At What Price? A Cost-Effectiveness Analysis Comparing Trial of Labour after Previous Caesarean versus Elective Repeat Caesarean Delivery

Abstract

BackgroundElective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk women in Ireland.MethodsUsing a decision analytic model, a cost-effectiveness analysis (CEA) was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. A review of international literature was conducted to derive representative estimates of adverse maternal health outcomes following a trial of labour after caesarean (TOLAC) and ERCD. Delivery/procedure costs derived from primary data collection and combined both “bottom-up” and “top-down” costing estimations.ResultsMaternal morbidities emerged in twice as many cases in the TOLAC group than the ERCD group. However, a TOLAC was found to be the most-effective method of delivery because it was substantially less expensive than ERCD (€1,835.06 versus €4,039.87 per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supported by probabilistic sensitivity analysis.ConclusionsClinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay and postpartum recovery time. While it is premature advocate a policy of TOLAC across maternity units, the results of the study prompt further analysis and repeat iterations, encouraging future studies to synthesis previous research and new and relevant evidence under a single comprehensive decision model.

Lifetime Cost-Effectiveness of Trial of Labor After Cesarean in the United States

“…The Grobman et al life-cycle model found that TOLAC would save $179 million per 100,000 women, however, QALYs were not included in the analysis. [7] The analyses by Chung et al [4], Gilbert et al [5] and Fawsitt et al [6] which incorporated only the pregnancy immediately following one prior cesarean found the TOLAC strategy to be cost-effective. Chung et al reported ERCD would cost $112,023 per QALY (no total QALYs were provided) whereas Gilbert et al reported $138.6 million saved and 1703 QALYs gained.…”

“…Chung et al reported ERCD would cost $112,023 per QALY (no total QALYs were provided) whereas Gilbert et al reported $138.6 million saved and 1703 QALYs gained. Fawsitt et al found TOLAC to be the dominant base case strategy saving almost €221 million and 1615 QALYs per 100,000 women, however no neonatal outcomes were incorporated in the analysis [6]. Pare et al; without incorporating costs or QALYs in their decision analysis, concluded that for a woman with a single prior cesarean and planning only one more pregnancy an ERCD was preferred since it results in fewer hysterectomies [8].…”

“…For example, three analyses provided the outcome of the initial decision without considering further pregnancies [4-6], and another did not take into consideration patient preferences [7]. A decision model comparing these two delivery strategies estimated the probabilities of maternal consequences throughout reproductive life, but did not include costs, preferences or infant outcomes [8].…”

Health economic analysis of a cluster‐randomised trial (OptiBIRTH) designed to increase rates of vaginal birth after caesarean section

“…A country‐specific cost‐effectiveness threshold was used: €37,719/QALY for Germany, €45,000/QALY for Ireland, and €27,219/QALY for Italy . The cost‐effectiveness threshold for Ireland was set historically at €45,000/QALY, and the gross domestic product per capita was used for Germany and Italy because national cost‐effectiveness thresholds did not exist.…”

Análise de custo-efetividade do parto vaginal espontâneo e da cesariana eletiva para gestantes de risco habitual no Sistema Único de Saúde

“…Para mulheres primíparas, Xu et al 42 investigaram a custo-efetividade da cesariana a pedido materno comparada ao trabalho de parto para o desfecho disfunção de assoalho pélvico na perspectiva da sociedade estadunidense. O modelo de decisão utilizado incluiu a morbimortalidade materna e neonatal, e a probabilidade da cesariana materna a pedido ser custo-efetiva foi de 82%, considerando-se um limiar por QALY de US$ 50.000 (R$ 159.500,00 45 . Mesmo considerando as especificidades entre os estudos, os resultados desta análise de custo-efetividade encontram consonância com estudos internacionais citados.…”