The MFMU Cesarean Registry: A Decision and Cost-Effectiveness Analysis of a Trial of labor Compared with an Elective Repeat Cesarean After a Previous Cesarean Using Propensity Scores
Open AccessObjective: To compare maternal and infant outcomes of a trial of labor after one previous cesarean delivery (TOLAC) with an elective repeat cesarean delivery (ERCD) using propensity scores and cost-effectiveness analysis (CEA).Methods: Three PS techniques, regression, stratification, and matching were compared to determine which resulted in minimal confounding bias. CEA was conducted in a short and a long-term model incorporating 1 more or up to 3 more pregnancies. CEA sensitivity analysis (one-way, multivariable as well as Monte Carlo simulation) was conducted to determine the robustness of the CEA.Results: PS matching was determined to produce minimal confounding bias. Women undergoing an ERCD were more likely to experience a hysterectomy (4.00 odds ratio [OR], 95% confidence interval [CI] 1.13-14.17) but they also experienced a lower chance of endometritis (0.57 OR, 95% CI 0.43-0.75). Neonatal composite morbidity was lower in the ERCD group (0.67 OR, 95% CI 0.55-0.80). The CEA found the TOLAC strategy preferred in the base case saving $138.6 to 164.2 million and 500 to 1703 QALYs per 100,000 women. One-way sensitivity analysis identified 5-6 variables where the preferred strategy changed. When variables were tested in Monte Carlo simulation, the model results were confirmed. The frequency of stress urinary incontinence particularly influenced the preferred strategy.Conclusions: Using PS matching, some maternal morbidity was higher and some lower in the ERCD group. CEA found the TOLAC strategy was preferred in the base case. These results were sensitive to a few variables that should be considered in the cost-effective assessment.
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