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Open Access

Peer-reviewed

Research Article


COSTS OF PLANNED HOME VS. HOSPITAL BIRTH IN BRITISH COLUMBIA ATTENDED BY
REGISTERED MIDWIVES AND PHYSICIANS

 * Patricia A. Janssen ,
   
   * E-mail: patti.janssen@ubc.ca
   
   Affiliations School of Population and Public Health, University of British
   Columbia, Vancouver, British Columbia, Canada, Child and Family Research
   Institute, Vancouver, British Columbia, Canada
   
   ⨯
 * Craig Mitton,
   
   Affiliations School of Population and Public Health, University of British
   Columbia, Vancouver, British Columbia, Canada, Centre for Clinical
   Epidemiology and Evaluation, Vancouver, British Columbia, Canada
   
   ⨯
 * Jaafar Aghajanian
   
   Affiliation BC Centre for Epidemiologic and International Ophthalmology,
   Vancouver, British Columbia, Canada
   
   ⨯


COSTS OF PLANNED HOME VS. HOSPITAL BIRTH IN BRITISH COLUMBIA ATTENDED BY
REGISTERED MIDWIVES AND PHYSICIANS

 * Patricia A. Janssen, 
 * Craig Mitton, 
 * Jaafar Aghajanian

x
 * Published: July 17, 2015
 * https://doi.org/10.1371/journal.pone.0133524
 * 


 * Article
 * Authors
 * Metrics
 * Comments
 * Media Coverage

 * Abstract
 * Introduction
 * Methods
 * Results
 * Discussion
 * Conclusion
 * Supporting Information
 * Author Contributions
 * References

 * Reader Comments
 * Figures





ABSTRACT


BACKGROUND

Home birth is available to women in Canada who meet eligibility requirements for
low risk status after assessment by regulated midwives. While UK researchers
have reported lower costs associated with planned home birth, there have been no
published studies of the costs of home versus hospital birth in Canada.


METHODS

Costs for all women planning home birth with a regulated midwife in British
Columbia, Canada were compared with those of all women who met eligibility
requirements for home birth and were planning to deliver in hospital with a
registered midwife, and with a sample of women of similar low risk status
planning birth in the hospital with a physician. We calculated costs of
physician service billings, midwifery fees, hospital in-patient costs,
pharmaceuticals, home birth supplies, and transport. We compared costs among
study groups using the Kruskall Wallis test for independent groups.


RESULTS

In the first 28 days postpartum, we report a $2,338 average savings per birth
among women planning home birth compared to hospital birth with a midwife and
$2,541 compared to hospital birth planned with a physician. In longer term
outcomes, similar reductions were observed, with cost savings per birth at
$1,683 compared to the planned hospital birth with a midwife, and $1,100
compared to the physician group during the first eight weeks postpartum. During
the first year of life, costs for infants of mothers planning home birth were
reduced overall. Cost savings compared to planned hospital births with a midwife
were $810 and with a physician $1,146. Costs were similarly reduced when
findings were stratified by parity.


CONCLUSIONS

Planned home birth in British Columbia with a registered midwife compared to
planned hospital birth is less expensive for our health care system up to 8
weeks postpartum and to one year of age for the infant.


FIGURES

  

Citation: Janssen PA, Mitton C, Aghajanian J (2015) Costs of Planned Home vs.
Hospital Birth in British Columbia Attended by Registered Midwives and
Physicians. PLoS ONE 10(7): e0133524.
https://doi.org/10.1371/journal.pone.0133524

Editor: Sari Helena Räisänen, Kuopio University Hospital, FINLAND

Received: January 22, 2015; Accepted: June 29, 2015; Published: July 17, 2015

Copyright: © 2015 Janssen et al. This is an open access article distributed
under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the
original author and source are credited

Data Availability: All relevant data are within the paper and its Supporting
Information files.

Funding: This study was funded by the Canadian Institutes of Health Research.
The agency does not issue grant numbers. The URL is
http://www.cihr-irsc.gc.ca/e/193.html. The funders had no role in study design,
data collection and analysis, decision to publish, or preparation of the
manuscript.

Competing interests: The authors have declared that no competing interests
exist.


