Maternal and Neonatal Hospitalization Costs Associated With Elective Induction of Labor at Term in California, 2007-2011

Comparison of outpatient with inpatient mifepristone usage for cervical ripening: A randomised controlled trial

Purpose

The efficacy and safety of using mifepristone for the preinduction/induction of labour (IOL) as the only method or in combination with others has been confirmed in observational and randomised trials. However, there are currently no studies comparing the efficacy and safety of using mifepristone for the preinduction of labour on an inpatient and outpatient basis.

Objective

To evaluate whether the outpatient use of mifepristone for cervical ripening before IOL at term is as efficient and safe as in inpatients.

Study design

This open-label, prospective, two-arm, non-inferiority randomised controlled trial (ISRCTN26164110) with a 1:1 allocation ratio was conducted in a single tertiary referral hospital. Overall, 322 pregnant women (gestational age: 39-41 weeks; Bishop score < 6, intact membranes, no contraindications for vaginal delivery, and no contraindications for IOL) were included and randomised:162 to the outpatient group and 160 to the inpatient group for cervical ripening with mifepristone. Analyses were performed based on the intention-to-treat principle.

Results

In 16 % and 17 % of the cases, labour began spontaneously within 24-36 h after taking mifepristone tablets. The additional use of prostaglandin E2 or a balloon for cervical ripening occurred equally often in the compared groups. Oxytocin was used more frequently to induce labour in the inpatient group (P = 0.035). There was no difference in the length of the interval from the onset of cervical ripening to the onset of labour between the groups (38.6 vs. 38.8 h, P = 0.900). The failed induction rate was 1.85 % vs. 0.63 % (P = 0.346).Regional analgesia (P = 0.011) and abnormal foetal heart rate patterns (P = 0.027) were more common in the inpatient group. In the outpatient mifepristone preinduction group, the average time interval from hospitalisation to discharge was 25 h shorter (P < 0.001). No statistically significant differences were observed between the groups in terms of the rates of adverse side effects or perinatal outcomes.

Conclusion

Outpatient cervical ripening with mifepristone reduced the hospital stay duration compared to inpatient ripening, with no difference in efficacy in terms of improvement in the Bishop score, frequency of additional induction method usage, interval from start of preinduction to onset of labour, and labour duration.No differences in the delivery methods, failure rates, or perinatal outcomes were observed. The frequency of adverse effects was low and not related to the setting of the preinduction site. Cervical ripening with mifepristone can be performed on an outpatient basis, because it is as effective and safe as inpatient ripening.

Analysis of Obstetric Outcomes by Hospital Location, Volume, and Teaching Status Associated With Non-Medically Indicated Induction of Labor at 39 Weeks

Importance

Non-medically indicated induction of labor has been demonstrated to potentially improve some obstetric outcomes, such as decreasing cesarean birth. It has been reported that rates of cesarean birth and other obstetric outcomes vary among hospitals with different characteristics.

Objective

To assess whether obstetric outcomes differ between nulliparous individuals with low-risk pregnancies managed with non-medically indicated induction of labor compared with expectant management in different types of hospitals.

Design, Setting, and Participants

This retrospective cohort study included non-medically indicated induction of labor at 39 weeks' gestation compared with expectant management of singleton, nonanomalous, births in nulliparous women with low-risk pregnancies in California between January 1, 2007, and December 31, 2011. The initial analysis of these data was performed in 2021. Outcomes were assessed by 3 hospital characteristics: location (urban vs rural), obstetric volume, and teaching (academic vs community) status. Volume was categorized based on the average number of births per year and grouped into low (<1200 births per year), medium (1200-2399 births per year), and high (≥2400 births per year). Births with previous or planned cesarean delivery were excluded, and non-medically indicated induction of labor was defined as induction of labor without a specific medical indication. Testing with χ2 and multivariable logistic regression analyses was used for statistical comparisons with a cutoff level of P = .01.

Exposure

Non-medically indicated induction of labor at 39 weeks' gestation.

Main Outcomes and Measures

The primary outcome was cesarean birth, and numerous secondary perinatal outcomes were also assessed.

