Issn Print: 0029-7828

Publication Date: 1998/07/01


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Induction of Labour Versus Expectant Management for Prelabour Rupture of the Membranes at Term: An Economic Evaluation

Amiram Gafni; Ron Goeree; Terri L. Myhr; Mary E. Hannah; Gord Blackhouse; Andrew R. Willan; Julie A. Weston; Elaine E. L. Wang; Ellen D. Hodnett; Sheila A. Hewson; Dan Farine; Arne Ohlsson

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Excerpt

The TERMPROM (Term Prelabor Rupture of the Membranes) Study is an extensive multicenter international trial that enrolled 5041 women and, using a randomized controlled design, contrasted four management strategies. At the 72 participating hospitals, women at 37 or more weeks of gestation whose membranes were ruptured and who had a single fetus presenting cephalically were assigned to: induction with oxytocin (IwO); induction with prostaglandin (IwP); or expectant management with-should complications supervene-induction by oxytocin (EM-O) or prostaglandin (EM-P). Maternal infections were less prevalent in the IwO than in the EM-O group, but there were no significant group differences in the risk of neonatal infection or the cesarean delivery rate. At the same time, an economic analysis was undertaken from the perspective of third-party payers, which included all treatment costs for the mother and infant. Unit costs were estimated for Canada, the United Kingdom, and Australia, which provided a large share of participants.
Infants in the IwO group were less likely than EM-O babies to be admitted to neonatal intensive care or a special care nursery (12 percent vs. 18 percent), and they spent less time in special care nurseries when they were admitted. The IwO group also spent significantly less time in the antenatal ward than either the EM-O or IwP infants. Comparing the two prostaglandin-treated groups, expectant management related to less time on the ward. Unit costs varied substantially in different countries. Figures for cost per patient were highly skewed for each group, in large part because of the high cost of neonatal intensive care and care in a special nursery. All unit cost estimates indicated that IwO was significantly less expensive than either EM-O or IwP. The IwP and EM-P groups did not differ significantly in this respect.
Oxytocin induction, although not clinically superior to the other options examined in the TERMPROM study, is definitely less costly. The cost differences, however, probably will not be very important in many countries. When this is the case, patients should be offered an informed choice between alternative management strategies for pre-labor rupture of the membranes.
(This study is an adjunct to one of the largest randomized, controlled trials of immediate induction of labor compared with expectant management for premature rupture of membranes (PROM) at term (ME Hannah et al., N Engl J Med 1996;334:1005; Survey 1996;51:552). That study showed a small but significant increase in the incidence of clinical chorioamnionitis and postpartum endometritis in patients managed expectantly. There was no significant difference in cesarean delivery rate or incidence of neonatal infection. As I mentioned in the editorial comment about that article, the four fetal deaths not associated with congenital defects all occurred in mothers managed expectantly. Also, women in the early induction group expressed more satisfaction with their care than did women assigned to expectant management.
The present study analyzes comparative costs of the management plans of a subset of patients from Canada, The United Kingdom, and Australia; the results showed a small but statistically significant lower median cost of patients induced with oxytocin compared with those randomized to expectant management or those in whom labor was induced with prostaglandin. As might be expected, the lower costs of the group induced with oxytocin related to the lower admission-to-delivery interval and the lower number of infants admitted to the neonatal intensive care unit in this group.
The problem of how to manage patients with PROM at term has generated an enormous amount of research interest and effort. For example, Mozurkewich and Wolf recently published a meta-analysis of 23 randomized controlled trials of PROM at term involving 7593 patients (Obstet Gynecol 1997;89:1035).

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