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

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.

Conflict of interest statement

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.

Figures

Fig 1 Cost effectiveness acceptability curves for planned place of birth for all low risk nulliparous women for adverse perinatal outcome avoided. At all £10 000 intervals, obstetric units were dominated by other settings and were found to have zero probability of cost effectiveness

Fig 2 Cost effectiveness plane: planned birth at home compared with planned birth in obstetric units for nulliparous low risk women without complicating conditions at start of care in labour

Fig 3 Cost effectiveness acceptability curves for planned place of birth for nulliparous low risk women without complicating conditions at start of care in labour for adverse perinatal outcome avoided