Download PDF
Am J Perinatol 2024; 41(S 01): e2878-e2885
DOI: 10.1055/s-0043-1776352
Original Article

Economic Analysis of Induction versus Elective Cesarean in Term Nulliparas with Supermorbid Obesity

Lea Nehme
1   Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
,
Rebecca Horgan 
1   Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
,
Jerri Waller
1   Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
,
Priyanka Kumar
2   Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, Virginia
,
Carole Barake
3   Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
,
Jim C. Huang
4   Department of Business Management, National Sun Yat-Sen University, Kaohsiung, Taiwan
,
George Saade
1   Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
,
Tetsuya Kawakita
1   Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective We sought to evaluate the economic benefit of the induction of labor compared with elective cesarean delivery in individuals with supermorbid obesity (body mass index 60 kg/m2 or greater) at term.

Study Design We developed an economic analysis model to compare induction of labor with elective cesarean delivery in nulliparous individuals with supermorbid obesity at term. The primary outcome was the total cost per strategy from a health system perspective with elective cesarean delivery as a reference group. Pregnancy outcomes for the index and subsequent pregnancies were considered. When available, probabilities of pregnancy outcomes were extracted from our institutions. Rare pregnancy outcomes, relative risks, and costs were derived from the literature. All costs in this analysis were inflated to 2022 USD (U.S. dollar). To determine the robustness of the decision model, we conducted one-way sensitivity analyses by changing point estimates of variables. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation repeating 1,000 times to test the robustness of the results in the setting of simultaneous changes in probabilities, relative risks, and costs.

Results In the base-case analysis, assuming that 72.7% of nulliparous individuals undergoing induction of labor would have a cesarean delivery, induction of labor would cost $41,084 compared with $40,742 for elective cesarean delivery, resulting in a higher cost of $342 per nulliparous individuals with supermorbid obesity. In a sensitivity analysis, we found that induction of labor compared with elective cesarean is less economical if the probability of cesarean delivery after induction of labor exceeds 71%. Monte Carlo simulation suggests that elective cesarean delivery was the preferred cost-beneficial strategy with a frequency of 53.5%.

Conclusion: Among our patient population, induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals with supermorbid obesity.

Key Points

  • The prevalence of obesity in the United States continues to rise.

  • Morbid obesity compared with normal weight is associated with increased risks of adverse pregnancy outcomes.

  • Induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals.

Keywords

obesity - induction of labor - cesarean delivery - economic analysis

Note

This paper was presented as a poster at the SMFM 43rd Annual Meeting-The pregnancy meeting, San Francisco, CA (February 2023).


