Issue 25 / 2 July 2012

THE cost-effectiveness of birth for women who ought to be at low risk of complications was the subject of a recent study. It looked at four settings — the home; free-standing midwifery units; hospital-based midwifery units; and obstetric units.

According to the abstract, this large prospective cohort study concluded that for “low-risk” pregnancies, homebirth was the most cost-effective option, regardless of the woman’s parity, although the authors concede that having a first baby at home was associated with an increase in “adverse perinatal outcomes”.

Delving into the text, though, it becomes clear that the situation is more complicated than this.

Costs included in the analysis were limited to those incurred during labour and the immediate postnatal period, and the acute stage if transfer took place to a higher level of care. This will underestimate the long-term cost of care for babies experiencing significant perinatal morbidity, a cost that can be considerable and one which is reflected, in Australia at least, in the high price paid by obstetricians for indemnity insurance.

That said, are there implications for maternity care in Australia and, in particular, for extending the option of homebirth to some women? Is homebirth in Australia likely to be as “cost-effective” as in Britain?

There are obvious and important geographical differences between Australia and Britain, differences that have the potential to decrease cost-effectiveness as well as affecting the provision of safe homebirth.

In Britain, homebirth midwives work in conjunction with staff at designated hospitals readily accessible to the woman’s home. When complications arise in a “low-risk” birth, transfer to hospital obstetric care can be timely and streamlined.

This British model has been established in some Australian states. A 2009 study from St George Hospital in Sydney reported on the first 100 cases using this model (it took more than 3 years to accumulate the cohort, suggesting a limited demand for such a service).

Thirty women were transferred to hospital care antenatally and seven during labour, while 63 gave birth at home. There were no deaths or significant complications reported from this small sample.

Women were accepted into the homebirth program after assessment by an obstetrician, and the midwives were part of the hospital team. In this way, the program model was closely allied to those in Britain (and the Netherlands). However, births were attended by two midwives, which must have significantly increased the cost in comparison to hospital birth.

In 2011, we reviewed all published studies of homebirth in Australia reported over the previous two decades. The data revealed that for low-risk multiparous women, attempting homebirth with ready access to obstetric care may have been as safe for the baby as midwifery care in a birth centre or hospital setting, though not as safe as obstetrician-led care.

However, for the small number of women and babies who developed serious intrapartum or postnatal complications, homebirth perinatal outcomes were worse than for women in conventional settings, and obviously correspondingly more costly to the health system.

Attempted homebirth for women whose pregnancy was not low risk — not uncommon in current Australian homebirth practice — was associated with correspondingly poorer perinatal outcomes. Undoubtedly, as far as morbidity is concerned, these outcomes will be more costly than if the cases had been managed in conventional obstetric units.

Major contributors to adverse outcomes were geographic difficulties in accessing obstetric care, as well as apparent reluctance to do so.

The immediate costs of childbirth and postnatal care are important considerations for hospital administrators. However, it is essential that the real costs, including sometimes those of a lifetime of institutional care, are taken into consideration in economic analyses.

As doctors, we must constantly advocate for the best interests of our patients, including babies who cannot speak for themselves.

Professor Caroline de Costa is professor of obstetrics and gynaecology at James Cook University School of Medicine, Queensland. Associate Professor Stephen Robson is a specialist obstetrician in Canberra and associate professor of obstetrics at the Australian National University.

