Homebirth does not save money

Homebirth advocates often argue that homebirth costs less than hospital birth, but a new study from The Netherlands reveals that homebirth does not save money. Even the authors were surprised by the results.

The study is Cost Analysis of the Dutch Obstetric System: low-risk nulliparous women preferring home or short-stay hospital birth – a prospective non-randomised controlled study. It is worth reading merely for the update on the Dutch system of homebirth. It differs in important ways from the perceptions of American homebirth advocates regarding the Dutch system. The homebirth rate is less than 30% and falling and transfer rates are extraordinarily high:

… [T]he organisation of the Dutch obstetric system is unique, with a high percentage of home births (about 29% of all pregnant women) and a low rate of medical interventions (the rate of Caesarean sections is about 15%)… Overall, the home birth rate has decreased during the last ten years (from 35% of all births in 1997-2000 to 29% in 2005-2008). For nulliparae, the home birth rate is much lower, namely 18% in 2006. There is a high referral rate during pregnancy (45% of all nulliparae in primary care) and delivery (43% of all nulliparae who started delivery in primary care)…

Rather than being a paradise of perfect obstetric outcomes, the system has been plagued with poorer than expected results:

The Dutch obstetric system has received a great deal of attention in the literature. However, the system has increasingly come under pressure since the national perinatal mortality rate (between 22 weeks of pregnancy and 7 days postpartum) was shown to be one of the highest in Europe (10‰ in 2004)…

The study is notable for the comprehensive view of obstetric costs. As the authors explain:

Several studies have examined the economic implications of home births or short-stay hospital births in comparison with a hospital birth. However, these studies were performed outside the Netherlands… Furthermore, some of these studies had a very limited time frame, not looking at the costs from an early stage of pregnancy until a fixed period after delivery. These studies also did not calculate the societal costs of giving birth, meaning that … [the] primary focus [was] on health care costs… [In this study] not only the health care costs (i.e. costs of care givers, medication and hospitalisation) are included, but also the costs of patients (i.e. out-of-pocket costs, travel expenses), their family (i.e. informal care) and other non health care costs (i.e. productivity losses).

The results were surprising:

… The total … costs over the whole period followed (from 16 weeks of pregnancy until six weeks after delivery) amounted to €3,695 for women who intended to give birth at home and €3,950 for women who intended to give birth in a short stay hospital setting… The costs of pregnancy and delivery are (slightly) higher in the home birth group, while the costs associated with postpartum period are higher in the short-stay hospital birth group.

When looking at the different cost categories, the costs for contacts with healthcare professionals are statistically significantly higher in the home birth group (€138.38 vs. €87.94). There are also statistically significant differences between both groups regarding ‘costs of maternity care assistance at home’ (€1,551.69 vs. €1,240.69, and ‘costs of hospitalisation mother'(€707.77 vs. 959.06).

According to the authors:

… We expected that the costs of home births would be much lower than those of short-stay hospital deliveries. From the results however, it can be concluded that there is no difference in the total costs between the home birth group and the short-stay hospital group. In the home birth group, more costs were spent on maternity care assistance in the postpartum period. This conclusion is in line with the result that the costs of hospitalisation of the mother and child in the postpartum period are higher for the short-stay hospital birth group. In the Dutch obstetric system, women who remain hospitalised after delivery receive fewer days of maternity care assistance at home …. This leads to lower costs for maternity care assistance at home than for the home birth group.

The results of the cost analysis for the actual place of birth showed a large difference in antenatal costs in “week 29-42” between women who gave birth in secondary [physicia] care and women who gave birth in primary [midwife] care. This means that most of the complications during pregnancy arise in the last period of the pregnancy. All respondents were at low risk at the beginning of their pregnancy. When complications occur during pregnancy, their midwife (primary care) has to refer them to much more expensive secondary care…

This study has several major strengths:

1. It involves only women who were considered low risk at the start of pregnancy.

2. The women differ only in their preference for place of delivery. All women would have qualified for a homebirth had they desired one.

3. Since the study considered pregnancy in its entirety, it took into account the additional costs incurred by women who were low risk at the start of pregnancy but became higher risk.

4. The study considered additional costs such as ambulance costs for transport during labor and costs for home care.

5. The study looked at the actual costs of providing services. In the US studies often look at the billing rates which are merely theoretical since hospitals providers are reimbursed for a fraction of the billing rate.

6. The study took place within a system that provides comprehensive care so all costs (including ambulances, home health aides, etc) were readily accessible and could be included.

The authors conclude:

The objective of this study was to give a view of the Dutch obstetric system from an economical perspective. This study provides insight into the societal costs of the two groups of women giving birth for the first time in the Netherlands with different intentions regarding place of giving birth. Because of the high rate of home births in the Netherlands, the obstetric system is currently a topic of debate. In summary, from the results of this cost analysis, it may be concluded that there is no difference in the total costs between low-risk nulliparae who prefer to give birth at home and low-risk nulliparae who prefer to give birth in a short-stay hospital setting.

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