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

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2292 (Published 19 April 2012)
Cite this as: BMJ 2012;344:e2292

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Dear Editor

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

Competing interests: None declared

Jessica A Farren, Speciality Trainee in Obstetrics and Gynaecology

Iruka Kumarage, Onsy Louca

Northwick Park Hospital, Watford Road, Harrow, HA1 3UJ

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This analysis of the 2011 Birthplace study(1) suffers from some of the same inherent flaws in the study’s collection and analysis of comparative data. But while all research has its limitations and weaknesses, the current economic climate and imminent restructuring of the NHS mean that the promise of “cost-effectiveness” here may well be used for political and ideological influence. As such, these are my concerns:

Incomplete cost analysis

As others have pointed out, the analysis does not include the downstream costs of adverse birth outcomes such as litigation, treatment of infant and maternal injuries, or counseling for psychological trauma. NICE, for example, in its cost model comparison of a planned caesarean versus planned vaginal delivery,(2) found that by introducing just ONE adverse downstream outcome (i.e. urinary incontinence), the headline difference of £720 was reduced to just £84. Further analysis like this is necessary before cost-effectiveness of any birth plan/place can be adequately demonstrated.

Other costs, women’s choice and midwifery ratios are not accounted for

A number of FMUs have (or are being) closed in the UK due to unsustainable running costs, undependable service(3) and not enough women choosing to give birth there.(4,5) In Kent, one unit managed just 300 births in 2010 and a third of women required transfer.(6) In Hull, births at a remote FMU cost £2,000 each, with a financial loss of £120,000 per year.(7) So it is crucial that we read this cost analysis of the Birthplace study (which itself cost “in the region of £12m”) in the context of real world events. That is, unit closures, and the fact that despite years of encouragement, the vast majority of women simply DO NOT want to give birth away from immediate obstetric care.

Study is weighted against OU births

The discrepancy between 20% of women with “complicating conditions” at the start of labour in OUs versus less than 7% in all others should have been adjusted throughout, and not consigned to the Appendix and occasional “sensitivity analysis”. For instance, the latter found a “significant increase in the odds of the primary outcome in planned FMU births” for nulliparous women. There were also more women at OUs with an intermediate level of risk due to “other” conditions, which “would have tended to make outcomes appear worse”. And furthermore, not only was there some general loss of paperwork/data during and after labour transfers, the authors state it’s possible that specifically, cases of intrapartum stillbirths or early neonatal deaths may not have been included. Finally, the ratio of midwives to women/babies at some OUs is very poor in comparison to midwife-led units, which can affect health outcomes and costs (e.g. 1 to 40 versus 1 to 9 in Kent(8) and 1 to 53 versus 1 to 4 in Portsmouth(9)).

Focus is on place, not mode of birth

The Birthplace study design excluded planned caesareans of women with low risk pregnancies; therefore conclusions could not be made about the comparative (short- and long-term) cost-effectiveness of consultant-led surgical care for women who choose this. In light of NICE’s conclusion that a caesarean should not be refused “on cost-effectiveness grounds", and given that a) more women request a caesarean than a home birth(10), and b) research has shown greater maternal satisfaction with maternal request CS than a planned homebirth,(11,12) future studies need to compare mode (as well as place) of birth – particularly when informing nulliparous women of birth risks (for whom, in all planned vaginal birth settings, intervention and adverse perinatal and maternal outcomes were more common).

Excludes stillbirths prior to onset of labour

The majority of stillbirths occur prior to labour, and indeed many full-term stillbirths occur in low risk pregnancies, yet the Birthplace study excluded all stillbirths prior to the onset of labour - it shouldn’t have. U.S. research into 10 years of births(13) found a significant increase in the stillbirth rate after 39 weeks’ gestation, and women deserve to know if there is a greater risk at term with a specific birth or birthplace plan. Other birth injury risks for babies were excluded too, all of which have physical, psychological and financial costs that should not be ignored.

Potential for self-serving interests

The data used to inform this study was compiled by midwives, whose own reputation, livelihood and job satisfaction are intrinsically linked with the study’s outcomes. For instance, “If the numbers of home births increases, the experience of midwives providing care at home will increase”. Also, the study design “only included women who received labour care from a midwife in their planned place of birth”, which excludes comparative health outcomes and costs with consultant-led care.

