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. 2013 Sep-Oct;16(6):953-64.
doi: 10.1016/j.jval.2013.06.014.

Lifetime cost-effectiveness of trial of labor after cesarean in the United States

Sharon A Gilbert  1 , William A Grobman, Mark B Landon, Michael W Varner, Ronald J Wapner, Yoram Sorokin, Baha M Sibai, John M Thorp, Susan M Ramin, Brian M Mercer; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network
Collaborators, Affiliations

Lifetime cost-effectiveness of trial of labor after cesarean in the United States

Sharon A Gilbert et al. Value Health. 2013 Sep-Oct.

Abstract

Objective: To estimate the cost-effectiveness of a trial of labor after one previous cesarean (TOLAC) when incorporating long-term events and outcomes.

Methods: A Markov model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Women were selected from a prospective study to derive probability estimates for potential events through three subsequent pregnancies. Probabilities for cerebral palsy and stress urinary incontinence, cost data, and quality-adjusted life-years (QALYs) were obtained from the literature. The primary outcome was cost-effectiveness measured as the marginal cost per QALY gained, with a $50,000 threshold per QALY used to define cost-effectiveness.

Results: The TOLAC strategy dominated the ERCD strategy at baseline, with $164.2 million saved and 500 QALYs gained per 100,000 women. The model was sensitive to six variables: the probability of uterine rupture and successful TOLAC among women with no prior vaginal delivery, the frequency of stress urinary incontinence, and the costs of failed TOLAC, successful TOLAC, and ERCD. When the probability of TOLAC success was at the base value, 67.2%, TOLAC was preferred if the probability of uterine rupture was 3.1% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 47.2% or more. Probabilistic sensitivity analysis confirmed the base-case analysis.

Conclusions: Under baseline circumstances, TOLAC is less expensive and more effective than an ERCD when considering long-term consequences when the likelihood of success is 47.2% or more.

Keywords: accreta; cost-effectiveness; elective repeat; trial of labor.

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Conflict of interest statement

None of the authors have a conflict of interest.

Figures

Figure 1
Figure 1
Flow chart illustrates the development of the index pregnancy study groups. TOLAC, trial of labor after a previous cesarean; CD, cesarean delivery; LTCS, low transverse cesarean section; CPD, cephalopelvic disproportion; FTP, failure to progress; ERCD, elective repeat cesarean delivery; pPROM, premature rupture of the membranes.
Figure 2
Figure 2. Example of the TOLAC 2 arm of the decision tree
CP, cerebral palsy; IR-2CDPV, indicated repeat cesarean with 2 prior cesareans and one or more prior vaginal deliveries; RDS, respiratory distress syndrome; TOLAC, trial of labor after a previous cesarean; TTN, transient tachypnea of the newborn
Figure 3
Figure 3
Cost-effectiveness acceptability curve for all variables without stress urinary incontinence, costs 50-400%. ERCD, elective repeat cesarean delivery; TOLAC, trial of labor after a previous cesarean.
Figure 4
Figure 4
Cost-effectiveness acceptability curve for all variables, costs 50-400%. ERCD, elective repeat cesarean delivery; TOLAC, trial of labor after a previous cesarean.
See this image and copyright information in PMC

References

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    1. Gilbert SA, Grobman WA, Landon MB, et al. Cost-effectiveness of trial of labor after previous cesarean in a minimally biased cohort. Am J Perinatol. 2013;30:11–20. - PMC - PubMed

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