Posted 2 July 2012

21 thoughts on “Caroline de Costa

  1. Sue Ieraci says:

    Kate Stewart – lots of errors in both fact and logic there, but I’ll try to answer as best I can. First of all, let me declare that I do not believe that all babies should be born by Caesarean section. As you correctly state, birth can be seen as a compromise in risks between mother and baby: I didn’t make it so – that’s reality. SO, no, because any surgery and anaesthetic carries both risk and expense, I an not promoting universal cesarean section – even though, on a population basis, that would cause fewer birth injuries to babies. IN fact, I have never heard anyone advocating universal cesearean surgery.My last question is neither irrelevant nor insulting – it is a real-world question. Obstetricians choose cesarean where there are signs (in history, examination or tests) that there are real risks to the newborn. WOuld all these babies die or be damaged without cesarean? OF course not! But, until we have a tool that tells us exactly which babies would die or be damaged, we have to take a precautionary approach. Kate – have you ever been in the position of trying to make this sort of decision, knowing that a baby could be seriously harmed or die? You say “Your attempt to pit the baby against his or her mother, in terms of who should suffer the most in the birthing process, seems unhelpful.” I am not attempting to do anything – the reality exists in spite of me. As for the neonatal gut flora comment, there are many many more influences on babies’ gut flora than mode of birth, and it is constantly changing throughout childhood.
    You also say “Hospital birth seems almost designed to prevent the normal physiological process of labour in many ways that I don’t have time to mention here.” Not true – the large majority of hospital births – especially in public hospitals – are vaginal. WHere interventions are done, they are either to supplement the progression of physiological processes, or rescue them. Pregnancy and birth are physiological processes with a high mortality rate for mothers and babies. That’s why the specialty of obstetrics (and science-based midwifery) exist. I am not confronted at all by vaginal birth, having emerged that way myself, but it isn’t a very reliable system, is it?

  2. Richard Emmett says:

    “Your attempt to pit the baby against his or her mother, in terms of who should suffer the most in the birthing process, seems unhelpful. The mother-baby dyad must be considered together as what is best for mum is also best for baby.”

    I don’t think Sue Ieraci is promoting mortal combat between mother and child, nor advocating a 100% CS rate! She can no doubt speak for herself. But her highlighting the stats and calmly pointing out the risk-benefit analysis that every obstetrician undertakes at every delivery (i.e. balancing “needs” if you prefer that term) is just what is required. What is not helpful is over simplification and generalisation. What is good for one is not always good for the other – that’s the whole point! But because (First World) maternal mortality is now so low (but still numerically much lower than perinatal mortality), the emphasis understandably leans towards providing mums with healthy infants rather than depriving children of their mothers.

    Good news…the other day I witnessed yet another VBAC (vaginal birth after caesarian) in a private hospital. So it is possible and it happens all the time but is rarely acknowledged in these emotive exchanges.

  3. Kate Stewart says:

    Sue: Your last question is irrelevant, and also slightly insulting to suggest that aiming for normal physiological birth in the hospital setting means that one is willing to accept a few more dead babies. I did some checking and you are right; the WHO changed their official statement on caesarean rate targets in 2010 and now state that “caesarean sections should be available to all women who need them”. A statement that I completely agree with. However, it’s a very long way from saying that *all* birthing women should have caesareans because they better protect babies, which appears to be what you are saying. The most important word in that statement is NEED. The gold standard for obstetric care is, and should be, that an uncomplicated vaginal delivery is best for mother and for baby. Your attempt to pit the baby against his or her mother, in terms of who should suffer the most in the birthing process, seems unhelpful. The mother-baby dyad must be considered together as what is best for mum is also best for baby. How much morbidity and mortality for women are you prepared to accept in a scenario where 100% of babies are born by caesarean section, Sue? Does the increased maternal mortality rates that will doubtless ensue on a population basis (bleeding, infection, post-operative PE, etc) seem worth it? It doesn’t have to be major abdominal surgery (which I never said that it was) to have a small but definite risk of death as with any surgery. The newborn will not thank you for depriving him of his mother (nor will his siblings), especially if his life was never at risk anyway (if all women are delivered surgically). And this does not even take into consideration the questions of establishing the breastfeeding relationship, a task made more difficult for post-CS women, or the findings that suggest that the establishment of normal gut flora is accomplished by the journey down the birth canal and the downstream effects on immunity, among many other considerations.

