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.

FIG. 1.

Decision tree model for one term singleton birth without medical or obstetric indications. Part A of the figure illustrates the portion of the decision tree related to short-term maternal and neonatal outcomes. Part B of the figure depicts the portion of the decision tree related to the long-term pelvic floor consequences. Square, decision node; circle, chance node; triangle, end node; double slash, branch continues with the Lifelong Pelvic Floor Consequences subtree.

FIG. 2.

Incremental cost-effectiveness plane. The horizontal axis represents the difference in quality-adjusted life-years (QALYs) between cesarean delivery on maternal request (CDMR) and trial of labor (TOL) (i.e., incremental QALY). The vertical axis represents the difference in the costs between CDMR and TOL (i.e., incremental cost). Each dot in the figure corresponds to one incremental cost and incremental QALY pair resulting from one iteration of the Monte Carlo simulation.

FIG. 3.

Cost-effectiveness acceptability curve. This figure illustrates the probability that cesarean delivery on maternal request (CDMR) is cost-effective compared with trial of labor (TOL) for a given cutoff cost-effectiveness ratio that a society is willing to pay. For example, if a society is willing to pay $50,000 for one QALY, there is an 82% chance that undergoing CDMR is cost-effective (i.e., there is an 82% chance that the additional cost of CDMR is < $50,000 for each additional QALY gained).