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An Overview of the Health Economic Implications of Elective Caesarean Section

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Abstract

The caesarean section rate has continued to increase in most industrialised countries, which raises a number of economic concerns. This review provides an overview of the health economic implications of elective caesarean section. It provides a succinct summary of the health consequences associated with elective caesarean section for both the infant and the mother over the perinatal period and beyond. It highlights factors that complicate our understanding of the health consequences of elective caesarean section, including inconsistencies in definitions and coding of the procedure, failure to adopt an intention-to-treat principle when drawing comparisons, and the widespread reliance on observational data. The paper then summarises the economic costs associated with elective caesarean section. Evidence is presented to suggest that planned caesarean section may be less costly than planned vaginal birth in some clinical contexts, for example where the singleton fetus lies in a breech position at term. In contrast, elective caesarean section (or caesarean section as a whole) appears to be more costly than vaginal delivery (either spontaneous or instrumented) in low-risk or unselected populations. The paper proceeds with an overview of economic evaluations associated with elective caesarean section. All are currently based on decision-analytic models. Evidence is presented to suggest that planned trial of labour (attempted vaginal birth) following a previous caesarean section appears to be a more cost-effective option than elective caesarean section, although its cost effectiveness is dependent upon the probability of successful vaginal delivery. There is conflicting evidence on the cost effectiveness of maternal request caesareans when compared with trial of labour. The paucity of evidence on the value pregnant women, clinicians and other groups in society place on the option of elective caesarean section is highlighted. Techniques that might be used to elicit preferences for elective caesarean section and its attributes are outlined. The review concludes with directions for future research in this area.

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References

  1. Meikle SF, Steiner CA, Zhang J, Lawrence WL. A national estimate of the elective primary cesarean delivery rate. Obstet Gynecol. 2005;105(4):751–6.

    Article  PubMed  Google Scholar 

  2. National Collaborating Centre for Women and Children’s Health (NCCWCH). Caesarean section. London: Royal College of Obstetricians and Gynaecologists, 2011.

  3. Visco AG, Viswanathan M, Lohr KN, Wechter ME, Gartlehner G, Wu JM, et al. Cesarean delivery on maternal request: maternal and neonatal outcomes. Obstet Gynecol. 2006;108(6):1517–29. doi:10.1097/01.AOG.0000241092.79282.87.

    Article  PubMed  Google Scholar 

  4. Niino Y. The increasing cesarean rate globally and what we can do about it. Biosci Trends. 2011;5(4):139–50.

    Article  CAS  PubMed  Google Scholar 

  5. MacDorman MF, Menacker F, Declercq E. Cesarean birth in the United States: epidemiology, trends, and outcomes. Clin Perinatol. 2008;35(2):293–307.

    Article  PubMed  Google Scholar 

  6. Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, et al. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet. 2006;367(9525):1819–29.

    Article  PubMed  Google Scholar 

  7. Ramachandrappa A, Jain L. Elective cesarean section: its impact on neonatal respiratory outcome. Clin Perinatol. 2008;35(2):373–93.

    Article  PubMed Central  PubMed  Google Scholar 

  8. McCourt C, Weaver J, Statham H, Beake S, Gamble J, Creedy DK. Elective cesarean section and decision making: a critical review of the literature. Birth. 2007;34(1):65–79.

    Article  PubMed  Google Scholar 

  9. Gruber J, Owings M. Physician financial incentives and cesarean section delivery. Rand J Econ. 1996;27(1):99–123.

    Article  CAS  PubMed  Google Scholar 

  10. Eckerlund I, Gerdtham UG. Econometric analysis of variation in cesarean section rates: a cross-sectional study of 59 obstetrical departments in Sweden. Int J Technol Assess. 1998;14(4):774–87.

    Article  CAS  Google Scholar 

  11. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356(9239):1375–83.

    Article  CAS  PubMed  Google Scholar 

  12. Lavender T, Hofmeyr GJ, Neilson JP, Kingdon C, Gyte GM. Caesarean section for non-medical reasons at term. Cochrane Database Syst Rev. 2012;(3):CD004660.

  13. Signore C, Klebanoff M. Neonatal morbidity and mortality after elective cesarean delivery. Clin Perinatol. 2008;35(2):361–71.

    Article  PubMed Central  PubMed  Google Scholar 

  14. MacDorman MF, Declercq E, Menacker F, Malloy MH. Infant and neonatal mortality for primary cesarean and vaginal births to women with “no indicated risk,” United States, 1998–2001 birth cohorts. Birth. 2006;33(3):175–82. doi:10.1111/j.1523-536X.2006.00102.x.

