Reducing caesarean delivery: An economic evaluation of routine induction of labour at 39 weeks in low-risk nulliparous women

Intrapartum use of sildenafil citrate to prevent fetal compromise and emergency operative birth in term pregnancies in the United Kingdom and Australia: A preliminary cost-effectiveness analysis

OBJECTIVE

To compare cost-effectiveness of oral sildenafil citrate, administered after onset of labor, with standard care to health system funders in the UK and Australia.

METHODS

We conducted a modeled cost-effectiveness analysis, measuring costs and quality adjusted life years (QALYs), using a decision-analytic model covering onset of labor to 1 month post-birth. The relative risk of emergency cesarean section and operative vaginal birth was taken from a Phase 2 placebo controlled double blinded randomized control trial.

RESULTS

Both options of care resulted in the same QALYs gained over the model time period (0.08). Sildenafil citrate was cost-saving compared with standard care, saving £92 per birth in the UK (AU$303 per birth in Australia). Sensitivity analyses did not identify any areas of uncertainty that stopped sildenafil citrate being cost saving compared with standard care. Threshold analysis revealed that sildenafil citrate would be cost saving up to a per birth drug or administration cost of £152.32 in the UK (AU$333.61 in Australia).

CONCLUSION

Oral sildenafil citrate may be cost saving compared with standard care; however, the effects on neonatal outcomes still need to be demonstrated in large randomized trials.

The role and scope of contemporary midwifery practice in Australia: A scoping review of the literature

PROBLEM

Little is known about the breadth of midwifery scope within Australia, and few midwives work to their full scope of practice.

BACKGROUND

Midwives in Australia are educated and professionally accountable to work in partnership with childbearing women and their families, yet they are currently hindered from practicing within their full scope of practice by contextual influences.

AIMS

To perform a scoping review of the literature to map out the role and scope of contemporary midwifery practice in Australia To identify any key issues that impact upon working within the full scope of midwifery practice in the Australian context METHODS: A scoping review of the literature guided by the Arksey and O'Malley's five-stage methodological framework, and the 'best fit' framework synthesis using the Nursing and Midwifery Board of Australia's Midwifery Standards for Practice.

FINDINGS

Key themes that emerged from the review included Partnership with women; The professional role of the midwife; and Contextual influences upon midwifery practice.Discussion Tensions were identified between the midwifery scope of practice associated with optimal outcomes for women and babies supported by current evidence and the actual role and scope of most midwives employed in models of care in the current Australian public healthcare system.

CONCLUSIONS

There is a mismatch between the operational parameters for midwifery practice in Australia and the evidence-based models of continuity of midwifery carer that are associated with optimal outcomes for childbearing women and babies and the midwives themselves.

Value in maternal care: Using the Learning Health System to facilitate action

There is an increasing need to deliver high-value health care. Here, we discuss how value should be measured and implemented in maternity care through a Learning Health System. High-value maternity care will produce the highest level of benefit for women at a given cost. As pregnancy is not an illness state, and there is no cure or remission to be achieved, we believe that patient-reported outcomes should be an integral component of benefit quantification when measuring value. Furthermore, as care impacts more than just health outcomes-particularly in maternity care-there is also a need to consider patient-reported experiences as a part of defining the level of benefit. However, to move beyond traditional narrow and passive measurement of value, we need to partner with stakeholders to identify priorities for change, identify evidence for how to achieve this change, integrate measurement activities, and promote effective implementation, in a continuous, learning cycle-a Learning Health System. A robust Framework for implementing a Learning Health System has been developed, which could be applied in maternity care.

Economic evaluations of audit and feedback interventions: a systematic review

BACKGROUND

The effectiveness of audit and feedback (A&F) interventions to improve compliance to healthcare guidelines is supported by randomised controlled trials (RCTs) and meta-analyses of RCTs. However, there is currently a knowledge gap on their cost-effectiveness.

OBJECTIVE

We aimed to assess whether A&F interventions targeting improvements in compliance to recommended care are economically favourable.

METHODS

We conducted a systematic review including experimental, observational and simulation-based economic evaluation studies of A&F interventions targeting healthcare providers. Comparators were a 'do nothing' strategy, or any other intervention not involving A&F or involving a subset of A&F intervention components. We searched MEDLINE, CINAHL, CENTRAL, Econlit, EMBASE, Health Technology Assessment Database, MEDLINE, NHS Economic Evaluation Database, ABI/INFORM, Web of Science, ProQuest and websites of healthcare quality associations to December 2021. Outcomes were incremental cost-effectiveness ratios, incremental cost-utility ratios, incremental net benefit and incremental cost-benefit ratios. Pairs of reviewers independently selected eligible studies and extracted relevant data. Reporting quality was evaluated using CHEERS (Consolidated Health Economic Evaluation Reporting Standards). Results were synthesised using permutation matrices for all studies and predefined subgroups.

RESULTS

Of 13 221 unique citations, 35 studies met our inclusion criteria. The A&F intervention was dominant (ie, at least as effective with lower cost) in 7 studies, potentially cost-effective in 26 and was dominated (ie, the same or less effectiveness and higher costs) in 2 studies. A&F interventions were more likely to be economically favourable in studies based on health outcomes rather than compliance to recommended practice, considering medical costs in addition to intervention costs, published since 2010, and with high reporting quality.

