Abstract
Background and aim:
In Italy, the main birthplace is a hospital, and only a few women choose an out-of-hospital setting. This study assessed the costs related to delivery in different birthplaces in Italy.
Methods:
The cost analysis considered direct and amortizable costs associated with mother-child care in physiological conditions. An analysis of the hospital births considered the Diagnoses-Related Groups 373 and 391. To estimate the cost of the births assisted privately by freelance midwives, an evaluation based on an experts’ opinion was carried out.
Results:
Childbirth hospital care in Italy amounts to € 1832.00, and birth in an out-of-hospital setting accredited with the National Health System has a full cost of € 1345.19 in the ‘maternity home’ and € 909.60 at home. The average cost of the birth in ‘private maternity homes’ amounted to € 3260.00, while at-home births amounted to € 2910.00.
Conclusions:
Any accreditation of out-of-hospital settings by the NHS would considerably reduce the waste of economic resources compared to hospital childbirth. (www.actabiomedica.it)
Keywords: Birth Setting, Birthing Centers, Costs and Cost Analysis, Midwifery
Introduction
Ideally, every woman should be able to give birth in a place that is perceived as safe and guarantees adequate, considerate, and timely perinatal care. A healthy woman with a low-risk pregnancy can comfortably give birth in either an obstetric unit (OU) of a hospital, a small maternity clinic, a birth centre, or at home (1). The latter three are commonly referred to as out-of-hospital birth settings. Several studies have reported that a planned choice of birthplace may influence perinatal outcomes in low-risk women (2–6). Furthermore, women with low-risk pregnancies who plan to give birth in an out-of-hospital setting are less exposed to invasive interventions (such as an episiotomy) and severe morbidity during labour and delivery (7).
The most recent data from Italy regarding care and outcomes of out-of-hospital birth is based on 1099 women who opted for delivery in an out-of-hospital setting from 2014–2018 (7). The authors reported a 9.2% and 11.7% prevalence of postpartum haemorrhage (> 500 mL blood loss) in the freestanding midwifery versus home-birth group, respectively (8). In general, the reported incidence of postpartum haemorrhage-related complications is between 1% and 10% of all deliveries (9). Among those delivering at home, six mothers (for break of stitches) and 19 newborns (five suspected of a brachial plexus injury, five with suspected infection, two with hyperpyrexia, two for jaundice, and five ill-defined cases) were transferred to the hospital within the first week post-delivery. None of the other characteristics related to birth or birth outcomes varied between the two birthplaces (8). Therefore, out-of-hospital births in women with low-risk pregnancies are a potentially safe choice. Nevertheless, the perinatal environment in these places must be monitored, evaluated, and regulated as per standard healthcare control systems to guarantee the safest and most effective care to a mother and her newborn (8), comparable to a hospital delivery.
Childbirth in an out-of-hospital setting is a widespread practice that is prevalent unevenly throughout the world. In the United States, the percentage of out-of-hospital births in 2017 stood at 1.61% (10), while Australia reported that 2.4% of deliveries were carried out in birth centres, 0.3% at home, and 0.7% in other contexts (11). In Japan, 0.6% of the mothers delivered in birth centres and 0.2% at home (12), while in New Zealand, the incidence of out-of-hospitals was 3.4% nationwide, except for the west coast, where the prevalence reached 10.5% (13). In European countries, the Netherlands is an exception, since about 20% of births occur at home (14), while in England 63% of women give birth in midwife-led birth centres and only 3% give birth at home (15). The prevalence of home births was 2.4% in Wales in 2019 (16), 2.2% in Iceland in 2012 (17), and 1.17% in Scotland (18). Denmark reported a 1–2% incidence; in Sweden 0.7 / 1000, Norway 1.5 / 1000 (19), and Belgium less than 1% in 2017 (20). In Germany, about 2% of births in 2010 took place in an out-of-hospital setting (21), and in France, the reported incidence in 2016 was about 1% (22).
