title: Cost effectiveness of alternative planned places of birth in woman at low risk of complications: evidence from the Birthplace in England national prospective cohort study.
abstract: OBJECTIVE
  To estimate the cost effectiveness of alternative planned places of birth.
  
  
  METHODS
  Economic evaluation with individual level data from the Birthplace national prospective cohort study.
  
  
  METHODS
  142 of 147 trusts providing home birth services, 53 of 56 freestanding midwifery units, 43 of 51 alongside midwifery units, and a random sample of 36 of 180 obstetric units, stratified by unit size and geographical region, in England, over varying periods of time within the study period 1 April 2008 to 30 April 2010.
  
  
  METHODS
  64,538 women at low risk of complications before the onset of labour.
  
  
  METHODS
  Planned birth in four alternative settings: at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units.
  
  
  METHODS
  Incremental cost per adverse perinatal outcome avoided, adverse maternal morbidity avoided, and additional normal birth. The non-parametric bootstrap method was used to generate net monetary benefits and construct cost effectiveness acceptability curves at alternative thresholds for cost effectiveness.
  
  
  RESULTS
  The total unadjusted mean costs were £1066, £1435, £1461, and £1631 for births planned at home, in freestanding midwifery units, in alongside midwifery units, and in obstetric units, respectively (equivalent to about €1274, $1701; €1715, $2290; €1747, $2332; and €1950, $2603). Overall, and for multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness when perinatal outcomes were considered. There was, however, an increased incidence of adverse perinatal outcome associated with planned birth at home in nulliparous low risk women, resulting in the probability of it being the most cost effective option at a cost effectiveness threshold of £20 000 declining to 0.63. With regards to maternal outcomes in nulliparous and multiparous women, planned birth at home generated the greatest mean net benefit with a 100% probability of being the optimal setting across all thresholds of cost effectiveness.
  
  
  CONCLUSIONS
  For multiparous women at low risk of complications, planned birth at home was the most cost effective option. For nulliparous low risk women, planned birth at home is still likely to be the most cost effective option but is associated with an increase in adverse perinatal outcomes.
authors.affiliation: National Perinatal Epidemiology Unit, Department of Public Health, University of Oxford, Oxford OX3 7LF, UK. liz.schroeder@npeu.ox.ac.uk
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Schroeder
authors.forename: Stavros
authors.initials: S
authors.lastname: Petrou
authors.forename: Nishma
authors.initials: N
authors.lastname: Patel
authors.forename: Jennifer
authors.initials: J
authors.lastname: Hollowell
authors.forename: David
authors.initials: D
authors.lastname: Puddicombe
authors.forename: Maggie
authors.initials: M
authors.lastname: Redshaw
authors.forename: Peter
authors.initials: P
authors.lastname: Brocklehurst
mesh_terms: D000328:Adult; D016550:Birthing Centers / Q000191:economics*; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D003696:Delivery Rooms / Q000191:economics*; D004739:England; D005260:Female; D006700:Home Childbirth / Q000191:economics*; D006801:Humans; D010347:Patient Care Planning / Q000191:economics*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000191:economics* / Q000517:prevention & control; D011446:Prospective Studies; D012044:Regression Analysis; D055815:Young Adult