Elective Repeat Caesarean Section in Low-Risk Women-Economic Evaluation Comparing Births Before vs. After 39 Weeks Gestation in Ontario, Canada.

PURPOSE: To undertake an economic analysis of repeat Caesarean births in low-risk women (LRW) not in labour in Ontario who delivered at 37-38 weeks (<39 weeks) vs. 39-40 weeks (≥39 weeks) gestation. METHODS: Data from the Better Outcomes Registry & Network (BORN) Information System for fiscal years 2012-2013 and 2013-2014 meeting the definition for elective repeat CS (ERCS) for LRW between 37 and 40 weeks gestation. Costs were obtained from the Ottawa Hospital Data Warehouse and applied through to discharge. RESULTS: For April 2012 to March 2013, we extracted 3637 ERCS dyads at <39 weeks and 3282 dyads at ≥39 weeks. There were 334 NICU admissions at <39 weeks (0.92%) and 235 at ≥39 weeks (0.72%). Average neonate cost was $1247.99 (<39 weeks) vs. $1200.77 (≥39 weeks)-a difference of $47.22. Average dyad cost was $3608.92 (<39 weeks) vs. $3577.04 (≥39 weeks)-a difference of $31.88 per birth. If these births were delayed to ≥39 weeks, net savings of $173 864 and $115 947 annually would be realized on "baby only" and "dyad" costs, respectively. For April 2013 to March 2014, we extracted 2875 ERCS dyads at ≤39 weeks and 3892 dyads at ≥39 weeks. There were 216 NICU admissions ≤39 weeks (0.75%) and 224 at ≥39 weeks (0.58%). Average neonate cost was $1268.56 (<39 weeks) vs. $1126.56 (≥39 weeks)-a difference of $142.00 per birth. Average dyad cost was $3605.70 (≤39 weeks) vs. $3456.61 (≥39 weeks)-a difference of $149.08. If these births were delayed to ≥39 weeks, net annual savings of $404 842 and $428 605 would be realized on "baby only" and "dyad" costs respectively. CONCLUSIONS: Restricting repeat CS in LRW to ≥39 weeks is a cost-effective strategy.

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.

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.

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.

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.

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.

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.

Clinical and economic impact of adhesiolysis during repeat cesarean delivery.

OBJECTIVE: To estimate adhesiolysis rates at cesarean delivery (CD) and to estimate costs and clinical implications of performing adhesiolysis at repeat CD. DESIGN: Retrospective cohort using secondary data. SETTING: Over 500 acute care hospitals in the USA. POPULATION: Women ≥15 years old with a medical claim for CD between 1 January 2007 and 31 December 2008 who were treated in a hospital that contributed data to the Premier Perspective™ database. METHODS: Using data from hospital discharge records, rates of adhesiolysis at the time of CD were calculated. Among patients with repeat CD, a propensity score was used to create matched cohorts with and without adhesiolysis. Unadjusted rates and means were compared between these cohorts. MAIN OUTCOME MEASURES: Cost, length of stay and selected clinical complications between repeat CD patients with and without adhesiolysis. RESULTS: Adhesiolysis was performed in 0.5% of primary and 6.1% of repeat CD patients. Using propensity scores, 10 261 women who experienced repeat CD with adhesiolysis were matched to 10 261 control women. Hospital cost ($5739 vs. $5448), length of stay (2.97 vs. 2.88 days) and operative time (84.0 vs. 74.2 min) were significantly greater in the adhesiolysis than in the non-adhesiolysis group (p < 0.01 for all comparisons), as was the overall complication rate (6.3 vs. 3.5%). CONCLUSIONS: Adhesiolysis rates were higher in repeat compared with primary CD. Among repeat CD patients, costs and complications were higher in the adhesiolysis group. Reducing adhesion formation after primary CD could reduce cost and complications at the time of repeat CD.

Trial of labor versus elective repeat cesarean: an administrator's perspective.

Hospital administrators are most concerned with the quality of medical care. With specific regard to vaginal birth after cesarean, it is essential that the surgical personnel and anesthesia be able to intervene in a timely manner for an obstetrical emergency. Other considerations are patient satisfaction, perception by the community, and cost. Budgets and balancing resources are important factors but pale in decision-making compared with the ill-publicity and medicolegal risk associated with an untoward outcome.

Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis.

OBJECTIVE: The purpose of this investigation was to examine the economic impact of performing elective repeat cesarean during 37 or 38 weeks of gestation relative to the American College of Obstetricians and Gynecologists recommendation of a 39-week delivery. STUDY DESIGN: Decision analysis modeling was used to estimate economic outcomes for a hypothetical cohort of neonates using data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network study of "Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes." Costs and charges were estimated using the Florida Healthcare Cost and Utilization Project. RESULTS: A total of 82,541 deliveries occurring between 37-39 completed weeks of gestation were analyzed for the incidence of adverse outcomes and their hospital costs and charges. The model demonstrated increased costs through increasing adverse outcomes among elective repeat cesarean deliveries performed <39 weeks of gestation. CONCLUSION: Our findings suggest that there are benefits to waiting until 39 weeks of gestation to perform an elective repeat cesarean delivery.

