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

OBJECTIVE: To perform a health economic analysis of an intervention designed to increase rates of vaginal birth after caesarean, compared with usual care. DESIGN: Economic analysis alongside the cluster-randomised OptiBIRTH trial (Optimising childbirth by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care). SETTING: Fifteen maternity units in three European countries - Germany (five), Ireland (five), and Italy (five) - with relatively low VBAC rates. POPULATION: Pregnant women with a history of one previous lower-segment caesarean section; sites were randomised (3:2) to intervention or control. METHODS: A cost-utility analysis from both societal and health-services perspectives, using a decision tree. MAIN OUTCOME MEASURES: Costs and resource use per woman and infant were compared between the control and intervention group by country, from pregnancy recognition until 3 months postpartum. Based on the caesarean section rates, and maternal and neonatal morbidities and mortality, the incremental cost-utility ratios were calculated per country. RESULTS: The mean difference in costs per quality-adjusted life years (QALYs) gained from a societal perspective between the intervention and the control group, using a probabilistic sensitivity analysis, was: €263 (95% CI €258-268) and 0.008 QALYs (95% CI 0.008-0.009 QALYs) for Germany, €456 (95% CI €448-464) and 0.052 QALYs (95% CI 0.051-0.053 QALYs) for Ireland, and €1174 (95% CI €1170-1178) and 0.006 QALYs (95% CI 0.005-0.007 QALYs) for Italy. The incremental cost-utility ratios were €33,741/QALY for Germany, €8785/QALY for Ireland, and €214,318/QALY for Italy, with a 51% probability of being cost-effective for Germany, 92% for Ireland, and 15% for Italy. CONCLUSION: The OptiBIRTH intervention was likely to be cost-effective in Ireland and Germany. TWEETABLE ABSTRACT: The OptiBIRTH intervention (to increase VBAC rates) is likely to be cost-effective in Germany and Ireland.

Vaginal birth after caesarean versus elective repeat caesarean delivery after one previous caesarean section: a cost-effectiveness analysis in four European countries.

BACKGROUND: The OptiBIRTH study incorporates a multicentre cluster randomised trial in 15 hospital sites across three European countries. The trial was designed to test a complex intervention aimed at improving vaginal birth after caesarean section (VBAC) rates through increasing women's involvement in their care. Prior to developing a robust standardised model to conduct the health economic analysis, an analysis of a hypothetical cohort was performed to estimate the costs and health effects of VBAC compared to elective repeat caesarean delivery (ERCD) for low-risk women in four European countries. METHODS: A decision-analytic model was developed to estimate the costs and the health effects, measured using Quality Adjusted Life Years (QALYs), of VBAC compared with ERCD. A cost-effectiveness analysis for the period from confirmation of pregnancy to 6 weeks postpartum was performed for short-term consequences and during lifetime for long-term consequences, based on a hypothetical cohort of 100,000 pregnant women in each of four different countries; Belgium, Germany, Ireland and Italy. A societal perspective was adopted. Where possible, transition probabilities, costs and health effects were adapted from national data obtained from the respective countries. Country-specific thresholds were used to determine the cost-effectiveness of VBAC compared to ERCD. Deterministic and probabilistic sensitivity analyses were conducted to examine the uncertainty of model assumptions. RESULTS: Within a 6-week time horizon, VBAC resulted in a reduction in costs, ranging from €3,334,052 (Germany) to €66,162,379 (Ireland), and gains in QALYs ranging from 6399 (Italy) to 7561 (Germany) per 100,000 women birthing in each country. Compared to ERCD, VBAC is the dominant strategy in all four countries. Applying a lifetime horizon, VBAC is dominant compared to ERCD in all countries except for Germany (probabilistic analysis, ICER: €8609/QALY). In conclusion, compared to ERCD, VBAC remains cost-effective when using a lifetime time. CONCLUSIONS: In all four countries, VBAC was cost-effective compared to ERCD for low-risk women. This is important for health service managers, economists and policy makers concerned with maximising health benefits within limited and constrained resources.

Economic Evaluations Comparing a Trial of Labor with an Elective Repeat Cesarean Delivery: A Systematic Review.

