Background
For women with a prior low transverse cesarean delivery, the decision to undergo a trial of labor after cesarean (TOLAC) or an elective repeat cesarean delivery (ERCD) has important clinical and economic ramifications.
Objective
The objective of this systematic review of the literature is to evaluate the cost-effectiveness of the alternative choices of a TOLAC and an ERCD for women with low-risk, singleton gestation pregnancies.
Methods
We searched EMBASE, MEDLINE, CINAHL, Cochrane Library, EconLit, and the Cost-Effectiveness Analysis Registry with no language, publication, or date restrictions up until October 2015. Studies were included if they were primary research, compared a TOLAC to an ERCD, and provided information on the relative cost of the alternatives. Abstracts and partial economic evaluations were excluded.
Results
Of 310 studies initially reviewed, seven studies were included in the systematic review. In the base case analyses, four studies concluded that TOLAC was dominant over ERCD, one study found ERCD to be dominant, and two studies found that while TOLAC was more costly, it also offered more benefit and was thus cost-effective from a population perspective when considering societal willingness to pay for better outcomes. In sensitivity analyses, cost-effectiveness was found to be dependent on a high likelihood of TOLAC success, low risk of uterine rupture, and low relative cost of TOLAC compared to ERCD.
Conclusion
For women who are likely to have a successful vaginal delivery, routine ERCD may result in excess morbidity and cost from a population perspective.
A case–control study was conducted to determine the association between maternal height and infant length‐for‐age, and to evaluate how this association is modified by either maternal or infant nutritional status. We hypothesised that maternal excess caloric intake [measured as body mass index (BMI)] would increase the association, while infant nutrition (measured in main meals consumed in addition to breastfeeding) will diminish the effect. Mother and infant pairs in Chimaltenango, Guatemala, were measured for anthropometric values and nutritional status, and mothers were interviewed to elicit nutritional and socio‐economic information. Infant length was converted into z‐scores based on the World Health Organization's (WHO) standards. Odds ratios (ORs), associated 95% confidence intervals (CIs) and the relative excess risk due to interaction (RERI) were calculated. Cases were infants below 2 z‐scores of the WHO's length‐for‐age, while controls were infants within the −2 to 2 z‐score range. Cases (n = 84) had an increased odds (OR: 3.00, 95% CI: 1.57–5.74) of being born to a stunted mother (below 145 cm) when compared with controls (n = 85). When adjusted for potential confounders, the OR decreased to 2.55 (95% CI: 1.30–5.02). Negative RERI values were produced for the joint exposure of maternal BMI ≥ 25 and maternal stuntedness (RERI: −0.96), as well as for the joint exposure of maternal stuntedness and infant nutrition (RERI: −2.27). Our results confirm that maternal stuntedness is a significant contributor to infant stuntedness; however, this association is modified negligibly by maternal nutritional status and significantly by infant nutritional status, each in a protective manner.
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