Assumption that midwife-led is the safest and most cost-effective care for all ‘low risk’ births

Firstly, incremental cost savings with “no significant effect on adverse perinatal outcomes” in home births for low risk multiparous women is not the same as finding ‘no effect’, especially given the potential loss of data described above. Secondly, since a “variability in experience and training is likely to affect midwives’ ability to provide safe and effective care”, we should be cautious about affecting any fundamental nationwide changes to maternity care policy (e.g. midwife-led care for ALL low risk women), especially at a time of well documented staff shortages. Thirdly, recent Dutch research found “a higher risk of delivery related perinatal death and the same risk of admission to the NICU” for babies under the (initial) supervision of a midwife compared to the supervision of an obstetrician.(14) Therefore, to reiterate an earlier BMJ letter,(15) it’s not proven that midwife-led care is most cost-effective, identifying “low risk” women can be very unreliable, and women should have the choice of consultant-led care too.

Summary

Somewhat ironically, while the UK seems to be trying to move towards a model of care closer to that of The Netherlands, the homebirth rate there is falling, and a spotlight remains on its poor perinatal mortality rate. Certainly homebirth and midwifery-led care deserve their place in the spectrum of birth choices, but I find it very concerning that the Birthplace study and its cost analysis might actually be used to restrict ‘low risk’ women’s choices. Surely if national maternity policy is to be informed by any study’s conclusions, then all modes of birth (incl. planned caesarean), all types of professional care (incl. consultant-led), and the most common postpartum consequences need to be examined?

References

(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. BMJ2011;343:d7400
(2) NHS National institute for Clinical Excellence, “Caesarean Section: Full Guideline” November 2011.
(3) “Ascot Birthing Centre should not reopen, says board,” BBC News Online, February 24, 2012.
(4) “Canterbury and Dover birthing centres 'should close',” BBC News Online, September 9, 2011.
(5) “NHS recommends closure of Derbyshire birth centres,” BBC News Online, December 5, 2011.
(6) “Kent and Canterbury birth unit remains shut for review,” BBC News Online, June 7, 2011.
(7) “Jubilee Birth Centre to shut after watchdog blow,” BBC News Online, July 27, 2011.
(8) “Health board expected to close birth centre,” thisiskent.co.uk, April 26, 2012.
(9) “Portsmouth hospital criticised over maternity care,” BBC News Online, August 4, 2011.
(10) National Collaborating Centre for Women’s and Children’s health, “Caesarean Section: Clinical Guideline 13,” NHS National institute for Clinical Excellence, April 2004.
(11) Perinatal factors related to negative or positive recall of birth experience in women 3 years postpartum in the Netherlands (Rijnders et al). Birth. 2008 Jun;35(2):107-16.
(12) Mothers' Satisfaction with Planned Vaginal and Planned Cesarean Birth (Blomquist et al). Am J Perinatol. 2011 Mar 4.
13) Cesarean Section on request at 39 Weeks: impact on Shoulder Dystocia, Fetal trauma, Neonatal Encephalopathy, and intrauterine Fetal Demise (Hankins, Clark, Munn). Seminars in Perinatology 30, no. 5 (October 2006): 276–87.
(14) Perinatal Mortality and Severe Morbidity in low and high risk term Pregnancies in the Netherlands: Prospective Cohort Study (Evers et al). BMJ2010;341:c5639
(15) Midwife led care may not be appropriate or cost effective (PM Hull). BMJ2011;342:d2298

Competing interests: Co-author of "Choosing Cesarean: A Natural Birth Plan" (Prometheus Books 2012)

Pauline M Hull, Author and Editor

electivecesarean.com, Surrey, UK

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I read with interest the article of Schroeder and al (1) who reported that a planned birth at home is the most cost effective option for multiparous women at low risk.

However, low risk does not exist in Obstetrics: only a relative low risk may be envisaged. This study focused on immediate economic benefits but omitted the costs of long term severe child handicap caused by perinatal asphyxia as well as costs of delayed management of severe maternal complications. Even though the economics aspect of childbirth should be considered, the most important aspect in medicine is to offer the best conditions to deliver and to have a healthy baby for all mothers and fathers. Indeed, this study did not take into account the obstetrical aspects and possible severe complications of delivery which could not be managed at home.