BACKGROUND: For women who have had a previous 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. OBJECTIVES: 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 with 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, 7 studies were included in the systematic review. In the base-case analyses, 4 studies concluded that TOLAC was dominant over ERCD, 1 study found ERCD to be dominant, and 2 studies found that although TOLAC was more costly, it offered more benefits 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 with ERCD. CONCLUSIONS: For women who are likely to have a successful vaginal delivery, routine ERCD may result in excess morbidity and cost from a population perspective.

The cost-effectiveness of a trial of labor accrues with multiple subsequent vaginal deliveries.

OBJECTIVE: The purpose of this study was to estimate costs and outcomes of subsequent trials of labor after cesarean delivery (TOLAC) compared with elective repeat cesarean deliveries (ERCD). STUDY DESIGN: To compare TOLAC and ERCD, maternal and neonatal decision analytic models were built for each hypothetic subsequent delivery. We assumed that only women without previa would undergo TOLAC for their second delivery, that women with successful TOLAC would desire future TOLAC, and that women who chose ERCD would undergo subsequent ERCD. Main outcome measures were maternal and neonatal mortality and morbidity rates, direct costs, and quality-adjusted life years. Values were derived from the literature. One-way and Monte-Carlo sensitivity analyses were performed. RESULTS: TOLAC was less costly and more effective for most models. A progression of decreasing incremental cost and increasing incremental effectiveness of TOLAC was found for maternal outcomes with increasing numbers of subsequent deliveries. This progression was also displayed among neonatal outcomes and was most prominent when neonatal and maternal outcomes were combined, with an incremental cost and effectiveness of -$4700.00 and .073, respectively, for the sixth delivery. Net-benefit analysis showed an increase in the benefit of TOLAC with successive deliveries for all outcomes. The maternal model of the second delivery was sensitive to cost of delivery and emergent cesarean delivery. Successive maternal models became more robust, with the models of the third-sixth deliveries sensitive only to cost of delivery. Neonatal models were not sensitive to any variables. CONCLUSION: Although nearly equally effective relative to ERCD for the second delivery, TOLAC becomes less costly and more effective with subsequent deliveries.

Lifetime cost-effectiveness of trial of labor after cesarean in the United States.

OBJECTIVE: To estimate the cost-effectiveness of a trial of labor after one previous cesarean (TOLAC) when incorporating long-term events and outcomes. METHODS: A Markov model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Women were selected from a prospective study to derive probability estimates for potential events through three subsequent pregnancies. Probabilities for cerebral palsy and stress urinary incontinence, cost data, and quality-adjusted life-years (QALYs) were obtained from the literature. The primary outcome was cost-effectiveness measured as the marginal cost per QALY gained, with a $50,000 threshold per QALY used to define cost-effectiveness. RESULTS: The TOLAC strategy dominated the ERCD strategy at baseline, with $164.2 million saved and 500 QALYs gained per 100,000 women. The model was sensitive to six variables: the probability of uterine rupture and successful TOLAC among women with no prior vaginal delivery, the frequency of stress urinary incontinence, and the costs of failed TOLAC, successful TOLAC, and ERCD. When the probability of TOLAC success was at the base value, 67.2%, TOLAC was preferred if the probability of uterine rupture was 3.1% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 47.2% or more. Probabilistic sensitivity analysis confirmed the base-case analysis. CONCLUSIONS: Under baseline circumstances, TOLAC is less expensive and more effective than an ERCD when considering long-term consequences when the likelihood of success is 47.2% or more.

Cost-effectiveness of trial of labor after previous cesarean in a minimally biased cohort.

OBJECTIVE: To estimate the cost-effectiveness of a trial of labor after one previous cesarean delivery (TOLAC). STUDY DESIGN: A model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Probabilistic estimates were obtained from women matched on their baseline characteristics using propensity scores. Cost data, quality-adjusted life-years (QALYs), and data on cerebral palsy were incorporated from the literature. RESULTS: The TOLAC strategy dominated the ERCD strategy at baseline, with $138.6 million saved and 1703 QALYs gained per 100,000 women. The model was sensitive to five variables: the probability of uterine rupture, the probability of successful TOLAC, the QALY of failed TOLAC, the cost of ERCD, and the cost of successful TOLAC without complications. When the probability of TOLAC success was at the base value, 68.5%, TOLAC was preferred if the probability of uterine rupture was 4.2% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 42.6% or more. CONCLUSION: A TOLAC is less expensive and more effective than an ERCD in a group of women with balanced baseline characteristics.

