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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: https://doi.org/10.1136/bmj.e2292 (Published 19 April 2012) Cite this as: BMJ 2012;344:e2292
  1. Elizabeth Schroeder, health economist1,
  2. Stavros Petrou, health economist12,
  3. Nishma Patel, health economist1,
  4. Jennifer Hollowell, epidemiologist1,
  5. David Puddicombe, researcher1,
  6. Maggie Redshaw, senior research fellow/social scientist1,
  7. Peter Brocklehurst, professor of perinatal epidemiology13
  8. on behalf of the Birthplace in England Collaborative Group
  1. 1National Perinatal Epidemiology Unit, Department of Public Health, University of Oxford, Oxford OX3 7LF, UK
  2. 2Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry
  3. 3Institute for Women’s Health, University College London, London
  1. Correspondence to: E Schroeder liz.schroeder{at}npeu.ox.ac.uk
  • Accepted 5 March 2012

Abstract

Objectives To estimate the cost effectiveness of alternative planned places of birth.

Design Economic evaluation with individual level data from the Birthplace national prospective cohort study.

Setting 142 of 147 trusts providing home birth services, 53 of 56 freestanding midwifery units, 43 of 51 alongside midwifery units, and a random sample of 36 of 180 obstetric units, stratified by unit size and geographical region, in England, over varying periods of time within the study period 1 April 2008 to 30 April 2010.

Participants 64 538 women at low risk of complications before the onset of labour.

Interventions Planned birth in four alternative settings: at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units.

Main outcome measures Incremental cost per adverse perinatal outcome avoided, adverse maternal morbidity avoided, and additional normal birth. The non-parametric bootstrap method was used to generate net monetary benefits and construct cost effectiveness acceptability curves at alternative thresholds for cost effectiveness.

Results The total unadjusted mean costs were £1066, £1435, £1461, and £1631 for births planned at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units, respectively (equivalent to about €1274, $1701; €1715, $2290; €1747, $2332; and €1950, $2603). Overall, and for multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness when perinatal outcomes were considered. There was, however, an increased incidence of adverse perinatal outcome associated with planned birth at home in nulliparous low risk women, resulting in the probability of it being the most cost effective option at a cost effectiveness threshold of £20 000 declining to 0.63. With regards to maternal outcomes in nulliparous and multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness.

Conclusions For multiparous women at low risk of complications, planned birth at home was the most cost effective option. For nulliparous low risk women, planned birth at home is still likely to be the most cost effective option but is associated with an increase in adverse perinatal outcomes.

Footnotes

  • The Birthplace in England Collaborative Group includes the wider group of coinvestigators, researchers, project staff, and coordinating midwives who contributed to the research programme. Members are listed in the cohort paper.12

  • Contributors: LS undertook all the economic analyses and contributed to the writing of the paper. SP led the study design and writing of the paper. NP collected the bulk of the unit cost data. JH was the Birthplace lead researcher who led the cohort study team and contributed to the study design, analyses, writing, and revisions of the paper. DP, PB, and MR contributed to the study design and the writing of the paper. PB was the chief investigator for Birthplace in England and had overall responsibility for the research programme. All members of the Birthplace in England Co-investigators Group contributed at various stages to the design and conduct of the economic evaluation and drafts of the paper. SP is guarantor.

  • Funding: This study was part of a larger study jointly funded by the Department of Health’s Policy Research Programme and the National Institute for Health Research Service Delivery and Organisation programme. The related study formed part of a project funded by the National Institute for Health Research Research for Patient Benefit Programme through grant PB-PG-0107-12209. The views expressed are not necessarily those of the funders.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: No additional data available.

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