Induction of Labor versus Scheduled Cesarean in Morbidly Obese Women: A Cost-Effectiveness Analysis

Abstract

Objective To assess the costs, complication rates, and harm-benefit tradeoffs of induction of labor (IOL) compared to scheduled cesarean delivery (CD) in women with class III obesity.

Study Design We conducted a cost analysis of IOL versus scheduled CD in nulliparous morbidly obese women. Primary outcomes were surgical site infection (SSI), chorioamnionitis, venous thromboembolism, blood transfusion, and readmission. Model outcomes were mean cost of each strategy, cost per complication avoided, and complication tradeoffs. We assessed the costs, complication rates, and harm-benefit tradeoffs of IOL compared with scheduled CD in women with class III obesity.

Results A total of 110 patients underwent scheduled CD and 114 underwent IOL, of whom 61 (54%) delivered via cesarean. The group delivering vaginally experienced fewer complications. SSI occurred in 0% in the vaginal delivery group, 13% following scheduled cesarean, and 16% following induction then cesarean. In the decision model, the mean cost of induction was $13,349 compared with $14,575 for scheduled CD. Scheduled CD costs $9,699 per case of chorioamnionitis avoided, resulted in 18 cases of chorioamnionitis avoided per additional SSI and 3 cases of chorioamnionitis avoided per additional hospital readmission. In sensitivity analysis, IOL is cost saving compared with scheduled CD unless the cesarean rate following induction exceeds 70%.

Conclusion In morbidly obese women, induction of labor remains cost-saving until the rate of cesarean following induction exceeds 70%.

Keywords

obesity - pregnancy - cesarean - surgical site infection - cost-effectiveness - induction of labor

Note

This article was presented as an oral presentation at the South Atlantic Association of Obstetricians and Gynecologist Annual Meeting, 2017.

• References

• 1 American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No 156: Obesity in Pregnancy. Obstetrics & Gynecology 2015; 126 (06) 1321-1322
• 2 Schneid-Kofman N, Sheiner E, Levy A, Holcberg G. Risk factors for wound infection following cesarean deliveries. Int J Gynaecol Obstet 2005; 90 (01) 10-15
• 3 Robinson HE, O'Connell CM, Joseph KS, McLeod NL. Maternal outcomes in pregnancies complicated by obesity. Obstet Gynecol 2005; 106 (06) 1357-1364
• 4 Chu SY, Kim SY, Lau J. , et al. Maternal obesity and risk of stillbirth: a metaanalysis. Am J Obstet Gynecol 2007; 197 (03) 223-228
• 5 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
• 6 Calderon AC, Quintana SM, Marcolin AC. , et al. Obesity and pregnancy: a transversal study from a low-risk maternity. BMC Pregnancy Childbirth 2014; 14: 249
• 7 Conner SN, Verticchio JC, Tuuli MG, Odibo AO, Macones GA, Cahill AG. Maternal obesity and risk of postcesarean wound complications. Am J Perinatol 2014; 31 (04) 299-304
• 8 Denison FC, Norwood P, Bhattacharya S. , et al. Association between maternal body mass index during pregnancy, short-term morbidity, and increased health service costs: a population-based study. BJOG 2014; 121 (01) 72-81
• 9 Girsen AI, Osmundson SS, Naqvi M, Garabedian MJ, Lyell DJ. Body mass index and operative times at cesarean delivery. Obstet Gynecol 2014; 124 (04) 684-689
• 10 Stamilio DM, Scifres CM. Extreme obesity and postcesarean maternal complications. Obstet Gynecol 2014; 124 (2 Pt 1): 227-232
• 11 World Health Organization (WHO) Global Database on Body Mass Index. Available at: http://apps.who.int/bmi/index.jsp?introPage=intro_3.html . Accessed January 12, 2018
• 12 Cedergren MI. Non-elective caesarean delivery due to ineffective uterine contractility or due to obstructed labour in relation to maternal body mass index. Eur J Obstet Gynecol Reprod Biol 2009; 145 (02) 163-166
• 13 Kaimal AJ, Little SE, Odibo AO. , et al. Cost-effectiveness of elective induction of labor at 41 weeks in nulliparous women. Am J Obstet Gynecol 2011; 204 (02) 137.e1-137.e9
• 14 Alexander JM, McIntire DM, Leveno KJ. Chorioamnionitis and the prognosis for term infants. Obstet Gynecol 1999; 94 (02) 274-278
• 15 Kim SY, Nguyen C, Russell LB. , et al. Cost-effectiveness of a potential group B streptococcal vaccine for pregnant women in the United States. Vaccine 2017; 35 (45) 6238-6247
• 16 Tita AT, Szychowski JM, Boggess K. , et al; C/SOAP Trial Consortium. Adjunctive azithromycin prophylaxis for cesarean delivery. N Engl J Med 2016; 375 (13) 1231-1241
• 17 Swift SH, Zimmerman MB, Hardy-Fairbanks AJ. Effect of single-use negative pressure wound therapy on postcesarean infections and wound complications for high-risk patients. J Reprod Med 2015; 60 (5-6): 211-218
• 18 Wolfe KB, Rossi RA, Warshak CR. The effect of maternal obesity on the rate of failed induction of labor. Am J Obstet Gynecol 2011; 205 (02) 128.e1-128.e7
• 19 Gunatilake RP, Smrtka MP, Harris B. , et al. Predictors of failed trial of labor among women with an extremely obese body mass index. Am J Obstet Gynecol 2013; 209 (06) 562.e1-562.e5
• 20 Subramaniam A, Corvey KJ, Kilgore ML, Edwards RK. Planned cesarean delivery compared to induction of labor in women with class III obesity: a cost-minimization analysis (.). J Matern Fetal Neonatal Med 2016; 29 (19) 3084-3088