Thursday, May 10, 2012

Spending Money Where it Matters: Maternity Care

I fully understand that resources in the health care system are limited - and that decisions must be made with regard to resource allocation. I know that providing health care services to the population is expensive. I know that these costs are increasing over time for a wide variety of reasons, including an increasingly older population, an increasing ability to treat what once was untreatable, increasing expectations to access treatment and inflation. I know there is tremendous pressure to 'bend the cost-curve' and improve health care system sustainability and that bending the cost-curve and ensuring health system sustainability is imperative.

I also know that maternity care is not the place to 'save money' and that doing so will and does come at a tremendous cost.

I am more than a little disturbed at efforts to turn back the clock on this area of care. I am disturbed at the efforts by provincial governments to encourage home births and 'invest' in birth centres that are basically places where women give birth 'in somebody else's home', and in particular I am disturbed because the primary motivation for encouraging these things is to save money. Money indeed will be saved, but it will be saved by limiting access to medical care and services during birth. Of course homebirth and birth centre births are cheaper than hospital births - if a woman does not have access to an epidural, the system does not have to pay for one. If a woman does not have access to fetal monitoring, then again, the system does not need to pay for it. If a woman does not have immediate access to a cesarean section - there is a chance a 'normal' birth will happen instead. When technology is not available, it does not get used.

I also know that proponents of homebirth will point to the few studies, like the recent BMJ article entitled "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," that show that outcomes between homebirth and hospital birth are comparable. However, they will fail to examine those studies with a critical eye. A study that uses composites for perinatal outcomes and maternal morbidity completely fails to recognize the huge difference between a death or a lifelong disability, with having a cesarean section or a fractured clavicle. This study also limits its scope to the birth itself and the period immediately after the birth (42 days) and as such fails to recognize the consequence and costs of longer-run morbidity and mortality. Further the study considers "normal birth" (defined as being without induction of labour, epidural or spinal anesthesia, general anesthesia, episiotomy, use of forceps, ventouse or cesarean section) as being a "good" in and of itself - without any justification for that position.

The fundamental flaw of course is the underlying assumption that the use of technology in birth in hospitals is done so without reason or merit and that using technology in birth does not 'buy' anything of value. This strikes me as being a rather large assumption, that should be extensively tested prior to being accepted. Use of technology in birth buys reduced pain. Use of technology in birth buys reduced risk of very severe outcomes and long-term disability. Use of technology in birth may make the difference between life and death, and it may make the difference between a 'normal' life and one filled with life-long challenges. Given the nature of the population being served (typically young, and healthy) what is being 'bought' with the use of technology in birth will have benefits over a very long time horizon, potentially 80 or more years.

It should be crystal clear that the government's embrace of out-of-hospital birth has nothing to do with supporting choice and everything to do with saving money. If it was truly about choice, government would increase access to hospital-based midwifery and make hospital environments nicer to facilitate the choices of women (for example private rooms, birthing tubs, increasing the ability of partners to stay with parturients, etc.) WITHOUT sacrificing their access to medical advancements. Facilitating a choice that denies or delays access to medical technology, particularly if it is proven to be needed is not good policy. It's cheap, but should not be considered cost-effective.