The latest available data (2019) for Italy show that only 0.1% of births took place in out-of-hospital settings, of which 0.03% were referred to as “other” places, and 0.07% deliveries were carried out at home with notable regional variations (23). Despite the low national prevalence of out-of-hospital deliveries, there has been a sharp increase in this trend due to the recent COVID-19 pandemic (24). In addition to the usual hospital OUs and delivery rooms in Italy, women often give birth in midwifery units (MUs) located inside (alongside midwifery units—AMUs) or outside the hospital (freestanding midwifery units—FMUs). Notably, in countries such as Great Britain, the AMUs and FMUs and the services provided therein are borne and managed by the National Health System (NHS). Whereas, in Italy, these facilities are very limited; there are only three AMUs belonging to the NHS placed exclusively in central-northern Italy—in Genoa, Turin, and Florence (7).
On the other hand, there are several groups of freelance midwives who assist the births at private FMUs (translated as ‘maternity homes’) or at home, whose services are paid for by the couple (7). Accordingly, we aimed to evaluate and compare the costs related to birth in hospital and out-of-hospital settings from the perspective of accreditation to the NHS.
Methods
The analysis was performed using the third-payer perspective (NHS) to estimate the overall cost of the birth in an out-of-hospital environment accredited to the NHS’ process, accounting for only the direct costs. Indirect and general costs (including energy, administration, insurance, structure, and depreciation) were not included in the analysis owing to their high variability. The direct cost estimation was initiated by identifying the goods used for each birth and the related unit prices.
To assess the frequency of use of the necessary tools in cases of complications requiring possible transfer to the hospital, we used the incidence rates described in the literature. This included the use of the Metergoline and Flebocortid drugs (reserved for cases of postpartum haemorrhage or 1–10% of all deliveries (9)), local anaesthetics used for repair of perineal trauma, which affects 10.9% of the births (25), anti-D immunoglobulins required in 16% of pregnancies (26), and the use of disposable catheters in cases of postpartum urinary retention, which occur in 0.05% to 37% of all cases (27). Additionally, we incorporated the use of materials required to cope with neonatal emergencies, including an emergency hypothermia blanket for transfer to hospital and a paediatric bag valve mask, which is required in 5% of births (28). For the estimation of direct costs, we used the frequency of access.
The operator time, which is one of highest-priced factors, was estimated considering a maximum time of 12 hours for labour-delivery and 2 hours of postpartum observation requiring 2 midwifery personnel per shift, 22 hours of observation in the puerperium with 1 midwifery personnel for birth in the maternity home, with a total of 24 hours of observation from birth as per the World Health Organisation’s (WHO) recommendations (29). Six hours for home visits in the puerperium were also provided, which included 1–2 visits per day about care needs in the first 4–5 days after birth and 1 visit between the 6th and 10th day after childbirth, with 1 midwife.
Regarding the cost of assets for repeated use, the ‘lifetime of the individual’ asset was estimated by identifying a likely depreciation based on the assumption of 300 births per year for childbirth in a maternity home and 100 births per year for home births. The estimation of the useful life of an asset, which refers to the deprecation rate, is based on the experience gained with similar assets (30).
In Italy, as per the current national rates recognized for childbirth, the remuneration of acute hospital activities is based on the Diagnosis Related Groups (DRG, homogeneous groupings of diagnosis) classification system, which is used as a reference to indicate the hospitalization services to be assigned at predetermined rates (31). The DRG model allows for the identification of different categories of hospital admissions that have similar clinical characteristics and require homogeneous volumes of hospital resources for their treatment (32). In the case of low-risk hospital birth, we used the DRG 373 category – “spontaneous birth without complicating diagnoses" and the DRG 391 “normal new-born”.
Since there is no standard tariff for the cost of birth in private maternity homes and at home, an evaluation based on expert opinions was carried out. Two freelance midwives were involved to explain the costs; accordingly, two scenarios were outlined and the average overall cost was computed.
