Re: Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study
I read with interest the recent study by Schroeder and colleagues concluding that, for multiparous women at low risk of complications, planned birth at home is the most cost-effective option.
I would like to contribute some data we collected prior to the publication of any results from the Birthplace in England Collaborative Group, relating to the personal opinions of midwives in and around London.
A questionnaire, answered only by female, nulliparous respondents, asked: if you were planning the birth of your first child, and had no contraindications to a normal vaginal delivery, would you choose to deliver in an obstetric unit, an alongside midwifery unit, a free-standing midwifery led unit, or at home?
There were 62 responses. 52% of midwives responded that they would choose home birth, 32% an along-side midwifery unit, 8% an obstetric unit, and 5% a free-standing midwifery unit.
Midwives provide a unique insight into the choice of birthplace since, as part of their training (largely in contrast to doctors), they will have seen first-hand the experience of labour in different settings. The high proportion choosing delivery at home suggests that this is deemed to provide a more positive experience for women, such that midwives would choose it for themselves.
There was a statistically significant relationship to midwives’ predominant place of work: midwives working predominantly on labour ward were less likely to opt for home birth than those working predominantly in the community or in a low-risk centre (43% .vs. 85%, p=0.01).
With available evidence now suggesting that home birth is both safe (1) and cost-effective, it is likely that interest in, and resources diverted towards, home birth will increase. The fact that a majority of midwives would choose this setting for themselves may well be a deciding factor for women weighing up their options.
Given that midwives working in community settings are more likely to have a personal preference for, and positive view of, home birth, one could infer that this will be reflected in the way they counsel women regarding their planned place of delivery. This bias may therefore be important to those planning how to improve uptake of this cost-effective option, and indeed to women interpreting such counseling.
(1) Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study, BMJ 2011;343:d7400