Health service use and health system costs associated with diabetes during pregnancy in Australia.

BACKGROUND AND AIMS: In the context of the rising rate of diabetes in pregnancy in Australia, this study aims to examine the health service and resource use associated with diabetes during pregnancy. METHODS AND RESULTS: This project utilised a linked administrative dataset containing health and cost data for all mothers who gave birth in Queensland, Australia between 2012 and 2015 (n = 186,789, plus their babies, n = 189,909). The association between maternal characteristics and diabetes status were compared with chi-square analyses. Multiple logistic regression produced the odds ratio of having different outcomes for women who had diabetes compared to women who did not. A two-sample t-test compared the mean number of health services accessed. Generalised linear regression produced the mean costs associated with health service use. Mothers who had diabetes during pregnancy were more likely to have their labour induced at <38 weeks gestation (OR:1.39, 95% CI:1.29-1.50); have a cesarean section (OR: 1.26, 95% CI:1.22-1.31); have a preterm birth (OR:1.24, 95%: 1.18-1.32); have their baby admitted to a Special Care Nursery (OR: 2.34, 95% CI:2.26-2.43) and a Neonatal Intensive Care Unit (OR:1.25, 95%CI: 1.14-1.37). On average, mothers with diabetes access health services on more occasions during pregnancy (54.4) compared to mothers without (50.5). Total government expenditure on mothers with diabetes over the first 1000 days of the perinatal journey was significantly higher than in mothers without diabetes ($12,757 and $11,332). CONCLUSION: Overall, mothers that have diabetes in pregnancy require greater health care and resource use than mothers without diabetes in pregnancy.

Reducing caesarean delivery: An economic evaluation of routine induction of labour at 39 weeks in low-risk nulliparous women.

BACKGROUND: Clinical interventions known to reduce the risk of caesarean delivery include routine induction of labour at 39 weeks, caseload midwifery and chart audit, but they have not been compared for cost-effectiveness. OBJECTIVE: To assesses the cost-effectiveness of three different interventions known to reduce caesarean delivery rates compared to standard care; and conduct a budget impact analysis. METHODS: A Markov microsimulation model was constructed to compare the costs and outcomes produced by the different interventions. Costs included all costs to the health system, and outcomes were quality-adjusted life years (QALY) gained. A budget impact analysis was undertaken using this model to quantify the costs (in Australian dollars) over three years for government health system funders. RESULTS: All interventions, plus standard care, produced similar health outcomes (mean of 1.84 QALYs gained over 105 weeks). Caseload midwifery was the lowest cost option at $15 587 (95% confidence interval [CI] 15 269, 15 905), followed by routine induction of labour ($16 257, 95% CI 15 989, 16 536), and chart audit ($16 325, 95% CI 15 979, 16 671). All produced lower costs on average than standard care ($16 905, 95% CI 16 551, 17 259). Caseload midwifery would produce the greatest savings of $172.6 million over three years if implemented for all low-risk nulliparous women in Australia. CONCLUSIONS: Caseload midwifery presents the best value for reducing caesarean delivery rates of the options considered. Routine induction of labour at 39 weeks and chart audit would also reduce costs compared to standard care.

Outpatient Cervical Ripening: A Cost-Minimization and Threshold Analysis.

OBJECTIVE: To evaluate cost of outpatient (OP) versus inpatient (IP) ripening with transcervical balloons, and determine circumstances in which each strategy would be cost saving. STUDY DESIGN: We created a decision model comparing OP and IP balloon ripening in term (≥37 weeks) singleton pregnancies with unfavorable cervix. We performed a cost-minimization analysis and threshold analyses comparing two OP ripening strategies (broad and limited use) to IP ripening from a health system perspective. Base case estimates of probability, utilization, and cost were derived from the literature. The primary outcome was incremental cost of OP versus IP ripening from a hospital perspective. One- and two-way sensitivity analyses explored uncertainty in the model. RESULTS: Both OP ripening strategies were cost saving compared with IP ripening: incremental cost -$228.40/patient with broad use and -$73.48/patient with limited use. OP ripening was no longer cost saving if hours saved on labor and delivery (L&D) were <3.5, insertion visit cost >$714, or facility cost/hour on L&D <$61. Two-way sensitivity analyses showed that OP ripening was cost saving under the most plausible clinical circumstances. CONCLUSION: In patients with unfavorable cervix, OP transcervical balloon ripening was cost saving under a wide range of circumstances, particularly if OP ripening can shorten time spent on L&D by 3.5 hours.