Economic implications of reducing caesarean section rates - Analysis of two health systems.

Caesarean section (CS) rates throughout Europe have risen significantly over the last two decades. As well as being an important clinical issue, these changes in mode of birth may have substantial resource implications. Policy initiatives to curb this rise have had to contend with the multiplier effect of women who had a CS for their first birth having a greater likelihood of requiring one during subsequent births, thus making it difficult to decrease CS rates in the short term. Our study examines the long-term resource implications of reducing CS rates among first-time mothers, as well as improving rates of vaginal birth after caesarean section (VBAC), among an annual cohort of women over the course of their most active childbearing years (18 to 44 years) in two public health systems in Europe. We found that the economic benefit of improvements in these two outcomes is considerable, with the net present value of the savings associated with a five-percentage-point change in nulliparous CS rates and VBAC rates being €1.1million and £9.8million per annual cohort of 18-year-olds in Ireland and England/Wales, respectively. Reductions in CS rates among first-time mothers are associated with a greater payoff than comparable increases in VBAC rates. The net present value of achieving CS rates comparable to those currently observed in the best performing Scandinavian countries was €3.5M and £23.0M per annual cohort in Ireland and England/Wales, respectively.

Predictors of perinatal outcomes and economic costs for late-term induction of labour.

OBJECTIVE: We aimed to predict the perinatal outcomes and costs of health services following labour induction for late-term pregnancies. MATERIALS AND METHODS: We conducted a cohort study of 245 women who underwent labour induction during their 41st week of gestation. The cervical condition was assessed upon admission using the Bishop score and ultrasound cervical length measurements. We estimated the direct costs of labour induction, and a predictive model for perinatal outcomes was constructed using the decision tree analysis algorithm and a logit model. RESULTS: A very unfavourable Bishop score at admission (Bishop score <2) (OR, 3.43 [95% CI, 1.77-6.59]), and a history of previous caesarean section (OR, 7.72 [95% CI, 2.43-24.43]) or previous vaginal delivery (OR, 0.24 [95% CI, 0.09-0.58]) were the only variables with predictive capacity for caesarean section in our model. The mean cost of labour induction was €3465.56 (95% confidence interval [CI], 3339.53-3591.58). Unfavourable Bishop scores upon admission and no history of previous deliveries significantly increased the cost of labour induction. Both of these criteria significantly predicted the likelihood of a caesarean section in the decision tree analysis. CONCLUSION: The cost of labour induction mostly depends on the likelihood of successful trial of labour. Combined use of the Bishop score and previous vaginal or caesarean deliveries improves the ability to predict the likelihood of a caesarean section and the economic costs associated with labour induction for late-term pregnancies. This information is useful for patient counselling.

A cluster-randomized trial to reduce major perinatal morbidity among women with one prior cesarean delivery in Québec (PRISMA trial): study protocol for a randomized controlled trial.

BACKGROUND: Rates of cesarean delivery are continuously increasing in industrialized countries, with repeated cesarean accounting for about a third of all cesareans. Women who have undergone a first cesarean are facing a difficult choice for their next pregnancy, i.e.: (1) to plan for a second cesarean delivery, associated with higher risk of maternal complications than vaginal delivery; or (b) to have a trial of labor (TOL) with the aim to achieve a vaginal birth after cesarean (VBAC) and to accept a significant, but rare, risk of uterine rupture and its related maternal and neonatal complications. The objective of this trial is to assess whether a multifaceted intervention would reduce the rate of major perinatal morbidity among women with one prior cesarean. METHODS/DESIGN: The study is a stratified, non-blinded, cluster-randomized, parallel-group trial of a multifaceted intervention. Hospitals in Quebec are the units of randomization and women are the units of analysis. As depicted in Figure 1, the study includes a 1-year pre-intervention period (baseline), a 5-month implementation period, and a 2-year intervention period. At the end of the baseline period, 20 hospitals will be allocated to the intervention group and 20 to the control group, using a randomization stratified by level of care. Medical records will be used to collect data before and during the intervention period. Primary outcome is the rate of a composite of major perinatal morbidities measured during the intervention period. Secondary outcomes include major and minor maternal morbidity; minor perinatal morbidity; and TOL and VBAC rate. The effect of the intervention will be assessed using the multivariable generalized-estimating-equations extension of logistic regression. The evaluation will include subgroup analyses for preterm and term birth, and a cost-effectiveness analysis. DISCUSSION: The intervention is designed to facilitate: (1) women's decision-making process, using a decision analysis tool (DAT), (2) an estimate of uterine rupture risk during TOL using ultrasound evaluation of low-uterine segment thickness, (3) an estimate of chance of TOL success, using a validated prediction tool, and (4) the implementation of best practices for intrapartum management. TRIAL REGISTRATION: Current Controlled Trials, ID: ISRCTN15346559 . Registered on 20 August 2015.