    Again, let me reiterate my original question: what are obstetricians going to do to increase the rate of *normal uncomplicated vaginal delivery* in the hospital setting? It is accepted that unforeseen complications will always arise and must be managed appropriately, and for many that will involve a quick, timely surgical intervention to prevent death or injury to the neonate. However. Hospital birth seems almost designed to prevent the normal physiological process of labour in many ways that I don’t have time to mention here. There is so much more that could be done to help women deliver safely and with confidence in the hospital setting, and obstetricians should be working with midwives to achieve this, for everyone’s benefit. THIS is what we should be working for, rather than encouraging higher rates of home birth on the one extreme or advocating universal caesareans, at the other. What is it about the notion that people are designed to be born via their mother’s vagina that you find so confronting?

  4. Sue Ieraci says:

    Kate Stewart – no need for astonishment – there is good evidence that cesarean birth is safer for babies – at the cost of some morbidity (usually minor and temporary) for the mother. Cesarean is relatively uncomplicated surgery, performed in healthy young women. In contrast, bowel resection for cancer, or aortic aneurysm repair, or nephrectomy would be “major abdominal surgery”. The WHO (no less) have withdrawn their cesarean targets, having admitted that the figures they previously recommended were not based on anything. Cesareans protect the brain cells and lives of newborn babies. They essentially pose no risk to the baby except for (i)small risk of minor nicks – which can be sutured and heal quickly; and (ii) moderately increased risk of TTN (transient tachyponoea of the newborn) – which has no long-term effects. Vaginal birth, on the other hand, carries about a 10% mortality risk to the baby with no intervention at all, and even with intervention involves a risk to the baby of hypopxic brain damage, nerve injury and other direct trauma (clavicle, skull). Kate: what increase in neonatal mortality would you accept for a decrease in the cesarean rate?

  5. drphil says:

    I started my fulltime O&G training in the UK in 1979. Arrived back in Australia at the end of 83. I know exactly what Alex is talking about. I’m so over the fight between public and private in this country. I no longer enjoy obstets because of all the defensiveness that has crept in, even in the public system.

  6. Alex says:

    Jonathan is right and it was just this sort of thing that worried and concerned me when I returned from the UK. I couldn’t believe the lack of “team work” and the way some of the midwives, fortunately few in numbers, would actively try to keep the registrar who was on for Labour Ward, away from patients. I have the impression that these midwives are having a bigger and bigger imput into obstetric care.
    Why in heaven’s name they think they should manage a complicated pregnancy/confinement is beyond me; their political agendas seem far more important than their care for their patient.

  7. Jonathan says:

    The comments by some of the midwives on this forum are giving me flashbacks to the moments when I decided not to pursue a career in obstetrics. Watching midwives openly lie to the obstetricians to keep them out of the room, then go back in and tell the mother how lucky she was to have a midwife keeping the doctors away – and the mother would believe her!! When it all went bad the emergency buzzer was the first warning to medical team had that something was wrong.

    I watched a baby become brain damaged in front of me this for lack of a caesar. For those of you who haven’t seen a baby severely brain damaged by shoulder dystocia in a few years, please try to remember how this looks and how common it would be if it were not for medical intervention.

  8. Kate Stewart says:

    “Outcomes for neonates are better with cesarean birth than vaginal.”
    I am not an obstetrician but I am amazed to read this. Really? If this is the case, why has the WHO (no less) recommended an ideal caesarean rate of 10-15%? Why are obstetricians and midwives not then pushing for 100% rates to protect every newborn? My understanding has been that an uncomplicated caesarean birth is certainly less desirable for the neonate than an uncomplicated vaginal birth – and only more so when the mother-and-baby are seen as one highly interconnected unit rather than two separate beings with competing interests.
    This astonishing statement aside, given that the safety of even well-regulated homebirth with medical backup is still uncertain, relative to hospital birth – what are obstetricians going to do to increase the rate of normal vaginal birth in a hospital setting, given that there is such a high rate of intervention in labour (much higher than 10%). Whoever said above that maternal satisfaction is not just a nice thing to have, it demonstrably improves neonatal *and* maternal health, is dead right. Obstetrician-led care is ‘safer’ in terms of perinatal morbidity and mortality but that does not mean that the model that is practised in Australia currently is the best we can do. Healthy mother, healthy baby is the most important consideration….but does it have to be the only consideration?

