Birth centres and homebirth
When integrated within the health system, birth with registered midwives in a birth centre or at home, is safe and beneficial for mothers and babies at low-risk of complications (Birthplace in England Collaborative Group, 2018; Olsen, 1997; Hutton et al., 2019; Scarf et al., 2018). Integration means that if complications arise, midwives can easily consult with an obstetrician, and transfer the woman to an obstetric-led unit if required. Hospital birth is resource-intensive, particularly because it increases the risk of instrumental and surgical birth, which leads to longer hospital stays for mother and baby (Scarf et al., 2018). So, what if only women with risk factors birthed in an obstetric-led unit, while low-risk women birthed at home or in a birth centre?
Simulating two hypothetical scenarios
New research, conducted by Transforming Maternity Care Collaborative researchers Associate Professor Emily Callander (Deputy Director) and Professor Rhona McInnes (Program Lead – Practice Translation), answers this question. The researchers used health economics techniques to simulate and model two hypothetical scenarios (Callander, Bull, McInnes & Toohill, 2021). First, they developed a baseline model, using pre-existing dataset from 2012-2015, weighted using the most recent nationally available data (2017). Next, using this model, they categorized women as either ‘women at low-risk’ or ‘women with risk factors’. Women with risk factors were those with multiple pregnancy, beyond 41 weeks gestation, non-cephalic presentation (e.g., breech), body mass index >30, prior CS, more than 5 previous birth, or any medical condition that affected the pregnancy (Callander et al., 2021). Finally, they used data for women at low risk, to estimate the use of health resources in Scenario 1 (planned homebirth) and Scenario 2 (planned birth centre).
Health resource implications
The COVID-19 pandemic has highlighted the need to safeguard hospital resources and look to community-based options for primary healthcare (Callander et al., 2021; Daviss et al., 2021). If all low-risk women gave birth at home, CS rates would reduce from 13.4% to 2.7%, which would result in 860 fewer inpatient bed days and 10.1 fewer hours in the Intensive Care Unit (ICU) per 1000 births (Callander et al., 2021). If all low-risk women gave birth in birth centres, CS rates would almost halve (13.4% to 6.7%), which would result in 760 fewer inpatient bed days and 5.6 fewer hours in the ICU per 1000 births (Callander et al., 2021). We know that providing women at low risk of complications with the option of homebirth or birth centre is cost-effective (Scarf et al., 2021). An Australian costing analysis has determined the cost difference as $AUD4802 for homebirth, $AUD4979 for a birth centre birth and $AUD5463 for a hospital birth (Scarf et al., 2021). A US analysis has determined an annual saving of $US11 billion if 10% of all births occurred at home or in a free-standing birth centre (Daviss et al., 2021).
Access to birth outside an obstetric-led unit
Women who plan homebirth do so because they want to avoid intervention, feel comfortable at home, feel free to make choices, and access midwifery continuity of carer (Hauck et al., 2020). Yet despite evidence of safety, only a small fraction of Australian women birth at home (<1%) or in a birth centre (3%) (REF). This is partially explained by lack of free access, close to where the woman lives. There are only 15 publicly funded homebirth programs in Australia. These programs are not available in every state and territory, are usually limited to urban centres, and use strict inclusion and exclusion criteria – together this limits women’s access and choice of place of birth (Blums et al., 2021).
Conclusion and Recommendations
Maternity services should re-orientate themselves to provide choice of place of birth. This research demonstrates that if most low-risk women chose birth centre or homebirth, it would deliver significant cost-savings. But prior to any major change, women’s views should be sought and incorporated to co-design the model. Co-design ensures women, midwives and other stakeholder voices are heard and incorporated into maternity services. In addition, women need access to accurate, evidence-based information that outlines the risks and benefits of birth outside an obstetric-led unit. While the cost savings would be attractive to planners, the central driver of service redesign should be to safely meet the woman’s physical, social, and emotional needs.
Callander, E. J., Bull, C., McInnes, R., & Toohill, J. (2021). The opportunity costs of birth in Australia: Hospital resource savings for a post-COVID-19 era. Birth (Berkeley, Calif.), 48(2), 274–282. https://doi.org/10.1111/birt.12538
Blog written by
Dr Jyai Allen and Professor Mary Sidebotham
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