Results

There were 455 044 births included in this study. When stratified by hospital variables, a number of sociodemographic characteristics were significantly different, such as race and ethnicity, age, body mass index, and insurance type. The adjusted odds ratios (aORs) of cesarean birth were significantly lower in all settings with induction of labor except for low-volume hospitals, in which there was no significant difference (aOR, 0.95; 95% CI, 0.82-1.09). Chorioamnionitis and postpartum hemorrhage were lower with induction of labor among nearly every hospital when stratified by hospital characteristics. Neonatal outcomes were improved in all settings with induction of labor compared with expectant management.

Conclusions and Relevance

These findings suggest that non-medically indicated induction of labor may be associated with a lower rate of cesarean births and some maternal and neonatal adverse outcomes in a range of hospital settings.

Cost-effectiveness analysis of induction of labour at 41 weeks and expectant management until 42 weeks in low risk women (INDEX trial)

Objective

To assess the cost-effectiveness of elective induction of labour (IOL) at 41 weeks and expectant management (EM) until 42 weeks.

Design

Cost-effectiveness analysis from a healthcare perspective alongside a randomised controlled trial (INDEX).

Setting

123 primary care midwifery practices and 45 obstetric departments of hospitals in the Netherlands.

Population

We studied 1801 low-risk women with late-term pregnancy, randomised to IOL at 41 weeks (N = 900) or EM until 42 weeks (N = 901).

Methods

The incremental cost-effectiveness ratio (ICER) was expressed as the ratio of the difference in costs and the difference in main perinatal outcomes. A Cost-Effectiveness Acceptability Curve (CEAC) was constructed to assess whether induction is cost-effective for a range of monetary values as thresholds. We performed subgroup analysis for parity.

Main outcome measures

Direct medical costs, composite adverse perinatal outcome (CAPO) (perinatal mortality, NICU admission, Apgar 5 min < 7, plexus brachialis injury and/or meconium aspiration syndrome) and composite severe adverse perinatal outcome (SAPO) (including Apgar 5 min < 4 instead of < 7).

Results

The average costs were €3858 in the induction group and €3723 in the expectant group (mean difference €135; 95 % CI -235 to 493). The ICERs of IOL compared to EM to prevent one additional CAPO and SAPO was €9436 and €14,994, respectively. The CEAC showed a 80 % chance of IOL being cost-effective with a willingness-to-pay of €22,000 for prevention of one CAPO and €50,000 for one SAPO. Subgroup analysis showed a willingness-to-pay to prevent one CAPO for nulliparous of €47,000 and for multiparous €190,000. To prevent one SAPO the willingness-to-pay is €62,000 for nulliparous and €970,000 for multiparous women.

Conclusions

Induction at 41 weeks has an 80 % chance of being cost-effective at a willingness-to-pay of €22,000 for prevention of one CAPO and €50,000 for prevention of one SAPO. Subgroup analysis suggests that induction could be cost-effective for nulliparous women while it is unlikely cost-effective for multiparous women.Cost-effectiveness in other settings will depend on baseline characteristics of the population and health system organisation and funding.

Cost-effectiveness of induction of labor at 39 weeks vs expectant management by cervical examination

BACKGROUND

Previous analyses have demonstrated the cost effectiveness of elective induction of labor at 39 weeks of gestation for healthy nulliparous people. However, elective induction of labor is resource intensive, and optimal resource allocation requires a thorough understanding of which subgroups of patients will benefit most.

OBJECTIVE

This study aimed to determine whether induction of labor at 39 weeks of gestation is more cost-effective in patients with favorable or unfavorable cervical examinations.

STUDY DESIGN

We constructed 2 decision analysis models using TreeAge software: one modeling induction of labor at 39 weeks of gestation vs expectant management for a group of nulliparous patients with unfavorable cervical examinations and the other modeling induction of labor at 39 weeks of gestation vs expectant management for a group with favorable cervical examinations. Estimates of cost, probability, and health state utility were derived from the literature. Based on previous literature, we assumed that people with favorable cervical examinations would have a lower baseline rate of cesarean delivery and higher rates of spontaneous labor.

RESULTS

In our base case analysis, induction of labor at 39 weeks of gestation was cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. The incremental cost per quality-adjusted life year was 50-fold lower for people with unfavorable cervical examinations ($2150 vs $115,100). Induction of labor resulted in 3885 fewer cesarean deliveries and 58 fewer stillbirths per 100,000 patients for those with unfavorable examinations, whereas induction of labor resulted in 2293 fewer cesarean deliveries and 48 fewer stillbirths with labor induction for those with favorable cervical examinations. The results were sensitive to multiple inputs, including the likelihood of cesarean delivery, the cost of induction, the cost of vaginal or cesarean delivery, and the probability of spontaneous labor. In Monte Carlo analysis, the base case findings held true for 64.1% of modeled scenarios for patients with unfavorable cervixes and 55.4% of modeled scenarios for patients with favorable cervixes.

