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Rogers AJ, Rogers NG, Kilgore ML, Subramaniam A, Harper LM. Economic Evaluations Comparing a Trial of Labor with an Elective Repeat Cesarean Delivery: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:163-173. [PMID: 28212958 PMCID: PMC5319694 DOI: 10.1016/j.jval.2016.08.738] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 08/01/2016] [Accepted: 08/19/2016] [Indexed: 05/16/2023]
Abstract
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.
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Affiliation(s)
- Anna Joy Rogers
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Nathaniel G Rogers
- Departments of Medicine and Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Meredith L Kilgore
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Akila Subramaniam
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lorie M Harper
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Friedman AM, Ananth CV, Chen L, D'Alton ME, Wright JD. An economic analysis of trial of labor after cesarean delivery. J Matern Fetal Neonatal Med 2015; 29:1030-5. [PMID: 25865742 DOI: 10.3109/14767058.2015.1035250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Alexander M Friedman
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and
| | - Cande V Ananth
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and.,b Department of Epidemiology , Joseph L. Mailman School of Public Health, Columbia University , New York , NY , USA
| | - Ling Chen
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and
| | - Mary E D'Alton
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and
| | - Jason D Wright
- a Division of Maternal-Fetal Fetal Medicine, Department of Obstetrics and Gynecology , Columbia University College of Physicians and Surgeons , New York , NY , USA and
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Bangal VB, Giri PA, Shinde KK, Gavhane SP. Vaginal birth after cesarean section. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2013; 5:140-4. [PMID: 23641377 PMCID: PMC3624716 DOI: 10.4103/1947-2714.107537] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The rate of primary cesarean section (CS) is on the rise. More and more women report with a history of a previous CS. A trial of vaginal delivery can save these women from the risk of repeat CS. AIMS The study was conducted to assess the safety and success rate of vaginal birth after CS (VBAC) in selected cases of one previous lower segment CS (LSCS). MATERIALS AND METHODS The prospective observational study was carried out in a tertiary care teaching hospital over a period of two years. One hundred pregnant women with a history of one previous LSCS were enrolled in the study. RESULTS In the present study, 85% cases had a successful VBAC and 15% underwent a repeat emergency LSCS for failed trial of vaginal delivery. Cervical dilatation of more than 3 cm at the time of admission was a significant factor in favor of a successful VBAC. Birth weight of more than 3,000 g was associated with a lower success rate of VBAC. The incidence of scar dehiscence was 2% in the present study. There was no maternal or neonatal mortality. CONCLUSION Trial of VBAC in selected cases has great importance in the present era of the rising rate of primary CS especially in rural areas.
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Affiliation(s)
- Vidyadhar B Bangal
- Department of Obstetrics and Gynaecology, Rural Medical College and Pravara Rural Hospital of Pravara Institute of Medical Sciences, (Deemed University) Loni, Maharashtra, India
| | - Purushottam A Giri
- Department of Community Medicine (PSM), Rural Medical College and Pravara Rural Hospital of Pravara Institute of Medical Sciences, (Deemed University) Loni, Maharashtra, India
| | - Kunaal K Shinde
- Department of Obstetrics and Gynaecology, Rural Medical College and Pravara Rural Hospital of Pravara Institute of Medical Sciences, (Deemed University) Loni, Maharashtra, India
| | - Satyajit P Gavhane
- Department of Obstetrics and Gynaecology, Rural Medical College and Pravara Rural Hospital of Pravara Institute of Medical Sciences, (Deemed University) Loni, Maharashtra, India
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Catling-Paull C, Johnston R, Ryan C, Foureur MJ, Homer CS. Non-clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review. J Adv Nurs 2011; 67:1662-76. [DOI: 10.1111/j.1365-2648.2011.05662.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Catling-Paull C, Johnston R, Ryan C, Foureur MJ, Homer CSE. Clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review. J Adv Nurs 2011; 67:1646-61. [DOI: 10.1111/j.1365-2648.2011.05635.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
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.
