At What Price A Cost-Effectiveness Analysis Comparing Trial of Labour after Previous Caesarean versus Elective Repeat Caesarean Delivery.docVIP

AtWhatPrice?ACost-EffectivenessAnalysisComparing TrialofLabourafterPreviousCaesareanversusElective RepeatCaesareanDelivery ChristopherG.Fawsitt1,2*,JaneBourke2,RichardA.Greene1,ClaireM.Everard3,AileenMurphy2, JenniferE.Lutomski1 1NationalPerinatalEpidemiologyCentre,Cork,Ireland,2SchoolofEconomics,UniversityCollegeCork,Cork,Ireland,3CorkUniversityMaternityHospital,Cork,Ireland Abstract Background: Elective repeat caesarean delivery (ERCD) rates have been increasing worldwide, thus prompting obstetric discourse on the risks and benefits for the mother and infant. Yet, these increasing rates also have major economic implications for the health care system. Given the dearth of information on the cost-effectiveness related to mode of delivery, the aim of this paper was to perform an economic evaluation on the costs and short-term maternal health consequences associated with a trial of labour after one previous caesarean delivery compared with ERCD for low risk womeninIreland. Methods:Usingadecisionanalyticmodel,acost-effectivenessanalysis(CEA)wasperformedwherethemeasureofhealth gainwasquality-adjustedlifeyears(QALYs)overasix-weektimehorizon.Areviewofinternationalliteraturewasconducted toderiverepresentativeestimatesofadversematernalhealthoutcomesfollowingatrialoflabouraftercaesarean(TOLAC) andERCD.Delivery/procedurecostsderivedfromprimarydatacollectionandcombinedboth‘‘bottom-up’’and‘‘top-down’’ costingestimations. Results:MaternalmorbiditiesemergedintwiceasmanycasesintheTOLACgroupthantheERCDgroup.However,aTOLAC wasfoundtobethemost-effectivemethodofdeliverybecauseitwassubstantiallylessexpensivethanERCD(J1,835.06 versus J4,039.87per women, respectively), and QALYs were modestly higher (0.84 versus 0.70). Our findings were supportedbyprobabilisticsensitivityanalysis. Conclusions: Clinicians need to be well informed of the benefits and risks of TOLAC among low risk women. Ideally, clinician-patientdiscoursewouldaddressdifferencesinlengthofhospitalstayandpostpartumrecoveryt