Friday, November 16, 2012

The Flawed Assumption of Cost-effective Natural Birth

I'm an economist by training - but more than that, I am a health economist by profession. I understand (probably better than most) the concepts of scarcity, risk, cost, expected cost and cost effectiveness. I also understand the challenges that are facing our health care system - both today and going into the future.

Perhaps that is why I am particularly perturbed when time and time again I hear that reducing the number of cesareans would save the health system money and in particular how reducing the number of maternal request cesareans would save the health system money. On it's face it seems to be such a no-brainer, after all how could an expensive surgery (cesarean birth) compete with the free birthing procedure that nature gave us (unmedicated vaginal birth)?

Of course not using health system resources is cheaper (on its face) than using the health system.

Have a heart attack and die where you stand: $0 health expenditures, alternatively have a heart attack and go to the hospital, get a coronary artery bypass and go on to live another decade or two: A whole lot more than $0 health expenditures. Develop cancer and let the disease progress as nature intended: $0 health expenditures, alternatively going to your doctor, get diagnosed (likely via some screening program), get chemotherapy/radiation therapy, and either cure the cancer or buy some additional time: A whole lot more than $0 health expenditures.

Yet there is no widespread calls for natural heart attack therapy or natural cancer care. Anyone who stood on the corner saying that people should put the needs of the health care system ahead of their own needs - would be told to apply their 'natural therapies' to themselves and to stuff it.

The natural childbirth movement is standing on the corner and shouting (rather loudly) that women should forego medical care during birth because it will save the system money. What's worse is that government seems to be encouraging them to shout even louder.

The assumption that is behind this is that intervening in birth does not buy better health outcomes. Either that or, because the better health outcomes accrue to women and their children, they simply aren't "worth it". I would hope that it is the former rather than the latter driving the "save the health system money by avoiding cesareans" mantra.

Unfortunately this assumption is flawed and very likely, very wrong.

Intervening in birth by providing pain relief or access to surgical delivery for those who want or need it does buy better health outcomes and may even save the health system money over the longer term.

Those who choose cesarean are doing so for a wide variety of reasons. They are doing it so that they may avoid the risk of an emergent cesarean. They are doing it to avoid the risk of a perineal tears. They are doing it to avoid a pelvic floor injury. They are doing it to reduce the risk of developing urinary or fecal incontinence. They are doing it to reduce the risk of severe disability or death to their unborn child. They are doing it to better arrange the support resources they need during and after the birth. They are doing it to avoid the risk of having a traumatic experience. They are doing it to reduce the risk of developing PTSD or PDD. They are doing it to protect their sex lives. They are doing it to avoid the risk of severe, uncontrolled pain.

Chances are they are doing it for several reasons and in all circumstances they are doing it because the benefits of choosing to intervene exceed the costs and/or risks of not intervening at an individual level.

I would even be so bold as to argue - that the government would do well to spend MORE on maternity than it does now as the expenditures on maternity are likely to buy more than expenditures in other areas of care. Those served by maternity services tend to be young and as such any gains in health outcomes are likely to accrue over many years. A single case of cerebral palsy that is averted could save the health care system millions of dollars in costs of future care. Avoiding a pelvic floor injury that requires subsequent repair, would likely save thousands. Avoiding a case of PTSD or PDD, again would result in significant savings.

Further, it is unclear whether or not maternal request cesarean is even significantly more expensive than planned vaginal delivery to begin with. A study entitled "Cesarean delivery on demand: What will it cost?" in the American Journal of Obstetrics and Gynaecology Volume 188, Issue 6, pp. 1418-1423 found that the average cost difference between women who attempted a vaginal delivery and those who had an elective cesarean was just 0.2% in favour of vaginal delivery. Hardly a cost savings to deprive women of their treatment of choice - which is perhaps why many US health insurers (arguably even more keen to save money to boost profits than Canadian medicare) now cover elective cesarean section.

So why don't we start with the assumption that healthcare providers and mothers who choose cesareans are doing so in their own best interests and that they are no more "milking the system" than those with cancer or cardiac problems are "milking the system"? And maybe, just maybe we ought to look at the real economics of birth choice - the answers might be very surprising indeed.


  1. Dear Mrs. W.,
    Keep up the great work!
    I just hope this post (as well as the others) will be read by the people who need to see this issue of costs from a new perspective. (And I also hope they take a look at your other posts and the links!)
    J. Braidz

  2. Not a very good analogy. Heart attacks and cancer are pathologies; pregnancy is not. In most cases, a pregnancy will indeed "resolve" itself without surgery or other intervention. I suppose that if one could simply squeeze out a tumour after several hours of intense labour, we could also to save costs by promoting "natural" cancer treatment, but that's not the case.

  3. Anonymous - The problem is that for many women pregnancy and childbirth does not 'resolve itself' after several hours of intense labour (that is extremely painful for many women). Many women (and rarely their children) are left with lasting impairments after pregnancy and birth - and it's a little disconcerting that these impairments are discounted as being the price of admission to motherhood. Why shouldn't women be entitled to preserve their functionality? Why shouldn't women be allowed to choose a delivery method that minimizes the risk of severe disability to their children? Why dissuade women from using pain relief?

    Pregnancy may not be pathological but it certainly exacts a toll on women and their children - and perhaps we should start considering what that toll is and doing what is possible to minimize it. It is a real shame that improving the lives of women who decide to bear children is not seen as being a worthwhile expenditure of healthcare resources.