INTRODUCTION

Recent large population-based studies using standardized third-party
ascertainment of outcomes have affirmed the safety of planned home vs. planned
hospital birth attended by regulated midwives or physicians among selected
women.[1–4] The desirability of the choice to give birth at home has been
supported in both quantitative [5–7] and qualitative [8–12] studies. In Canada,
planned home birth attended by regulated midwives was first introduced in 1994
in the province of Ontario, where the number of home births has risen to 3,000
annually.[13] In British Columbia, 11% of births are currently attended by
midwives.[14] Among these, approximately 20% take place at home.[15]

The only Canadian evaluation of costs of out of hospital birth to date evaluated
free standing birth centres in Quebec.[16] This study suggested that midwifery
care in Quebec birth centres differs little from conventional medical care in
terms of costs. An American study reported average costs in 1991 to be $1,711
for home births and for hospital births $5,382.[17] In the Netherlands, where
29% of births are planned to be at home with regulated midwives, a recent
prospective study of healthy primiparous women reported a decrease in cost of
177 Euros associated with home versus hospital birth.[18] A 2008 review of
economic implications of out of hospital births was unable to report definitive
conclusions due to the paucity of economic literature relating to home birth,
but concluded that home birth is likely to be a cost-effective option.[19] Most
recently the Birthplace in England Collaborative Group, reporting on a sample of
home births attended by midwives, midwifery units and in-hospital obstetric
units, concluded that planned home birth was the most cost effective option for
women at low risk of pregnancy complications.[20] In the current study, we
present a detailed economic analysis of all home births attended by regulated
midwives in the Province of British Columbia, Canada.


METHODS

The current study undertakes a government payer perspective to compare costs of
planned home birth attended by regulated midwives with those of planned hospital
births attended by regulated midwives and by physicians. Details of the study
are presented elsewhere.[21] In brief, costs for all women planning home birth
with a regulated midwife between 2001 to 2004 in British Columbia, Canada were
compared with those of all women who met eligibility requirements for home birth
as defined by the College of Midwives of BC [22] and were planning to deliver in
hospital with a registered midwife, and with a random sample of women of similar
low risk status matched on age, parity, marital status, and year of birth, and
planning birth in hospital with a physician.

Linked data was obtained for this study from Population Data BC. Population Data
BC is a health data resource linking heath data through a unique 10-digit
personal health number assigned to all subscribers of the British Columbia
Medical Services Plan (MSP). All BC residents must enroll with MSP. Personal
health numbers for individuals designated to each of our study cohorts defined
from the BC Perinatal Data Registry were linked to five health data registries:
Medical Services Plan Payment Information;[23] and its associated Registration
and Premium Billing file;[24] BC Ambulance Service;[25] Discharge Abstract
Database;[26] and PharmaNet. [27]

This study was undertaken with approval from the University of British Columbia
Research Ethics Board, the Children's and Women's Health Centre of British
Columbia Research Review Committee, the British Columbia Ministry of Health
Services, and the British Columbia College of Pharmacists.

The Medical Services Plan (MSP) Payment Information file contains data on
services provided by fee-for-service practitioners to individuals covered by
MSP, BC’s universal insurance program (Table 1). We assigned costs associated
with fee payments to physicians by summing the amount for fee item codes
specific to maternity services associated with each patient’s personal health
number in the MSP records. Midwives bill the Medical Services Plan for a set fee
for each proportion of a course of midwifery care, as opposed to specific
maternity codes, as all of their service is related to maternity care. For our
analysis of birth to 28 days postpartum, we allocated 100% of the fee schedule
for labor/delivery for deliveries conducted at home by midwives. We allocated
40% if the midwife attended the birth in hospital but did not deliver the baby
(after transfer of care to a physician) and 0 if the midwife was not in
attendance, as per MSP protocol. We allocated two thirds of the cost of a course
of postpartum care for 28 days if the midwife billed for postpartum care. For
our analysis of birth to 56 days (8 weeks) we similarly assigned costs of
labour/delivery and allocated 100% of the postpartum component of care. Tota
costs from which proportionate costs were derived were obtained from the Medical
Services Payment Plan.[28]

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Table 1. Data Sources.



https://doi.org/10.1371/journal.pone.0133524.t001

Mode of emergency transport, air or ground, was obtained from BC Ambulance
Service data files obtained by Population Data BC. In consultation with BC
Ambulance Service, (personal communication D. Andrusiek, Research Director,
Medical Programs, Emergency and Health Services Commission of BC Ambulance
Service), ambulance costs were attributed as follows: $500 for ground, $1000 for
air, and $1500 for a combination of air and ground. If transport included both
mother and baby, the cost is listed for the infant only.

