AJOG — anti-phb paper ~ section on Cost-effectiveness
Cost-effectiveness
In the United States and throughout the world fiscal responsibility and accountability have become essential components in clinical practice and organizational leadership.44 It might at first appear that planned home birth offers the potential for cost-savings by avoiding a relatively more expensive hospital admission. The Birthplace in England national cohort study “priced” planned home birth, birth in freestanding midwifery units, “alongside” midwifery units, and obstetric units at, respectively, £1066, 1435, 1461, and 1631, and concluded that “for multiparous women at low risk of complications, planned home birth is the most cost-effective option. For nulliparous low-risk women, planned birth at home is likely to be the most cost-effective option but associated with an increase in adverse perinatal outcomes.”45
This is selective and a defective cost-effectiveness analysis. A more comprehensive Dutch report calculates a general 3-fold increase of costs in patients transported during labor, when the costs of the midwife, the transport system, and the obstetricians are included. Even more important, Svensson46 exposed the failure to include the lifetime costs for support of disabled children, which he estimates to be £5 million per handicapped child. In addition, the potential increased cost of professional liability must be considered.47 A comprehensive and reliable cost-effectiveness analysis would have also to take into account the cost of maintaining an adequate transport system, hospital admission for the pregnant women, admissions to the neonatal intensive care unit, the lifetime costs of supporting the neurologically disabled children who will result from planned home birth, and potentially increased professional liability costs.
In summary, selective cost-effectiveness analysis is not consistent with professional responsibility and may seriously mislead public officials in policy deliberations about permitting and funding planned home birth. If we regard the increased “event” of perinatal or even maternal death−which appears in the British Birthplace study only in an appendix−these calculations become even more problematic, inasmuch as the least expensive patient is a dead patient.
