Cost-effectiveness of a trial of labor after previous cesarean

Objective: To determine the cost-effective method of delivery, from society 's perspective, in patients who have had a previous cesarean. Methods: We completed an incremental cost-effectiveness analysis of a trial of labor relative to cesarean using a computerized model for a hypothetica l 30-year old parturient. The model incorporated data from peer-reviewed st udies, actual hospital costs, and utilities to quantify health-related qual ity of life. A threshold of $50,000 per quality-adjusted life-years was use d to define cost-effective. Results: The model was most sensitive to the probability of successful vagi nal delivery. If the probability of successful vaginal birth after cesarean (VBAC) was less than 0.65, elective repeat cesarean was both less costly a nd more effective than a trial of labor. Between 0.65 and 0.74, elective re peat cesarean was cost-effective (the cost-effectiveness ratio was less tha n $50,000 per quality-adjusted life-years), because, although it cost more than VBAC, it was offset by improved outcomes. Between 0.74 and 0.76, trial of labor was cost-effective. If the probability of successful vaginal deli very exceeded 0.76, trial of labor became less costly and more effective. C osts associated with a moderately morbid neonatal outcome, as well as the p robabilities of infant morbidity occurring, heavily impacted our results. Conclusion: The cost-effectiveness of VBAC depends on the likelihood of suc cessful trial of labor. Our modeling suggests that a trial of labor is cost -effective if the probability of successful vaginal delivery is greater tha n 0.74. Improved algorithms are needed to more precisely estimate the likel ihood that a patient with a previous cesarean will have a successful vagina l delivery. (Obstet Gynecol 2001;97:932-41. (C) 2001 by The American Colleg e of Obstetricians and Gynecologists.).