The Discharge Abstract Database houses data on discharges, transfers and deaths
of in-patients and day surgery patients from acute care hospitals in BC. The
hospitalization cost was derived by multiplying the In-Patient Resource
Intensity Weight (P-RIW) by the Cost Per Weighted Case (CPWC) for the
corresponding site and fiscal year. The RIW measures the intensity of resources
used based on patient diagnosis, surgical procedure performed and the case mix
group assigned to the individual patient. Case mix is an inpatient grouping
methodology used in Canada to create discrete clusters of patients using
clinical, administrative and resource consumption data. The case mix group takes
into consideration the patient’s age, health status, and discharge status. The
result is groups of patients that are clinically similar and/or homogeneous with
respect to hospital resources used.[29] The Canadian Institute for Health
Information (CIHI) defines RIWs for case mix groups. RIWs for individuals are
available from the Discharge Abstract Database. To convert the RIWs into actual
dollars, the RIW is multiplied by the CPWC. When the total expenditures for
inpatient care in a particular acute care hospital for one year is divided by
the total weighted cases of the same hospital during the same year, the result
is the average cost of providing care to a patient with a weighted case value of
1.00. Thus, the CPWC is the cost of a stay with a weight of 1.00. The CPWC is
different for each hospital each year. Province-wide CPWCs for the study period
were obtained from the BC Ministry of Health. We applied the CPWC value specific
to each year and each hospital when computing costs.[30]

PharmaNet records all prescriptions dispensed by British Columbia pharmacists in
an outpatient setting. PharmaNet is administered by the British Columbia
Ministry of Health for residents of BC. PharmaNet records include the ingredient
cost, professional fees, and third-party costs (administrative costs of
adjudicators/employers). Records also include non-drug items such as diabetic
test strips. Cost data was not available for residents paid through federal
plans, including federal police officers, veterans or individuals funded through
Indian Affairs, but ‘quantity dispensed’ and ‘days supply’ was available and
corresponding costs were estimated from provincial costs for these entities.

To capture costs associated with the intrapartum period, we included costs from
all data sources for the 48 hour period before the date and time of birth for
the mother. In our first analysis, we included maternal costs until and
including 28 days postpartum to correspond to the completion of the neonatal
period for the baby (Mom -2 to +28, Baby +28). Our second framework for
comparison was the postpartum period for the mother, defined as 8 weeks or 56
days, and the first year of life or 365 days for the infant (Mom -2 to +56, Baby
+365). To exclude births by non-BC residents, all mothers included had to be
registered with the provincial medical services plan during the follow-up
period.

We excluded from our analysis, 217 mother-baby pairs in which the babies had one
or more ICD-10 codes for congenital malformations. After removal of one birth
with data entry errors, and 19 births in hospitals where the cost per weighted
case (CPWC) was not available, the study population comprised records related to
9,864 live births.

We compared costs among study groups using the non-parametric Kruskal Wallis
test for independent samples, as distributions were not normally distributed. We
report mean costs per group, and groups stratified by parity. The data were
analysed using SAS software (version 9.3, SAS Institute, Cary, N.C.)


RESULTS

In total our study sample included 9864 women: all women who planned a home
birth with a regulated midwife (n = 2243); all planned hospital midwife-attended
births meeting the eligibility requirements for home birth (n = 3610) and a
sample of women planning hospital birth with a physician, also meeting
eligibility requirements for home birth and matched on age category, parity, and
restricted to hospitals in which midwives had admitting privileges (n = 4011).
Comparison groups were similar with respect to age, lone parent status, income
quintile, BMI, use of substances and gestational age at start of prenatal care
(Table 2).

