Ontario recently announced funding for two birth centres that will be led by midwives.
The government has indicated it is opening birth centres partly to move care out of hospitals and save money.
Although birth centres are probably safe and may improve maternity care, it is less clear whether Ontario’s birth centres will indeed reduce costs.
The Ontario government recently announced that it will provide funding for two birth centres in the province. Many news reports, as well as the Association of Ontario Midwives, have claimed that the birth centres have the potential to decrease costs. But with no details about how the birth centres will operate, that claim requires further exploration.
A third option
Obstetricians, midwives and family doctors all provide maternity care in Ontario. While obstetricians deliver the vast majority of babies – around 90% – a substantial proportion of women would prefer a midwife. In Ontario, midwives currently deliver babies both at home and in hospitals, but birth centres are a third option.
In many countries, a substantial proportion of women deliver their babies in birth centres. Unlike the birth centres that have been proposed in Ontario, however, many of these are directly attached to a hospital labour and delivery ward, and staffed by both midwives and obstetricians. Closer to home, Quebec introduced freestanding midwife-led birth centres in the mid-1990s, and there is at least one freestanding birth centre in Western Canada.
The hope is that freestanding birth centres will provide a better experience for mothers than hospitals, while also providing equivalent or better quality care. In particular, midwife care may increase the chances of a woman having a vaginal birth with minimal medical intervention. If complications occur, women are rapidly transferred to a hospital where obstetricians are available to perform Caesarean sections.
The Ontario Medical Association responded to the government’s announcement by expressing concern that freestanding birth centres “may fragment or silo the delivery of maternity care in Ontario.” William Mundle, the chair of the obstetrics and gynecology section of the Ontario Medical Association also noted that “minutes can mean the difference between life and death” and that even women with low-risk pregnancies may need rapid access to surgeons and hospitals.
The evidence for birth centres
A study published last year in the British Medical Journal has helped garner support for freestanding birth centres. The study analyzed 64,538 births in England and reported that compared to women who gave birth in hospitals, women in freestanding birth centres experienced fewer medical and surgical interventions. For example, only 3.5% of low-risk women who started their labour in a freestanding birth centre underwent a Caesarean section, compared with 11% of women who started their labour in hospital.
In all settings, the risk of a serious complication associated with childbirth was low, but the risk of a serious complication for the baby was slightly higher with home births than it was with hospital births. In some analyses, the risk of a serious complication was also higher when women started their labour at a freestanding birth centre. Overall, the study was not large enough to conclusively answer the question of whether care provided in freestanding birth centres is as safe as hospital care or not.
Will birth centres reduce costs?
Many news reports following the birth centre announcement claimed that birth centres are expected to reduce health care costs. What is the evidence for this?
In Ontario, midwives and obstetricians are paid under very different models. In 2006, midwives were paid between $2,500 and $3,000 (plus an additional 18% in lieu of benefits) for a full course of prenatal, delivery and postnatal care. Midwives in Ontario are currently restricted to attending only 40 births per year as the primary midwife and another 40 as an assistant, and the average annual income for a midwife is less than $100,000.
In contrast, obstetricians are paid about $35 for each prenatal visit and $500 for an uncomplicated vaginal delivery. However, obstetricians have no limit to the number of deliveries they can attend, and many deliver several hundred babies per year. Obstetricians also take care of women with high-risk pregnancies, perform Caesarean sections and provide gynecological care. So even though obstetricians are paid less for each birth, the median income for an Ontario obstetrician, before accounting for overhead, is over $400,000.
However, the financial argument for freestanding birth centres also focuses on reducing the costs associated with hospital care. Childbirth accounts for about 10% of what hospitals spend on inpatient care, and if birth centres decrease the likelihood of Caesarean sections and other interventions then the shift away from hospitals may markedly lower costs. Notably, the Caesarean section rate in Ontario is 28%, nearly twice the rate recommended by the World Health Organization. However, if a substantial proportion of women who plan to deliver at birth centres need to be transferred to a hospital—and in the British Medical Journal study about 1 in 5 women did—then birth centres may paradoxically result in higher costs.
More evidence needed
The Ministry of Health and Long-Term Care frequently asks the Medical Advisory Secretariat – now an arm of Health Quality Ontario – to prepare evidence-based analyses of new health technologies or new ways of delivering care, before instituting major policy changes. However, despite the government’s claim that birth centres are “good quality health care for good value,” the Medical Advisory Secretariat was not asked to assess the evidence related to birth centres.
Since details about how the Ontario birth centres will operate have not been made public, it is unclear whether evidence from other jurisdictions can be extrapolated to Ontario. For example, the authors of the British Medical Journal study noted that in England there are “clear referral pathways to obstetric units if complications occur, using a comprehensive ambulance network with trained staff.” Similarly, whether birth centres increase costs or save money depends to a considerable extent on how they are funded and on how much midwives are paid.
Closer to home, Emanuelle Hébert, a practicing midwife in Quebec and professor at Université du Québec à Trois-Rivières notes “the major problem with the Quebec birth centres has been that since their founding in the 1990s there has been little data collection.” When asked to provide details about how Ontario’s birth centres will be evaluated, the Ministry of Health and Long-Term Care did not provide healthydebate.ca with a comment by press time.
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For me the question of “cost” is quite secondary. I think birth centres are an excellent initiative. The more we can move away from “medicalized” childbirth, the better we are in general. The problem with alternative childbirth within the confines of a hospital ward is the inevitable conflict that happens between the medical team and the alternative team. In some hospitals, Toronto East General as an example, the integration is quite good, and a number of midwives operate out of that hospital. My own experience was with St. Michael’s hospital in Toronto and it was a very stressful experience. The medical team was pushing for all sorts of interventions, which was in conflict with our own wishes and the advice of the alternative team.
Doesn’t it come down to insurance and the CYA principle (cover your assets)? Hospitals need to control as much as possible in order to meet their SLAs whereas alternative childbirth certainly allows for more variance within the birthing process.
Any costing of these centers must of course include the costs of treating the inevitable catastrophes that, as surely as the moon rises and the sun sets, will come.
NICU care for an infant with asphyxia, lifetime care for CP/Seizure/G-Tube patients produced as a natural byproduct of the process of birth and our society’s inability to accept death…hope the economists remember all that stuff too.
As a frontline provider you learn about the inevitable natural outcomes. I have seen them in the labor wards, the pediatric wards, and the clinic. And having worked in the third world you quickly learn the advantages of “medicalized” childbirth. No one needs to explain that to a third world mother with a dead baby stuck in the birth canal with shoulder dystocia cuz no c-section was available.
The problem with this thought process is that it still buys into the process of medicalized birth as being the most progressive and best choice for birthing practices. The reality is that these problems you’ve listed are a rarity afforded to an extremely small percent of births, but that percentage often goes up when that birth is in the hospital as medical staff prescribe intervention methods that are not necessary and cause distress and harm to a child as a result. Out of hospital birthing centres are designed to limit that risk by stopping the medicalization of a process that often needs no medical interference what so ever.
A dead infant stuck in the birth canal is a tragic thing. Medicalized birth, especially a c-section, is not the only way to prevent or deal with that that, and it most certainly won’t be the least invasive method with the lowest risk to both child and mother.