International Urogynecology Journal

, Volume 16, Issue 1, pp 19–28 | Cite as

Elective cesarean section to prevent anal incontinence and brachial plexus injuries associated with macrosomia—a decision analysis

  • Patrick J. CulliganEmail author
  • John A. Myers
  • Roger P. Goldberg
  • Linda Blackwell
  • Stephan F. Gohmann
  • Troy D. Abell
Original Article


Our aim was to determine the cost-effectiveness of a policy of elective C-section for macrosomic infants to prevent maternal anal incontinence, urinary incontinence, and newborn brachial plexus injuries. We used a decision analytic model to compare the standard of care with a policy whereby all primigravid patients in the United States would undergo an ultrasound at 39 weeks gestation, followed by an elective C-section for any fetus estimated at ≥4500 g. The following clinical consequences were considered crucial to the analysis: brachial plexus injury to the newborn; maternal anal and urinary incontinence; emergency hysterectomy; hemorrhage requiring blood transfusion; and maternal mortality. Our outcome measures included (1) number of brachial plexus injuries or cases of incontinence averted, (2) incremental monetary cost per 100,000 deliveries, (3) expected quality of life of the mother and her child, and (4) “quality-adjusted life years” (QALY) associated with the two policies. For every 100,000 deliveries, the policy of elective C-section resulted in 16.6 fewer permanent brachial plexus injuries, 185.7 fewer cases of anal incontinence, and cost savings of $3,211,000. Therefore, this policy would prevent one case of anal incontinence for every 539 elective C-sections performed. The expected quality of life associated with the elective C-section policy was also greater (quality of life score 0.923 vs 0.917 on a scale from 0.0 to 1.0 and 53.6 QALY vs 53.2). A policy whereby primigravid patients in the United States have a 39 week ultrasound-estimated fetal weight followed by C-section for any fetuses ≥4500 g appears cost effective. However, the monetary costs in our analysis were sensitive to the probability estimates of urinary incontinence following C-section and vaginal delivery and the cost estimates for urinary incontinence, vaginal delivery, and C-section.


Elective cesarean section Anal incontinence Brachial plexus injuries Macrosomia 


Contributions of authors

Dr. Culligan conceived of the idea, reviewed all of the referenced articles, helped with the tree design, and wrote the manuscript. Mr. Myers built the tree using the TreeAge software under the guidance of his professor, Dr. Abell. Dr. Abell served as mentor to Mr. Myers and built a significant portion of the tree himself. Dr. Gohmann performed the economic analysis and served as a consultant regarding cost analysis. Ms. Blackwell performed the initial literature searches for all nodes within the tree. Dr. Goldberg assisted in development of the concept for the study and aided in the manuscript preparation.


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Copyright information

© International Urogynecological Association 2004

Authors and Affiliations

  • Patrick J. Culligan
    • 1
    Email author
  • John A. Myers
    • 2
  • Roger P. Goldberg
    • 3
  • Linda Blackwell
    • 1
  • Stephan F. Gohmann
    • 4
  • Troy D. Abell
    • 5
  1. 1.Department of Obstetrics, Gynecology and Women’s Health, Division of Urogynecology and Reconstructive Pelvic SurgeryUniversity of Louisville Health Sciences CenterLouisvilleUSA
  2. 2.School of Public Health and Health Informatics, Biostatistics—Decision Science ProgramUniversity of Louisville Health Sciences CenterLouisvilleUSA
  3. 3.Evanston Continence CenterNorthwestern University Medical SchoolEvanstonUSA
  4. 4.Department of EconomicsUniversity of Louisville College of Business and Public AdministrationLouisvilleUSA
  5. 5.Abell Research ConsultingOurayUSA

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