title: Economic Evaluations Comparing a Trial of Labor with an Elective Repeat Cesarean Delivery: A Systematic Review.
abstract: For women who have had a previous low transverse cesarean delivery, the decision to undergo a trial of labor after cesarean (TOLAC) or an elective repeat cesarean delivery (ERCD) has important clinical and economic ramifications.
  
  
  
  To evaluate the cost-effectiveness of the alternative choices of a TOLAC and an ERCD for women with low-risk, singleton gestation pregnancies.
  
  
  
  We searched EMBASE, MEDLINE, CINAHL, Cochrane Library, EconLit, and the Cost-Effectiveness Analysis Registry with no language, publication, or date restrictions up until October 2015. Studies were included if they were primary research, compared a TOLAC with an ERCD, and provided information on the relative cost of the alternatives. Abstracts and partial economic evaluations were excluded.
  
  
  
  Of 310 studies initially reviewed, 7 studies were included in the systematic review. In the base-case analyses, 4 studies concluded that TOLAC was dominant over ERCD, 1 study found ERCD to be dominant, and 2 studies found that although TOLAC was more costly, it offered more benefits and was thus cost-effective from a population perspective when considering societal willingness to pay for better outcomes. In sensitivity analyses, cost-effectiveness was found to be dependent on a high likelihood of TOLAC success, low risk of uterine rupture, and low relative cost of TOLAC compared with ERCD.
  
  
  
  For women who are likely to have a successful vaginal delivery, routine ERCD may result in excess morbidity and cost from a population perspective.
authors.affiliation: Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA. Electronic address: rogersaj@uab.edu.
authors.forename: Anna Joy
authors.initials: AJ
authors.lastname: Rogers
authors.affiliation: Departments of Medicine and Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.
authors.forename: Nathaniel G
authors.initials: NG
authors.lastname: Rogers
authors.affiliation: Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
authors.forename: Meredith L
authors.initials: ML
authors.lastname: Kilgore
authors.affiliation: Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
authors.forename: Akila
authors.initials: A
authors.lastname: Subramaniam
authors.affiliation: Maternal-Fetal Medicine Division, Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
authors.forename: Lorie M
authors.initials: LM
authors.lastname: Harper
mesh_terms: D017604:Cesarean Section, Repeat / Q000191:economics*; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D017059:Models, Econometric; D011247:Pregnancy; D015203:Reproducibility of Results; D014219:Trial of Labor; D016064:Vaginal Birth after Cesarean / Q000191:economics*
keywords: cesarean delivery; cost; economics; effectiveness; elective surgical procedures; pregnancy complications; probability; quality-adjusted life-years; trial of labor; utility; vaginal birth after cesarean