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Affiliation(s)
- Michael L Socol
- Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Abstract
Four million deliveries occur annually in the United States, and obstetric care has traditionally constituted a substantial portion of medical costs for young women, as well as being a major source of uncompensated care. The economic implications of a large shift in the mode of delivery are potentially important. This article reviews the relevant economic issues surrounding elective cesarean section and cesarean section at maternal request, summarizes the methodological quality and results of current literature on the topic, and presents recommendations for further study.
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Affiliation(s)
- John A F Zupancic
- Division of Newborn Medicine, Harvard Medical School, 300 Longwood Avenue, Enders 9, Boston, MA, USA.
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Allen VM, O'Connell CM, Farrell SA, Baskett TF. Economic implications of method of delivery. Am J Obstet Gynecol 2005; 193:192-7. [PMID: 16021078 DOI: 10.1016/j.ajog.2004.10.635] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE This study was undertaken to examine the costs of hospital care associated with different methods of delivery. STUDY DESIGN An 18-year population-based cohort study (1985-2002) using the Nova Scotia Atlee Perinatal Database compared outcomes in nulliparous women at term undergoing spontaneous or induced labor for planned vaginal delivery, or undergoing cesarean delivery without labor. Costs that were assessed included physician fees, nursing hours in the labor and delivery, postpartum and neonatal intensive care units, epidural use, induction of labor agents, and consumables. RESULTS A total of 27,614 pregnancies satisfied inclusion and exclusion criteria, 5233 of which had labor induced. A comparison of mean costs per mother/infant pair demonstrated that cesarean delivery in labor ($2137) was increased compared with spontaneous vaginal delivery ($1340, P=.01), assisted vaginal delivery ($1594, P=.01), and cesarean delivery without labor ($1532, P=.01). The cost of delivery after induction of labor ($1715) was increased compared with spontaneous onset of labor ($1474, P<.001). CONCLUSION Cesarean delivery in labor occurs more frequently with labor induction and is associated with increased costs compared with other methods of delivery.
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Affiliation(s)
- Victoria M Allen
- Department of Obstetrics and Gynecology, Perinatal Epidemiology Research Unit, Dalhousie University, Halifax, Nova Scotia, Canada.
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Plunkett BA, Grobman WA. Routine hepatitis C virus screening in pregnancy: a cost-effectiveness analysis. Am J Obstet Gynecol 2005; 192:1153-61. [PMID: 15846195 DOI: 10.1016/j.ajog.2004.10.600] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether routine hepatitis C virus screening in pregnancy is cost-effective. STUDY DESIGN A decision tree with Markov analysis was developed to compare 3 approaches to asymptomatic hepatitis C virus infection in low-risk pregnant women: (1) no hepatitis C virus screening, (2) hepatitis C virus screening and subsequent treatment for progressive disease, and (3) hepatitis C virus screening, subsequent treatment for progressive disease, and elective cesarean delivery to avert perinatal transmission. Lifetime costs and quality-adjusted life years were evaluated for mother and child. RESULTS In our base case, hepatitis C virus screening and subsequent treatment of progressive disease was dominated (more costly and less effective) by no screening, with an incremental cost of 108 US dollars and a decreased incremental effectiveness of 0.00011 quality-adjusted life years. When compared with no screening, the marginal cost and effectiveness of screening, treatment, and cesarean delivery was 117 US dollars and 0.00010 quality-adjusted life years, respectively, which yields a cost-effectiveness ratio of 1,170,000 US dollars per quality-adjusted life year. CONCLUSION The screening of asymptomatic pregnant women for hepatitis C virus infection is not cost-effective.
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Affiliation(s)
- Beth A Plunkett
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Plunkett BA, Grobman WA. Elective cesarean delivery to prevent perinatal transmission of hepatitis C virus: a cost-effectiveness analysis. Am J Obstet Gynecol 2004; 191:998-1003. [PMID: 15467579 DOI: 10.1016/j.ajog.2004.05.062] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE This study was undertaken to determine whether elective cesarean delivery to avert perinatal hepatitis C virus (HCV) transmission is cost-effective. STUDY DESIGN Using decision analysis, we compared 2 approaches: (1) offering elective cesarean delivery to avert perinatal HCV transmission, (2) performing a cesarean delivery only for obstetric indications. Lifetime cost and quality-adjusted-life-years (QALYs) for HCV-infected neonates were evaluated with Markov analysis. We assumed elective cesarean delivery reduces perinatal HCV transmission, and we varied both the risk reduction caused by elective cesarean delivery and the background risk of perinatal HCV infection. RESULTS When elective cesarean section prevents all perinatal HCV transmission, 18 elective cesarean deliveries are necessary to avert 1 neonatal infection with a cost-effectiveness ratio of 34,812 dollars/QALY. At a background perinatal transmission rate of 7.7% elective cesarean deliveries is cost-effective only if it reduces the risk of perinatal transmission by more than 77%. CONCLUSION Elective cesarean delivery is cost-effective only if it substantially reduces the risk of perinatal HCV transmission.