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Table 2. Sociodemographic and Pregnancy Related Characteristics of Study
Participants.



https://doi.org/10.1371/journal.pone.0133524.t002

During the initial 28 days postpartum, average costs per mother were
significantly reduced among women planning home birth compared to hospital
birth, planned either with a midwife or a physician (Table 3). Compared to those
who planned hospital birth with a midwife, provider fees, hospital charges, and
pharmaceutical costs were significantly less. Compared to planned hospital
births with a physician, provider fees and transport costs were higher and
hospital costs and pharmaceutical costs were less. Similarly, average costs per
newborn during this period, corresponding to the early neonatal period, were
significantly reduced in the home birth group. Provider fees and pharmaceutical
costs were lower in the home birth group compared to both planned hospital birth
groups. Our data indicate a $2,338 average cost savings per birth among women
planning home birth compared to hospital birth with a midwife and $2,541
compared to hospital birth planned with a physician.

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Table 3. Average Costs of Planned Home vs. Hospital Birth by Regulated Midwife
or Physician, 0–28 days.



https://doi.org/10.1371/journal.pone.0133524.t003

Our findings were similar among nulliparous women, for whom overall average
costs among women planning home birth were significantly reduced by $2,122 and
$2,518 for planned hospital birth with a midwife and physician respectively
(Table 4). Among multiparous women, corresponding cost savings were $2,307 and
$2,579 per birth (Table 4).

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Table 4. Average Costs of Planned Home vs. Hospital Birth by Regulated Midwife
or Physician and Parity, 0–28 days.



https://doi.org/10.1371/journal.pone.0133524.t004

During the first 56 days, corresponding to the eight week postpartum period,
maternal costs for women planning home birth were significantly reduced overall
and for sub-categories of hospital and pharmaceutical costs. Costs for transport
were higher in the home birth group. Costs savings per birth were $1,683
compared to the planned hospital birth with a midwife, and $1,100 compared to
the physician group (Table 5).

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Table 5. Costs of Planned Home vs. Hospital Birth by Regulated Midwife or
Physician, 0–56 days (Maternal) and 0–1 Year (Infant).



https://doi.org/10.1371/journal.pone.0133524.t005

For nulliparous women these cost savings were $1,514 and $1,133 and for
multiparous women $1,679 and $1,095. (Table 6).

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Table 6. Costs of Planned Home vs. Hospital Birth by Regulated Midwife or
Physician, 0–56 days (Maternal) and 0–1 Year (Infant) by Parity.



https://doi.org/10.1371/journal.pone.0133524.t006

During the first year of life, costs for infants of mothers planning home birth
were reduced overall, and for physician fees and pharmaceutical costs compared
to both planned hospital cohorts. Cost savings compared to planned hospital
births with a midwife were $810 and with a physician $1,146 (Table 5).

Costs were similarly reduced when findings were stratified by parity. Cost
savings among infants of primiparous women were $749 and $1,095 for hospital
births planned with a midwife and physician respectively and for infants of
multiparous women were $802 and $1,186 (Table 6).


DISCUSSION

Our study demonstrates a significant cost savings for planned home birth in
British Columbia with a regulated midwife compared to planned hospital birth,
either with a regulated midwife or with a physician. As expected, transport
costs were higher for mothers in the home birth group, but provider fees,
hospital costs and pharmaceutical costs were lower for both mothers and infants.
We would expect hospital costs to be lower since most women in the planned home
birth would not be admitted to hospital. Provider fees and pharmaceutical costs
are reduced in both midwifery cohorts compared to the physician group and likely
reflect both the reduced rates of interventions among women receiving care by
midwives, and, since these differences persist beyond 28 days, self-selection to
planned home birth of women who are particularly healthy and do not wish to have
pharmacological interventions during labour and birth. This is the first study
of home birth to extend analysis of cost to the conclusion of the postpartum
period for mothers and to one year for infants. This is noteworthy because
“hidden” risks of home birth, that is morbidity manifesting beyond the immediate
postpartum period, if it existed, would be reflected in higher costs during the
prolonged period of observation in this study. However, delayed morbidity does
not appear to be a consequence of home birth.

