At what price? a cost-effectiveness analysis comparing trial of labour after previous caesarean versus elective repeat caesarean delivery

Objective To perform an economic evaluation on the costs and maternal health consequences associated with a trial of labour (TOL) after one previous caesarean delivery compared with elective repeat caesarean delivery (ERCD) for low risk women in an Irish context. Methods Incidence rates of adverse maternal health outcomes following a TOL and ERCD were unavailable for Ireland, therefore representative estimates were derived from a review of international literature and pooled data. Delivery/procedure costs were micro-costed based on information derived from primary data collection. Using a hypothetical cohort of 1,000 women, a cost-effectiveness analysis was performed where the measure of health gain was quality-adjusted life years (QALYs) over a six-week time horizon. Results TOL was substantially less expensive than ERCD (€1,744.48 versus €4039.87 respectively), and QALYs were modestly higher (0.84 versus 0.70). Despite maternal morbidities being twice as likely following a failed TOL than an ERCD, a TOL was found to be the most cost-effective method of delivery. The main advantages of a TOL were reduced length of stay in hospital and higher utility following a vaginal delivery. Our findings were supported by probabilistic sensitivity analysis, and net benefit analysis confirmed that the probability that a TOL was cost-effective was 100%. Conclusions In light of the revised NICE guidelines permitting caesarean delivery upon maternal request, clinicians need to be well informed of the benefits and risks of TOL among low risk women. Ideally, clinician-patient discourse would address differences in length of hospital stay, postpartum recovery time and potential obstetric complications.