    Article  PubMed  Google Scholar 

  15. Signore C, Hemachandra A, Klebanoff M. Neonatal mortality and morbidity after elective cesarean delivery versus routine expectant management: a decision analysis. Semin Perinatol. 2006;30(5):288–95. doi:10.1053/j.semperi.2006.07.010.

    Article  PubMed  Google Scholar 

  16. Hankins GD, Clark SM, Munn MB. Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise. Semin Perinatol. 2006;30(5):276–87. doi:10.1053/j.semperi.2006.07.009.

    Article  PubMed  Google Scholar 

  17. Lee YM, D’Alton ME. Cesarean delivery on maternal request: maternal and neonatal complications. Curr Opin Obstet Gyn. 2008;20(6):597–601.

    Google Scholar 

  18. Silver RM. Delivery after previous cesarean: long-term maternal outcomes. Semin Perinatol. 2010;34(4):258–66. doi:10.1053/j.semperi.2010.03.006.

    Article  PubMed  Google Scholar 

  19. Smith GC, Pell JP, Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003;362(9398):1779–84.

    Article  PubMed  Google Scholar 

  20. Allen VM, O’Connell CM, Farrell SA, Baskett TF. Economic implications of method of delivery. Am J Obstet Gynecol. 2005;193(1):192–7.

    Article  PubMed  Google Scholar 

  21. Allen VM, O’Connell CM, Baskett TF. Cumulative economic implications of initial method of delivery. Obstet Gynecol. 2006;108(3, Part 1):549–55.

    Article  PubMed  Google Scholar 

  22. Bost BW. Cesarean delivery on demand: what will it cost? Am J Obstetr Gynecol. 2003;188(6):1418–23.

    Article  Google Scholar 

  23. Clark SL, Scott JR, Porter TF, Schlappy DA, McClellan V, Burton DA. Is vaginal birth after cesarean less expensive than repeat cesarean delivery? Am J Obstet Gynecol. 2000;182(3):599–602.

    Article  CAS  PubMed  Google Scholar 

  24. Comas M, Català L, Sala M, Payà A, Sala A, Del Amo E, et al. Descriptive analysis of childbirth healthcare costs in an area with high levels of immigration in Spain. BMC Health Serv Res. 2011;11(1):77.

    Article  PubMed Central  PubMed  Google Scholar 

  25. Declercq E, Barger M, Cabral HJ, Evans SR, Kotelchuck M, Simon C, et al. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstet Gynecol. 2007;109(3):669–77.

    Article  PubMed  Google Scholar 

  26. DiMaio H, Edwards RK, Euliano TY, Treloar RW, Cruz AC. Vaginal birth after cesarean delivery: an historic cohort cost analysis. Am J Obstet Gynecol. 2002;186(5):890–2.

    Article  PubMed  Google Scholar 

  27. Heer I, Kahlert S, Rummel S, Kümper C, Jonat W, Strauss A. Hospital treatment-is it affordable? A structured cost analysis of vaginal deliveries and planned caesarean sections. Eur J Med Res. 2009;14(11):502.

    CAS  PubMed Central  PubMed  Google Scholar 

  28. James M, Hunt K, Burr R, Johanson R. A decision analytical cost analysis of offering ECV in a UK district general hospital. BMC Health Serv Res. 2001;1(1):6.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  29. Kamath BD, Todd JK, Glazner JE, Lezotte D, Lynch AM. Neonatal outcomes after elective cesarean delivery. Obstet Gynecol. 2009;113(6):1231–8.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Kazandjian VA, Chaulk CP, Ogunbo S, Wicker K. Does a Cesarean section delivery always cost more than a vaginal delivery? J Eval Clin Pract. 2007;13(1):16–20.

    Article  PubMed  Google Scholar 

  31. Khan A, Zaman S. Costs of vaginal delivery and Caesarean section at a tertiary level public hospital in Islamabad, Pakistan. BMC Pregnancy Childbirth. 2010;10(1):2.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Palencia R, Gafni A, Hannah ME, Ross S, Willan AR, Hewson S, et al. The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial. CMAJ. 2006;174(8):1109–13. doi:10.1503/cmaj.050796.

    Article  PubMed Central  PubMed  Google Scholar 

  33. Petrou S, Glazener C. The economic costs of alternative modes of delivery during the first two months postpartum: results from a Scottish observational study. BJOG Int J Obstet Gy. 2002;109(2):214–7.