Results
Using the process analysis, we found that births in out-of-hospital settings accredited to the NHS incur a total cost of €1042.27 in maternity homes (Table 1) and €707,20 at home (Table 2).
Table 1.
Direct costs and depreciable good costs – BIRTH AT MATERNITY HOME
| Direct Costs | Price in Euro | Quantity for single service | Price in euro for single service |
|---|---|---|---|
| Assistance material: | Total: 279,1 | Total: 34,15 | |
| Sterile latex gloves in different sizes (1 pair) | 1,00 | 3 | 3,00 |
| Non-sterile gloves (100 pieces) | 3,00 | 20 | 0,60 |
| Sterile gauze (1 kg) | 8,00 | 500 gr | 4,00 |
| Surgical drapes 100x100 (10 pcs) | 17,00 | 3 | 5,10 |
| Collector bag | 2,00 | 1 | 2,00 |
| Cannula needles n 16G - 18G - 21G (3 packs of 20 pieces) | 4,50 | 1 | 0,075 |
| Butterfly n 18G - 21G (100 pieces) | 4,00 | 2 | 0,08 |
| 5 and 10 cc syringes (10 pieces) | 2,00 / 3,00 | 2 | 1,00 |
| Disposable catheters (10 pieces) | 30,00 | 0.05% - 37% of births | 11,1 |
| Band-aid adhesive 10 meters x 10 cm | 3,60 | 10x50cm | 0,20 |
| Infusion set | 1,00 | 1 | 1,00 |
| Suture Threads (36 pieces) | 200,00 | 1 | 6,00 |
| Medicines: | Total: 96,99 | Total: 23,63 | |
| 1000/1500 ml physiological saline | 2,30 | 2 | 4,60 |
| Oxytocin (Syntocinon 1 box) | 3,10 | 1 | 3,10 |
| Metergoline (Methergin 1 box) | 2,94 | 10% of births | 0,29 |
| Flebocortid ampoules | 3,50 | 10% of births | 0,04 |
| Local anaesthetics: Carbocaine or Xylocaine or 2% lidocaine in ampoules | 3,20 | 10.9% of births | 0,35 |
| Disinfectant 500cc | 5,00 | 1 | 5,00 |
| Anti-D immune globulin (if needed) | 57,95 | 16% of births | 9,27 |
| Antibiotic eye drops (10 single doses) | 8,00 | 1 | 0,80 |
| Vitamin K drops (6 ml) | 11,00 | 0,1 ml | 0,18 |
| Neonatal care material: | Total: 73,15 | Total: 6,02 | |
| Tubes for funicular sampling | 0,40 | 2 | 0,80 |
| Cord-clamps (50 pieces) | 17,00 | 1 | 0,34 |
| Emergency Hypothermia blanket | 30,00 | 5% of births | 1,5 |
| Paediatric bag valve mask (n 1) | 19,60 | 5% of births | 0,98 |
| Blood Lancet (100 pieces) | 4,00 | 1 | 0,40 |
| New-born screening card | Data not found | 1 | Data not found |
| Disposable baby diapers | 0,50 | 4 | 2,00 |
| Time-operator | 15 euros/h (12 euros/h Rate recorded by the current National Collective Labour Agreement. + 26% average allowance |
46 hours N = 2 midwives 14 hours (labour / delivery / postpartum) N = 1 midwife 22 hours (puerperium) 10 hours N = 1 midwife (About 6 home visits) |
900,00 |
| Full day food | 11,00 | 2 | 22,00 |
| Paediatric home visit (ticket rate) | 36,00 | 1 | 36,00 |
| Total: 1021,80 | |||
| Depreciable goods costs | Price in Euro | Estimated time to wear (years) | Depreciation (Estimated over 300 annual births) |
| Assistance material | Total: 216,57 | Total: 0,0756 | |
| Thermometer | 6,00 | 5 | 0,004 |
| Phonendoscope and sphygmomanometer | 160,00 | 10 | 0,053 |
| Medical tourniquet | 5,00 | 5 | 0,003 |
| 2 Kocher | 14,00 | 10 | 0,004 |
| 1 straight scissors with blunt tips | 3,50 | 10 | 0,002 |
| 1 bowl for disinfectant | 8,60 | 10 | 0,003 |
| Pliers Foerster | 11,50 | 10 | 0,004 |
| 1 needle holder | 6,08 | 10 | 0,002 |
| 1 tissue pliers anatomical | 1,89 | 10 | 0,0006 |
| Sonicaid | 750,00 | 10 | 0,25 |
| Autoclave | 1500,00 | 10 | 0,5 |
| Furnishings for living room, clinic, 2 labour-delivery rooms, kitchen, fire-fighting system, emergency trolley, changing table with baby bath | 45.800,00 | 20 | 7,63 |
| Waste disposal | 200,00 | 1 | 0,66 |
| Linen | 900,00 | 5 | 0,59 |
| Labour-delivery tub | 32.000,00 | 10 | 10,67 |
| Crib | 150,00 | 5 | 0,10 |
| Total: 20,47 |
Table 2.