It is comprehensible as there were no obstetricians involved in this study which related to a major topic in obstetrics. Two situations are totally unpredictable: the prolapse of the umbilical cord which occurs after rupture of membranes during labour or prematurely, and postpartum hemorrhage. In the case of umbilical cord prolapse, delivery should occur in less than fifteen minutes (2). If it is not the case the newborn could have severe cerebral damages. In the case of severe post partum hemorrhage, management should be very quick. The severe hemorrhage could not be managed at home as it needs the intervention and the cooperation of obstetrical and anesthesiologist teams. They should restore blood loss, find the reason for the hemorrhage and stop the blood loss by different means, starting with medical treatments (oxytocin, prostaglandin) and passing to more aggressive ones if the medical treatments fail (embolisation, haemostatic sutures, vascular ligation and finally hysterectomy) (3). All these means should be offered very quickly. We can easily imagine that transfer of the woman from home to hospital will delay the management of severe hemorrhage and threaten the life of the woman.

Furthermore, the management of foetal heart rate abnormalities at home is impossible as in some cases an emergency caesarean section needs to be performed to prevent foetal brain lesions.

For all these reasons, delivery at home for multiparous women does not enable secure conditions for mothers and newborns and should not be recommended.

References

1.Schroeder E, Petrou S, Patel N, Hollowell J, Puddicombe D, Redshaw M, Brocklehurst P; on behalf of the Birthplace in England Collaborative Group. 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. BMJ. 2012 Apr 18;344:e2292. doi: 10.1136/bmj.e2292.

2. Alouini S, Mesnard L, Megier P, Lemaire B, Coly S, Desroches A. Management of umbilical cord prolapse and neonatal outcomes. J Gynecol Obstet Biol Reprod. 2010;39:471-7.

3. Alouini S, Coly S, Mégier P, Lemaire B, Mesnard L, Desroches A. Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment. Am J Obstet Gynecol. 2011;205:335.e1-6.

Competing interests: None declared

Souhail ALOUINI, Obstetrician and Gynaecologist Surgeon, M.D., Ph.D..

Regional Hospital Center of Orleans, 1 Porte Madeleine, 45000, France

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The methodology of the paper includes the low risk pregnancies for home-births etc. as per NICE Guidelines (1) which gives an exhaustive list of medical and obstetric risk factors that should be excluded before labeling the woman low-risk. However, short stature (less than 155 cms in European women) is and independent risk factor/ indication for cesarean section (2,3) is not included included in obstetric risk factors in NICE guidelines.

References:

1.National Institute for Health and Clinical Excellence (NICE). Intrapartum care of healthy women and their babies during childbirth. National Collaborating Centre for Women’s and Children’s Health. RCOG, 2007. www.nice.org.uk/nicemedia/pdf/IPCNICEguidance.pdf

2. Sheinera E, Levyb A, Katza M, Mazora M. Shortstature—an independent riskfactor for Cesarean delivery. European Journal of Obstetrics & Gynecology and Reproductive Biology 120 (2), 1 June 2005,175–178.

3.Kappel B, Eriksen G, Hansen KB, Hvidman L, Krag-Olsen B, Nielsen J, Videbech P, Wohlert M. Short stature in Scandinavian women. An obstetrical risk factor. Acta Obstet Gynecol Scand. 1987;66(2):153-8.

Competing interests: None declared

Neeru Gupta, neerujani@yahoo.co.in

Indian Council of Medical Research, Ansari Nagar, New Delhi-110029

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It appears that the findings of this study are so restrictive as to render any conclusions highly doubtful.

First, as the authors acknowledge in the supporting materials, they did not take into account long term costs. In the case of adverse outcomes, the cost of caring for the medical needs of a disabled child, and the cost of any legal settlement dwarf other costs by orders of magnitude. In the absence of data about long term costs, it is impossible to reach conclusions about cost effectiveness.

Second, the eligibility criteria for inclusion in the study are far more strict than the actual eligibility requirements for homebirth in the UK. While the authors may have reached a conclusion about the women and babies in the study, they haven't even investigated the actual costs of homebirth in the UK, only a subset of homebirths that meet stricter requirements.

In other words, the authors have found that in an ideal homebirth population, short term costs may be slightly lower for homebirth than for hospital birth. However, the real issue is the long term costs in a real world population. Without that, no conclusion can be drawn about the cost effectiveness of homebirth.

Competing interests: None declared

Amy Tuteur, MD, obstetrician

self-employed, Boston, MA

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