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Eden KB, Perrin NA, Vesco KK, Guise JM. A Randomized Comparative Trial of Two Decision Tools for Pregnant Women with Prior Cesareans. J Obstet Gynecol Neonatal Nurs 2014; 43:568-579. [DOI: 10.1111/1552-6909.12485] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2014] [Indexed: 11/24/2022] Open
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Petrou S, Khan K. An overview of the health economic implications of elective caesarean section. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:561-76. [PMID: 24155076 DOI: 10.1007/s40258-013-0063-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
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.
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Affiliation(s)
- Stavros Petrou
- Clinical Trials Unit, Gibbet Hill Road, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK,
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Salemi JL, Comins MM, Chandler K, Mogos MF, Salihu HM. A practical approach for calculating reliable cost estimates from observational data: application to cost analyses in maternal and child health. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2013; 11:343-357. [PMID: 23807539 DOI: 10.1007/s40258-013-0040-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Comparative effectiveness research (CER) and cost-effectiveness analysis are valuable tools for informing health policy and clinical care decisions. Despite the increased availability of rich observational databases with economic measures, few researchers have the skills needed to conduct valid and reliable cost analyses for CER. OBJECTIVE The objectives of this paper are to (i) describe a practical approach for calculating cost estimates from hospital charges in discharge data using publicly available hospital cost reports, and (ii) assess the impact of using different methods for cost estimation in maternal and child health (MCH) studies by conducting economic analyses on gestational diabetes (GDM) and pre-pregnancy overweight/obesity. METHODS In Florida, we have constructed a clinically enhanced, longitudinal, encounter-level MCH database covering over 2.3 million infants (and their mothers) born alive from 1998 to 2009. Using this as a template, we describe a detailed methodology to use publicly available data to calculate hospital-wide and department-specific cost-to-charge ratios (CCRs), link them to the master database, and convert reported hospital charges to refined cost estimates. We then conduct an economic analysis as a case study on women by GDM and pre-pregnancy body mass index (BMI) status to compare the impact of using different methods on cost estimation. RESULTS Over 60 % of inpatient charges for birth hospitalizations came from the nursery/labor/delivery units, which have very different cost-to-charge markups (CCR = 0.70) than the commonly substituted hospital average (CCR = 0.29). Using estimated mean, per-person maternal hospitalization costs for women with GDM as an example, unadjusted charges ($US14,696) grossly overestimated actual cost, compared with hospital-wide ($US3,498) and department-level ($US4,986) CCR adjustments. However, the refined cost estimation method, although more accurate, did not alter our conclusions that infant/maternal hospitalization costs were significantly higher for women with GDM than without, and for overweight/obese women than for those in a normal BMI range. CONCLUSIONS Cost estimates, particularly among MCH-related services, vary considerably depending on the adjustment method. Our refined approach will be valuable to researchers interested in incorporating more valid estimates of cost into databases with linked hospital discharge files.
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Affiliation(s)
- Jason L Salemi
- The MCH Comparative Effectiveness Research Group, Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, 13201 Bruce B Downs, MDC56, Tampa, FL 33612, USA.
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Fahy M, Doyle O, Denny K, Mcauliffe FM, Robson M. Economics of childbirth. Acta Obstet Gynecol Scand 2013; 92:508-16. [DOI: 10.1111/aogs.12117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 02/10/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Michael Fahy
- School of Economics and Geary Institute; University College Dublin; Dublin; Ireland
| | - Orla Doyle
- School of Economics and Geary Institute; University College Dublin; Dublin; Ireland
| | - Kevin Denny
- School of Economics and Geary Institute; University College Dublin; Dublin; Ireland
| | - Fionnuala M. Mcauliffe
- UCD Obstetrics & Gynecology; School of Medicine and Medical Science; University College Dublin; National Maternity Hospital; Dublin; Ireland
| | - Michael Robson
- UCD Obstetrics & Gynecology; School of Medicine and Medical Science; University College Dublin; National Maternity Hospital; Dublin; Ireland
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Fawsitt CG, Bourke J, Greene RA, Everard CM, Murphy A, Lutomski JE. At what price? A cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery. PLoS One 2013; 8:e58577. [PMID: 23484038 PMCID: PMC3590223 DOI: 10.1371/journal.pone.0058577] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 02/07/2013] [Indexed: 12/04/2022] Open
Abstract
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.