Direct costs and depreciable good costs – HOME BIRTH
| Direct costs | Price in Euro | Quantity for single service | Price in euro for single service |
|---|---|---|---|
| Assistance material: | Total: 279,1 | Total: 34,15 | |
| Sterile latex gloves in different sizes (1 pair) | 1,00 | 3 | 3,00 |
| Non-sterile gloves (100 pieces) | 3,00 | 20 | 0,60 |
| Sterile gauze (1 kg) | 8,00 | 500 gr | 4,00 |
| Surgical drapes 100x100 (10 pcs) | 17,00 | 3 | 5,10 |
| Collector bag | 2,00 | 1 | 2,00 |
| Cannula needles n 16G - 18G - 21G (3 packs of 20 pieces) | 4,50 | 1 | 0,075 |
| Butterfly n 18G - 21G (100 pieces) | 4,00 | 2 | 0,08 |
| 5 and 10 cc syringes. (10 pieces) | 2,00 / 3,00 | 2 | 1,00 |
| Disposable catheters (10 pieces) | 30,00 | 0.05% - 37% of births | 11,1 |
| Band-aid adhesive 10 meters x 10 cm | 3,60 | 10x50cm | 0,20 |
| Infusion set | 1,00 | 1 | 1,00 |
| Suture Threads (36 pieces) | 200,00 | 1 | 6,00 |
| Medicines: | Total: 96,99 | Total: 23,63 | |
| 1000/1500 ml physiological saline | 2,30 | 2 | 4,60 |
| Oxytocin (Syntocinon 1 box) | 3,10 | 1 | 3,10 |
| Metergoline (Methergin 1 box) | 2,94 | 10% of births | 0,29 |
| Flebocortid ampoules | 3,50 | 10% of births | 0,04 |
| Local anaesthetics: Carbocaine or Xylocaine or 2% lidocaine in ampoules. | 3,20 | 10.9% of births | 0,35 |
| Disinfectant 500cc | 5,00 | 1 | 5,00 |
| Anti-RH IMMUNOGLOBULINS (if needed) | 57,95 | 16% of births | 9,27 |
| Antibiotic eye drops (10 single doses) | 8,00 | 1 | 0,80 |
| Vitamin K in drops (6 ml) | 11,00 | 0,1 ml | 0,18 |
| Neonatal care material: | Total: 73,15 | Total: 4,02 | |
| Tubes for funicular sampling | 0,40 | 2 | 0,80 |
| Cord-clamps (50 pieces) | 17,00 | 1 | 0,34 |
| Emergency Hypothermia blanket | 30,00 | 5% of births | 1,5 |
| Paediatric bag valve mask (n 1) | 19,60 | 5% of births | 0,98 |
| Blood Lancet (100 pieces) | 4,00 | 1 | 0,40 |
| New-born screening card | Data not found | 1 | Data not found |
| Time-operator | 15 euros / h (12 euros / h Rate recorded by the current National Collective Labour Agreement. + 26% average allowance |
24 hours N = 2 midwives 14 hours (labour / delivery / postpartum) 10 hours N=1 midwife (About 6 home visits) |
570,00 |
| Paediatric home visit (ticket rate) | 36,00 | 1 | 36,00 |
| Total: 667,80 | |||
| Depreciable goods costs | Price in Euro | Estimated time to wear (years) | Depreciation (Estimated over 100 annual births) |
| Assistance material | Total: 216,57 | Total: 0,227 | |
| Thermometer | 6,00 | 5 | 0,012 |
| Phonendoscope and sphygmomanometer | 160,00 | 10 | 0,16 |
| Tourniquet | 5,00 | 5 | 0,01 |
| 2 Kocher | 14,00 | 10 | 0,014 |
| 1 pair of straight blunt-tipped scissors | 3,50 | 10 | 0,003 |
| 1 bowl for disinfectant | 8,60 | 10 | 0,009 |
| Ring pliers | 11,50 | 10 | 0,011 |
| 1 needle holder | 6,08 | 10 | 0,002 |