    Article  Google Scholar 

  34. Sarowar M, Medin E, Gazi R, Koehlmoos T, Rehnberg C, Saifi R, et al. Calculation of costs of pregnancy- and puerperium-related care: experience from a hospital in a low-income country. J Health Popul Nutr. 2010;28(3):264.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  35. Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. BMJ. 2013;346:f1049. doi:10.1136/bmj.f1049.

    Article  PubMed  Google Scholar 

  36. Henderson J, McCandlish R, Kumiega L, Petrou S. Systematic review of economic aspects of alternative modes of delivery. BJOG Int J Obstet Gy. 2001;108(2):149–57. doi:10.1111/j.1471-0528.2001.00044.x.

    Article  CAS  Google Scholar 

  37. Liu TC, Chen CS, Lin HC. Does elective caesarean section increase utilization of postpartum maternal medical care? Med Care. 2008;46(4):440–3. doi:10.1097/MLR.0b013e31816493e9.

    Article  PubMed  Google Scholar 

  38. Steer PJ, Modi N. Elective caesarean sections: risks to the infant. Lancet. 2009;374(9691):675–6. doi:10.1016/S0140-6736(09)61544-0.

    Article  PubMed  Google Scholar 

  39. Chen KT, Sell RL, Tuomala RE. Cost-effectiveness of elective cesarean delivery in human immunodeficiency virus-infected women. Obstet Gynecol. 2001;97(2):161–8.

    Article  CAS  PubMed  Google Scholar 

  40. Chung A, Macario A, El-Sayed YY, Riley ET, Duncan B, Druzin ML. Cost-effectiveness of a trial of labor after previous cesarean. Obstet Gynecol. 2001;97(6):932–41.

    Article  CAS  PubMed  Google Scholar 

  41. Culligan PJ, Myers JA, Goldberg RP, Blackwell L, Gohmann SF, Abell TD. Elective cesarean section to prevent anal incontinence and brachial plexus injuries associated with macrosomia: a decision analysis. Int Urogynecol J. 2005;16(1):19–28.

    Article  Google Scholar 

  42. Fawsitt CG, Bourke J, Greene RA, Everard CM, Murphy A, Lutomski JE. At what price? A cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery. PloS One. 2013;8(3):e58577.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  43. Grobman WA, Peaceman AM, Socol ML. Cost-effectiveness of elective cesarean delivery after one prior low transverse cesarean. Obstet Gynecol. 2000;95(5):745–51.

    Article  CAS  PubMed  Google Scholar 

  44. Halpern MT, Read JS, Ganoczy DA, Harris DR. Cost-effectiveness of cesarean section delivery to prevent mother-to-child transmission of HIV-1. AIDS. 2000;14(6):691–700.

    Article  CAS  PubMed  Google Scholar 

  45. Herbst MA. Treatment of suspected fetal macrosomia: a cost-effectiveness analysis. Am J Obstet Gynecol. 2005;193(3 Pt 2):1035.

    Article  PubMed  Google Scholar 

  46. Mrus JM, Goldie SJ, Weinstein MC, Tsevat J. The cost-effectiveness of elective cesarean delivery for HIV-infected women with detectable HIV RNA during pregnancy. AIDS. 2000;14(16):2543–52.

    Article  CAS  PubMed  Google Scholar 

  47. Plunkett BA, Grobman WA. Elective cesarean delivery to prevent perinatal transmission of hepatitis C virus: a cost-effectiveness analysis. Am J Obstet Gynecol. 2004;191(3):998–1003.

    Article  PubMed  Google Scholar 

  48. Schackman BR, Oneda K, Goldie SJ. The cost-effectiveness of elective cesarean delivery to prevent hepatitis C transmission in HIV-coinfected women. AIDS. 2004;18(13):1827–34.

    Article  PubMed  Google Scholar 

  49. Xu X, Ivy JS, Patel DA, Patel SN, Smith DG, Ransom SB, et al. Pelvic floor consequences of cesarean delivery on maternal request in women with a single birth: a cost-effectiveness analysis. J Women’s Health. 2010;19(1):147–60.

    Article  Google Scholar 

  50. Eden KB, Hashima JN, Osterweil P, Nygren P, Guise JM. Childbirth preferences after cesarean birth: a review of the evidence. Birth. 2004;31(1):49–60.

