Modelling the cost of place of birth: a pathway analysis

Background In New South Wales (NSW), Australia there are three settings available for women at low risk of complications to give birth: home, birth centre and hospital. Between 2000 and 2012, 93.6% of babies were planned to be born in hospital, 6.0% in a birth centre and 0.4% at home. Availability of alternative birth settings is limited and the cost of providing birth at home or in a birth centre from the perspective of the health system is unknown. Objectives The objective of this study was to model the cost of the trajectories of women who planned to give birth at home, in a birth centre or in a hospital from the public sector perspective. Methods This was a population-based study using linked datasets from NSW, Australia. Women included met the following selection criteria: 37-41 completed weeks of pregnancy, spontaneous onset of labour, and singleton pregnancy at low risk of complications. We used a decision tree framework to depict the trajectories of these women and Australian Refined-Diagnosis Related Groups (AR-DRGs) were applied to each trajectory to estimate the cost of birth. A scenario analysis was undertaken to model the cost for 30 000 women in one year. Findings 496 387 women were included in the dataset. Twelve potential outcome pathways were identified and each pathway was costed using AR-DRGs. An overall cost was also calculated by place of birth: $AUD4802 for homebirth, $AUD4979 for a birth centre birth and $AUD5463 for a hospital birth. Conclusion The findings from this study provides some clarity into the financial saving of offering more options to women seeking an alternative to giving birth in hospital. Given the relatively lower rates of complex intervention and neonatal outcomes associated with women at low risk of complications, we can assume the cost of providing them with homebirth and birth centre options could be cost-effective.

ASK a Midwife: A Qualitative Study Protocol

Midwife-led institutions, also called free-standing birth centres, offer birth assistance to women at low risk for complications. Free-standing birth centres, because they are the institutions that provide low intervention birth assistance, also present the possibility to conduct research on the skills and knowledge that are necessary to provide safe care for women who are at low risk for complications desiring an out-of-hospital birth. The aim of this study is to reveal the skills and knowledge necessary to provide care at low intervention births in free-standing birth centres in Germany for midwives post-certification. The theoretical and methodological standpoint of this study is hermeneutic phenomenology. In-depth qualitative methods will be used that are particularly sensitive to the research participants and their social context and allow for complexity, detail and context. The research sites are free-standing birth centres in Germany. Three strands of data will be collected. Each birth centre has its own quality management handbook. From this handbook, the chapter concerning the induction of new midwives will be analysed. Small focus groups will be held in ten birth centres throughout Germany; and data will be collected from 10 to 20 midwives during their induction period at the birth centre. The data collection methods will be open-ended interviews, data capture, journaling and non-participant observation with the new midwives. In-depth data analysis will reveal midwives’ experiences of skill acquisition in free-standing birth centres. The findings will be used to produce key recommendations for training midwives to work in birth centres.

How can consultant-led childbirth care at time of delivery be maximised? A modelling study

ObjectiveThe Royal College of Obstetricians and Gynaecologists has advised that consolidation of birth centres, where reasonable, into birth centres of at least 6000 admissions per year should allow constant consultant presence. Currently, only 17% of mothers attend such birth centres. The objective of this work was to examine the feasibility of consolidation of birth centres, from the perspectives of birth centre size and travel times for mothers.DesignComputer-based optimisation.SettingHospital-based births.Population or sample1.91 million admissions in 2014–2016.MethodsA multiple-objective genetic algorithm.Main outcome measuresTravel time for mothers and size of birth centres.ResultsCurrently, with 161 birth centres, 17% of women attend a birth centre with at least 6000 admissions per year. We estimate that 95% of women have a travel time of 30 min or less. An example scenario, with 100 birth centres, could provide 75% of care in birth centres with at least 6000 admissions per year, with 95% of women travelling 35 min or less to their closest birth centre. Planning at local level leads to reduced ability to meet admission and travel time targets.ConclusionsWhile it seems unrealistic to have all births in birth centres with at least 6000 admissions per year, it appears realistic to increase the percentage of mothers attending this type of birth centre from 17% to about 75% while maintaining reasonable travel times. Planning at a local level leads to suboptimal solutions.