Supplementary Material



Publication History

Received: 30 July 2023

Accepted: 25 September 2023

Article published online:
10 November 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity among adults and youth: United States,. 2015–2016. 2017
    Google Scholar
  • 2 Ogden CL, Fryar CD, Martin CB. et al. Trends in obesity prevalence by race and Hispanic origin—1999–2000 to 2017–2018. JAMA 2020; 324 (12) 1208-1210
    CrossrefPubMedGoogle Scholar
  • 3 Chung JH, Melsop KA, Gilbert WM, Caughey AB, Walker CK, Main EK. Increasing pre-pregnancy body mass index is predictive of a progressive escalation in adverse pregnancy outcomes. J Matern Fetal Neonatal Med 2012; 25 (09) 1635-1639
    CrossrefPubMedGoogle Scholar
  • 4 Pettersen-Dahl A, Murzakanova G, Sandvik L, Laine K. Maternal body mass index as a predictor for delivery method. Acta Obstet Gynecol Scand 2018; 97 (02) 212-218
    CrossrefPubMedGoogle Scholar
  • 5 Chu SY, Kim SY, Schmid CH. et al. Maternal obesity and risk of cesarean delivery: a meta-analysis. Obes Rev 2007; 8 (05) 385-394
    CrossrefPubMedGoogle Scholar
  • 6 Blomberg M. Maternal obesity and risk of postpartum hemorrhage. Obstet Gynecol 2011; 118 (03) 561-568
    CrossrefPubMedGoogle Scholar
  • 7 American College of Obstetricians and Gynecologists. Obesity in pregnancy: ACOG practice bulletin, number 230. Obstet Gynecol 2021; 137 (06) e128-e144
    CrossrefPubMedGoogle Scholar
  • 8 Hibbard JU, Gilbert S, Landon MB. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery. Obstet Gynecol 2006; 108 (01) 125-133
    CrossrefPubMedGoogle Scholar
  • 9 Leth RA, Uldbjerg N, Nørgaard M, Møller JK, Thomsen RW. Obesity, diabetes, and the risk of infections diagnosed in hospital and post-discharge infections after cesarean section: a prospective cohort study. Acta Obstet Gynecol Scand 2011; 90 (05) 501-509
    CrossrefPubMedGoogle Scholar
  • 10 Allen VM, O'Connell CM, Baskett TF. Maternal morbidity associated with cesarean delivery without labor compared with induction of labor at term. Obstet Gynecol 2006; 108 (02) 286-294
    CrossrefPubMedGoogle Scholar
  • 11 Paidas Teefey C, Reforma L, Koelper NC. et al. Risk factors associated with cesarean delivery after induction of labor in women with class III obesity. Obstet Gynecol 2020; 135 (03) 542-549
    CrossrefPubMedGoogle Scholar
  • 12 Bjorklund J, Wiberg-Itzel E, Wallstrom T. Is there an increased risk of cesarean section in obese women after induction of labor? A retrospective cohort study. PLoS One 2022; 17 (02) e0263685
    CrossrefPubMedGoogle Scholar
  • 13 Hopkins MK, Grotegut CA, Swamy GK, Myers ER, Havrilesky LJ. Induction of labor versus scheduled cesarean in morbidly obese women: a cost-effectiveness analysis. Am J Perinatol 2019; 36 (04) 399-405
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Yao R, Ananth CV, Park BY, Pereira L, Plante LA. Perinatal Research Consortium. Obesity and the risk of stillbirth: a population-based cohort study. Am J Obstet Gynecol 2014; 210 (05) 457.e1-457.e9
    CrossrefPubMedGoogle Scholar
  • 15 Hermesch AC, Allshouse AA, Heyborne KD. Body mass index and the spontaneous onset of parturition. Obstet Gynecol 2016; 128 (05) 1033-1038
    CrossrefPubMedGoogle Scholar
  • 16 Jardine J, Blotkamp A, Gurol-Urganci I. et al. Risk of complicated birth at term in nulliparous and multiparous women using routinely collected maternity data in England: cohort study. BMJ 2020; 371: m3377
    CrossrefPubMedGoogle Scholar
  • 17 Landon MB, Hauth JC, Leveno KJ. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004; 351 (25) 2581-2589
    CrossrefPubMedGoogle Scholar
  • 18 Riskin-Mashiah S. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol 2004; 104 (03) 633-634 , author reply 633
    CrossrefPubMedGoogle Scholar
  • 19 Subramaniam A, Jauk VC, Goss AR, Alvarez MD, Reese C, Edwards RK. Mode of delivery in women with class III obesity: planned cesarean compared with induction of labor. Am J Obstet Gynecol 2014; 211 (06) 700.e1-700.e9
    CrossrefPubMedGoogle Scholar
  • 20 Clark-Ganheart CA, Reddy UM, Kominiarek MA, Huang CC, Landy HJ, Grantz KL. Pregnancy outcomes among obese women and their offspring by attempted mode of delivery. Obstet Gynecol 2015; 126 (05) 987-993
    CrossrefPubMedGoogle Scholar
  • 21 Spiliopoulos M, Kareti A, Jain NJ, Kruse LK, Hanlon A, Dandolu V. Risk of peripartum hysterectomy by mode of delivery and prior obstetric history: data from a population-based study. Arch Gynecol Obstet 2011; 283 (06) 1261-1268
