Cost minimisation analyses of birth care in low-risk women in Norway: a comparison between planned home birth and birth in a standard obstetric unit.

BACKGROUND: Evidence exists that planned home births for low-risk women in settings in which they have access to hospital transfer if needed are safe. The costs of planned home births, compared to low-risk births in obstetric units, are not clear. The aim of this study was to compare costs associated with hospital births versus home births under different home birth organizations. METHODS: We performed a cost minimisation analysis (CMA) based on decision-analytic modelling while assuming that health outcomes were not affected by place of birth. Estimations of resource use were mainly based on three existing Norwegian datasets: (1) women with planned home births (n = 354), (2) women with planned home births (n = 482) of which 63 were transferred to a hospital, and (3) women with planned births in a hospital (n = 1550). RESULTS: Planned home birth costs 45.9% (credibility interval [CrI] 39.1-54.2) of a low-risk birth at a hospital. For planned home birth, the birth was the costliest activity (32.1%). The costs for planned home birth were estimated to be €1872 (CrI 1694-2071) and included hospitalisations for some. Costs for only those with actual home birth was €1353 (CrI 1244-1469). Costs of a birth, including possible birth-related complications, in low-risk women in a hospital was €4077 (CrI 3575-4615). When including the costs of being on call for one woman at a time, a planned home birth costs €5,531 (CrI 5,171-5,906), which is 135.7% (CrI 117.7-156.8) of low-risk births at a hospital. When organizing midwives in the on call teams for multiple women at a time, a planned home birth costs € 2,842 (CrI 2,647-3,053), which is 69.7% (CrI 60.3-80.9) of a low-risk birth in a hospital. CONCLUSIONS: Home birth can be cost-effective if the midwives who facilitate home births are organised into larger groups, or they work for hospitals that also facilitate home births. A model in which midwives work separately or in pairs to assist with a home birth and are on call for one birth at a time may not be cost-effective.

Transfers to hospital in planned home birth in four Nordic countries - a prospective cohort study.

INTRODUCTION: Women planning a home birth are transferred to hospital in case of complications or elevated risk for adverse outcomes. The aim of the present study was to describe the indications for transfer to hospital in planned home births, and the proportion of cases in which this occurs. MATERIAL AND METHODS: Women in Norway, Sweden, Denmark and Iceland who had opted for, and were accepted for, home birth at the onset of labor, were included in the study. Data from 3068 women, 572 nulliparas and 2446 multiparas, were analyzed for proportion of transfers during labor and within 72 h after birth, indications for transfer, how long before or after birth the transfer started, time from birth to start of transfer, duration and mode of transfer, and whether the transfer was classified as potentially urgent. Analyses were stratified for nulliparity and multiparity. RESULTS: One-third (186/572) of the nulliparas were transferred to hospital, 137 (24.0%) during labor and 49 (8.6%) after the birth. Of the multiparas, 195/2446 (8.0%) were transferred, 118 (4.8%) during labor and 77 (3.2%) after birth. The most common indication for transfers during labor was slow progress. In transfers after birth, postpartum hemorrhage, tears and neonatal respiratory problems were the most common indications. A total of 116 of the 3068 women had transfers classified as potentially urgent. CONCLUSIONS: One-third of all nulliparous and 8.0% of multiparous women were transferred during labor or within 72 h of the birth. The proportion of potentially urgent transfers was 3.8%.

How Long Is a Normal Labor? Contemporary Patterns of Labor and Birth in a Low-Risk Sample of 1,612 Women from Four Nordic Countries.

OBJECTIVE: Normal progress of labor is a subject for discussion among professionals. The aim of this study was to assess the duration of labor in women with a planned home birth and spontaneous onset who gave birth at home or in hospital after transfer. METHODS: This is a population-based study of home births in four Nordic countries (Denmark, Iceland, Norway, and Sweden). All midwives assisting at a home birth from 2008 to 2013 were asked to provide information about home births using a questionnaire. RESULTS: Birth data from 1,612 women, from Denmark (n = 1,170), Norway (n = 263), Sweden (n = 138), and Iceland (n = 41) were included. The total median duration from onset of labor until the birth of the baby was approximately 14 hours for primiparas and 7.25 hours for multiparas. The duration of the different phases varied between countries. Blood loss more than 1,000 mL and perineal ruptures that needed suturing were associated with a longer pushing phase and the latter with country of residence, parity, single status, and the baby's weight. CONCLUSION: In this population of healthy women with a low prevalence of interventions, the total duration of labor was fairly similar to what is described in the literature for multiparas, but longer for primiparas. Although the duration of the phases of labor differed among countries, it was to a minor extent associated with severe outcomes.

Outcomes of planned home births and planned hospital births in low-risk women in Norway between 1990 and 2007: a retrospective cohort study.

BACKGROUND: The safety of planned home births remains controversial in Western countries. The aim of the present study was to compare outcomes in women who planned, and were selected to, home birth at the onset of labor with women who planned for a hospital birth. METHODS: Data from 1631 planned home births between 1990 and 2007 were compared with a random sample of 16,310 low-risk women with planned hospital births. The primary outcomes were intrapartum intervention rates and complications. Secondary outcomes were perinatal and neonatal death rates. RESULTS: Primiparas who planned home births had reduced risks for assisted vaginal delivery (OR 0.32; 95% CI 0.20-0.48), epidural analgesia (OR 0.21; CI 0.14-0.33) and dystocia (OR 0.40; CI 0.27-0.59). Multiparas who planned home births had reduced risks for operative vaginal delivery (OR 0.26; CI 0.12-0.56), epidural analgesia (OR 0.08; CI 0.04-0.16), episiotomy (OR 0.48; CI 0.31-0.75), anal sphincter tears (OR 0.29; CI 0.12-0.70), dystocia (OR 0.10; CI 0.06-0.17) and postpartum hemorrhage (OR 0.27; CI 0.17-0.41). We found no differences in cesarean section rate. Perinatal mortality rate was 0.6/1000 (CI 0-3.4) and neonatal mortality rate 0.6/1000 (CI 0-3.4) in the home birth cohort. In the hospital birth cohort, the rates were 0.6/1000 (CI 0.3-1.1) and 0.9/1000 (CI 0.5-1.5) respectively. CONCLUSIONS: Planning for home births was associated with reduced risk of interventions and complications. The study is too small to make statistical comparisons of perinatal and neonatal mortality.