Induction of labor at 39 weeks of gestation versus expectant management for low-risk nulliparous women: a cost-effectiveness analysis.

BACKGROUND: A large, recent multicenter trial found that induction of labor at 39 weeks for low-risk nulliparous women was not associated with an increased risk of cesarean delivery or adverse neonatal outcomes. OBJECTIVE: We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks vs expectant management for low-risk nulliparous women in the United States. STUDY DESIGN: A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks vs expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the United States annually that are considered low risk. Outcomes included mode of delivery, hypertensive disorders of pregnancy, macrosomia, stillbirth, permanent brachial plexus injury, and neonatal death, in addition to cost and quality-adjusted life years for both the woman and neonate. Model inputs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/quality-adjusted life years. RESULTS: In our theoretical cohort of 1.6 million women, induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy. We also found that induction of labor resulted in 795 fewer cases of stillbirth and 11 fewer neonatal deaths, despite 86 additional cases of brachial plexus injury. Induction of labor resulted in increased costs but increased quality-adjusted life years with an incremental cost-effectiveness ratio of $87,691.91 per quality-adjusted life year. In sensitivity analysis, if the cost of induction of labor was increased by $180, elective induction would no longer be cost effective. Similarly, we found that if the rate of cesarean delivery was the same in both strategies, elective induction of labor at 39 weeks would not be a cost-effective strategy. In probabilistic sensitivity analysis via Monte Carlo simulation, we found that induction of labor was cost effective only 65% of the time. CONCLUSION: In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes but increased costs. The incremental cost-effectiveness ratio was marginally cost effective but would lead to an additional 2 billion dollars of healthcare costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity, careful evaluation and allocation of healthcare resources, and patient preferences. KEY WORDS: cesarean delivery, decision analysis, healthcare resources, induction of labor, low-risk nulliparous women, mode of delivery, obstetric outcomes.

Induction of Labor versus Scheduled Cesarean in Morbidly Obese Women: A Cost-Effectiveness Analysis.

OBJECTIVE: To assess the costs, complication rates, and harm-benefit tradeoffs of induction of labor (IOL) compared to scheduled cesarean delivery (CD) in women with class III obesity. STUDY DESIGN: We conducted a cost analysis of IOL versus scheduled CD in nulliparous morbidly obese women. Primary outcomes were surgical site infection (SSI), chorioamnionitis, venous thromboembolism, blood transfusion, and readmission. Model outcomes were mean cost of each strategy, cost per complication avoided, and complication tradeoffs. We assessed the costs, complication rates, and harm-benefit tradeoffs of IOL compared with scheduled CD in women with class III obesity. RESULTS: A total of 110 patients underwent scheduled CD and 114 underwent IOL, of whom 61 (54%) delivered via cesarean. The group delivering vaginally experienced fewer complications. SSI occurred in 0% in the vaginal delivery group, 13% following scheduled cesarean, and 16% following induction then cesarean. In the decision model, the mean cost of induction was $13,349 compared with $14,575 for scheduled CD. Scheduled CD costs $9,699 per case of chorioamnionitis avoided, resulted in 18 cases of chorioamnionitis avoided per additional SSI and 3 cases of chorioamnionitis avoided per additional hospital readmission. In sensitivity analysis, IOL is cost saving compared with scheduled CD unless the cesarean rate following induction exceeds 70%. CONCLUSION: In morbidly obese women, induction of labor remains cost-saving until the rate of cesarean following induction exceeds 70%.