| 1 anatomic forceps | 1,89 | 10 | 0,006 |
| Sonicaid | 750,00 | 10 | 0,75 |
| Autoclave | 1500,00 | 10 | 1,5 |
| Waste disposal | 200,00 | 1 | 2,00 |
| Linen | 100 | 5 | 5,00 |
| Company car | 15000,00 | 10 | 15,00 |
| Company car maintenance | 1492,00 | 1 | 14,92 |
| Total: 39,40 |
The total direct costs related to maternity home births is €1021.80, of which €20.47 are related to reusable costs. Assuming that the indirect and general costs account for 30% of the direct costs, the full cost would be €1354.95.
As anticipated, we observed that the time-operator item assumes the greatest weight among the total direct cost, amounting to €900.00. Specifically, the hourly rate of the National Collective Workers Agreement in force, i.e., about €12/h, was taken as a reference, to which 26% equal to the average indemnity was added, making up an amount of €15/h. Among the costs of depreciable assets, the heaviest weights are attributed to the furnishings (estimated time to wear 20 years) and the labour tub (estimated lifetime of 10 years) whose depreciation rates are €7.63 and €10.67, respectively.
The total direct costs related to home birth equals to €667.80, while the quota related to reusable costs amounts to €39.40. Assuming that a share of the indirect and general costs is equal to 30% of direct costs, in this case, the full cost would be €919.36. Like the maternity home births, the greatest weight of the direct costs in home births is also attributable to the operator-time item, equal to €570.00 accounting for all the previously mentioned elements. However, this cost is considerably lower than that related to births at a maternity home, since there is no 24-hour observation period following the delivery. Among the costs of depreciable assets, the greatest weights are attributable to the use of a company car (depreciation rate = €15.00) and its maintenance (€1492.00 per year), the depreciation rate of which is €14.92.
Currently, the DRG 373 allows an all-inclusive rate of €1,272.00 for “spontaneous birth without complicating diagnoses” while DRG 391 provides a rate of €560.00 for the “normal infant”. These rates are also applied in NHS-accredited MUs. Therefore, we inferred how much care to the mother-child dyad costed in physiological conditions by adding both DRGs, which resulted in a total cost of €1832.00.
Calculating the average of the overall cost was done starting from an evaluation based on experts’ opinion, which envisaged the involvement of two freelance midwives, from which 2 scenarios were outlined. Therefore, the average cost of the birth event carried out in private maternity homes managed by freelance midwives equals to €3260.00, while at home birth amounts to €2910.00 if the distance is < 40 km; otherwise, a surcharge is applicable, which averages to €400.00 (Table 3).
Table 3.