Hippocratic ideal, Faustian bargain and Damocles' sword: erosion of patient autonomy in obstetrics.

Respect for patient autonomy remains a foundational principle guiding the ethical practice of medicine-a mission first articulated by Hippocrates. Damocles, another figure from ancient Greece, provides a useful parable for describing performance under distress: Damocles loses his desire for opulence and power when he notices a sword dangling precariously above his head. Contemporary obstetricians deciding whether to forestall or impose major abdominal surgery on parturients entrusted to their care struggle valiantly in the chasm dividing Hippocratic idealism from the economic realism driven by the medicolegal sword of Damocles. Given the inherent risk of unforeseeable and unsalvageable fetal catastrophe during labor and vaginal delivery, and the often unsubstantiated, yet automatic, allegation of negligence that follows a labor-associated adversity, obstetricians-and their liability insurance carriers-have recalibrated obstetric practice in alignment with the increasingly risk-averse preferences of most patients. Indeed, less intrapartum risk for patients and less corresponding medicolegal exposure for obstetricians help explain the rising cesarean delivery rate and, more importantly, the steady disappearance of higher-risk interventions such as vaginal birth after cesarean (VBAC). Is this increasing reluctance to offer VBAC supervision ethically defensible? This paper argues that it is. Fiduciary professionalism mandates physician self-sacrifice, not self-destruction; a VBAC gone awry without negligence or substandard care may, nevertheless, render future affordable liability coverage unattainable. Yet, the unavailability of VBAC infringes on the autonomy of women who want to assume the intrapartum risks of a VBAC in lieu of a repeat cesarean delivery. The proposed solution is the regionalization of VBAC care provision in designated medical centers and/or the implementation of binding arbitration in an ethical trade-off to enhance patient autonomy regarding the preferred mode of delivery despite parallel constraint on legal options.

Experiencias en el parto vaginal poscesárea en un hospital haitiano / Experience in vaginal delivery after cesarean section in a haitian hospital

Se realizó un estudio de 129 gestantes con cesárea anterior que acudieron al hospital de la Gonave, Haití, durante los años 1999 y 2000. Se descartaron aquellas que según criterio especializado no debían someterse al trabajo de parto. Se consultó la disposición a someterse al trabajo de parto, se negaron 11 pacientes y se seleccionaron 95, de las cuales 70 tuvieron un parto transpelviano y al resto se les realizó la cesárea iterada, cuya principal causa fue la necesidad de utilizar oxitocina. Se analizaron las ventajas desde el punto de vista económico del empleo de este método, lo que representó en este medio un ahorro de $186,67 por cada cesárea iterada que se evita, además de los beneficios que le reportó a cada paciente evitar una cesárea, si se consideran sus riesgos y complicaciones. En esta serie no hubo complicaciones(AU)

Experiencias en el parto vaginal poscesárea en un hospital haitiano / Experience in vaginal delivery after cesarean section in a haitian hospital

Se realizó un estudio de 129 gestantes con cesárea anterior que acudieron al hospital de la Gonave, Haití, durante los años 1999 y 2000. Se descartaron aquellas que según criterio especializado no debían someterse al trabajo de parto. Se consultó la disposición a someterse al trabajo de parto, se negaron 11 pacientes y se seleccionaron 95, de las cuales 70 tuvieron un parto transpelviano y al resto se les realizó la cesárea iterada, cuya principal causa fue la necesidad de utilizar oxitocina. Se analizaron las ventajas desde el punto de vista económico del empleo de este método, lo que representó en este medio un ahorro de $186,67 por cada cesárea iterada que se evita, además de los beneficios que le reportó a cada paciente evitar una cesárea, si se consideran sus riesgos y complicaciones. En esta serie no hubo complicaciones

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.

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.

Trial of labor versus elective repeat cesarean section for the women with a previous cesarean section: a decision analysis.

In order to reduce the cesarean-delivery rate, more and more pregnant women are offered trials of labor (TOL) after their previous cesarean sections. TOL and elective repeat cesarean section (ERCS) have different risks and benefits. We constructed a decision analysis to explore this issue. Probabilities were derived from literature reviews. Health state utilities were derived from the authors' clinical judgement. The analysis considered the disutility of the procedures and the disutilities of the morbidity. Using the baseline assumption, ERCS was superior to TOL. One-way sensitivity analyses showed that the result was insensitive to all of the probability estimates and the disutilities of the morbidity. However, the result was sensitive to the patient's preference for ERCS, successful TOL, or failed TOL. The analysis indicates that the best delivery method for a woman who has had a previous cesarean section depends on patient's preference. More patients' preference studies are needed.