Foley catheterisation versus oral misoprostol for induction of labour in hypertensive women in India (INFORM): a multicentre, open-label, randomised controlled trial.

BACKGROUND: Between 62 000 and 77 000 women die annually from pre-eclampsia and eclampsia. Prompt delivery, preferably by the vaginal route, is vital for good maternal and neonatal outcomes. Two low-cost interventions-low-dose oral misoprostol tablets and transcervical Foley catheterisation-are already used in low-resource settings. We aimed to compare the relative risks and benefits of these interventions. METHODS: We undertook this multicentre, open-label, randomised controlled trial in two public hospitals in Nagpur, India. Women (aged ≥18 years) who were at 20 weeks' gestation or later with a live fetus and required delivery as a result of pre-eclampsia or hypertension were randomly assigned (1:1), via computer-generated block randomisation (block sizes of four, six, and eight) with concealment by use of opaque, sequentially numbered, sealed envelopes, to receive labour induction with either oral misoprostol 25 µg every 2 h (maximum of 12 doses) or a transcervical Foley catheter (silicone, size 18 F with 30 mL balloon). Randomisation was stratified by study centre. The catheter remained in place until active labour started, the catheter fell out, or 12 h had elapsed. If the catheter did not fall out within 12 h, induction continued with artificial membrane rupture and oxytocin, administered through a micro-drip gravity infusion set. Fetal monitoring was by intermittent auscultation. The primary outcome was vaginal birth within 24 h. Due to the nature of the interventions, masking of participants, study investigators, and care providers to group allocation was not possible. We analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01801410. FINDINGS: Between Dec 20, 2013, and June 29, 2015, we randomly assigned 602 women to induction with misoprostol (n=302) or the Foley catheter (n=300; intention-to-treat population). Vaginal birth within 24 h was more common in women in the misoprostol group than in the Foley catheter group (172 [57·0%] vs 141 [47·0%] women; absolute risk difference 10·0%, 95% CI 2·0-17·9; p=0·0136). Rates of uterine hyperstimulation were low in both the misoprostol and Foley catheter groups (two [0·7%] vs one [0·3%] cases; absolute risk difference 0·3%, 95% CI -0·8 to 1·5; p=0·566) and neonatal deaths did not differ significantly between groups (six [2·0%] vs three [1·0%] neonatal deaths; 1·0, -1·04 to 2·97; p=0·322). 17 serious adverse events (3%) were reported during the study: one case of intrapartum convulsion and one case of disseminated intravascular coagulation (both in the Foley group); ten perinatal deaths, including two stillbirths (both in the Foley catheter group) and eight neonatal deaths (n=5 in the misoprostol group and n=3 in the Foley catheter group); and five of neonatal morbidity, comprising birth asphyxia (n=3), septicaemia (n=1), and neonatal convulsion (n=1). INTERPRETATION: Oral misoprostol was more effective than transcervical Foley catheterisation for induction of labour in women with pre-eclampsia or hypertension. Future studies are required to assess whether oxytocin augmentation following misoprostol can be replaced by regular doses of oral misoprostol tablets. FUNDING: Medical Research Council, Department for International Development, and Wellcome Trust Joint Global Health Trials Scheme.

Foley catheter vs. oral misoprostol to induce labour among hypertensive women in India: a cost-consequence analysis alongside a clinical trial.