Planned cesarean delivery compared to induction of labor in women with class III obesity: a cost-minimization analysis (.).

OBJECTIVE: To compare the costs between planned cesarean delivery (CD) and induction of labor (IOL) in women with class III obesity. METHODS: We conducted a cost-minimization analysis using data from a previous study of women with a BMI ≥40 kg/m(2) delivering term singletons via planned CD or after IOL. Decision trees were built with branches for two "treatments": planned CD and IOL (probabilities derived from parent study). Direct and total costs were obtained for each mother-infant pair. Sensitivity analyses for probability of successful IOL were performed. RESULTS: A total of 661 mother-infant pairs were included - 399 IOLs and 262 planned CDs. Of 399 IOLs, 236 (59%) delivered vaginally and 163 (41%) had a CD. IOL was slightly less costly. For IOL and planned CD, respectively, direct costs were $7416 versus $7474, and total costs were $11 545 versus $11 665. Sensitivity analyses indicated that IOL was the least costly strategy if the probability of vaginal delivery after IOL was >57% (0.575 for direct costs; 0.570 for total costs). There was, however, a slight cost advantage to planned CD in women with a prior cesarean. CONCLUSIONS: In women with class III obesity, IOL is less costly than planned CD if the probability of vaginal delivery after IOL in an individual patient is greater than 57%.

An economic analysis of trial of labor after cesarean delivery.

OBJECTIVE: Given that cesarean delivery is one of the most commonly performed surgical procedures in the United States and an important contributor to obstetric care costs, this analysis sought to examine maternal hospital costs associated with trial of labor after cesarean delivery (TOLAC) versus repeat cesarean delivery (RCD). METHODS: A national sample was used to identify women with singleton pregnancy who underwent either TOLAC or RCD from 2006 to 2012. Women with diagnoses that could confound cost via extended hospital length of stay prior to delivery were excluded. Other medical and obstetric covariates that could influence cost were included in an adjusted model. RESULTS: A total of 485,247 women were identified, including 365,596 (75.3%) cesarean deliveries without labor, 41,988 (8.6%) successful and 77,663 (16.0%) unsuccessful TOLAC deliveries. The inflation-adjusted median costs in this cohort were $5512 for cesarean without labor, $4175 for successful TOLAC, $5166 for all TOLAC attempts, and $5759 for failed TOLAC. In a multivariable model, hospital region was a major predictor of median cost as were demographic variables and medical comorbidities. CONCLUSION: TOLAC is associated with modest reductions of cost for maternal hospitalizations. However, other medical, demographic and hospital factors appear to be more important factors.

Improving the organisation of maternal health service delivery and optimising childbirth by increasing vaginal birth after caesarean section through enhanced women-centred care (OptiBIRTH trial): study protocol for a randomised controlled trial (ISRCTN10612254).