Due to differences in how costs are assigned across studies and countries, our
findings may be cautiously compared to those of Hendrix et al. in the
Netherlands, comparing costs of births to nulliparous women planning birth at
home with a regulated midwife versus women planning birth in short stay units
attended by either midwives or family practice physicians.[18] The study
examined 100 midwifery practices sampled at random from across the Netherlands.
Costs for provider fees, hospital, and transport from the intrapartum period to
six weeks postpartum were €339 ($495 Cdn) less in the planned home birth group.
This analysis, however, does not separate births attended by midwives and
physicians.

A cost analysis of home birth from Washington State, USA during the same time
period as ours, reported cost savings of $2,971 for planned home births attended
by licensed midwives vs. planned hospital births resulting in vaginal delivery
attended by midwives and $5, 550 for hospital births attended by midwives
resulting in cesarean delivery. These differences, which correspond only to the
intrapartum period, are larger than ours, but again must be viewed cautiously as
costs in a Canadian context do not necessarily align well with costs (or
charges) reported in US studies.[31]

A British study reporting on 142 of 147 regional health authorities (“trusts”)
estimated costs for provider fees and salaries, hospital, transport and
pharmaceutical costs from finance departments of participating trusts,
consultations with midwives, and national sources of data. The mean savings for
home births (maternal and newborn) during the intrapartum period versus
obstetrical units was £564.6 ($1073.93 Cdn).

Strengths of our study include complete ascertainment of planned home and of
hospital births attended by midwives in an entire province. The same midwives
attend both home and hospital birth in British Columbia since they are required
to offer eligible women the choice of either setting. Our comparison of home vs.
hospital in the midwifery groups therefore reflects a true comparison of place
of birth un-confounded by type of caregiver. Both midwifery groups and our
random sample of physician-attended birth were of comparable low risk status. We
report costs assigned to individual hospitals within each study year, accounting
for potential confounding by hospital size and location. In addition, our period
of observation was longer than reported in the literature to date. Our study is
limited by our inability to ascertain actual transport costs, although the
proportion of costs for transportation was less than one percent of all costs.
More importantly, our hospital costing data is limited to membership in case mix
groups rather than individual costs as individual costing data is not collected
by hospitals in BC. The number of case mix groups that can be assigned to
mothers is 25 and to infants 31, however, indicating a wide range of
designations for complexity. We were also unable to include costs incurred due
to lost productivity, although it might reasonably be expected that differences
between our groups would not be observed. In addition, our data do not include
costs from long term morbidity such as neurological sequelae that may not have
manifested in the first year of life.


CONCLUSION

We conclude that planned home birth in British Columbia with a registered
midwife compared to birth planned for hospital with a registered midwife or a
physician is less expensive for our health care system for mothers up to 8 weeks
postpartum and infants up to one year of age. Our findings should reassure
health planners and policy makers that there are not deferred excess costs
associated with planned home birth with a registered midwife and encourage home
birth in similar settings as a choice for healthy women.


SUPPORTING INFORMATION

Janssen Home vs Hospital Birth Outcomes paper.

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S1 FIG. JANSSEN HOME VS HOSPITAL BIRTH OUTCOMES PAPER.

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AUTHOR CONTRIBUTIONS

Conceived and designed the experiments: PJ CM. Performed the experiments: PJ JA.
Analyzed the data: PJ JA. Wrote the paper: PJ JA CM. Obtained data from
Population Data BC: PJ FA.


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     http://www.health.gov.bc.ca/msp/infoprac/midbilling/Midwifery%20Payment%20Schedule%20-%20Preamble.pdfMidwifery.
 29. 29. Canadian Institutes of Health Research. Giving Birth in Canada: The
     Costs. ISBN 1-55392-817-2. 2006 Contract No.: ISBN 1-55392-817-2.
 30. 30. University of Manitoba- Manitoba Centre for Health Policy. Concept:
     Calculating Hospital Costs Using Cost Per Weighted Case (CPWC) Values 2012.
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     http://mchp-appserv.cpe.umanitoba.ca/viewConcept.php?conceptID=1100.
 31. 31. Health Management Associates. Midwifery licensure and discipline
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