Letters Planned place of birth analysis

Flawed analysis may be used to restrict birth choices

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e3842 (Published 01 June 2012) Cite this as: BMJ 2012;344:e3842
  1. Pauline M Hull, author and editor1
  1. 1electivecesarean.com, Farnham, UK
  1. info{at}electivecesarean.com

This analysis of the Birthplace study has some of the same inherent flaws in its collection and analysis of comparative data, but worse, its promise of “cost effectiveness” in today’s economic climate and imminent restructuring of the NHS may be improperly used for political and ideological restriction of “low risk” women’s choices.1

The cost analysis is incomplete. Adverse downstream costs such as litigation, infant and maternal injuries, and trauma counselling are absent (a National Institute for Health and Clinical Excellence (NICE) caesarean versus vaginal cost model incorporating urinary incontinence alone reduced a £720 (€901; $1121) difference to £84).2

It excludes stillbirths before onset of labour, when most occur (many in low risk pregnancies), as well as other infant injury risks. Risk of stillbirth significantly increases at +39 weeks’ gestation.3

It ignores reality and maternal choice. Many freestanding midwifery units have closed owing to unsustainable financial losses, undependable service, and insufficient demand.

It focuses on birthplace, not mode, so maternal request caesareans (more common than homebirth, with higher satisfaction rates4 5; NICE recommends they should not be refused on cost effectiveness grounds2) are excluded.

It is weighted against obstetric units, which have worse midwife to birth ratios and more “intermediate” cases with worse outcomes. Crucially, data on infant deaths during and after labour transfers “may have been lost” and the significant “complicating conditions” discrepancy needed adjustment throughout.

The data were compiled by midwives, whose reputation, livelihood, and job satisfaction are linked with its outcomes, so there may have been a conflict of interests.

The assumption that midwife led care is safest and most cost effective remains unproven, and the identification of “low risk” is unreliable.6 Given current staff shortages, fundamental policy changes such as “midwife led care for all low risk women” are ill advised.

To properly inform national maternity policy, analysis should include all modes of birth (including planned caesarean), all types of care (including consultant led), and common postpartum consequences.


Cite this as: BMJ 2012;344:e3842


  • Competing interests: PMH is co-author of Choosing Cesarean: A Natural Birth Plan, Prometheus Books, 2012.