OBJECTIVE: To determine the effectiveness and economic impact of two methods for induction of labour in hypertensive women, in low-resource settings. DESIGN: Cost-consequence analysis of a previously reported multicentre, parallel, open-label randomised trial. SETTING & POPULATION: A total of 602 women with a live fetus, aged ≥18 years requiring delivery for pre-eclampsia or hypertension, in two public hospitals in Nagpur, India. METHODS: We performed a formal economic evaluation alongside the INFORM clinical trial. Women were randomised to receive transcervical Foley catheterisation or oral misoprostol 25 mcg. Healthcare expenditure was calculated using a provider-side microcosting approach. MAIN OUTCOME MEASURES: Rates of vaginal this delivery within 24 hours of induction, healthcare expenditure per completed treatment episode. RESULTS: Induction with oral misoprostol resulted in a (mean difference) $20.6USD reduction in healthcare expenditure [95% CI (-) $123.59 (-) $72.49], and improved achievement of vaginal delivery within 24 hours of induction, mean difference 10% [95% CI (-2 to 17.9%), P = 0.016]. Oxytocin administration time was reduced by 135.3 minutes [95% CI (84.4-186.2 minutes), P < 0.01] and caesarean sections by 9.1% [95% CI (1.1-17%), P = 0.025] for those receiving oral misoprostol. Following probabilistic sensitivity analysis, oral misoprostol was cost-saving in 63% of 5,000 bootstrap replications and achieved superior rates of vaginal delivery, delivery within 24 hours of induction and vaginal delivery within 24 hours of induction in 98.7%, 90.7%, and 99.4% of bootstrap simulations. Based on univariate threshold analysis, the unit price of oral misoprostol 25 mcg could feasibly increase 31-fold from $0.24 to $7.50 per 25 mcg tablet and remain cost-saving. CONCLUSION: Compared to Foley catheterisation for the induction of high-risk hypertensive women, oral misoprostol improves rates of vaginal delivery within 24 hours of induction and may also reduce costs. Additional research performed in other low-resource settings is required to determine their relative cost-effectiveness. TWEETABLE ABSTRACT: Oral misoprostol less costly and more effective than Foley catheter for labour induction in hypertension.

Labour induction near term for women aged 35 or over: an economic evaluation.

OBJECTIVE: Induction of labour at 39 weeks for nulliparous women aged 35 years and over may prevent stillbirths and does not increase caesarean births, so it may be popular. But the overall costs and benefits of such a policy have not been compared. DESIGN: A cost-utility analysis alongside a randomised controlled trial (the 35/39 trial). SETTING: Obstetric departments of 38 UK National Health Service hospitals and one UK primary-care trust. POPULATION: Nulliparous women aged 35 years or over on their expected due date, with a singleton live fetus in a cephalic presentation. METHODS: Costs were estimated from the National Health Service and Personal Social Services perspective and quality-adjusted life-years (QALYs) were calculated based on patient responses to the EQ-5D at baseline and 4 weeks. MAIN OUTCOME MEASURES: Data on antenatal care, mode of delivery, analgesia in labour, method of induction, EQ-5D (baseline and 4 weeks postnatal) and participant-administered postnatal health resource use data were collected. RESULTS: The intervention was associated with a mean cost saving of £263 and a small additional gain in QALYs (though this was not statistically significant), even without considering any possible QALY gains from stillbirth prevention. CONCLUSION: A policy of induction of labour at 39 weeks for women of advanced maternal age would save money. TWEETABLE ABSTRACT: A policy of induction of labour at 39 weeks of gestation for women of advanced maternal age would save money.

An economic analysis of immediate delivery and expectant monitoring in women with hypertensive disorders of pregnancy, between 34 and 37 weeks of gestation (HYPITAT-II).

