The cost-effectiveness of a trial of labor accrues with multiple subsequent vaginal deliveries.
OBJECTIVE
The purpose of this study was to estimate costs and outcomes of subsequent trials of labor after cesarean delivery (TOLAC) compared with elective repeat cesarean deliveries (ERCD).


METHODS
To compare TOLAC and ERCD, maternal and neonatal decision analytic models were built for each hypothetic subsequent delivery. We assumed that only women without previa would undergo TOLAC for their second delivery, that women with successful TOLAC would desire future TOLAC, and that women who chose ERCD would undergo subsequent ERCD. Main outcome measures were maternal and neonatal mortality and morbidity rates, direct costs, and quality-adjusted life years. Values were derived from the literature. One-way and Monte-Carlo sensitivity analyses were performed.


RESULTS
TOLAC was less costly and more effective for most models. A progression of decreasing incremental cost and increasing incremental effectiveness of TOLAC was found for maternal outcomes with increasing numbers of subsequent deliveries. This progression was also displayed among neonatal outcomes and was most prominent when neonatal and maternal outcomes were combined, with an incremental cost and effectiveness of -$4700.00 and .073, respectively, for the sixth delivery. Net-benefit analysis showed an increase in the benefit of TOLAC with successive deliveries for all outcomes. The maternal model of the second delivery was sensitive to cost of delivery and emergent cesarean delivery. Successive maternal models became more robust, with the models of the third-sixth deliveries sensitive only to cost of delivery. Neonatal models were not sensitive to any variables.


CONCLUSIONS
Although nearly equally effective relative to ERCD for the second delivery, TOLAC becomes less costly and more effective with subsequent deliveries.
Pritzker School of Medicine, University of Chicago, Chicago, IL.
Kevin M
KM
Wymer
Department of Medicine, University of Chicago, Chicago, IL.
Ya-Chen Tina
YC
Shih
Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, IL. Electronic address: bplunkett@northshore.org.
Beth A
BA
Plunkett
D017604:Cesarean Section, Repeat / Q000191:economics*; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D007232:Infant, Newborn, Diseases / Q000191:economics; D008428:Maternal Mortality; D018803:Models, Economic; D009010:Monte Carlo Method; D011183:Postoperative Complications / Q000191:economics; D011247:Pregnancy; D011248:Pregnancy Complications / Q000191:economics; D011256:Pregnancy Outcome / Q000191:economics; D019057:Quality-Adjusted Life Years; D014219:Trial of Labor; D014481:United States; D016064:Vaginal Birth after Cesarean / Q000191:economics*
cost-effectiveness analysis; trial of labor after cesarean delivery