    CrossrefPubMedGoogle Scholar
  • 22 Shellhaas CS, Gilbert S, Landon MB. et al; Eunice Kennedy Shriver National Institutes of Health and Human Development (NICHD) Maternal–Fetal Medicine Units Network (MFMU). The frequency and complication rates of hysterectomy accompanying cesarean delivery. Obstet Gynecol 2009; 114 (2 Pt 1): 224-229
    CrossrefPubMedGoogle Scholar
  • 23 James AH, Jamison MG, Brancazio LR, Myers ER. Venous thromboembolism during pregnancy and the postpartum period: incidence, risk factors, and mortality. Am J Obstet Gynecol 2006; 194 (05) 1311-1315
    CrossrefPubMedGoogle Scholar
  • 24 Gomaa K, Abdelraheim AR, El Gelany S, Khalifa EM, Yousef AM, Hassan H. Incidence, risk factors and management of post cesarean section surgical site infection (SSI) in a tertiary hospital in Egypt: a five year retrospective study. BMC Pregnancy Childbirth 2021; 21 (01) 634
    CrossrefPubMedGoogle Scholar
  • 25 Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 2008; 199 (01) 36.e1-36.e5 , discussion 91–92, e7–e11
    CrossrefPubMedGoogle Scholar
  • 26 Getahun D, Oyelese Y, Salihu HM, Ananth CV. Previous cesarean delivery and risks of placenta previa and placental abruption. Obstet Gynecol 2006; 107 (04) 771-778
    CrossrefPubMedGoogle Scholar
  • 27 Cooper Z, Craig S, Gaynor M, Harish NJ, Krumholz HM, Van Reenen J. Hospital prices grew substantially faster than physician prices for hospital-based care in 2007–14. Health Aff (Millwood) 2019; 38 (02) 184-189
    CrossrefPubMedGoogle Scholar
  • 28 Bost BW. Cesarean delivery on demand: what will it cost?. Am J Obstet Gynecol 2003; 188 (06) 1418-1421 , discussion 1421–1423
    CrossrefPubMedGoogle Scholar
  • 29 Olsen MA, Butler AM, Willers DM, Gross GA, Hamilton BH, Fraser VJ. Attributable costs of surgical site infection and endometritis after low transverse cesarean delivery. Infect Control Hosp Epidemiol 2010; 31 (03) 276-282
    CrossrefPubMedGoogle Scholar
  • 30 Barrett ML, Wier LM, Jiang HJ, Steiner CA. All-cause readmissions by payer and age,. 2009–2013: Statistical brief# 199. 2016
    PubMedGoogle Scholar
  • 31 Echebiri NC, McDoom MM, Aalto MM, Fauntleroy J, Nagappan N, Barnabei VM. Prophylactic use of negative pressure wound therapy after cesarean delivery. Obstet Gynecol 2015; 125 (02) 299-307
    CrossrefPubMedGoogle Scholar
  • 32 Phibbs CS, Schmitt SK. Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants. Early Hum Dev 2006; 82 (02) 85-95
    CrossrefPubMedGoogle Scholar
  • 33 Lefebvre P, Laliberté F, Nutescu EA. et al. All-cause and potentially disease-related health care costs associated with venous thromboembolism in commercial, Medicare, and Medicaid beneficiaries. J Manag Care Pharm 2012; 18 (05) 363-374
    PubMedGoogle Scholar
  • 34 Cowett AA, Golub RM, Grobman WA. Cost-effectiveness of dilation and evacuation versus the induction of labor for second-trimester pregnancy termination. Am J Obstet Gynecol 2006; 194 (03) 768-773
    CrossrefPubMedGoogle Scholar
  • 35 Skeith AE, Niu B, Valent AM, Tuuli MG, Caughey AB. Adding azithromycin to cephalosporin for cesarean delivery infection prophylaxis: a cost-effectiveness analysis. Obstet Gynecol 2017; 130 (06) 1279-1284
    CrossrefPubMedGoogle Scholar
  • 36 Al-Arydah M. Population attributable risk associated with lung cancer induced by residential radon in Canada: Sensitivity to relative risk model and radon probability density function choices: In memory of Professor Jan M. Zielinski. Sci Total Environ 2017; 596-597: 331-341
    CrossrefPubMedGoogle Scholar
  • 37 Kissell R, Poserina J. Advanced math and statistics. In Optimal Sports Math, Statistics, and Fantasy. 2017: 103-135
    Google Scholar
  • 38 Manchanda R, Patel S, Antoniou AC. et al. Cost-effectiveness of population based BRCA testing with varying Ashkenazi Jewish ancestry. Am J Obstet Gynecol 2017; 217 (05) 578.e1-578.e12
    CrossrefPubMedGoogle Scholar
  • 39 Silver RM, Landon MB, Rouse DJ. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107 (06) 1226-1232
    CrossrefPubMedGoogle Scholar
  • 40 Jude G, Fain A, Raker C. et al. The association between trial of labor after cesarean in obese patients and adverse maternal outcomes. Arch Gynecol Obstet 2023
    PubMedGoogle Scholar
  • 41 Grobman WA, Sandoval G, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity. Am J Obstet Gynecol 2021; 225 (06) 664.e1-664.e7
    CrossrefPubMedGoogle Scholar