care found a significant reduction in LoS following the adoption of DRG-based payments [76]. However, it did not specifically address NICUs patients. The meta-analysis also found no compelling evidence for negative consequences regarding readmissions or in-hospital mortality.

A key issue in NICUs payment systems is how newborns are classified based on gestational age and birth weight as these factors significantly affect LoS and resource utilization, with very LBW newborns showing the greatest variation [72]. While using gestational age and birth weight as classification variables in DRGs could enhance its validity, it also increases the risk of manipulation or upcoding by hospitals. For instance, healthy infants are more often assigned higher diagnostic codes compared to neonatal deaths within the first four days [70]. A study by Shigeoka & Fushimi found that, despite a 5-day increase in the LoS for very LBW infants, the intensity of care remained unchanged, while the costs increased due to the additional days spent in the NICUs, which could have been spent under regular hospital care [17].

Policy recommendations

Policymakers and clinicians should assess how different payment methods influence service delivery and maternal health outcomes, including the quality and completeness of services, provider satisfaction and workload, and birth outcomes. Increasing the uptake of antenatal care in low-resource settings should also be prioritized, alongside examining the indirect or long-term effects of payment methods on other outcomes, such as neonatal outcomes and NICUs costs.

For neonatal care under the DRGs payment system, it is recommended to adjust the DRGs classification and payment rates to reflect the costs and outcomes of various infant conditions. Close monitoring of coding and billing accuracy is also essential. Gestational age is a key indicator of an infant’s health and development, directly affecting NICUs LoS and associated costs. Premature infants, with their higher risks of complications and mortality, require more intensive and expensive care than full-term infants. Increasing antenatal consultations can reduce preterm birth-related costs by improving care continuity and preventing or identifying risk factors for preterm births.

In terms of cesarean rates, it is essential to adopt payment methods that align financial incentives with patients’ clinical needs, ensuring that service quality and outcomes are continuously monitored. Policies should also account for contextual factors influencing cesarean rates, such as the patient clinical status, the provider preferences, available resources, and cultural norms. This policies should be supported by evidence-based guidelines, training, and audit-and-feedback mechanisms to ensure appropriate use of CS.

Additionally, policymakers must recognize that some payment models are susceptible to gaming, such as upcoding. This practice, where providers submit codes for more severe procedures than actually performed in order to receive higher reimbursement, undermines the integrity of payment models and contributes to increased healthcare costs. Models vulnerable to manipulation should be critically assessed and potentially reconsidered. Policymakers should focus on designing and implementing payment models that are robust and resistant to such practices, ensuring healthcare systems are fair, efficient, and capable of delivering high-quality care without encouraging unethical behaviors.

Given the high variability among the included studies and the lack of robust, consistent evidence from randomized controlled trials (RCTs), causal claims were made. Instead, the study highlights observed associations. While the study suggests the potential of various payment models and points out their shortcomings (e.g., the risk of upcoding), it does not comprehensively analyze each model. Previous research indicates that disappointing outcomes in some maternity care payment programs may be due to weak program designs, rather than flaws in the payment models themselves [78]. These programs typically failed to focus on advancing equity in healthcare access and quality. Their primary goals—improving care quality and reducing costs—show limited evidence of success, largely due to weak program structures and market constraints in the healthcare systems where they were implemented.

Study limitations and strength

Our study included a comprehensive literature review, encompassing a broad range of studies from various countries and health systems, which enhances the generalizability of our findings. By examining various payment methods, we provided a holistic understanding of their effects on maternal and newborn health outcomes. The findings are highly relevant to current health policy and practice, offering valuable insights for policymakers and healthcare providers. The study also highlights areas for further research, encouraging the development of more robust and equitable payment models in maternal and newborn healthcare. However, we acknowledge several limitations of our review, primarily due to the types of studies included. Most studies relied on retrospective data, which limited the choice of quality indicators. They also lacked randomization, excluded centers with low implementation capacity, and featured short control periods. These factors may introduce selection bias, unobservable confounders, and regression to the mean, potentially affecting the validity and generalizability of our findings. Two excluded studies provide valuable context despite their high risk of bias. One study assessed a Maryland Medicaid policy that raised reimbursement fees for deliveries to private insurer levels, which stabilized and slightly increased provider participation. Another retrospective cohort study at Johns Hopkins compared the effects of FFS versus managed care on maternal and neonatal outcomes among patients with prior preterm deliveries. While both studies were excluded due to lack of lack of randomization, and potential selection bias, they offer important insights into provider participation and the effects of care delivery systems. Additionally, our literature search may have missed relevant studies in the gray literature, potentially limiting the comprehensiveness and reliability of our review.

Conclusion

This article systematically analyzes how various payment methods for prenatal, delivery, and neonatal NICUs care affect quality, costs, and clinical outcomes. The findings suggest that payment models such as P4P, episode-based, and blended payment models can enhance care quality and reduce costs by encouraging evidence-based practices and reducing unnecessary interventions. Conversely, capitation and FFS payments align with patient preferences and clinical circumstances but may negatively affect birth outcomes and readmission rates. DRGs, bundled, and blended payment methods are associated with lower cesarean costs, whereas case-specific and FFS payments tend to increase them. In NICUs context, DRGs systems may lower overall costs and out-of-pocket expenses but may also extend the LoS and lead to practices like upcoding birth weights.

The influence of payment methods on perinatal care outcomes is multifaceted, encompassing both immediate and long-term effects. Success or failure heavily depends on the context and the robustness of program design. Poorly designed payment models can lead to suboptimal results, even if their theoretical is significant. This point underscores the need for further research to develop payment systems that equitably and sustainably improve maternal and newborn health outcomes. Future studies should focus on strengthening the design, implementation, and evaluation of these models to ensure equitable and effective care delivery.

In addition to structural factors, the incentives, behaviors, and resources of both providers and patients play a pivotal role in shaping the quality, costs, and outcomes of care. However, the empirical evidence on the impact of alternative payment methods on health system outcomes and costs remains limited. Continued research is crucial to understanding the potential of these payment methods to improve maternal and neonatal health with the goal of identifying the most effective approaches for achieving better and more equitable outcomes [79].

Authors' contributions

Z.O, M.H, and M.N: conception or design of the work. Z.O, V.Y, and R.G: literature review, quality assessment, data extraction, data analysis. Z.O and V.Y: quality assessment, interpretation and drafting of the manuscript. Z.O, A.Q, V.Y, and M.N: critically reviewing and editing the manuscript.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.