Costs of out-of-hospital deliveries in a private regime
| Maternity home | Home | Surcharge distance >40 km | |
|---|---|---|---|
| Scenario 1/ Midwife 1 | 2500,00 euros The price includes maternity home contribution; visits from on-call at the time of delivery; 24-hour availability of 2 midwives from 37 weeks; N = 5 - 6 home visits in the puerperium; and n. 1 visit at the maternity home. |
2200,00 euros The price includes visits from availability to the time of delivery; 24-hour availability, 2 midwives from 37 weeks; n = 5-6 home visits in the puerperium; and n = 1 visit at the maternity home. |
500,00 euros |
| Scenario 2/ Midwife 2 | 3720,00 euros 3400.00 euros, including maternity home contribution; visits from on-call at the time of delivery; availability h24 of n.2 midwives from 37 weeks. + 320.00 euros home visits in the puerperium (average 8 home visits costing 40 euros each) |
3320,00 euros 3000.00 euros, including visits from on-call to the time of delivery; availability h24 of n.2 midwives from 37 weeks. + 320.00 euros home visits in the puerperium (average 8 home visits costing 40 euros each) |
300,00 euros |
| Paediatric visit | 150,00 euros | 150,00 euros | |
| Total cost average | 3260,00 euros | 2910,00 euros | 3310,00 euros |
Specifically, scenario 1 describes a ‘package of services’ with an all-inclusive price of €2500.00 for birth in a maternity home, and a €2200.00 package which includes visits from the moment of availability until delivery, 24-hour availability from two midwives from the 37th week of gestation, childbirth care by two midwives, 5–6 home visits in the puerperium, and one visit at the maternity home.
On the other hand, scenario no. 2 described an assistance package up to childbirth with an all-inclusive price of €3400.00 for birth in a maternity home and €3000.00 for home birth, which includes all visits from availability to the birth, 24-hour availability of two midwives from the 37th week and childbirth care by two midwives. Home visits in the puerperium costed around €40.00 each, which assumed an average of 8 visits, amounting to a total of €320.00 while determining the total cost. If the distance from the home is > 40 km, an average surcharge of €400 is applied. In both cases, the paediatric visit has a separate cost, estimated at a maximum of €150.00.
Discussion
Since the clinical characteristics and volume of resources per treatment are homogeneous, and therefore comparable, the overall cost obtained from the sum of the tariffs provided for by DRGs 373 and 391 can be compared with the estimated values from the cost-analysis of the “out-of-hospital birth accredited to the NHS”. We found that the total cost associated with birth in a maternity home was lower than the sum of the aforementioned DRG rates for childbirth and neonatal care by a significant 26.04%. Likewise, the total cost associated with home births is 49.82% lower than the sum of the DRG tariffs.
A similar comparative analysis carried out in 2008 took into consideration the costs and related average reimbursements according to the DRG prices of spontaneous hospital births without complications in nine European countries (33). They reported that the cost of hospital birth varied from €342.00 in Hungary to €2365.00 in Germany, with an average of about €1260.00 for the nine countries. The reported average reimbursement of the DRG tariff is €1286.11.
These results concur with the existing literature; a comparative economic analysis of care paths for low-risk women showed that MUs are cheaper and advantageous in terms of cost-effectiveness compared to the ‘classic OU’ (34). Schroeder et al. (2011) reported that the total cost incurred by pregnant women without any risk factors during labour at the start of care approximated to: OU or hospital delivery room: £1,511 (€1679.13), AMUs: £1,427 (€1585.78), FMUs: £1,405 (€1561.33), and home: £1,027 (€1141.27) (35). All cost differences were negative even after adjusting costs for confounders, asymmetry, and weight in the dataset, and reflected the cost-saving effect of planned delivery in out-of-hospital birth settings (35). Furthermore, a recent systematic review reported that cost savings associated with out-of-hospital delivery ranged from 3% to 28%, depending on the location, health system characteristics, and methods of delivery analyses used (36). Another recent Australian study described a significant reduction in the use of resources by health services in cases where low-risk births occurred at home or in MUs (37).