CONCLUSION

With a willingness-to-pay threshold of $100,000 per quality-adjusted life year, induction of labor at 39 weeks of gestation may be cost-effective for patients with unfavorable cervical examinations, but not for patients with favorable cervical examinations. This result was driven by the likelihood of labor in patients with favorable cervical examinations, and the resultant avoidance of prolonged pregnancy and its complications, including hypertensive disorders of pregnancy and stillbirths. Health systems may wish to prioritize patients with unfavorable cervical examinations for elective induction of labor at 39 weeks of gestation, which may be opposite to common practice.

Elective Induction of Labor or Expectant Management: Outcomes Among Nulliparous Women with Uncomplicated Pregnancies

INTRODUCTION

Cesarean birth rates among women who are nulliparous with uncomplicated full-term pregnancies have been shown to decrease if labor is electively induced. The purpose of this study was to compare the cesarean birth rate for women with pregnancies at 39.0 weeks' gestation or later admitted for spontaneous labor or medically indicated induction of labor (IOL) with that of women receiving elective IOL at term.

METHODS

A retrospective cohort study was conducted by searching electronic health records of all nulliparous women with uncomplicated pregnancies who gave birth between January 2018 through February 2020 at one academic medical center. Select maternal demographic data and approach to labor management were the primary variables analyzed in determining the odds of cesarean birth.

RESULTS

A total of 1528 women were included in this study. Among these, 158 received elective IOL, and 1370 did not. The cesarean birth rates (31.0% vs 23.9%, elective induction of labor vs expectant management, respectively, P = .048), neonatal intensive care admissions (9.5% vs 7.6%, P = .41), and Apgar scores were similar among women in both management groups, respectively (P = .08). Accounting for other potential risk factors, the odds of having cesarean birth were not statistically different between management groups (adjusted odds ratio, 0.73; 95% CI, 0.5-1.1; P = .09). There were 2 fetal deaths among women whose labor was not electively induced. In the total cohort, women who were older, who had higher body mass index (BMI), and who identified as non-Hispanic Black had an increased odds of experiencing a cesarean birth. The associations between women in management groups and cesarean birth were not modified by age, BMI, race, or ethnicity (P = .33, .67, and .87, respectively).

DISCUSSION

Elective IOL was not associated with lower cesarean rates in this study. Further research is needed before implementing clinical practice changes that encourage more use of IOL.

Optimal timing of labour induction in contemporary clinical practice

Induction of labour (IoL) is generally conducted when maternal and foetal risks of remaining pregnant outweigh the risks of delivery. With emerging literature around non-medically indicated IoL, contemporary clinical practice has seen an increase in IoL at 39 weeks' gestation. This review highlights recent evidence on the most common indications for IoL including gestational diabetes, hypertensive disorders of pregnancy, intrahepatic cholestasis of pregnancy, and post-term pregnancies. It also summarizes the evidence related to the timing of IoL for other common conditions based on recent literature reviews.

Outpatient labour induction

The inexorable rise in induction rates over the past two decades, in parallel with increasing medical costs and pressure to reduce length of stay, has led to marked logistic difficulties for health care workers, managers and planners. Maternity services are being overwhelmed by the need to allocate staff and delivery suite space for the scheduling and undertaking of induction processes, rather than focussing care for women in spontaneous labour. Induction of labour according to the majority of current protocols and guidelines necessitates increased length of stay and relatively aggressive use of oxytocin (to reduce the time expended in the labour ward from artificial rupture of membranes (AROM) to establishment of labour). This increased oxytocin usage requires increased use of continuous electronic foetal monitoring, and may also increase epidural usage, further increasing the complexity of labour for the woman and her health care workers. Outpatient care after cervical priming and even outpatient care after AROM may help to ease these pressures and may reduce the medicalisation of the birth experience when induction is indicated, with a potential to reduce oxytocin use and associated interventions. If the period between cervical priming to AROM is managed as outpatient care, then the woman may be able to find better psychological and social support at home, as well as maintain autonomy and get better rest prior to the onset of labour. Inpatient AROM could also be followed by outpatient care until the pregnant person returns to the hospital, either in spontaneous labour, or for initiation of syntocinon after 12-18 h. High-quality research has already demonstrated that outpatient care for cervical ripening is acceptable to mothers and caregivers, has economic benefits and has an acceptable safety profile in appropriately selected low-risk inductions.

