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

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Abstract

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.

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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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Authors and Affiliations

  1. Department of Obstetrics, Gynecology and Women’s Health, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Louisville Health Sciences Center, 315 East Broadway M-18, Louisville, KY 40202, USA

    Patrick J. Culligan & Linda Blackwell

  2. School of Public Health and Health Informatics, Biostatistics—Decision Science Program, University of Louisville Health Sciences Center, Louisville, KY, USA

    John A. Myers

  3. Evanston Continence Center, Northwestern University Medical School, Evanston, IL, USA

    Roger P. Goldberg

  4. Department of Economics, University of Louisville College of Business and Public Administration, Louisville, KY, USA

    Stephan F. Gohmann

  5. Abell Research Consulting, Ouray, CO, USA

    Troy D. Abell

Authors
  1. Patrick J. Culligan
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  2. John A. Myers
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  3. Roger P. Goldberg
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  4. Linda Blackwell
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  5. Stephan F. Gohmann
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  6. Troy D. Abell
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Corresponding author

Correspondence to Patrick J. Culligan.

Additional information

Editorial Comment: This is an interesting decision analysis looking at a unique method for determining who would be a candidate for an elective cesarean section. In this decision analysis, all patients have an ultrasound at 39 weeks estimated gestational age (EGA) and if it is estimated that the fetal weight is greater than 4500 g, that patient would be recommended for an elective cesarean section. This would then be a cost-effective way of reducing the risk of brachial plexus injury to the infant and reduce the risk of fecal incontinence. One of the most fascinating aspects of this paper is that even though they looked at this as a strategy to prevent urinary incontinence, they could not show that this would significantly reduce the incidence of urinary incontinence. This together with several other large epidemiologic studies are starting to cast doubt on the strategy of elective cesarean section to prevent urinary incontinence. One of the questions that always surfaces after reviewing this type of article is that while we can pick out specific diseases such as brachial plexus injury and anal incontinence, it is difficult to determine the impact of all the other potential complications and benefits. Until a large prospective randomized trial is done comparing a strategy of offering patients elective cesarean versus planned vaginal delivery, it will be impossible to know what the real impact of elective cesarean sections will be.

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Culligan, P.J., Myers, J.A., Goldberg, R.P. et al. Elective cesarean section to prevent anal incontinence and brachial plexus injuries associated with macrosomia—a decision analysis. Int Urogynecol J 16, 19–28 (2005). https://doi.org/10.1007/s00192-004-1203-3

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  • DOI: https://doi.org/10.1007/s00192-004-1203-3

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