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Affiliation(s)
- Beth A Plunkett
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Ill, USA
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Abstract
OBJECTIVE To apply published scoring systems retrospectively to patients who had undergone a trial of labor after cesarean delivery to estimate whether there was a score at which a trial of labor should be discouraged. METHODS Patients with 1 previous cesarean delivery who then delivered between January 1, 1998, and December 31, 1998, were studied. An investigator blinded to outcome assigned scores using 3 different scoring systems. Student t test, chi(2), analysis of variance, and receiver operating curve analysis were performed. P <.05 was significant. RESULTS Seventy-six percent (117/153) of trial of labor patients had a vaginal birth after cesarean delivery. Successful vaginal birth after cesarean delivery patients had significantly different mean scores using all 3 scoring systems, but none of the systems accurately predicted failed trial of labor resulting in cesarean delivery. Unfavorable scores were associated with high rates of major complications. CONCLUSIONS An unfavorable score predicting a high rate of complications and more failed trials of labor may help in counseling patients considering trial of labor. A better system to predict the success or failure of trial of labor is needed. LEVEL OF EVIDENCE III
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Affiliation(s)
- Mara J Dinsmoor
- Department of Obstetrics and Gynecology, Medical College of Virginia Physicians and Hospitals of the Virginia Commonwealth University Health System, Richmond, Virginia, USA.
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Edwards RK, Harnsberger DS, Johnson IM, Treloar RW, Cruz AC. Deciding on route of delivery for obese women with a prior cesarean delivery. Am J Obstet Gynecol 2003; 189:385-9; discussion 389-90. [PMID: 14520202 DOI: 10.1067/s0002-9378(03)00710-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study was undertaken to estimate the vaginal birth after cesarean (VBAC) success rate, compare rates of infections in women attempting VBAC and those undergoing planned repeat cesarean, and compare the cost of these two plans of care for obese women. STUDY DESIGN We performed a historical cohort analysis of singleton deliveries at >/=36 weeks' gestation in women with a body mass index 40 or greater and one prior cesarean delivery. Outcomes included rates of VBAC success and puerperal infections and mean cost of care. RESULTS The cohort consisted of 122 mother-infant pairs, 61 each in the VBAC and cesarean groups. In the VBAC group, 57% (95% CI 45-70) of women were delivered vaginally. The VBAC group had higher rates of chorioamnionitis (13.1% vs 1.6%, P=.02), endometritis (6.6% vs 0%, P=.06), and composite puerperal infection (24.6% vs 8.2%, P=.01). Mean cost of care was similar for mothers ($4439 vs $4427, P=.95), infants ($1241 vs $1422, P=.49), and mother-infant pairs ($5680 vs $5851, P=.64). CONCLUSION Compared with planned cesarean delivery, VBAC trials in obese women are three times as likely to be complicated by infection and do not result in reduced costs.
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Affiliation(s)
- Rodney K Edwards
- Department of Obstetrics and Gynecology, University of Florida, and Clinical Resources, Shands Hospital, University of Florida, Gainesville, FL, USA
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Abstract
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.
