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Am J Perinatol 2013; 30(01): 011-020
DOI: 10.1055/s-0032-1333206
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Cost-Effectiveness of Trial of Labor after Previous Cesarean in a Minimally Biased Cohort

Sharon A. Gilbert
1   The George Washington University Biostatistics Center, Washington, District of Columbia
,
William A. Grobman
2   The Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
,
Mark B. Landon
3   The Ohio State University, Columbus, Ohio
,
Catherine Y. Spong
4   The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
,
Dwight J. Rouse
5   University of Alabama at Birmingham, Alabama
,
Kenneth J. Leveno
6   University of Texas Southwestern Medical Center, Dallas, Texas
,
Michael W. Varner
7   University of Utah, Salt Lake City, Utah
,
Ronald J. Wapner
8   Thomas Jefferson University, Philadelphia, Pennsylvania
,
Yoram Sorokin
9   Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan
,
Mary J. O'Sullivan
10   University of Miami, Miami, Florida
,
Baha M. Sibai
11   University of Tennessee, Memphis, Tennessee
,
John M. Thorp
12   University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
,
Susan M. Ramin
13   The University of Texas Health Science Center at Houston, Houston, Texas
,
Brian M. Mercer
14   Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio
,
for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network › Author Affiliations
Further Information

Publication History

29 November 2012

06 December 2012

Publication Date:
04 January 2013 (online)

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Abstract

Objective To estimate the cost-effectiveness of a trial of labor after one previous cesarean delivery (TOLAC).

Study Design A model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Probabilistic estimates were obtained from women matched on their baseline characteristics using propensity scores. Cost data, quality-adjusted life-years (QALYs), and data on cerebral palsy were incorporated from the literature.

Results The TOLAC strategy dominated the ERCD strategy at baseline, with $138.6 million saved and 1703 QALYs gained per 100,000 women. The model was sensitive to five variables: the probability of uterine rupture, the probability of successful TOLAC, the QALY of failed TOLAC, the cost of ERCD, and the cost of successful TOLAC without complications. When the probability of TOLAC success was at the base value, 68.5%, TOLAC was preferred if the probability of uterine rupture was 4.2% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 42.6% or more.

Conclusion A TOLAC is less expensive and more effective than an ERCD in a group of women with balanced baseline characteristics.

Keywords

cost-effectiveness - elective repeat cesarean - trial of labor - propensity scores

Presented at the 32nd Annual Meeting of the Society for Maternal-Fetal Medicine. February 6 to 11, 2012. Dallas, Texas.


 

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