Cost-Effectiveness of Planned Hospital vs Out-of-Hospital Vaginal Births after Cesarean in Term Pregnancies [18D]

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Given the upward trend of cesarean deliveries in the last decade, more women face the decision to pursue either a trial of labor after cesarean (TOLAC) or a repeat elective cesarean delivery. Women choose to pursue TOLAC both in the hospital setting and out of the hospital. Our study sought to evaluate the cost-effectiveness of planned hospital vs out-of-hospital vaginal birth after cesarean (VBAC) in term pregnancies.


A decision-analytic model was built using TreeAge software with probabilities, costs, and utilities derived from the literature. The primary outcomes included: cesarean sections, hypoxic ischemic encephalopathy (HIE), cerebral palsy (CP), and neonatal mortality. Secondary outcomes included: cost per quality-adjusted life year (QALY), and maternal mortality. Sensitivity analyses were employed to determine the robustness of the results.


In a theoretical cohort of 750,000 women representing yearly otherwise low-risk term attempted-VBAC in the US, planned VBAC in the hospital resulted in 282 fewer cases of neonatal HIE, 63 fewer cases of CP, and 1,419 fewer neonatal deaths when compared to intended delivery out-of-hospital. Our model suggests that planned hospital birth is cost-effective, with an incremental cost-effectiveness ratio (ICER) of $25,782/QALY. Planned hospital births also resulted in 77,550 more cesarean sections, but there was no observed difference in rates of maternal mortality.


Planned VBAC in the hospital are more expensive than home deliveries for term pregnancies, but are cost-effective. Planned hospital births reduce neonatal morbidity and mortality, and on balance increases overall QALYs, but at the cost of an increased cesarean section rate.

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