Cost-effectiveness of trial of labor after previous cesarean in a minimally biased cohort

Abstract

Objective: To estimate the cost-effectiveness of a trial of labor after one previous cesarean delivery (TOLAC).

Study design: A model comparing TOLAC with elective repeat cesarean delivery (ERCD) was developed for a hypothetical cohort with no contraindication to a TOLAC. Probabilistic estimates were obtained from women matched on their baseline characteristics using propensity scores. Cost data, quality-adjusted life-years (QALYs), and data on cerebral palsy were incorporated from the literature.

Results: The TOLAC strategy dominated the ERCD strategy at baseline, with $138.6 million saved and 1703 QALYs gained per 100,000 women. The model was sensitive to five variables: the probability of uterine rupture, the probability of successful TOLAC, the QALY of failed TOLAC, the cost of ERCD, and the cost of successful TOLAC without complications. When the probability of TOLAC success was at the base value, 68.5%, TOLAC was preferred if the probability of uterine rupture was 4.2% or less. When the probability of uterine rupture was at the base value, 0.8%, the TOLAC strategy was preferred as long as the probability of success was 42.6% or more.

Conclusion: A TOLAC is less expensive and more effective than an ERCD in a group of women with balanced baseline characteristics.

Figure 1

Tornado Diagram of Five Variables with Thresholds. QALY, quality-adjusted life years; TOLAC, trial of labor after a previous cesarean; ERCD, elective repeat cesarean delivery