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Mei JY, Mallampati D, Pluym ID, Han CS, Afshar Y. Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis. Am J Perinatol 2023; 40:290-296. [PMID: 33878770 DOI: 10.1055/s-0041-1727213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR. STUDY DESIGN We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY). RESULTS In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis. CONCLUSION Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources. KEY POINTS · Cost effectiveness of twin VDs in the LDR versus OR was assessed.. · Twin VDs in the LDR are cost effective based on current neonatal outcome data.. · Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis..
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Affiliation(s)
- Jenny Y Mei
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Divya Mallampati
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Ilina D Pluym
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Christina S Han
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
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Mengistu TS, Turner JM, Flatley C, Fox J, Kumar S. The Impact of Severe Maternal Morbidity on Perinatal Outcomes in High Income Countries: Systematic Review and Meta-Analysis. J Clin Med 2020; 9:E2035. [PMID: 32610499 PMCID: PMC7409239 DOI: 10.3390/jcm9072035] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/10/2020] [Accepted: 06/23/2020] [Indexed: 12/27/2022] Open
Abstract
While there is clear evidence that severe maternal morbidity (SMM) contributes significantly to poor maternal health outcomes, limited data exist on its impact on perinatal outcomes. We undertook a systematic review and meta-analysis to ascertain the association between SMM and adverse perinatal outcomes in high-income countries (HICs). We searched for full-text publications in PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Scopus databases. Studies that reported data on the association of SMM and adverse perinatal outcomes, either as a composite or individual outcome, were included. Two authors independently assessed study eligibility, extracted data, and performed quality assessment using the Newcastle-Ottawa Scale. We used random-effects modelling to calculate odds ratios (ORs) with 95% confidence intervals. We also assessed the risk of publication bias and statistical heterogeneity using funnel plots and Higgins I2, respectively. We defined sub-groups of SMM as hemorrhagic disorders, hypertensive disorders, cardiovascular disorders, hepatic disorders, renal disorders, and thromboembolic disorders. Adverse perinatal outcome was defined as preterm birth (before 37 weeks gestation), small for gestational age (SGA) (birth weight (BW) < 10th centile for gestation), low birthweight (LBW) (BW < 2.5 kg), Apgar score < 7 at 5 min, neonatal intensive care unit (NICU) admission, stillbirth and perinatal death (stillbirth and neonatal deaths up to 28 days). A total of 35 studies consisting of 38,909,426 women were included in the final analysis. SMMs associated with obstetric hemorrhage (OR 3.42, 95% CI: 2.55-4.58), severe hypertensive disorders (OR 6.79, 95% CI: 6.06-7.60), hepatic (OR 3.19, 95% CI: 2.46-4.13) and thromboembolic disorders (OR 2.40, 95% CI: 1.67-3.46) were significantly associated with preterm birth. SMMs from hypertensive disorders (OR 2.86, 95% CI: 2.51-3.25) or thromboembolic disorders (OR 1.48, 95% CI: 1.09-1.99) were associated with greater odds of having SGA infant. Women with severe hemorrhage had increased odds of LBW infant (OR 2.31, 95% CI: 1.57-3.40). SMMs from obstetric hemorrhage (OR 4.16, 95% CI: 2.54-6.81) or hypertensive disorders (OR 4.61, 95% CI: 1.17-18.20) were associated with an increased odds of low 5-min Apgar score and NICU admission (Severe obstetric hemorrhage: OR 3.34, 95% CI: 2.26-4.94 and hypertensive disorders: OR 3.63, 95% CI: 2.63-5.02, respectively). Overall, women with SMM were 4 times more likely to experience stillbirth (OR 3.98, 95%C 3.12-7.60) compared to those without SMM with cardiovascular disease (OR 15.2, 95% CI: 1.29-180.60) and thromboembolic disorders (OR 9.43, 95% CI: 4.38-20.29) conferring greatest risk of this complication. The odds of neonatal death were significantly higher in women with SMM (OR 3.98, 95% CI: 2.44-6.47), with those experiencing hemorrhagic (OR 7.33, 95% CI: 3.06-17.53) and hypertensive complications (OR 3.0, 95% CI: 1.78-5.07) at highest risk. Overall, SMM was also associated with higher odds of perinatal death (OR 4.74, 95% CI: 2.47-9.12) mainly driven by the increased risk in women experiencing severe obstetric hemorrhage (OR 6.18, 95% CI: 2.55-14.96). Our results highlight the importance of mitigating the impact of SMM not only to improve maternal health but also to ameliorate its consequences on perinatal outcomes.
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Affiliation(s)
- Tesfaye S. Mengistu
- Mater Research Institute, University of Queensland, Level 3 Aubigny Place, Raymond Terrace, South Brisbane, QLD 4101, Australia; (T.S.M.); (J.M.T.); (C.F.)
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, P.O. Box 79, Ethiopia
- Faculty of Medicine, The University of Queensland, Herston, QLD 4072, Australia;
| | - Jessica M. Turner
- Mater Research Institute, University of Queensland, Level 3 Aubigny Place, Raymond Terrace, South Brisbane, QLD 4101, Australia; (T.S.M.); (J.M.T.); (C.F.)
- Faculty of Medicine, The University of Queensland, Herston, QLD 4072, Australia;
| | - Christopher Flatley
- Mater Research Institute, University of Queensland, Level 3 Aubigny Place, Raymond Terrace, South Brisbane, QLD 4101, Australia; (T.S.M.); (J.M.T.); (C.F.)
| | - Jane Fox
- Faculty of Medicine, The University of Queensland, Herston, QLD 4072, Australia;
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, Level 3 Aubigny Place, Raymond Terrace, South Brisbane, QLD 4101, Australia; (T.S.M.); (J.M.T.); (C.F.)
- Faculty of Medicine, The University of Queensland, Herston, QLD 4072, Australia;
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