Induction of labour at 41 weeks of gestation versus expectant management and induction of labour at 42 weeks of gestation: a cost-effectiveness analysis

OBJECTIVE

To assess the cost-effectiveness of induction of labour (IOL) at 41 weeks of gestation compared with expectant management until 42 weeks of gestation.

DESIGN

A cost-effectiveness analysis alongside the Swedish Post-term Induction Study (SWEPIS), a multicentre, randomised controlled superiority trial.

SETTING

Fourteen Swedish hospitals during 2016-2018.

POPULATION

Women with an uncomplicated singleton pregnancy with a fetus in cephalic position were randomised at 41 weeks of gestation to IOL or to expectant management and induction at 42 weeks of gestation.

METHODS

Health benefits were measured in life years and quality-adjusted life years (QALYs) for mother and child. Total cost per birth was calculated, including healthcare costs from randomisation to discharge after delivery, for mother and child. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the difference in mean cost between the trial arms by the difference in life years and QALYs, respectively. Sampling uncertainty was evaluated using non-parametric bootstrapping.

MAIN OUTCOME MEASURES

The cost per gained life year and per gained QALY.

RESULTS

The differences in life years and QALYs gained were driven by the difference in perinatal mortality alone. The absolute risk reduction in mortality was 0.004 (from 6/1373 to 0/1373). Based on Swedish life tables, this gives a mean gain in discounted life years and QALYs of 0.14 and 0.12 per birth, respectively. The mean cost per birth was €4108 in the IOL group (n = 1373) and €4037 in the expectant management group (n = 1373), with a mean difference of €71 (95% CI -€232 to €379). The ICER for IOL compared with expectant management was €545 per life year gained and €623 per QALY gained. Confidence intervals were relatively wide and included the possibility that IOL had both lower costs and better health outcomes.

CONCLUSIONS

Induction of labour at 41 weeks of gestation results in a better health outcome and no significant difference in costs. IOL is cost-effective compared with expectant management until 42 weeks of gestation using standard threshold values for acceptable cost per life year/QALY.

TWEETABLE ABSTRACT

Induction of labour at 41 weeks of gestation is cost-effective compared with expectant management until 42 weeks of gestation.

Herpes Simplex Virus Serotyping in Pregnant Women With a History of Genital Herpes and an Outbreak in the Third Trimester of Pregnancy: A Cost-Effectiveness Analysis

OBJECTIVE

To estimate whether serotyping women with a history of genital herpes simplex virus (HSV) and an outbreak during the third trimester of pregnancy is cost effective compared with no serotyping.

METHODS

We designed a decision-analytic model using TreeAge Pro software to assess an approach of routine HSV serotyping in a theoretical cohort of 63,582 women (an estimate of the number of women in the United States with a history of genital HSV and an outbreak during the third trimester of pregnancy). Outcomes included mild, moderate, and severe neonatal HSV, neonatal death, costs, and quality-adjusted life-years (QALYs) for both the woman and neonate. Probabilities, utilities, and costs were derived from the literature, and we used a willingness-to-pay threshold of $100,000 per QALY. Sensitivity analyses were performed to assess the robustness of the results.

RESULTS

In our theoretical cohort, HSV serology screening resulted in 519, 8, and 15 cases of mild, moderate, and severe neonatal HSV, whereas no serology screening resulted in 745, 65, and 85 cases, respectively. Thus, HSV serology screening led to 226, 57, and 70 fewer cases of mild, moderate, and severe neonatal HSV, respectively, as well as 91 fewer neonatal deaths. Additionally, serology screening saved $61 million and gained 7,900 QALYs, making it a dominant strategy. Univariate sensitivity analysis demonstrated that serology screening was cost effective until the chance of progression from neonatal HSV infection to disease despite empiric antiviral treatment was greater than 23%.

CONCLUSION

Serology screening in pregnant women with an outbreak in the third trimester of pregnancy and a history of genital HSV resulted in improved outcomes and decreased costs.