  9. B.E.V. says:

    I find it interesting to read what Professor de Costa has to say. I heard her state in an interview with Norman Swan on the 9th November 2009 ” that women now had a safe choice between caesarian birth (major abdominal surgery) and vaginal birth!” I have had both types of birth and there a vast difference in outcomes and the slowest recovery and debilitating movement restricting access to the baby. I had one of the best obstetricans in private care chosen by me. What many doctors appear to lack is a knowledge about effects on bonding and breastfeeding success – that is the long-term flourishing of the mother and baby. The only “success” or choice is that the non-specialist surgeons in the form of obstetricians are able to perform a safe abdominal invasion of the abdomen where they strip back the bladder and many other tissues and vessels and organs, from the uterus. The bladder and the uterus both need Post Traumatic Caesar counselling. In my opinion as a former Senior Unversity Lecturer in Health Sciences for undergraduate and post graduate midwives from 1962 to date when I updated my brain from obstetric nurse to true midwife. Of course during that time I realised the limits of knowledge of most obstetricians and many midwives about the value of an intact aminiotic sac and how breastfeeding releases more oxytocic than any artificial hormone extracted from horse’s urine. Enough said I know I am wasting my breath on the ingrained medicalisation of women and the hero worship of the doctor who collects a huge salary and fee for merely turning up after the woman has done all of the work – called labour. Angry cranky activist and advocate. Pleading with the ignorant to stop fixing what aint broke? The hidden insertion of gels with names which do not clearly represent or are accompained by known harm which exhaust the mother so she is not able to labour well – the unbelievable sending home of these women to monitor themselves. No explanantion of the harmful chemicals within used in the hands of the inexperienced. The added effect of synthetic hormones – when the fetus fails to respond to this artificial stimulation and even some women deciding to respond to the pressure for abdominal surgery by impatient doctors. One impatient private obstetrician even pulling on a cord and breaking it and expressing her impatience with the woman who withstood the pressure to have a caeasarian. This doctor refuses to work after 5pm. The woman had an haemorrhage as a result of not leaving nature to take its course. This story is one of many I have witness over 45 years of practice in every area of birth.

  10. Sue Ieraci says:

    Jennifer Cameron – placenta accreta remains very rare – a recent paper in Archives of Disease of Childhood estimated the UK incidence as 1.7 per 10,000 maternities (data from 2010-2011). This is less of an issue these days because women are having less children. You say that a cesarean that results in a well baby is “not a defensible argument” and quote ‘I have regretted not doing a C/S but I never regretted doing one’. What that actually means is “I have regretted my decisions that lead to harm to babies, but not those that have reduced the risk for babies. Outcomes for neonates are better with cesarean birth than vaginal. That’s why they are done. The rise in incidence is also because they are replacing a falling rate of instrumental (forceps) births, which can be traumatic to both mother and baby. This is reality in the real world. I know of no clinician who wants to be responsible for damaging a newborn.

  11. Jennifer Cameron says:

    Unecesarean is any C/S done for no obstetric reason, e.g some repeat C/S. Women are paying the price with an increase in placenta accreta and PPH, some leading to hysterectomy. The situation Sue describes where the baby comes out with a apgar of 10/10 is not a defensible argument. It is reflected in the old obstetric adage ‘I have regretted not doing a C/S but I never regretted doing one’. Yep, makes you feel good!

  12. Sue Ieraci says:

    Vee – you ask “how has humankind survived?” The answer is clear: by having lots of babies, and only wasting some (if I recall correctly, about 10% of mothers and babies). Our community no longer accepts a 10% chance of a mother or baby dying in childbirth – that’s why we have modern midwifery and obstetrics. I would also caution against the pronouncement of a cesarean being “unnecessary”. If we had a perfect tool for predicting prospectively which cesareans were absolutely necessary, it would certainly be used. But is a cesarean prounounced unnecessary retrospectively because the baby came out just fine? Surely that means it was done in time – before the baby was damaged. Remember, obstetricians are held accountable for not intervening early enough.