At present, the only Italian cities where childbirth care in out-of-hospital settings is provided free of charge are Turin, Reggio Emilia, Modena, and Parma because accreditation to the NHS is envisaged here (38). In some regions, it is possible to request a reimbursement to partially cover the expenses incurred: the Piedmont region provides a maximum amount of €930.00 (39); the Emilia-Romagna region repays 80% of the documented expenditure up to a maximum of €1231.61 (40); the Marche region provides up to €1200.00 (41); the provinces of Bolzano and Trento offer €516.46 (42) and €750.00 (43), respectively, and Lazio provides a €800.00 reimbursement (44). It is reasonable to think that increasing the reimbursement amount would further increase the request for out-of-hospital birth. Many couples who cannot afford this expense do not even consider this a real possibility; consequently, there are left to choose hospital births, where the costs are covered by the NHS.
An additional barrier to choosing an out-of-hospital birthplace is posed by the national regulations in force, which do not provide clear information but refer to purely regional provisions.
Certain Italian regions have issued protocols, guidelines, and care profiles to outline the conditions and requirements necessary to ensure adequate levels of safety. Specifically, the Lazio region adopted a care protocol in 2016 for out-of-hospital births in birth centres and maternity homes (45). In 2003, the Piedmont region defined the care profile in the case of out-of-hospital physiological labour and delivery (46), while Emilia-Romagna published the guidelines on low-risk childbirth care in out-of-hospital settings in 2019 (21). Also, the National Cultural Association of Midwives-Home Birth and Maternity Home published updated guidelines in 2017 for physiological childbirth care at home and maternity homes (47). Nevertheless, a care package aimed at guaranteeing quality, safety, and appropriateness, which is oriented towards the promotion of mother-infant health, should take into consideration NHS accreditation for each type of birthplace.
Despite its many important strengths and findings, this study has some limitations. First, we did not account for the indirect and general costs while estimating the overall cost of “birth in an out-of-hospital environment accredited to the NHS,” as it was not possible to know the exact amount. This latter is very variable depending on the context that is taken as a reference. Therefore, an estimate of these costs was based on the general assumption that they equal 30% of direct costs. Furthermore, to estimate the cost of the birth managed by freelance midwives, an evaluation based on expert opinion was carried out involving two midwives, assuming they represented the entire national scenario.
Since such comprehensive data were not available, future studies should focus on these variables.
Despite these limitations, to the best of our knowledge, this is the first study to provide an estimate of the costs of out-of-hospital birth in the Italian context.
Conclusions
A possible NHS accreditation of maternity homes would help reduce the expenditure of economic resources compared to childbirth in a hospital setting. Additionally, the non-economical aspect is associated with contributing to the ‘de-medicalisation’ of the birth event in Italy and a consequently greater satisfaction during the delivery. It is often reported that the medicalisation of pregnancy and childbirth has negatively impacted the level of satisfaction among pregnant women and couples (48,49). Furthermore, the continuity of care guaranteed by a midwife during the postnatal period may help achieve long-term benefits for the health of the mother and child, including an increase in the breastfeeding prevalence (50). In fact, the latter is sometimes undermined by inappropriate hospital practices (e.g., prescription of artificial infant formula) and/or poor knowledge, attitudes, and practices by healthcare professionals on infant feeding (51–53).
Finally, the opportunity to access out-of-hospital birthplaces accredited by the NHS would offer alternative affordable options to women and couples with low incomes, thereby reducing health inequalities and ascertaining their freedom to go for private care. This may also have significant social ramifications, leading to further enhancement in midwifery, for instance, providing the opportunity to deploy professional intramural activities.
Therefore, the accreditation of maternity homes may help harmonize the process around international policies, as well as promote and boost the development of midwifery-led care services as an appropriate and efficient model.
Conflict of Interest:
Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article
Ethical Approval:
Not requested
Funding:
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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