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Eden KB, Denman MA, Emeis CL, McDonagh MS, Fu R, Janik RK, Broman AR, Guise J. Trial of Labor and Vaginal Delivery Rates in Women with a Prior Cesarean. J Obstet Gynecol Neonatal Nurs 2012; 41:583-98. [DOI: 10.1111/j.1552-6909.2012.01388.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Cox KJ. Providers' perspectives on the vaginal birth after cesarean guidelines in Florida, United States: a qualitative study. BMC Pregnancy Childbirth 2011; 11:72. [PMID: 21992871 PMCID: PMC3203084 DOI: 10.1186/1471-2393-11-72] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 10/12/2011] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Women's access to vaginal birth after cesarean (VBAC) in the United States has declined steadily since the mid-1990s, with a current rate of 8.2%. In the State of Florida, less than 1% of women with a previous cesarean deliver vaginally. This downturn is thought to be largely related to the American College of Obstetricians and Gynecologists (ACOG) VBAC guidelines, which mandate that a physician and anesthesiologist be "immediately available" during a trial of labor. The aim of this exploratory qualitative study was to explore the barriers associated with the ACOG VBAC guidelines, as well as the strategies that obstetricians and midwives use to minimize their legal risks when offering a trial of labor after cesarean. METHODS Semi-structured interviews were conducted with 11 obstetricians, 12 midwives, and a hospital administrator (n = 24). Interviews were recorded and transcribed verbatim, and thematic analysis informed the findings. RESULTS Fear of liability was a central reason for obstetricians and midwives to avoid attending VBACs. Providers who continued to offer a trial of labor attempted to minimize their legal risks by being highly selective in choosing potential candidates. Definitions of "immediately available" varied widely among hospitals, and providers in solo or small practices often favored the convenience of a repeat cesarean delivery rather than having to remain in-house during a trial of labor. Midwives were often marginalized due to restrictive hospital policies and by their consulting physicians, even though women with previous cesareans were actively seeking their care. CONCLUSIONS The current ACOG VBAC guidelines limit US obstetricians' and midwives' ability to provide care for women with a previous cesarean, particularly in community and rural hospitals. Although ACOG has proposed that women be allowed to accept "higher levels of risk" in order to be able to attempt a trial of labor in some settings, access to VBAC is unlikely to increase in Florida as long as systemic barriers and liability risks remain high.
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Affiliation(s)
- Kim J Cox
- College of Nursing, University of New Mexico, Albuquerque, NM 87131-0001, 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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Preferred and actual delivery mode after a cesarean in London, UK. Int J Gynaecol Obstet 2008; 102:156-9. [DOI: 10.1016/j.ijgo.2008.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Revised: 02/23/2008] [Accepted: 03/04/2008] [Indexed: 11/21/2022]
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Agarwal A, Chowdhary P, Das V, Srivastava A, Pandey A, Sahu MT. Evaluation of pregnant women with scarred uterus in a low resource setting. J Obstet Gynaecol Res 2007; 33:651-4. [PMID: 17845324 DOI: 10.1111/j.1447-0756.2007.00627.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM Management of post cesarean pregnancy continues to be a dilemma. The present study was undertaken to evaluate the outcome of such pregnancies in a resource constrained setting so that an appropriate management protocol can be decided. METHODS An observational study was conducted in the Department Of Obstetrics And Gynecology, King George's Medical University, Lucknow, India. The outcome of all of the women admitted with pregnancy with a previous cesarean section was noted. RESULTS A total number of 447 women with a post cesarean pregnancy underwent delivery. These comprised 13.7% of total deliveries over the same period. 124 women (27.7%) had successful vaginal delivery while 323 (72.3%) had a repeat cesarean section. Maternal morbidity and perinatal mortality were both significantly higher in the vaginal delivery group (P = 0.00211 and P = 0.0426, respectively). CONCLUSIONS Vaginal birth after cesarean (VBAC) is associated with higher maternal morbidity and perinatal mortality. Therefore the decision for VBAC must be taken only after proper consideration and counseling of the couple.