  13. Vee says:

    In response to two posts, I agree wholeheartedly with Jennifer Cameron regarding unnecessary caesarean sections and the financial, physical, emotional and social cost thereof. These frequently occur in busy units where labour is often induced or augmented for expedience rather based on evidence. That is a very strong argument for publicly funded home birthing as happens in the UK and elsewhere, even in some progressive Australian maternity services. To juleslegrand , if you read the evidence (supported by doctors comments in this thread), you would know that homebirth can be a very safe option, with rates of caesarean section resulting from failed home births being far lower for low risk women than birthing in hospital. Your quotes regarding nature being a poor midwife (how has humankind survived?) and equating home birth with child abuse are unhelpful and alarmist to say the least.

  14. James Currie FRCSC says:

    I’m surprised that this is an issue in Australia of all places. The midwives from Australia were the most well trained and competent I met during my training in the UK.
    I’m just not certain that hypoxic/ischaemic injury necessarily occurs during labour and delivery. With well trained domiciliary midwives I believe home birth can be very safe, especially because the woman feels secure in her environment. In our Province of Alberta, Canada, midwives are baccalaureate certified and recognised. With their care I have no doubts about safety of home birth. We all can quote events of obstetric disasters, but the case for universal hospital birth, or for that matter elective C/S, is not proven.

  15. Sue Ieraci says:

    The recent UK Birthplace Study looked at homebirth outcomes in a well-structured system. With strict rule-out criteria and a 40% transfer rate, there was still an excess neonatal mortality for first-time mothers. They did not report the babies that suffered disability. It is particularly hypoxic-ischaemic injury that occurs intra-partum that can be prevented in the hospital environment. No matter how normally a pregnancy progresses, and how healthy, fit, and relaxed a mother is, unforeseen mechanical complications can occur – things like shoulder dystocia, cord accidents. The incidence might be small, but the potential outcomes catastrophic.

  16. Margaret Smith says:

    I agree with Alex Crandon The British system works very well with midwives are given respect and allowed to deliver the normal births.I trained there in the sixties.
    I spent 7 years in New Guinea as the only obstetrician for the HIghlands. There I learned that “natural” is not always “normal”! I wish we could get women and some midwives to understand this. Home birth with a good midwife and proper backup with an obstetrician and hospital can prevent the disasters written about in The Australian Weekend Magazine.”Risky Birth” I wrote a letter saying all this but it was not published!!

  17. Anonymous says:

    By all means lets measure the full costs of all births. Let’s measure the costs of poor perinatal mental health resulting from traumatic births, lower breastfeeding rates for traumatised babies from an unnecessary instrumental or caesarean births and fragmented care models, the costs of increased admissions to neo-natal units from caesarean birth and fragmented care models, the increased costs of anaesthesia in fragmented care models. Maternal satisfaction is not just a nice thing to have, it results in real cost reductions. Long-term costs of ‘conventional’ obstetric driven models of care have never been taken into account.
    Thank you Alex Crandon for pointing out one of the huge issues that prevents improvements in maternity care in Australia. Doctors Robson and de Costa contribute to this “us and them” culture by focusing on the homebirth debate rather than on improving access to continuity of care models for all women with seamless referral to specialist obstetric care as necessary.

  18. Alex Crandon says:

    I find this a very interesting discussion. I did my obstetric training and worked in the UK for some years before coming back to Australia. I was brought up with a system that I thought worked extremely well. All patients were seen at the Maternity Hospital for their first antenatal visit. They were then given a choice if all was normal; domiciliary confinement or hospital confinement. Those that chose domiciliary confinement were then seen for their antenatal visits by the domiciliary midwife except for a further visit at about 32-34 weeks at the Maternity Hospital, just to check that all was normal and nothing subtle had occurred. If all was normal then the patient proceeded to a domiciliary confinement. The Flying Squad was always available is things went wrong at home.

