Purpose: The rising cesarean delivery rate is attributable in part to a decline in vaginal births after cesarean (VBAC). In the 80’s and 90’s, women who had previously undergone a cesarean were encouraged to attempt a VBAC. More restrictive guidelines issued in 2004 regarding the situations in which VBAC should be offered resulted in a reversal of this trend, despite evidence that VBAC and repeat cesarean are comparable in safety. Previous cost-effective analyses of VBAC have used "expert" estimates or classification systems of patient utilities and have tended to focus on a narrow range of maternal and neonatal outcomes. In this study, we aimed to compare the cost-effectiveness of a trial of labor (TOL) to an elective repeat cesarean delivery (ERCD) for a woman with one prior cesarean delivery using utilities obtained from pregnant women and a broad range of clinical outcomes.
Method: We conducted a cost-utility analysis comparing the strategy of a TOL to that of an ERCD for women with one prior cesarean delivery. Probabilities and costs were obtained from the literature and utilities were elicited from a diverse population of pregnant women receiving prenatal care at the University of California, San Francisco, or San Francisco General Hospital.
Result: In the base case scenario, we found ERCD to be marginally cost effective, with an incremental cost-effectiveness ratio of $50,696 per quality-adjusted life-year (QALY). If the likelihood of successful VBAC is less than 35%, ERCD is the dominant strategy, as it is less costly and more effective than a TOL. In a sensitivity analysis using the 75th percentile of utilities for all TOL outcomes, TOL was found to be the dominant strategy. When the 25th percentile of utilities was applied for the most catastrophic neonatal outcomes (severe disability or death), ERCD became more cost effective with an incremental cost-effectiveness ratio of $41,122 per QALY.
Conclusion: Both TOL and ERCD are cost-effective strategies for women who have had one prior cesarean delivery. The best approach for an individual patient, however, is largely determined by her preferences. Providers should engage patients who have had one prior cesarean in meaningful discussions about their preferences and values during the process of making a patient-centered evidence-based decision regarding the approach to their next delivery.
Candidate for the Lee B. Lusted Student Prize Competition