BACKGROUND: The proportion of pregnant women who have a caesarean section shows a wide variation across Europe, and concern exists that these proportions are increasing. Much of the increase in caesarean sections in recent years is due to a cascade effect in which a woman who has had one caesarean section is much more likely to have one again if she has another baby. In some places, it has become common practice for a woman who has had a caesarean section to have this procedure again as a matter of routine. The alternative, vaginal birth after caesarean (VBAC), which has been widely recommended, results in fewer undesired results or complications and is the preferred option for most women. However, VBAC rates in some countries are much lower than in other countries. METHODS/DESIGN: The OptiBIRTH trial uses a cluster randomised design to test a specially developed approach to try to improve the VBAC rate. It will attempt to increase VBAC rates from 25 % to 40 % through increased women-centred care and women's involvement in their care. Sixteen hospitals in Germany, Ireland and Italy agreed to join the study, and each hospital was randomly allocated to be either an intervention or a control site. DISCUSSION: If the OptiBIRTH intervention succeeds in increasing VBAC rates, its application across Europe might avoid the 160,000 unnecessary caesarean sections that occur every year at an extra direct annual cost of more than €150 million. TRIAL REGISTRATION: Current Controlled Trials ISRCTN10612254 , registered 3 April 2013.

Cost-effectiveness of elective cesarean delivery after one prior low transverse cesarean.

OBJECTIVE: This analysis was undertaken to better understand the costs and health consequences of a trial of labor after cesarean when compared with a policy of routine elective repeat cesarean delivery. METHODS: A decision-tree model incorporating a Markov analysis was used to examine the reproductive life of a hypothetical cohort of 100,000 pregnant women whose only prior pregnancy was delivered through a low transverse cesarean incision. Using this model, the policy of performing routine elective cesarean delivery was compared with a policy of allowing a trial of labor. Main outcome measures were maternal and neonatal morbidity and mortality, total costs to the health care system, and cost per major neonatal complication avoided (death or permanent neurologic sequelae). RESULTS: The consequences of routine elective cesarean delivery for a second birth are significant, with an additional 117,748 cesarean deliveries, 5500 maternal morbid events, and $179 million incurred during the reproductive life of 100,000 women. The prevention of one major adverse neonatal outcome requires 1591 cesarean deliveries and $2.4 million. Sensitivity analysis confirms the robustness of the analysis. CONCLUSION: Routine elective cesarean for a second delivery for women with a prior low transverse cesarean incision results in an excess of maternal morbidity and mortality and a high cost to the medical system.

Cost-effectiveness of a trial of labor after previous cesarean.

OBJECTIVE: To determine the cost-effective method of delivery, from society's perspective, in patients who have had a previous cesarean. METHODS: We completed an incremental cost-effectiveness analysis of a trial of labor relative to cesarean using a computerized model for a hypothetical 30-year old parturient. The model incorporated data from peer-reviewed studies, actual hospital costs, and utilities to quantify health-related quality of life. A threshold of $50,000 per quality-adjusted life-years was used to define cost-effective. RESULTS: The model was most sensitive to the probability of successful vaginal delivery. If the probability of successful vaginal birth after cesarean (VBAC) was less than 0.65, elective repeat cesarean was both less costly and more effective than a trial of labor. Between 0.65 and 0.74, elective repeat cesarean was cost-effective (the cost-effectiveness ratio was less than $50,000 per quality-adjusted life-years), because, although it cost more than VBAC, it was offset by improved outcomes. Between 0.74 and 0.76, trial of labor was cost-effective. If the probability of successful vaginal delivery exceeded 0.76, trial of labor became less costly and more effective. Costs associated with a moderately morbid neonatal outcome, as well as the probabilities of infant morbidity occurring, heavily impacted our results. CONCLUSION: The cost-effectiveness of VBAC depends on the likelihood of successful trial of labor. Our modeling suggests that a trial of labor is cost-effective if the probability of successful vaginal delivery is greater than 0.74. Improved algorithms are needed to more precisely estimate the likelihood that a patient with a previous cesarean will have a successful vaginal delivery.

VBAC--is it worth the risk?

Enthusiasm for vaginal birth after cesarean section has waned. As a result, the cesarean birth rate is again on the rise. As a medical community and society we must decide whether the most appropriate question is "What is safest for my baby?" or "Is the risk associated with vaginal birth after cesarean acceptable?" There are risks associated with vaginal birth after cesarean, but in a hospital setting with appropriate resources these risks are low and would still seem to be acceptable.

Rates of successful vaginal delivery after cesarean for patients with private versus public insurance.