OBJECTIVE: To assess the economic consequences of immediate delivery compared with expectant monitoring in women with preterm non-severe hypertensive disorders of pregnancy. DESIGN: A cost-effectiveness analysis alongside a randomised controlled trial (HYPITAT-II). SETTING: Obstetric departments of seven academic hospitals and 44 non-academic hospitals in the Netherlands. POPULATION: Women diagnosed with non-severe hypertensive disorders of pregnancy between 340/7 and 370/7  weeks of gestation, randomly allocated to either immediate delivery or expectant monitoring. METHODS: A trial-based cost-effectiveness analysis was performed from a healthcare perspective until final maternal and neonatal discharge. MAIN OUTCOME MEASURES: Health outcomes were expressed as the prevalence of respiratory distress syndrome, defined as the need for supplemental oxygen for >24 hours combined with radiographic findings typical for respiratory distress syndrome. Costs were estimated from a healthcare perspective until maternal and neonatal discharge. RESULTS: The average costs of immediate delivery (n = 352) were €10 245 versus €9563 for expectant monitoring (n = 351), with an average difference of €682 (95% confidence interval, 95% CI -€618 to €2126). This 7% difference predominantly originated from the neonatal admissions, which were €5672 in the immediate delivery arm and €3929 in the expectant monitoring arm. CONCLUSION: In women with mild hypertensive disorders between 340/7 and 370/7  weeks of gestation, immediate delivery is more costly than expectant monitoring as a result of differences in neonatal admissions. These findings support expectant monitoring, as the clinical outcomes of the trial demonstrated that expectant monitoring reduced respiratory distress syndrome for a slightly increased risk of maternal complications. TWEETABLE ABSTRACT: Expectant management in preterm hypertensive disorders is less costly compared with immediate delivery.

An economic evaluation of planned immediate versus delayed birth for preterm prelabour rupture of membranes: findings from the PPROMT randomised controlled trial.

OBJECTIVE: This study is an economic evaluation of immediate birth compared with expectant management in women with preterm prelabour rupture of the membranes near term (PPROMT). DESIGN: A cost-effectiveness analysis alongside the PPROMT randomised controlled trial. SETTING: Obstetric departments in 65 hospitals across 11 countries. POPULATION: Women with a singleton pregnancy with ruptured membranes between 34+0 and 36+6 weeks gestation. METHODS: Women were randomly allocated to immediate birth or expectant management. Costs to the health system were identified and valued. National hospital costing data from both the UK and Australia were used. Average cost per recruit in each arm was calculated and 95% confidence intervals were estimated using bootstrap re-sampling. Averages costs during antenatal care, delivery and postnatal care, and by country were estimated. MAIN OUTCOMES MEASURES: Total mean cost difference between immediate birth and expectant management arms of the trial. RESULTS: From 11 countries 923 women were randomised to immediate birth and 912 were randomised to expectant management. Total mean costs per recruit were £8852 for immediate birth and £8740 for expectant delivery resulting in a mean difference in costs of £112 (95% CI: -431 to 662). The expectant management arm had significantly higher antenatal costs, whereas the immediate birth arm had significantly higher delivery and neonatal costs. There was large variation between total mean costs by country. CONCLUSION: This economic evaluation found no evidence that expectant management was more or less costly than immediate birth. Outpatient management may offer opportunities for cost savings for those women with delayed delivery. TWEETABLE ABSTRACT: For women with preterm prelabour rupture of the membranes, the relative benefits and harms of immediate and expectant management should inform counselling as costs are similar.

What can we do to reduce the associated costs in induction of labour of intrauterine growth restriction foetuses at term? A cost-analysis study.

OBJECTIVE: To evaluate the costs associated with induction of labour in intrauterine growth restriction fetuses comparing different procedures. STUDY DESIGN: 150 pregnancies at term diagnosed with intrauterine growth restriction and indication for induction of labour were included. 24 were ripened with misoprostol 25 µg tablets, 24 with dinoprostone 10 mg vaginal insert, and 77 with Cook® cervical ripening balloon. To determine the costs of induction of labour, method of induction, intrapartum medication, epidural analgesia, type of delivery, and maternal and neonatal admissions were considered. Statistical analysis was performed using the G-Stat 2.0 free statistical software. ANOVA test was used for comparisons between quantitative parametric variables. Chi-squared test or Fisher test was used for qualitative variables. A value of p < 0.05 was considered statistically significant. RESULTS: Up to 70.83% women in dinoprostone group gave birth within the first 24 h compared to 42.66% in misoprostol group and 36.36% in CG (p < 0.01). Misoprostol tablets were cheaper (9.45 ± 1.52 US dollars) than dinoprostone or Cook® balloon (41.67 ± 0 and 59.85 ± 0 54.45 ± 0 US dollars, respectively) (p < 0.01). Costs related to maternal admissions were higher in CG (475.13 ± 146.95$) than dinoprostone group (475.13 ± 146.95$) or MG (427.97 ± 112.65$) (p = 0.03). Total costs in misoprostol group (2765.18 ± 495.38$) were lower than in the dinoprostone group (3075.774 ± 896.14$) or Cook® balloon group (3228.02 ± 902.06$) groups. CONCLUSIONS: Misoprostol for induction of labour had lower related costs than dinoprostone or Cook® balloon, with similar obstetrical and perinatal outcomes.