Mapping the trajectories for women and their babies from births planned at home, in a birth centre or in a hospital in New South Wales, Australia, between 2000 and 2012

Background In New South Wales (NSW) Australia, women at low risk of complications can choose from three birth settings: home, birth centre and hospital. Between 2000 and 2012, around 6.4% of pregnant women planned to give birth in a birth centre (6%) or at home (0.4%) and 93.6% of women planned to birth in a hospital. A proportion of the woman in the home and birth centre groups transferred to hospital. However, their pathways or trajectories are largely unknown. Aim The aim was to map the trajectories and interventions experienced by women and their babies from births planned at home, in a birth centre or in a hospital over a 13-year period in NSW. Methods Using population-based linked datasets from NSW, women at low risk of complications, with singleton pregnancies, gestation 37–41 completed weeks and spontaneous onset of labour were included. We used a decision tree framework to depict the trajectories of these women and estimate the probabilities of the following: giving birth in their planned setting; being transferred; requiring interventions and neonatal admission to higher level hospital care. The trajectories were analysed by parity. Results Over a 13-year period, 23% of nulliparous and 0.8% of multiparous women planning a home birth were transferred to hospital. In the birth centre group, 34% of nulliparae and 12% of multiparas were transferred to a hospital. Normal vaginal birth rates were higher in multiparous women compared to nulliparous women in all settings. Neonatal admission to SCN/NICU was highest in the planned hospital group for nulliparous women (10.1%), 7.1% for nulliparous women planning a birth centre birth and 5.1% of nulliparous women planning a homebirth. Multiparas had lower admissions to SCN/NICU for all thee settings (hospital 6.3%, BC 3.6%, home 1.6%, respectively). Conclusions Women who plan to give birth at home or in a birth centre have high rates of vaginal birth, even when transferred to hospital. Evidence on the trajectories of women who choose to give birth at home or in birth centres will assist the planning, costing and expansion of models of care in NSW.

Caesarean Delivery Rates in Birth Centres: confrontation using Robson Classification

Background A caesarean section (CS) is a life-saving procedure, reducing perinatal mortality and morbidity, over last decades CS rates are increasing. In 2015 the Robson classification (RC) was introduced by WHO as a global standard for assessing, monitoring and comparing CS rates within healthcare facilities and between them. The aim of this cross-sectional study was to identify the most numerous groups according to RC. Methods All women, who delivered by CS from January 2015 to June 2017 in two hospitals in the province of Siena (Italy): I level Birth Centre of Grosseto (GR) and II level Birth Centre of Siena (SI) were included. Age, type of hospital and group based on RC were extracted from Medical Register. The RC divides women into 10 groups based on 5 basic obstetric characteristics (parity, number of foetuses, previous CS, onset of labour, gestational age, foetus presentation). The percentages of the group’s contribution to the overall CS rate were calculated and confronted for two birth centres. All analysis was performed with Stata. Results A total of 2115 women was analysed, 50.5% from SI. Average age was 34.3±5.7; significantly higher for SI (34.7±5.6vs33.9±5.8). Most contributing groups were group V: multiparous, singleton, cephalic, term, with previous CS (24.2%), group II: nulliparous, singleton, cephalic, term, induced labour or CS (24%), group I: nulliparous, singleton, cephalic, term, spontaneous labour (11.45%), group VIII: multiple pregnancy (10.7%) and group X: singleton, cephalic, pre-term (10.4%). Differences for type of birth centre were observed for groups I, II, V and VIII: I and VIII were more numerous in SI, II and V in GR (chi2; p < 0.05). Conclusions The most numerous groups were I, II e V, concordant with literature. Reduction of CS rates in group V could be obtained through lowering of primary CS rates and by promotion of Vaginal Birth After CS. Healthcare professionals could help to reduce labour-related anxiety and elective CS rates. Key messages The most contributing groups to overall caesarean section rates were groups I, II e V, as reported in literature. Reduction of CS rates could be obtained through lowering rates of primary CS, but also by promotion of Vaginal Birth After CS.