title: Pelvic floor consequences of cesarean delivery on maternal request in women with a single birth: a cost-effectiveness analysis.
abstract: BACKGROUND
  The potential benefit in preventing pelvic floor disorders (PFDs) is a frequently cited reason for requesting or performing cesarean delivery on maternal request (CDMR). However, for primigravid women without medical/obstetric indications, the lifetime cost-effectiveness of CDMR remains unknown, particularly with regard to lifelong pelvic floor consequences. Our objective was to assess the cost-effectiveness of CDMR in comparison to trial of labor (TOL) for primigravid women without medical/obstetric indications with a single childbirth over their lifetime, while explicitly accounting for the management of PFD throughout the lifetime.
  
  
  METHODS
  We used Monte Carlo simulation of a decision model containing 249 chance events and 101 parameters depicting lifelong maternal and neonatal outcomes in the following domains: actual mode of delivery, emergency hysterectomy, transient maternal morbidity and mortality, perinatal morbidity and mortality, and the lifelong management of PFDs. Parameter estimates were obtained from published literature. The analysis was conducted from a societal perspective. All costs and quality-adjusted life-years (QALYs) were discounted to the present value at childbirth.
  
  
  RESULTS
  The estimated mean cost and QALYs were $14,259 (95% confidence interval [CI] $8,964-$24,002) and 58.21 (95% CI 57.43-58.67) for CDMR and $13,283 (95% CI $7,861-$23,829) and 57.87 (95% CI 56.97-58.46) for TOL over the combined lifetime of the mother and the child. Parameters related to PFDs play an important role in determining cost and quality of life.
  
  
  CONCLUSIONS
  When a woman without medical/obstetric indications has only one childbirth in her lifetime, cost-effectiveness analysis does not reveal a clearly preferable mode of delivery.
authors.affiliation: Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan 48109, USA. xiaox@med.umich.edu
authors.forename: Xiao
authors.initials: X
authors.lastname: Xu
authors.forename: Julie S
authors.initials: JS
authors.lastname: Ivy
authors.forename: Divya A
authors.initials: DA
authors.lastname: Patel
authors.forename: Sejal N
authors.initials: SN
authors.lastname: Patel
authors.forename: Dean G
authors.initials: DG
authors.lastname: Smith
authors.forename: Scott B
authors.initials: SB
authors.lastname: Ransom
authors.forename: Dee
authors.initials: D
authors.lastname: Fenner
authors.forename: John O L
authors.initials: JO
authors.lastname: Delancey
mesh_terms: D000465:Algorithms; D002585:Cesarean Section / Q000009:adverse effects / Q000191:economics* / Q000523:psychology; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D036861:Delivery, Obstetric / Q000191:economics / Q000379:methods*; D017558:Elective Surgical Procedures / Q000191:economics*; D005242:Fecal Incontinence / Q000209:etiology; D005260:Female; D020073:Gravidity; D006801:Humans; D009010:Monte Carlo Method; D017773:Pelvic Floor; D056887:Pelvic Organ Prolapse / Q000209:etiology; D011247:Pregnancy; D011256:Pregnancy Outcome; D011788:Quality of Life; D019057:Quality-Adjusted Life Years; D014219:Trial of Labor; D014549:Urinary Incontinence / Q000209:etiology