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Affiliation(s)
- Anjoo Agarwal
- Department of Obstetrics and Gynaecology, King George's Medical University, Lucknow (UP), India.
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Abstract
OBJECTIVE To examine the cumulative costs of hospital care in the first and subsequent pregnancies associated with different methods in the initial delivery of nulliparous women. METHODS An 18-year population-based cohort study (1985-2002) using the Nova Scotia Atlee Perinatal Database compared cumulative delivery costs in the first and subsequent pregnancies. Women were identified by initial method of delivery for nulliparous women with singleton cephalic presentation at term undergoing spontaneous or induced labor for planned vaginal delivery, and for nulliparous women undergoing cesarean delivery without labor. Costs that were assessed included nursing hours in antepartum, labor and delivery, postpartum and neonatal intensive care units, physician costs, labor induction agents, consumables, and costs for postpartum hysterectomy, tubal ligation, and dilatation and curettage. RESULTS A total of 27,613 pregnancies satisfied inclusion and exclusion criteria. When cumulative costs by type of labor at first delivery were considered, induction of labor (7,220 dollars) was more costly than spontaneous onset of labor (6,919 dollars, P = .006). The cumulative costs of assisted vaginal delivery at first delivery (7,288 dollars) and cesarean delivery in labor at first delivery (9,524 dollars) were similar in magnitude and were higher than spontaneous vaginal delivery at first delivery (P < .001). Cesarean delivery in labor in the first delivery was the most costly type of delivery (9,524 dollars), and the differences in cost increased with increasing number of deliveries (P < .05). CONCLUSION Cesarean delivery in labor in the first delivery is associated with increased cumulative costs compared with other methods of delivery, regardless of the number or type of subsequent deliveries.
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Affiliation(s)
- Victoria M Allen
- Department of Obstetrics and Gynaecology, Perinatal Epidemiology Research Unit, Dalhousie University, Halifax, Nova Scotia, Canada.
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Paré E, Quiñones JN, Macones GA. General obstetrics: Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes. BJOG 2005; 113:75-85. [PMID: 16398775 DOI: 10.1111/j.1471-0528.2005.00793.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the maternal implications of strategies of vaginal birth after caesarean section (VBAC) attempt versus elective repeat caesarean section in women with one previous lower segment caesarean section. DESIGN Decision model. POPULATION Women with one prior low transverse caesarean section who are eligible for trial of labour. METHODS Two decision models were built: the first one applying to women planning only one more pregnancy, the second one applying to women planning two more pregnancies. Probability estimates for VBAC success rate and risks of uterine rupture, placenta praevia, placenta accreta and hysterectomy were extracted from the available literature. MAIN OUTCOME MEASURES Hysterectomy for uterine rupture, placenta accreta or other indications. RESULTS In the first model VBAC attempt led to a higher hysterectomy rate (267/100,000) compared with repeat caesarean section (187/100,000). However, in the second model a policy of elective repeat caesarean section led to higher cumulative hysterectomy rate: 1465/100,000 versus 907/100,000 for VBAC. The first model was robust to all but one variable in sensitivity analyses. The second model was robust to all variables in sensitivity analyses. CONCLUSIONS These results indicate that long term reproductive consequences of multiple caesarean sections should be considered when making policy decisions regarding the risk-benefit ratio of VBAC.
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Affiliation(s)
- Emmanuelle Paré
- Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, 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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Park JS. Is VBAC(Vaginal Birth After Cesarean) Really Safe? JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2005. [DOI: 10.5124/jkma.2005.48.5.489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Joong Shin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea.
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Abstract
PURPOSE OF REVIEW To review the current literature on vaginal birth after cesarean delivery efficacy and safety. RECENT FINDINGS There are two major themes in current vaginal birth after cesarean delivery research. The first is continued work on the short-term safety, including maternal events such as uterine rupture and perinatal death. The second theme focuses on identifying predictors for success and failure. SUMMARY Current information suggests that the rate of major maternal and neonatal complications with vaginal birth after cesarean delivery is low, and this option should be offered to women with a single prior low transverse cesarean. Future research should focus on an evaluation of both short-term and long-term consequences of vaginal birth after cesarean delivery compared with elective repeat cesarean section.