DISCUSSION

Results suggest that A&F interventions may have a high potential to be cost-effective. However, as is common in systematic reviews of economic evaluations, publication bias could have led to an overestimation of their economic value.

Head in the sand: Contemporary Australian attitudes towards induction of labour

Ambivalence in Australian thought on induction of labour, despite recent evidence, stands out in contrast to ever-increasing rates of this intervention. As consent obligations on information provision have crystallised in maternity care, this article examines whether consumer-led expectations and legal obligations may precipitate change to end the cultural stigma around induction of labour.

Using epidemiological and health economic measures to inform maternity staffing decisions: A guide

BACKGROUND

There is growing concern around unnecessary intervention (particularly caesarean section) at birth in high-income countries. Caseload midwifery care aims to offset this, but is perceived to be costly to health services.

AIM

To use epidemiological and health economic techniques to estimate health outcomes and cost-savings of different levels of equivalent full time (EFT) midwives working in caseload midwifery care.

METHODS

Two simulations were conducted - one assuming 10 EFT midwives working in a caseload model, with 35 women per caseload, and one assuming 50 EFT midwives working in a caseload model, with 45 women per caseload. Both were based on a sample of 5000 women. The main model inputs included rates of health outcomes for women (caesarean section, epidural anaesthesia, and episiotomy) and infants (low birthweight and admissions to special care nursery (SCN) or neonatal intensive care unit (NICU)), and the cost savings associated with health outcome avoidance.

FINDINGS

The first simulation estimated 27 fewer caesarean sections, 12 fewer epidurals, 12 fewer episiotomies, 10 fewer low birthweight births, and 23 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$1,874,715. The second simulation estimated 173 fewer caesarean sections, 76 fewer epidurals, 76 fewer episiotomies, 65 fewer low birthweight births, and 150 fewer infants admitted to SCN or NICU annually, at a total cost saving of AU$12,051,741.

CONCLUSION

This study provides local-level decision-makers with a decision-tool to calculate the potentially avoidable health outcomes and cost savings associated with implementing caseload midwifery care in their own service.

A cascade of interventions: A classification tree analysis of the determinants of primary cesareans in Australian public hospitals

BACKGROUND

Both globally and in Australia, there has been a sharp rise in cesarean births (CB). Commonly, this rise has been attributed to the changing epidemiology of women giving birth. A significant body of knowledge exists on the risk factors associated with a greater need for cesarean. Yet, we have little information on the reasons recorded by clinicians as to why cesareans are provided. This study aimed to explore the drivers of primary cesareans in Australian public hospitals.

METHODS

Using a linked administrative data set, the frequency and percent of mothers' characteristics were compared between those who had a cesarean birth and those who had a vaginal birth (n = 98 967) with no history of previous cesareans in Queensland public hospitals between July 1, 2012, and June 30, 2015. The top 10 reasons recorded by clinicians for a primary cesarean were reported. Using a machine-learning algorithm, two decision trees were built to determine factors driving primary cesarean birth.

RESULTS

"Labour and delivery complicated by fetal heart rate anomaly" (23%) and "primary inadequate contractions" (22.8%) were the top two reasons for a primary cesarean birth. The most common characteristics among mothers who had fetal heart rate anomalies were as follows: artificial rupture of membranes (39%), oxytocin (32%), no obstruction of labor (42%), and epidural (52%). For women who had primary inadequate contractions, the most common characteristics were as follows: epidural (33%), oxytocin (49%), artificial rupture of membranes (45%), and fetal stress (56%).

CONCLUSIONS

Efforts should be made by health practitioners during the antenatal period to maximize the use of preventative measures that minimize the need for medical interventions.

Trends and characteristics of women undergoing induction of labour in a tertiary hospital setting: A cross-sectional study

BACKGROUND

In many well-resourced countries, rising rates of intervention are being observed during pregnancy, labour and childbirth with induction of labour (IOL) fast becoming one of the most common. In Australia, the rate of induction of labour has increased by over 30% since 2007, and today one in three women have their labours induced. We do not however have a good understanding of the contribution of specific obstetric populations to this trend.

METHODS

We examine the contribution of specific obstetric populations to induction of labour over a six-year period at one tertiary maternity service, using the Nippita classification system. Average Annual Percentage Changes (AAPC) were calculated along with 95% confidence intervals and P values set at 0.05.

RESULTS

The overall rate of induction of labour increased from 21.3% in 2012 to 30.9% in 2017, representing an Average Annual Percent Change of 8.1, P<0.0001 (95% CI 7-9.6). The greatest AAPC was seen in group 5 (parous, no previous caesarean section, 39-40 weeks, single cephalic), followed by group 2 (nulliparous, 39-40 weeks, single cephalic) and 1 (nulliparous, 37-38 weeks, single cephalic).

CONCLUSIONS

The use of the Nippita classification system allowed for standardised comparison across timepoints, facilitating identification of the subpopulations driving changes in rates of induction of labour. Rates of induction of labour saw a year on year increase which in this maternity service, it is not being driven by post-dates pregnancies. Further work is required to understand the role of other potential contributors such as diabetes.