Costs Associated with Anesthesia-Related Adverse Events During Labor and Delivery in New York State, 2010.

BACKGROUND: The safety of anesthetic care provided during childbirth has improved during the past 2 decades in the United States, with a marked decrease in the rate of anesthesia-related adverse events (ARAEs). To date, there is little research on the costs of ARAEs in obstetrics. This study aims to assess the excess cost and cost per admission associated with ARAEs during labor and delivery. METHODS: Data came from the New York State Inpatient Database 2010. Discharge records indicating labor and delivery and ARAEs were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. ARAEs were defined as minor if not associated with maternal death, cardiac arrest, or severe morbidity. Costs were calculated as the product of hospital charges and the group average all-payer inpatient charge-to-cost conversion ratio. Excess cost was calculated as the difference between the mean cost of discharges with and without ARAEs. The cost per admission was calculated as the product of the excess cost and ARAE incidence. Excess costs and cost per admission were also calculated for 2 pregnancy-related complications: postpartum hemorrhage and preeclampsia/eclampsia. RESULTS: There were 228,104 delivery-related discharges in the study; of these, 1053 recorded at least 1 ARAE (4.6 per 1000), with 1034 (98.2%) of the ARAEs being minor. The adjusted excess cost associated with ARAEs was $1189 (95% confidence interval [CI], 1033-1350) and the cost per admission $5.49 (95% CI, 4.77-6.23). The incidence of postpartum hemorrhage and preeclamspia/eclampsia was 25.1 and 43.8 per 1000, respectively. The adjusted excess cost was $679 (95% CI, 608-748) and $1328 (95% CI, 1272-1378), respectively; the cost per admission was $17.07 (95% CI, 15.27-18.81) and $58.16 (95% CI, 55.72-60.34), respectively. CONCLUSIONS: ARAEs during labor and delivery are associated with significant excess cost. However, the excess cost per admission for ARAEs is significantly less compared with the excess cost per admission for preeclampsia/eclampsia and postpartum hemorrhage.

Economic analysis comparing induction of labor and expectant management in women with preterm prelabor rupture of membranes between 34 and 37 weeks (PPROMEXIL trial).

OBJECTIVE: To compare the costs of induction of labor and expectant management in women with preterm prelabor rupture of membranes (PPROM). DESIGN: Economic analysis based on a randomized clinical trial. SETTING: Obstetric departments of eight academic and 52 non-academic hospitals in the Netherlands. POPULATION: Women with PPROM near term who were not in labor 24 h after PPROM. METHODS: A cost-minimization analysis was done from a health care provider perspective, using a bottom-up approach to estimate resource utilization, valued with unit-costs reflecting actual costs. MAIN OUTCOME MEASURES: Primary health outcome was the incidence of neonatal sepsis. Direct medical costs were estimated from start of randomization to hospital discharge of mother and child. RESULTS: Induction of labor did not significantly reduce the probability of neonatal sepsis [2.6% vs. 4.1%, relative risk 0.64 (95% confidence interval 0.25-1.6)]. Mean costs per woman were €8094 for induction and €7340 for expectant management (difference €754; 95% confidence interval -335 to 1802). This difference predominantly originated in the postpartum period, where the mean costs were €5669 for induction vs. €4801 for expectant management. Delivery costs were higher in women allocated to induction than in women allocated to expectant management (€1777 vs. €1153 per woman). Antepartum costs in the expectant management group were higher because of longer antepartum maternal stays in hospital. CONCLUSIONS: In women with pregnancies complicated by PPROM near term, induction of labor does not reduce neonatal sepsis, whereas costs associated with this strategy are probably higher.