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Affiliation(s)
- Anthony O Odibo
- Department of Obstetrics and Gynecology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, 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
OBJECTIVE The purpose of this study was to estimate the cost differences between elective cesarean delivery and the alternative of attempted vaginal delivery and to assess the economic impact of cesarean delivery on demand. STUDY DESIGN Cost data were obtained over a 12-month period from a not-for-profit community hospital to calculate a per-patient cost for clinical alternatives. RESULTS The average cost of an attempted vaginal delivery without oxytocin (Pitocin) or epidural anesthesia was 15.1% lower in nulliparous women and 20% lower in multiparous women than with elective cesarean delivery. However, in nulliparous women, the addition of Pitocin nullified any cost differences; if epidural anesthesia was also used, total costs exceeded the cost of elective cesarean delivery by almost 10%. The cost of a failed attempt at vaginal delivery was much higher than elective cesarean delivery for both groups. The average cost for all women who attempted vaginal delivery was only 0.2% less than the per-patient cost of elective cesarean delivery. CONCLUSION The adoption of a policy of cesarean delivery on demand should have little impact on the overall cost of obstetric care.
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Affiliation(s)
- Brent W Bost
- Department of Economics and Finance, Lamar University, Beauville, Texas 77702, USA
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Carroll CS, Magann EF, Chauhan SP, Klauser CK, Morrison JC. Vaginal birth after cesarean section versus elective repeat cesarean delivery: Weight-based outcomes. Am J Obstet Gynecol 2003; 188:1516-20; discussion 1520-2. [PMID: 12824987 DOI: 10.1067/mob.2003.472] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The study was undertaken to compare infectious morbidity and trial of labor (TOL) success stratified by weight in women. STUDY DESIGN Vaginal birth after cesarean section (VBAC) candidates were divided into groups based on prepregnancy weight: group I, 70 (<200 pounds); group II, 70 (200-300 pounds); and group III, 69 (>300 pounds). RESULTS The TOL success rate was 81.8% in group I compared with 57.1% in group II and 13.3% in group III (P =.001). The overall infectious morbidity was significantly greater in the obese women 39% (P =.001) compared with the average women at 11.4% and the lean women at 5.7%. CONCLUSION Infectious morbidity is increased and VBAC success is reduced in patients who weigh more than 300 pounds.
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Affiliation(s)
- C Shannon Carroll
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, USA
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Abstract
PURPOSE OF REVIEW The management of cesarean sections causes much controversy among healthcare providers, patients, and insurers. A trial of vaginal birth after previous cesarean is reported to be a safe and practical method to reduce the rate of cesarean sections. The popularity of vaginal birth after previous cesarean has increased over the past two decades, but rates have recently started to decline again. This review will evaluate recent literature that might be responsible for this reversal in trend. RECENT FINDINGS Earlier studies on previous cesarean section pregnancies focused primarily on the success rate of vaginal birth after previous cesarean, which is reported to be 60-80%. Recent large, retrospective, population-based cohort studies examined the maternal and neonatal safety of trial of labour compared with elective repeat cesarean delivery, and confirmed that the risks of uterine rupture and neonatal mortality were significantly increased after trial of labour, particularly when induced with prostaglandins. However, the absolute risk of adverse events remains small. The maternal and neonatal morbidity risk increases when vaginal birth after previous cesarean attempts fails, which emphasizes the importance of careful case selection. SUMMARY Recent studies highlighted the risks of attempted vaginal birth after previous cesareans, especially when trials fail, but have not addressed the long-term risks of an elective repeat cesarean delivery. The assessment of treatment risks by observational studies is subject to bias, because the different treatment groups may not be comparable at the outset. In the absence of better data, the counselling of such women must currently be based on this evidence.
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Affiliation(s)
- Arijit Biswas
- Department of Obstetrics and Gynaecology, National University Hospital, National University of Singapore, Singapore.
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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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