Maternity Care in Alberta Report



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  • I have reviewed the reference I was using when posting about BC data, and incorrectly said the data showed FPs lower cost than MW for in-hospital births, when in fact the group of physicians was not separated into FP and OB (something that should be done to try and make more equitable comparisons). In studies out of Ontario, there is a lower FP cost as well as MW cost vs Obstetrician cost in low risk patients delivering in hospital.

    In the document ““Costs of Planned Home vs. Hospital Birth in British Columbia Attended by Registered Midwives and Physicians” Patricia A. Janssen, Craig Mitton, Jaafar Aghajanian PLOS ONE|DOI:10.1371/journal.pone.0133524 July 17, 2015” the following tables appear (*I have summarized the findings and added the line with the totals to Table 5 – which showed Total Physician costs lower than Total MW costs – as this had been left off in the article). “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.” All tables included physician fees, Midwifery fee, hospital charges, transport cost, pharmaceuticals and home birth supplies. When looking at the detailed tables, the significant cost avoidance that is seen from home birth vs hospital birth is primarily due to hospital related costs.:

    Table 3. Average Costs of Planned Home vs. Hospital Birth by Regulated Midwife or Physician, 0–28 days.
    Planned Home Birth with Midwife n = 2243 Planned Hospital Birth with Midwife n = 3610 p-value Planned Hospital Birth with Physician n = 4011
    Maternal Costs:
    MW home delivery: $1858
    MW planned hospital delivery: $3546
    Physician planned hospital delivery: $3507

    Newborn Costs:
    MW home delivery: $417
    MW planned hospital delivery: $1068
    Physician planned hospital delivery: $1310

    Total Maternal/Newborn Costs:
    MW home delivery: $2275
    MW planned hospital delivery: $4614
    Physician planned hospital delivery: $4817

    Table 5. Costs of Planned Home vs. Hospital Birth by Regulated Midwife or Physician, 0–56 days (Maternal) and 0–1 Year (Infant).
    Planned Home Birth with Midwife n = 2243 Planned Hospital Birth with Midwife n = 3610 p-value Planned Hospital Birth with Physician n = 4011

    Maternal Costs:
    MW home delivery: $2468
    MW planned hospital delivery: $4152
    Physician planned hospital delivery: $3569

    Newborn Costs:
    MW home delivery: $854
    MW planned hospital delivery: $1664
    Physician planned hospital delivery: $2000

    *Total Maternal/Newborn Costs:
    MW home delivery: $3322
    MW planned hospital delivery: $5816
    Physician planned hospital delivery: $5569

    When looking at the details of the Newborn costs out to 1 year in Table 5, there is a significant lower expenditure in midwife delivered babies (especially those with a home birth), but there is not indication in the study of why this occurred nor anything about longer term outcomes. If this reduction in cost is simply because these babies did not receive their well child assessments for growth and development, possibly including immunizations, then this is not an appropriate (short term) cost avoidance. It would be appropriate for an unbiased, independent multi-disciplinary group to review all data, including longer term outcomes, so that the system is fully aware of impacts on broader population health of all options of care along this important life journey. Choices must be fully informed by accurate information.
  • Comparing Midwives (low-risk providers) to Obstetrician (all levels of risk providers) in this way is very misleading as you are not comparing the same patient population. Other that a few short paragraphs, there is very little information shown about FPs who do obstetrics. In BC, when looking at the in-hospital delivery data, FPs are lower than midwives, who are both lower than obstetricians, but again, our patient populations are different. To truly compare apples to apples, the data should be based on women in the same risk cohort.

    There are many assumptions made in the paper and they even admit “It is assumed that on average midwives order tests and ultrasounds less frequently than their physician counterparts, which would increase the cost savings associated with prenatal care, but this could not be confirmed with the level of data available at the time of this report.” No comment on whether this is appropriately less testing, just less testing so less cost. As another comment below indicated, basing decisions on cost alone without looking at the outcomes or reasons for the test/procedure is not in the best interest of women and their babies.

    I also find it interesting that this paper appears to indicate that increasing the supply of midwives will be the answer to access in rural communities. In BC, the vast majority of midwives are in the urban and suburban areas, as it would appear they too face the same barriers to recruitment to rural areas.

    Choice with clear information about all care options should be promoted for women but choice availability should not be based on cost alone.
  • Care must be exercised in interpreting such broad statistics. C-Sections for example, should be much lower among the carefully screened low-risk population seeking care from a midwife vs. a higher-risk population (including needed repeat C-Sections) being seen in an Obstetrician practice.
    Also, while comparing procedures such as epidural on strictly a “cost” basis can be informative, other potential benefits and values need to be included, such as pain relief, patient preference, and the ability for some to proceed to a successful vaginal delivery (thus actually saving operative and hospital costs) by having the procedure available.
    I agree that we should support women in every way to have the most “natural” delivery possible, and that we as practitioners need to carefully analyze the costs and benefits of what we do both on an individual and a community scale, but we also need to be cautious in establishing artificial targets for intervention rates based on cost. Not all patients (or practitioners) share that value system and we must allow for informed choice at all levels.
  • Interesting summary , thanks …can you please reference the statement …only 7% of pregnancies are considered high risk…..as the levels of co-mordidity such as BMI, diabetes, maternal age etc all add to the complexity and move those woman into more complex care / risk areas …they are not low risk …real understanding of risk / morbidity / apprpriate triage as …important for the right patient to be with the right provider in the right location ….support low risk maternity providers…just need the right measures of risk…RDW
  • I think it’s important for balance that anyone reading this report also reads the November 2016 birth cost report published by Birth Trauma Canada (@btcanada): ‘The High Cost of a ‘Normal’ Birth Policy’ (http://www.birthtraumacanada.org/50.html)

    Also, my September 2016 article, published by the NHE in the UK (@paulinemhull): ‘Caesarean rates don’t indicate quality of care and targets are dangerous’ (http://www.nationalhealthexecutive.com/Health-Service-Focus/caesarean-rates-dont-indicate-quality-of-care-and-targets-are-dangerous#)

    Promoting normal birth and VBACs is very different to promoting choice, and I am especially concerned when organizations want to promote VD in the context of reducing caesareans, but then don’t include maternal request caesarean on their ‘Birth Options’ page (see link above). This does not promote real birth choice, it does not respect all women’s autonomy, and it does not acknowledge the fact that both birth plans (VD and caesarean) have risks and benefits that need to be considered.

    Only today I was told of a recent birth in which a woman expecting twins was denied her repeated caesarean request here in Calgary, and forced to have an induced trial of labor instead. This is simply unacceptable practice.