Costs of elective induction of labor.

Multiple authors have documented that maternal outcomes differ depending on whether labor is spontaneous or electively induced. Correspondingly, there is evidence that women who are electively induced generate more costs than those in spontaneous labor. However, to determine the resource utilization of women who are electively induced, one must compare them to women who experience the actual alternative to induction, namely, expectant management. Observational studies using these comparison groups have not replicated many of the findings that lead to elective inductions being more costly. Moreover, there is little information about the contribution of outpatient costs from expectant management.

Global perspectives on elective induction of labor.

Elective labor induction is an increasingly common practice not only in high-income countries, but also in many low-income and middle-income countries. Many questions remain unanswered on the safety and cost-effectiveness of elective labor induction, particularly in resource-constrained settings where there may be a high unmet need for medically indicated inductions, as well as limited or no access to appropriate medications and equipment for induction and monitoring, comprehensive emergency obstetric care, safe and timely cesarean section, and appropriate supervision from health professionals. This article considers the global perspective on the epidemiology, practices, safety, and costs associated with elective labor induction.

The clinical and economic impact of nurse to patient staffing ratios in women receiving intrapartum oxytocin.

OBJECTIVE: To examine the relationship between nurse-to-patient staffing ratios and perinatal outcomes in women receiving oxytocin during labor. STUDY DESIGN: A retrospective analysis of perinatal outcomes in women receiving oxytocin for induction or augmentation of labor during 2010. Outcomes examined were fetal distress, birth asphyxia, primary cesarean delivery, chorioamnionitis, endomyometritis, and a composite of adverse events. Frequency of 1:1 nurse-to-patient staffing was determined for each hospital. Outcomes were compared between hospitals categorized into quartiles of staffing ratios. RESULTS: In 208,033 women delivering during 2010, there was no relation between frequency of 1:1 nurse-to-patient staffing ratio and improved perinatal outcomes. Adoption of universal 1:1 staffing in the United States would result in the need for an additional 27,000 labor nurses and a cost of $1.6 billion. CONCLUSION: Available data do not support the imposition of mandatory 1:1 nurse-to-patient staffing ratios for women receiving oxytocin in all U.S. facilities.

Randomization of two dosing regimens of vaginal misoprostol for cervical ripening and labor induction in a low resource setting.

OBJECTIVES: To compare the effectiveness of two dosing regimens of vaginal misoprostol for cervical ripening and induction of labour. MATERIALS AND METHODS: Pregnant women with singleton low risk pregnancy at term scheduled for elective induction of labour were randomized to receive either 25 µg or 50 µg of vaginal misoprostol for pre-labour cervical ripening. All the patients received antenatal care and delivered at the University College Hospital (UCH) from January 1 st to May 31 st 2006. A total of 128 patients were randomized; 65 patients received 25 µg and 63 patients received 50 µg of vaginal misoprostol. RESULTS: Significantly higher number of patients in the 50 µg group progressed to active labour as compared with the 25 µg group (95.2% versus 84.6%, P < 0.05). The need for oxytocin augmentation of labour was higher among the 25 µg as compared with 50 µg (39.7% versus 16.4%, P = 0.007). There was higher proportion of patients in the 50 µg group delivering vaginally within 24 hours as compared with the 25 µg group (98.2% versus 90.0%, P = 0.063). However, the mean interval between the first dose of misoprostol and vaginal delivery was not statistically different in the two groups (754 ± 362 minutes and 885 ± 582 minutes, P = 0.152). The incidence of caesarean section was similar in the two groups (7.7% versus 11%, P = 0.580). Labour complications, such as precipitate labour, tachysystole and abnormal fetal heart rate patterns were greater in the 50 µg group. CONCLUSION: Twenty-five microgram of misoprostol appears to be as effective as 50 µg for pre-induction cervical ripening and labour induction. Though 50 µg of vaginal misoprostol resulted in relatively faster delivery and less need for oxytocin augmentation, it was associated with more labour complications as compared with 25 µg of misoprostol.

