Study says home births 'cost-effective'

“Planned births at home and in midwifery units are more cost-effective than giving birth in hospital,” BBC News has today reported.

The news is based on a large study that examined the costs and safety of births in various planned settings, including at home and in hospital. It used data on almost 65,000 women with pregnancies considered to be at low risk of complications, and compared planned births at home, in stand-alone midwife-led units, in midwife-led units located alongside hospital facilities and in hospital. Researchers found that the average cost for a home birth was lowest, at £1,066. The most expensive were hospital births, at £1,631 on average, while midwife-led births came in at around £1,450.

Importantly, though, the research did not simply rank birth options on cost. It also looked at how safe each setting was. It found that the four settings had comparable risks of adverse birth outcomes, although first-time births at home were more likely to have them.

Overall, this study provides evidence supporting home birth as a cost-effective option for women with low risk pregnancies, particularly if they are having their second or subsequent baby. The findings should not be misinterpreted as meaning that home birth is always the most cost-effective or most low risk option. This study did not look at women with complicated pregnancies or those expected to have birth complications.

Where did the story come from?

The study was carried out by researchers from the University of Oxford, the University of Warwick and University College London. It received funding from the Department of Health’s Policy Research Programme and the National Institute for Health Research. The study was published in the peer-reviewed British Medical Journal.

News coverage has generally accurately reflected the findings of this study.

What kind of research was this?

This was an economic analysis looking at the cost-effectiveness of births planned to occur in various different locations, including births at home. It looked at low risk pregnancies only – that is, pregnancies not considered to be at risk of pregnancy complications or birth complications. Medical cost-effectiveness studies do not simply look at the costs of different treatments or interventions (in this case, birth location), but also their effect on health outcomes, (in this case complications for the baby and mother). They are used to assess which treatments or interventions can be considered to give the best “value for money”. This sort of information helps decision-makers choose how best to allocate limited healthcare resources.

As this approach takes into account not only the costs of each option, but also their health effects and any costs associated with these, the cheapest option is not necessarily the most cost-effective. For example, if a particular birth location was found to be the cheapest, but was found to have a higher risk of adverse outcomes compared with another slightly more expensive location, it would not necessarily be the most cost-effective option. On the other hand, if two locations had comparable risks of adverse outcomes then the cheapest would be considered to be the most cost-effective option.

The authors of this research say that robust assessments of the cost-effectiveness of birth in alternative settings are a priority in health research, as the National Institute for Health and Clinical Excellence (NICE) points out in its recent guidance on care during childbirth.

What did the research involve?

This cost-effectiveness analysis was based on data from a recent cohort study, which had compared medical outcomes associated with different planned locations for low risk births. This cohort study was conducted between April 2008 and April 2010, and over this time period the researchers aimed to collect data from:

• every NHS trust in England that provides home birth services
• every free-standing midwife-led unit
• every midwife-led unit located alongside hospital services
• a random sample of hospital maternity units of different unit sizes and from different geographical regions

The study included a total of 64,538 women who were considered to be at a low risk of complications before the start of their labour. The study examined 142 of the total 147 NHS trusts providing home birth services, 53 of 56 free-standing midwife units, 43 of 51 midwife units located alongside hospital services and a random sample of 36 of 180 hospital maternity units.

The main health outcome that the researchers looked at was adverse birth outcomes, including death of the baby around the time of birth (perinatal mortality) and various specific complications in the newborn. These included injuries to the nerves around the upper arm, fractures around the shoulder or meconium aspiration (when the baby breathes in a mixture of amniotic fluid and their own early stool). They also looked at complications in the mother, such as requiring an instrumental delivery or caesarean.

This cost-effectiveness study compared four types of locations by looking at any extra (incremental) costs associated with birth at the particular locations, considered alongside any extra (incremental) adverse effects that occurred in home or midwife-led settings compared with planned birth in a hospital maternity unit. This allowed them to calculate a standard measure of the extra costs and adverse events for each location, called an ‘incremental cost-effectiveness ratio (ICER)’.

What were the basic results?

The total healthcare costs for birth at each location were calculated. These costs included travel, professionals involved and different drugs and treatments given. The average costs for each birth location were as follows.

• £1,066 for a birth at home
• £1,435 for a birth in a free-standing midwife unit
• £1,461 for a birth in a midwife unit alongside hospital services
• £1,631 for a birth in a hospital maternity unit

Overall, births in any of the three non-hospital settings were at no significantly greater risk of adverse outcomes than births in a hospital maternity unit.

For low risk women having their second or subsequent baby (multiparous women), planned birth at home was the most cost-effective option. For low risk women having their first baby (nulliparous women) home birth gave cost savings, but there was a higher risk of adverse outcomes in the newborn around the time of birth. This meant that it was less likely to be cost-effective.

When looking at the outcome of complications in the mother, there were reduced chances of complications in non-hospital settings, and home births were, again, the most cost-effective option.

How did the researchers interpret the results?

The researchers concluded that planning for a home birth is the most cost-effective option for women with an uncomplicated pregnancy who are having their second or subsequent baby. For low risk women having their first baby, planned home birth is still cost-effective, but there is an increased risk of birth complications.

Conclusion

This valuable study provides good evidence on the cost-effectiveness of planned birth at alternative locations. It found that, for women with an uncomplicated pregnancy having their second or subsequent child, home birth had a low risk of adverse outcomes for the mother or baby and was cheaper. The average price estimates given by the researchers were £1,066 for a planned home birth and £1,435 for the next-cheapest option, a planned birth at a free-standing midwife unit. This meant that, on average, planned births were at least a quarter cheaper than any of the alternative locations.

For women with an uncomplicated pregnancy having their first baby, home birth was still cheaper but there was slightly higher risk of complications with the newborn, though there was no increased risk of complications with the mother.

Importantly, the study should not be misinterpreted as meaning that home birth is always the most cost-effective option. This study did not look at women with complicated pregnancies or who were expected to have birth complications. For these women, birth in a facility where expertise is readily to hand is still likely to be the best option.

All women in this study had pregnancies that were judged to be uncomplicated prior to the start of their labour, but the researchers did find that among women having hospital births there was a higher proportion of women who had complications that were identified once their labour began. This, they say, means that, although these were all low risk pregnancies, the women in each group may not have been equivalent in terms of risk when they went into labour. This increased chance of having to deal with complications during hospital births may have made them appear less cost-effective than the other options.

The differences in cost between the groups became smaller if the researchers only looked at women who did not have complications at the start of their labour. In this analysis, the risk of adverse outcomes was also higher for births planned at home than those planned in hospital maternity units.

This large study is strengthened by its good coverage of different birth settings in NHS services across England, although the researchers note that there are still some limitations to their study. For example, they may not have captured all relevant costs because they relied on returns from finance departments. However, the researchers’ analyses suggested that varying these underlying costs generally had little effect on the results. Also, extended follow-up of the babies and their mothers would be required to capture the cost-effectiveness of each birth location taking into account possible longer-term health effects.

Overall, the study provides evidence to support home birth as a cost-effective option for women with a low-risk pregnancy, particularly if they are having their second or subsequent baby.