Cost-effectiveness of a trial of labor after previous cesarean.
OBJECTIVE
To determine the cost-effective method of delivery, from society's perspective, in patients who have had a previous cesarean.


METHODS
We completed an incremental cost-effectiveness analysis of a trial of labor relative to cesarean using a computerized model for a hypothetical 30-year old parturient. The model incorporated data from peer-reviewed studies, actual hospital costs, and utilities to quantify health-related quality of life. A threshold of $50,000 per quality-adjusted life-years was used to define cost-effective.


RESULTS
The model was most sensitive to the probability of successful vaginal delivery. If the probability of successful vaginal birth after cesarean (VBAC) was less than 0.65, elective repeat cesarean was both less costly and more effective than a trial of labor. Between 0.65 and 0.74, elective repeat cesarean was cost-effective (the cost-effectiveness ratio was less than $50,000 per quality-adjusted life-years), because, although it cost more than VBAC, it was offset by improved outcomes. Between 0.74 and 0.76, trial of labor was cost-effective. If the probability of successful vaginal delivery exceeded 0.76, trial of labor became less costly and more effective. Costs associated with a moderately morbid neonatal outcome, as well as the probabilities of infant morbidity occurring, heavily impacted our results.


CONCLUSIONS
The cost-effectiveness of VBAC depends on the likelihood of successful trial of labor. Our modeling suggests that a trial of labor is cost-effective if the probability of successful vaginal delivery is greater than 0.74. Improved algorithms are needed to more precisely estimate the likelihood that a patient with a previous cesarean will have a successful vaginal delivery.
Chung
A
A
Department of Anesthesia and Gynecology and Obstetrics, Stanford University School of Medicine, Stanford, California 94305-5640, USA.
Macario
A
A
El-Sayed
Y Y
YY
Riley
E T
ET
Duncan
B
B
Druzin
M L
ML
D000328:Adult; D002140:California; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005260:Female; D017048:Health Care Costs; D006801:Humans; D007226:Infant Mortality / Q000639:trends*; D007231:Infant, Newborn; D017059:Models, Econometric; D007744:Obstetric Labor Complications / Q000191:economics* / Q000453:epidemiology; D011247:Pregnancy; D011256:Pregnancy Outcome; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D014219:Trial of Labor; D016064:Vaginal Birth after Cesarean / Q000191:economics* / Q000379:methods*