    Article  PubMed  Google Scholar 

  51. Mazzoni A, Althabe F, Liu NH, Bonotti AM, Gibbons L, Sánchez AJ, et al. Women’s preference for caesarean section: a systematic review and meta-analysis of observational studies. BJOG Int J Obstet Gynaecol. 2011;118(4):391–9. doi:10.1111/j.1471-0528.2010.02793.x.

    Article  CAS  Google Scholar 

  52. Paterson-Brown S. Should doctors perform an elective caesarean section on request? Yes, as long as the woman is fully informed. BMJ. 1998;317(7156):462–3.

    Article  CAS  PubMed  Google Scholar 

  53. Cotzias CS, Paterson-Brown S, Fisk NM. Obstetricians say yes to maternal request for elective caesarean section: a survey of current opinion. Eur J Obstet Gynecol Reprod Biol. 2001;97(1):15–6.

    Article  CAS  PubMed  Google Scholar 

  54. Klein MC, Liston R, Fraser WD, Baradaran N, Hearps SJ, Tomkinson J, et al. Attitudes of the new generation of Canadian obstetricians: how do they differ from their predecessors? Birth. 2011;38(2):129–39. doi:10.1111/j.1523-536X.2010.00462.x.

    Article  PubMed  Google Scholar 

  55. Gartoulla P, Liabsuetrakul T, Pradhan N. Change in willingness to pay for normal delivery and caesarean section during pregnancy and after delivery in Kathmandu. Trop Med Int Health. 2010;15(10):1227–34. doi:10.1111/j.1365-3156.2010.02596.x.

    Article  PubMed  Google Scholar 

  56. Petrou S, Gray A. Economic evaluation alongside randomised controlled trials: design, conduct, analysis, and reporting. BMJ. 2011;342:d1548. doi:10.1136/bmj.d1548.

    Article  PubMed Central  PubMed  Google Scholar 

  57. OECD Health Data: health care resources. OECD Health Statistics. Paris: Organisation for Economic Co-operation and Development (OECD); 2012. Available from: http://www.oecd-ilibrary.org/social-issues-migration-health/data/oecd-health-statistics_health-data-en.

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Acknowledgements

The Warwick Clinical Trials Unit benefited from facilities funded through the Birmingham Science City Translational Medicine Clinical Research and Infrastructure Trials Platform, with support from Advantage West Midlands. The funding bodies had no influence on the writing of this paper or the decision to submit the paper for publication. The views contained in the paper are those of the authors and not necessarily of the funding bodies.

Conflicts of interest

Stavros Petrou and Kamran Khan have no conflicts of interest to declare that are directly relevant to the content of this review.

Author contributions

Stavros Petrou designed this review article, synthesised and interpreted the relevant information, and wrote the article. Kamran Khan conducted the literature reviews and extracted relevant data from selected studies. Stavros Petrou acts as the guarantor for the overall content.

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Authors and Affiliations

  1. Clinical Trials Unit, Gibbet Hill Road, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL, UK

    Stavros Petrou & Kamran Khan

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  1. Stavros Petrou
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  2. Kamran Khan
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Correspondence to Stavros Petrou.

Appendices

Appendix A: Search Strategy

Research studies on the costs and cost effectiveness of aspects of elective caesarean section were identified by searches of the following electronic bibliographic databases: PubMed, MEDLINE, EMBASE, CINAHL, The Cochrane Library (CDSR), Web of Knowledge and Google Scholar.

In order for the analyses to be considered appropriate to the modern context, studies were excluded from the literature search if they were published before 2000. Studies were also excluded if the abstract was not published in the English language or if the focus was animal research. The Medical Subject Heading (MeSH) terms used in all searches were:

“Caesarean section” or “Cesarean section” or “Cesarean section” or “C section” or “Laparotomy” or “Hysterotomy”—[All Fields] and [MeSH Terms]

combined with:

“Economics” or “Economic” or “Cost” or “Financial” or “cost-effectiveness”—[All Fields] and [MeSH Terms], “Burden”—[All Fields].

Appendix B

See Table 4.

Table 4 Results of studies reporting economic costs by mode of delivery; studies including a caesarean section comparator published since 2000
Full size table

Appendix C

See Table 5.

Table 5 Results of economic evaluations; studies including a caesarean section comparator published since 2000
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Petrou, S., Khan, K. An Overview of the Health Economic Implications of Elective Caesarean Section. Appl Health Econ Health Policy 11, 561–576 (2013). https://doi.org/10.1007/s40258-013-0063-8

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