The financial performance of labor and delivery units.

Hospitals and health care systems are already seeing the effect of health care reform with declining dollars. Hospital services, which had narrow financial margins in the past, will have further challenges. This article will review definitions, challenges, and potential financial solutions for labor and delivery units. Improving quality, efficiency, and cost requires substantial physician cooperation in the changing paradigm from physician-centric care to the transparent safety of teams. The financial contribution margin should increase the net revenue, but significant volumes are also needed. The challenge of this model for obstetrics is the slowing birth rate with the ultimate limitation for growth. Therefore, cost containment is imperative for sustainability. Standardization of hospital policies and procedures can improve quality and cost-savings with new incentive models. Examples include decreasing expensive pharmaceuticals, minimizing elective inductions of labor, and encouraging breast-feeding. As providers of health care to women, we all must engage in the triple aim of (1) improving the experience of care, (2) improving the health of populations, and (3) reducing per capita costs of health care. Although accountable care organizations presently are focused on Medicare populations for cost containment, all health care providers and institutions must be vigilant on both quality cost-effective care for sustainability, especially in obstetrics.

Cost-effectiveness of induction of labour at term with a Foley catheter compared to vaginal prostaglandin E2 gel (PROBAAT trial).

OBJECTIVE: To assess the economic consequences of labour induction with Foley catheter compared to prostaglandin E2 gel. DESIGN: Economic evaluation alongside a randomised controlled trial. SETTING: Obstetric departments of one university and 11 teaching hospitals in the Netherlands. POPULATION: Women scheduled for labour induction with a singleton pregnancy in cephalic presentation at term, intact membranes and an unfavourable cervix; and without previous caesarean section. METHODS: Cost-effectiveness analysis from a hospital perspective. MAIN OUTCOME MEASURES: We estimated direct medical costs associated with healthcare utilisation from randomisation to 6 weeks postpartum. For caesarean section rate, and maternal and neonatal morbidity we calculated the incremental cost-effectiveness ratios, which represent the costs to prevent one of these adverse outcomes. RESULTS: Mean costs per woman in the Foley catheter group (n = 411) and in the prostaglandin E2 gel group (n = 408), were €3297 versus €3075, respectively, with an average difference of €222 (95% confidence interval -€157 to €633). In the Foley catheter group we observed higher costs due to longer labour ward occupation and less cost related to induction material and neonatal admissions. Foley catheter induction showed a comparable caesarean section rate compared with prostaglandin induction, therefore the incremental cost-effectiveness ratio was not informative. Foley induction resulted in fewer neonatal admissions (incremental cost-effectiveness ratio €2708) and asphyxia/postpartum haemorrhage (incremental cost-effectiveness ratios €5257) compared with prostaglandin induction. CONCLUSIONS: Foley catheter and prostaglandin E2 labour induction generate comparable costs.

Economics of childbirth.

BACKGROUND: Increasing birth rates have raised questions for policy makers and hospital management about the economic costs of childbirth. OBJECTIVE: The purpose of this article is to identify and review all existing scientific studies in relation to the economic costs of alternative modes of childbirth delivery and to highlight deficiencies in the existing scientific research. METHOD: We searched Cochrane, Centre for Reviews and Dissemination, EconLit, the Excerpta Medica Database, the Health Economic Evaluations Database, MEDLINE and PubMed. RESULTS: Thirty articles are included in this review. The main findings suggest that there is no internationally acceptable childbirth cost and clinical outcome classification system that allows for comparisons across different delivery modes. CONCLUSION: This review demonstrates that a better understanding and classification of the costs and associated clinical outcomes of childbirth is required to allow for valid comparisons between maternity units, and to inform policy makers and hospital management.