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Affiliation(s)
- Michael L Socol
- Department of Obstetrics and Gynecology, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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DiMaio H, Edwards RK, Euliano TY, Treloar RW, Cruz AC. Vaginal birth after cesarean delivery: an historic cohort cost analysis. Am J Obstet Gynecol 2002; 186:890-2. [PMID: 12015504 DOI: 10.1067/mob.2002.123073] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the relative cost-effectiveness of attempted vaginal birth after cesarean delivery compared with elective repeat cesarean delivery. STUDY DESIGN We performed an historic cohort analysis of women with a single prior cesarean delivery who were delivered at our institution during 1999. Inclusion criteria were > or =36 weeks' gestation and carrying a live, singleton fetus with no antenatally diagnosed anomalies. The primary outcome variable was mean cost of hospital care for mother-infant pairs, as obtained from the hospital's Clinical Resources Department. RESULTS The cohort consisted of 204 mother-infant pairs, 65 in the elective repeat cesarean group and 139 in the attempted vaginal birth group. Mean cost of care was higher for mothers ($4155 vs $3675;P <.001), neonates ($1794 vs $1187; P =.03), and mother-infant pairs ($5949 vs $4863; P =.001) for the elective repeat cesarean group compared with the attempted vaginal delivery group. CONCLUSION In women with a single prior cesarean delivery, a trial of labor is more cost-effective than an elective repeat cesarean delivery.
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Affiliation(s)
- Heather DiMaio
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, and Shands Hospital, University of Florida, Gainesville, USA
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Affiliation(s)
- M T November
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Henderson J, McCandlish R, Kumiega L, Petrou S. Systematic review of economic aspects of alternative modes of delivery. BJOG 2001; 108:149-57. [PMID: 11236114 DOI: 10.1111/j.1471-0528.2001.00044.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To carry out a systematic review of the literature relating to economic aspects of alternative modes of delivery. METHODS A comprehensive literature search of the years 1990-1999 was conducted of electronic and non-electronic sources using a tested search strategy. Papers considered to contain useful cost or resource use data were read in full and classified according to their relevance to the review and their methodological quality. Relevant cost and resource use data were converted to pound sterling and inflated to 1998-1999 price levels. RESULTS The literature search resulted in 975 papers, 49 of which met criteria for the review. Thirty-two papers were from the USA where the organisation, structure and costs of health care are significantly different from that of other industrialised countries. The aggregate costs of different modes of delivery reported in these American studies were between four and five times higher than costs reported in other studies. The majority of included studies were of poor quality. Data from the better quality studies demonstrated that caesarean section costs a health service substantially more than other modes of delivery. The range of costs of an uncomplicated vaginal delivery were 629 pound sterling - 1,298 pound sterling compared with1,238 pound sterling - 3,551 pound sterling for a caesarean section. However, papers have so far only considered short term health service costs. CONCLUSIONS Research is required to estimate the cost and resource use attributable to alternative modes of delivery. Future research should investigate the long term health service costs and the costs that arise outside the health service which are likely to vary according to mode of delivery.
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Affiliation(s)
- J Henderson
- National Perinatal Epidemiology Unit, Institute of Health Sciences, Headington, Oxford, UK
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Petrou S, Henderson J, Glazener C. Economic aspects of caesarean section and alternative modes of delivery. Best Pract Res Clin Obstet Gynaecol 2001; 15:145-63. [PMID: 11359320 DOI: 10.1053/beog.2000.0154] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Increases in caesarean section rates worldwide have raised questions about the economic implications of caesarean section and alternative modes of delivery. This chapter reviews economic aspects of caesarean section and alternative modes of delivery and identifies areas where further research is required. The chapter presents the results of a systematic review of the literature and analyses of three large observational data sets. It provides evidence for the cost of labour and delivery, the cost of the postnatal stay and the cost of the long-term health consequences of alternative modes of delivery. The chapter highlights the paucity of methodologically robust economic analyses in this area of health care and concludes that primary research is required to estimate the cost and utilization of services attributable to caesarean section and alternative modes of delivery. Future research studies should recognize the long-term health service costs and the costs that arise outside the health service, which are likely to vary according to mode of delivery.
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Affiliation(s)
- S Petrou
- National Perinatal Epidemiology Unit, Institute of Health Sciences, University of Oxford, Old Road, Headington, Oxford, OX3 7LF, UK
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Henderson J, McCandlish R, Kumiega L, Petrou S. Systematic review of economic aspects of alternative modes of delivery. ACTA ACUST UNITED AC 2001. [DOI: 10.1016/s0306-5456(00)00044-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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