OBJECTIVE: To examine the effect of insurance status on method of delivery while controlling for clinical and sociodemographic characteristics of women delivering at a single medical center. STUDY DESIGN: Sociodemographic and clinical characteristics of 878 women, who delivered their infants between 1985 and 1991 at a university hospital, were analyzed. Women were included if their previous infant was delivered by cesarean section and if the current pregnancy was > or = 37 weeks' gestation at nonemergent delivery with insurance status clearly specified. The outcome of interest was the rate of successful vaginal births after cesarean (VBAC) delivery by insurance status. RESULTS: The trial of labor rate for the cohort, defined as the rate of VBAC or cesarean deliveries following labor, was 55%; 61% were vaginal deliveries. Significant differences with regard to insurance status and several maternal factors were noted between trial of labor and cesarean section--no labor groups. After controlling for potentially confounding variables, the Medicaid/indigent group was more likely than the privately insured group to undergo a trial of labor (odds ratio, 1.5; 95% confidence interval, 1.1 to 2.4). Of women who underwent a trial of labor, after controlling for other characteristics, the Medicaid/indigent group was more likely than the privately insured group to deliver vaginally (odds ratio, 1.9; 95% confidence interval, 1.1 to 3.2). CONCLUSION: After controlling for other covariables, women with a history of a prior cesarean section with Medicaid/indigent insurance were more likely than privately insured women to attempt a trial of labor, and subsequently, to deliver vaginally, given that a trial of labor was attempted.

An overview of the health economic implications of elective caesarean section.

The caesarean section rate has continued to increase in most industrialised countries, which raises a number of economic concerns. This review provides an overview of the health economic implications of elective caesarean section. It provides a succinct summary of the health consequences associated with elective caesarean section for both the infant and the mother over the perinatal period and beyond. It highlights factors that complicate our understanding of the health consequences of elective caesarean section, including inconsistencies in definitions and coding of the procedure, failure to adopt an intention-to-treat principle when drawing comparisons, and the widespread reliance on observational data. The paper then summarises the economic costs associated with elective caesarean section. Evidence is presented to suggest that planned caesarean section may be less costly than planned vaginal birth in some clinical contexts, for example where the singleton fetus lies in a breech position at term. In contrast, elective caesarean section (or caesarean section as a whole) appears to be more costly than vaginal delivery (either spontaneous or instrumented) in low-risk or unselected populations. The paper proceeds with an overview of economic evaluations associated with elective caesarean section. All are currently based on decision-analytic models. Evidence is presented to suggest that planned trial of labour (attempted vaginal birth) following a previous caesarean section appears to be a more cost-effective option than elective caesarean section, although its cost effectiveness is dependent upon the probability of successful vaginal delivery. There is conflicting evidence on the cost effectiveness of maternal request caesareans when compared with trial of labour. The paucity of evidence on the value pregnant women, clinicians and other groups in society place on the option of elective caesarean section is highlighted. Techniques that might be used to elicit preferences for elective caesarean section and its attributes are outlined. The review concludes with directions for future research in this area.

At what price? A cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery.

BACKGROUND: Elective 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. METHODS: Using 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. RESULTS: Maternal 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. CONCLUSIONS: Clinicians 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.

The increasing cesarean rate globally and what we can do about it.

Cesarean sections sometimes save the lives of mothers and babies; however, they are excessively used compared to medical necessity, which is influenced by various factors that are explored in this article. Since, in most cases the risks of cesarean sections are greater than the benefits, particularly in cesareans that are not medically indicated, it is astonishing that cesarean surgery is the most common surgical procedure, taking away resources from medically necessary care. While economic incentive is counted among the reasons for the increasing cesarean trend, the situation is not so simple since many factors interact to cause the trend. Since reversal of the vaginal birth after cesarean (VBAC) trend downward is correlated with revised policy statements by e.g. American College of Obstetricians and Gynecologists (ACOG), which have since been partially moderated, it became much more difficult for medical institutions to provide VBACs due to concerns about liability. Although whether to give birth by cesarean delivery is a matter for informed consent, yet childbearing women are influenced significantly by their health service providers' opinions. Even though the World Health Organization (WHO) recommends the most peripheral level of maternity care for normal pregnancy and childbirth that is safe using midwives, yet the percentage of midwife deliveries is low. Among other things, it has been suggested that more childbirth by midwife delivery and in out-of-hospital settings can reduce medically unnecessary cesareans and the undue risks associated with them, and free up medical resources for those in need.