Is vaginal birth after cesarean less expensive than repeat cesarean delivery?

OBJECTIVE: This study was undertaken to compare total medical costs of tria l of labor after cesarean with those of elective repeat cesarean without la bor, with both short- and long-term neonatal costs associated with such pro cedures taken into account. STUDY DESIGN: Costs associated with All Patient Refined diagnosis-related g roups and Current Procedural Terminology for a large not-for-profit health care system were applied to an algorithm describing maternal and neonatal o utcomes of trial of labor. Perinatal morbidity rates and cost estimates for long-term neurologic damage associated with uterine rupture were derived f rom published literature. RESULTS: If a 70% vaginal birth rate for women undergoing a trial of labor and delivery in a tertiary center with a mean uterine rupture to delivery t ime of 13 minutes is assumed, the net cost differential ranged from a savin g of $149 to a loss of $217, depending on morbidity assumptions. For vagina l birth after cesarean success rates <70%, trial of labor in the presence o f two previous scars, and institutional factors increasing the perinatal mo rbidity rate by just 4% with respect to that seen in tertiary centers, tria l of labor resulted in a net financial loss to the health care system regar dless of all other assumptions made. CONCLUSIONS: When costs as opposed to charges are considered and the cost o f long-term care for neurologically injured infants is taken into account, trial of labor after previous cesarean is unlikely to be associated with a significant cost saving for the health care system. Recent government-manda ted length-of-stay requirements are likely to make the economic benefit of vaginal birth after cesarean even less favorable. Factors other than cost m ust govern decisions regarding trial of labor or repeat cesarean.