quence of impaired uterine or ovarian development during the mother's own fetal life.34One observational study cannot form the basis for changing dietary recommendations to pregnant women. The differing relations of nutrient intakes in early and late pregnancy to placental and fetal growth need replication in other studies. Our findings, however, do parallel those of experimental studies in sheep in which high nutrient intakes in early pregnancy have been shown to suppress placental and fetal growth.We thank the mothers who gave us their time; the staff on the antenatal clinic, labour ward, and postnatal ward for their considerable assistance in the study; Mr T Wheeler and Professor E J Thomas for their guidance and for allowing us to include their patients; and Mr D Howe for advice and for performing ultrasound scans. The fieldwork was carried out by S Crofts, V Davill, J Hammond, L Greenaway, S Mitcham, and S White.

BackgroundInsomnia is perhaps the most common sleep disorder in the general population, and is characterised by a range of complaints around difficulties in initiating and maintaining sleep, together with impaired waking function. There is little quantitative information on treatment pathways, costs and outcomes. The aims of this New Zealand study were to determine from which healthcare practitioners patients with insomnia sought treatment, treatment pathways followed, the net costs of treatment and the quality of life improvements obtained.MethodsThe study was retrospective and prevalence based, and was both cost effectiveness (CEA) and a cost utility (CUA) analysis. Micro costing techniques were used and a societal analytic perspective was adopted. A deterministic decision tree model was used to estimate base case values, and a stochastic version, with Monte Carlo simulation, was used to perform sensitivity analysis. A probability and cost were attached to each event which enabled the costs for the treatment pathways and average treatment cost to be calculated. The inputs to the model were prevalence, event probabilities, resource utilisations, and unit costs. Direct costs and QALYs gained were evaluated.ResultsThe total net benefit of treating a person with insomnia was $482 (the total base case cost of $145 less health costs avoided of $628). When these results were applied to the total at-risk population in New Zealand additional treatment costs incurred were $6.6 million, costs avoided $28.4 million and net benefits were $21.8 million. The incremental net benefit when insomnia was "successfully" treated was $3,072 per QALY gained.ConclusionsThe study has brought to light a number of problems relating to the treatment of insomnia in New Zealand. There is both inadequate access to publicly funded treatment and insufficient publicly available information from which a consumer is able to make an informed decision on the treatment and provider options. This study suggests that successful treatment of insomnia leads to direct cost savings and improved quality of life.

The objective of this study was to evaluate the costs and benefits of influenza vaccination for the population aged 65 years and over, from the perspectives of individuals and health insurers, government and society. The annual incremental direct medical costs and benefits of influenza vaccination (compared with the nonvaccination, or 'do nothing', option) were evaluated using New Zealand healthcare resource usage and unit cost data [in 1992 New Zealand dollars ($NZ); $NZ1 = $US0.5458, June 1992] applied to cohort studies reported in the literature. The costs and benefits to society as a result of vaccination of people aged 65 years and older (20% of people in this age group are currently vaccinated) were estimated to be: (i) additional direct medical costs of vaccination of $NZ1.42 million [$NZ17.78 per vaccination]; (ii) direct medical costs avoided of $NZ5.35 million ($NZ67.18 per vaccination); and (iii) net benefits of $NZ3.93 million ($NZ49.40 per vaccination). The direct medical costs avoided per dollar cost of vaccination were $NZ1.04 for individuals, $NZ4.69 for government and $NZ3.78 for society as a whole. If the vaccination uptake for this group is increased in 20% increments, the net benefit to society increases by a further $NZ3.93 million per year at each step. If the economic evaluation is extended to include vaccination of at-risk individuals under 65 years of age, net benefits to society increase by 15%. Influenza vaccination for people aged 65 years and over is cost effective from the perspective of society, government and the individual. If the vaccination rate for at-risk individuals in New Zealand could be increased to 60%, the net benefits reported in this study would increase by 200%. However, the costs of promotion and education to achieve this vaccination rate would need to be deducted from the net benefits. Strategies to increase the vaccination rate include altering the cost of vaccinations to the individual, intensifying education and promotion programmes, and changing the mode of delivery.

Benign prostatic hyperplasia (BPH) has been regarded as part of the normal aging process in men and little attention has been focused on the cost of the disease in New Zealand. The purpose of this study was to estimate the direct and indirect costs of treating BPH in both the public and the private sectors in New Zealand. The costs of treatment were estimated from public and private hospital data on admissions for BPH, obtained from the New Zealand Department of Health, medical insurance reimbursement schedules, hospital ward costs at one centre, and urology and general practitioner consultation fees. The length of time spent off work, as a measure of indirect costs, during urological investigations or treatment was estimated from interviews with urologists. The annual 1991 total direct medical costs of treated BPH as primary diagnosis in New Zealand were estimated at $NZ16 million (the average of the end-month mid-point exchange rate for the first quarter of 1992 was $US0.5457 per $NZ1), and the costs of lost production plus loss of leisure time by patients was estimated at $NZ4 million (1992 dollars). Patients with a principal diagnosis of BPH stayed on average 8.9 days in a public hospital and 4.6 days in a private hospital. Based on the above costs, if the average length of stay of public hospital patients could be reduced to that of private hospital patients, then hospital ward costs for BPH could fall by 37% and the total direct medical costs by 21%. The most commonly performed surgical operation for BPH was transurethral prostatectomy (TURP). For operations performed in a public hospital, patients stayed on average 8.5 days, while patients whose operations were performed in private hospitals stayed 4.3 days. The mean age of these public hospital patients was 71 years compared with 67 years for those in private hospitals. A complication rate of 2.02% was recorded for TURP in public hospitals but audits (conducted by the researchers) in both public and private settings indicated that the complication rate was substantially under-recorded.