Labour saving

A recent paper published in the British Medical Journal reported the cost effectiveness of home births, particularly for those expecting their second and subsequent children.  Links to the paper and a BBC news article included below, and a little splurge by me covering the costs (of many forms) associated with intervention vs. no intervention (i.e., a normal birth).

Oxford study source: Schroeder et al., (2012). 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:e2292. For the abstract summary please see end of this blog*.

BBC news: Home births are more 'cost effective', says Oxford study

Win Win situation

I'd noticed the cost effectiveness of home births from the earlier paper published by the Oxford NPEU Birthplace group: any choices which avoid intervention are going to cost the NHS less too. 

So why is such costly intervention occurring?

Obstetric interventions are available at hospital to make delivery of babies possible where otherwise not intervening would / could affect the health of the baby or mother, or both (and thank goodness for them). These include induction of labour; epidural or spinal analgesia; general anaesthetic; episiotomy; forceps, ventouse, or caesarean section. Could it be the availability of interventions to those labouring in hospital, but not elsewhere (i.e., at home / midwife led units), that brings additional costs to the NHS? Midwife-led, low risk pregnancies don't always lead to normal births**, which do not include intervention and have been shown to result in improved maternal outcomes.

What could be asked now is why are women that present with a low risk history of pregnancy receiving costly intervention during childbirth? What were the reasons for the intervention? What are the consequences (positive and negative, e.g., medical, psychological) of such interventions to the mother and child, both in the immediate perinatal and postnatal weeks and months? Were the interventions necessary? Is there a way of reversing the trend away from hospital births towards midwife units and home births, particularly (though not exclusively) for low risk, multiparous births? And if not, why are hospital births being preferred? What patterns of childbirth preferences are there in other countries, e.g., in Europe, if the pattern is the same/different, why is this so and what can we learn from them?

What convinced me

I didn't imagine having a home birth for my second child - I only ever thought I'd try a hospital birth, to see if I could experience a normal, non-induced labour, but with the medical support there if I needed it. I most wanted to see what natural labour was like and if I could do it. Upon achieving that, I thought I'd be able to go for a home birth for my third child at some time in the future. I had to disprove the negative expectations of labour built up by my first experience, before committing to really do it for myself at home without the added security of the obstetric staff and facilities.

The factors that led to a shift in my decision were multiple:
First, was that the midwife who delivered Abigail reassured me that my next labour would be alot faster and easier, that I wouldn't have to go through the same experience again. Although this wasn't enough to reassure me completely, it helped. Second was the knowledge of two friends having successful homebirths with their second children, despite interventions with first; another two friends' second labours also involved no intervention whilst occurring in hospital. It seemed that subsequent childbirth experiences were much quicker and more straightforward, involving minimal pain relief (entonox or nothing at all). By now, I was quite convinced about a home birth and avoiding induction, as a result of an increased confidence in my own capacity for having my baby. I decided on having a home birth in time for my first meeting with my midwife (6 weeks or so pregnant). Further reading fuelled and supported the confidence further (which was necessary for me, particularly when some questioned my decision and I had to defend the decision, even if that was just internally). I read books in order to understand i) what induction was, ii) the reasons for/against it, iii) the reasons for women being induced when going overdue, iv) the preparation that I could make in pregnancy to give myself better chances of a more optimal labour (e.g., optimal foetal positioning - Abbie was back-to-back), v) a background of what home births involve, their history and who is able to have them. I couldn't say that my community midwife encouraged or discouraged me in my decision to have a home birth - I would have appreciated more encouragement, as I did feel a little like a lone-home-birth-freak-woman in a case load of hospital birth ladies at times. But maybe that was just me...

I'm not against intervention, or hospital births... honest!

If obstetric intervention is needed it is there...and it is a good thing that we have them available for those times. Furthermore, not everyone is affected negatively by having intervention - I don't know the statistics but I'd hope that most are not affected - that any cons are outweighed by the pros. It's not that having a baby in hospital predicates having an intervention either, instead it may just be the preferred option for that person, what feels right for them. Having had an intervened birth in hospital and a normal birth at home, I would always choose homebirth if I had the opportunity to again - this is my view, based on my particular circumstances. What works for me, may not for another - biologically or otherwise.

I am concerned about:

i) Whether there is a lack of informed choice surrounding interventions (e.g., the "cascade of intervention" effect, see image left, whereby once an intervention is introduced, it sets off the need for additional interventions that wouldn't have occurred if intervention were avoided to begin with). Making a decision mid-labour about whether you consent to a procedure, knowing if there are alternatives or if you have a right to say no is not the right time to find out! Women, and their partners, should have enough of an understanding of what each intervention involves before they might need to apply that knowledge. Could antenatal classes be improved? Is it up to our midwives to inform us?

ii) When there has been a negative cost of intervention to the mother and baby, particularly if it wasn't necessary, or could have been done differently. Negative costs maybe psychological, e.g., a lost confidence in the mother themselves and their ability to deliver her baby for herself. Costs maybe physical, e.g., the extended physical recovery required after intervention that may interfere with other elements of the mother-baby relationship (for example, exhaustion may affect breastfeeding) and the associated feelings involved.  It is possible to discuss the first experiences of childbirth with a doctor or midwife, and go through previous hospital notes to find out more about what happened, and the likelihood of what will happen next time - what the choices are available. Perhaps this is something that should be made aware of, as it may help people to make more informed decisions and be more confident about future pregnancies and childbirth choices.

Back to the study

This blog has been alot longer than planned, I didn't realise how many points this would raise and out they came! The Birthplace in England study is certainly going to bring very interesting findings that may shape childbirth in the NHS; providing more positive outcomes for the mother, baby and the financial health of the NHS, for decades to come.Thank you Oxford NPEU!

* 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.

 ** Normal birth: defined by the Maternity Care Working Party14 as birth without any of: induction of labour; epidural or spinal analgesia; general anaesthetic; episiotomy; forceps, ventouse, or caesarean section (Quoted from the paper)