    If the woman chose hospital confinement then she was largely seen for antenatal care in the midwives clinic. Again the woman would be checked by the Obstetric staff at about 32-34 weeks. If all remained normal then the woman would come in in labour, be delivered by a midwife and apart from a single postnatal check of mother and baby by obstetric Reg or SHO would go home within a day or so.

    The one thing you could absolutely guarantee was that there was NO “them and us” attitude between the midwives and the obstetric staff. If anything varied from the normal then the midwives took the view that this was now an abnormal event and as midwives are trained to manage the normal, they would call in the obstetric service. Remember that these were British trained Domiciliary Midwives with many years of experience and with skill levels and obstetric knowledge not often seen in Australia. Never ever did a situation arise where a midwife pressed on with the management of a known non-normal process, let alone try and manage a multiple birth, breech etc in the domiciliary situation.

    When I came back to Australia I was shocked by the attitude of many midwives who never saw themselves as part of a team providing a continuem of obstetric care, with them at the normal end and the obstetrician at the other end and fairly clear lines of delineation of roles. It was as if the midwives had to keep the women away from the obstetric services at all costs, for the women’s safety.

    I think until this attitudinal problem is overcome and people start working as a team, we will continue with these difficulties and with unhappy patients.

    Mother nature is a damn awful accoucher. She shows no mercy and is very happy to sacrifice mothers and babies to the “survival of the fittest” principle. Not uncommonly problems arise that show previous evidence of being present. For example, the death of a normal term baby in NSW, recently the subject of a Coroner’s Inquest, where the baby was lost because of a cord entanglement – a non-event with a midwife or obstetrician present. Unfortunately the woman only had her partner and a friend present and no one knew what to do.

  19. Vee says:

    As a midwife practicing in a public hospital I agree that the safety of both mother and baby is paramount. However I do believe there should be greater choice for birthing women and that publicly funded home birth for low risk women has many advantages including cost, safety and client satisfaction. This option also allows ready access to the woman’s history should transfer be necessary and also requires that both the midwives and birthing women adhere to hospital guidelines and policies. Providing greater access to this service may reduce the incidence of unsafe home birthing as well as decreasing the patient load in maternity units. Unfortunately nothing short of legislation will stop those who insist on birthing at home despite being distant for obstetric care in case of emergency or not being low risk.

  20. Jennifer Cameron says:

    If looking at the cost of birth shouldn’t the costs of unnecessary caesarean section be factored in? I agree the costs of women at high risk of complications or with known complications such as breech or multiples birthing at home has the potential to be considerable. Though most women in this situation are birthing at home because of a previous traumatic hospital birth. Having spent most of my midwifery career in hospital maternity units that are usually very busy, women’s rights tend get lost in the day to day hurly burly of the units and this can result in unrecognised trauma for some women. If we look at the long term costs, having satisfying birthing experiences that empower women & their families and result in effective parenting should show good public health outcomes down the track. And if our hospital units are more woman-friendly I would think more women would use these. By our actions we are forcing certain women to birth at home. And really how do we define ‘safe’, just in physical terms or in terms of mental health as well? Part of the problem is control; I worked with an obstetrician once who would OK a VBAC even though he was fairly sure it would end up as another C/S because of the reasons for the previous C/S. The women were fully informed that it was not likely that a VBAC would result but they were in control and whatever the outcome it was their decision. Even though they did end up with another C/S they were satisfied, control. My thoughts.

  21. juleslegrand says:

    “Nature makes a very poor midwife”, my own professor used to say. On the subject of home birth, I can fully appreciate the attraction relating to being in the bosom of one’s family and friends, as well remaining outside of those “fearful” hospitals and birth centres, but at what cost in a few “risk free” pregnancies, let alone those of the “high risk” variety? A former president of the American College of Obstetricians and Gynecologists once said, “One day home birth will be viewed as the earliest form of child abuse.”

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