Abstract
BACKGROUND
In worldwide literature, it has been found that cesarean deliveries represent higher costs and are associated with maternal morbidity and other complications.
OBJECTIVE
This study aimed to estimate the cost-effectiveness of elective cesarean delivery compared with spontaneous vaginal delivery in short-term maternal outcomes for low-risk obstetrical population in Colombia.
STUDY DESIGN
A cost-effectiveness study using a healthcare-system perspective was performed in 2019 in Colombia. The reference population were women with full-term and low-risk pregnancy, either by spontaneous vaginal delivery or elective cesarean delivery under medical or nonmedical indications. An analytical decision model (decision tree) was designed for maternal outcomes. The time horizon was 42 days postpartum, and the health effects were measured by Quality Adjusted Life Years. A review of the literature and a validation process by a national expert committee were conducted to determine the maternal outcomes and estimate their probabilities. Costs were estimated with a top-down analysis, an incremental cost-effectiveness ratio was calculated, and finally, a sensitivity analysis was performed.
RESULTS
Within a 42-day time horizon, it was found that spontaneous vaginal delivery is the less-expensive and more-effective mode of delivery, it showed a reduction in costs (324 USD) and a gain in Quality Adjusted Life Years (0.03) compared with elective cesarean delivery. Our analysis suggests that spontaneous vaginal delivery is the dominant alternative compared with elective cesarean delivery.
CONCLUSION
Spontaneous vaginal delivery showed to be the cost-effective mode of delivery for low-risk obstetrical population in Columbia. These results are useful not only for obstetricians but for decision makers, who should encourage nationwide health policies in favor of spontaneous vaginal delivery.
Key words: cesarean delivery, cost-effectiveness analysis, vaginal delivery
AJOG Global Reports at a Glance.
Why was this study conducted?
In worldwide literature, it has been found that cesarean deliveries represent higher costs and are associated with maternal morbidity and other complications. Currently, there are no cost-effectiveness analyses comparing vaginal delivery and cesarean delivery in Colombia.
Key findings
The highest likelihood of maternal complications from the decision tree comes from elective cesarean delivery. The most expensive birth-route alternative from the decision tree was the intrapartum cesarean delivery, and the less expensive was the unassisted vaginal delivery. Elective cesarean delivery is more expensive and less effective for low-risk women in Colombia.
What does this add to what is known?
This is the first economic evaluation comparing 2 alternatives of childbirth in Colombia. The results highlight that spontaneous vaginal delivery represents the dominant alternative in terms of cost-effectiveness compared with elective cesarean delivery.
Introduction
Till date, the discussion around delivery options for full-term, noncomplicated pregnancies, has been a global topic of controversy, primarily when an unusually high cesarean delivery is a common prevalent indicator in the evaluation of clinical practice. Worldwide, the rate of cesarean delivery has increased from 6% to 19% between 1990 and 2014.1,2 In 1985, a panel of experts, in a meeting organized by the World Health Organization (WHO), recommended that the ideal rate of cesarean delivery should be between 10% and 15%.3 However, in 2015, the WHO declared that beyond reaching a specific rate, a cesarean delivery should be an available procedure for every woman who may need it.3
Colombia has shown an increase in the rate of cesarean deliveries from 24.9% in 1998 to 44.5% in 2019.4,5 Moreover, there are major disparities in cesarean delivery rates between different geographic regions within the country. As a matter of fact, in 2019, 642,660 births were registered, of which 286,035 were through cesarean delivery.6 Furthermore, 49.7% of the women who received a cesarean delivery were from the subsidized regime and 39.6% from the contributive regime.6 Colombia's Social Security and Healthcare General System aims to create equal access opportunities to public health services for the entire Colombian population. There are 2 ways in which people can have access to these resources: (1) contributive regime, in which people make a monthly payment to a Health Promoting Entity to have access to healthcare services; and (2) subsidized regime, in which people who are not able to pay the contribution, have access to healthcare services through financial assistance offered by the state.7,8 According to the vital statistics data provided by the National Administrative Department of Statistics (DANE in Spanish), Sucre (70%), Córdoba (68%), San Andrés (67%), and Atlántico (66%) were the departments with the highest rates of cesarean delivery. In contrast, the ones with the lowest rates were Guainía (15%), Vichada (11%), and Vaupes (8%).6
The increase in the cesarean delivery rate has generated concerns in obstetricians because of a possible negative impact on maternal and neonatal outcomes. Likewise, the financial issues have generated concerns in decision makers, where for a usually fixed health budget, the cost overruns trend and could represent a threat.2,4 Although we do not yet fully understand why Colombia has a high cesarean delivery rate or why there is a large disparity between regions, it has been described that high rates of cesarean delivery are associated with different obstetrical care models depending on geographic regions, along with medical factors such as excessive use of technology, fear of legal lawsuits, economic interests or optimizing time, and with patients sociocultural factors such as fear of childbirth or of losing control, potential pelvic and sexual sequelae, and even the interest of planning a date for convenience.4 Therefore, some nonclinical interventions have been described, mostly in high-income countries, to reduce unnecessary cesarean deliveries without adverse effects on maternal or neonatal outcomes. These include clinical guidelines combined with a mandatory second opinion before scheduling an elective cesarean delivery or combined with audit and feedback about cesarean delivery practices; and physician education by local obstetrician-gynecologist leaders.9
In worldwide literature, it has been found that cesarean deliveries represent higher costs in delivery care.10 In a cost analysis in Argentina, the authors found that, on average, cesarean delivery costs were >5 times higher than those for a vaginal delivery.10 In addition, other studies have found that cesarean delivery was associated with an increased risk of extreme maternal morbidity and other complications (hemorrhage requiring hysterectomy, blood transfusion, venous thromboembolism, or major infection).11, 12, 13 Furthermore, there are studies analyzing the cost-effectiveness of the birth route, which consist of a comparative analysis of the different birth alternatives in terms of costs and consequences14; although most differ in the selected population, the perspective, the effectiveness, and the costs estimation.15, 16, 17
In Colombia, few studies have been conducted to address the comparative cost of delivery options in low-risk obstetrical populations. All of them have a local context and demonstrate institutional results that cannot necessarily be extrapolated for the whole country. An analysis performed in Medellín revealed that cesarean delivery has a higher average cost than vaginal delivery.18 Besides, a study based on a Health Promotion Entity (EPS in Spanish) population in Bogotá determined that cesarean delivery care represented higher costs than established standard costs.19 Nevertheless, there is scarce evidence in our country on the medical outcomes of each of the alternatives. Contrary to what is observed in other countries, a study conducted in a private hospital in Bogotá suggested that in a well-controlled low-risk obstetrical population, cesarean delivery indicated under maternal request could present as much or even fewer complications compared with vaginal delivery.20 However the study results did not pretend to be extrapolated to other clinical scenarios or even be considered as a valid recommendation.20 Considering that these studies have involved small populations, to date, there is no global perspective of the entire country during the same observation period.
Even though we have a high cesarean delivery rate in Colombia, to the best of our knowledge, there is no evidence of economic evaluations of delivery routes for low-risk obstetrical population from a global perspective that involves all births registered in the same observation period. Given the differences in costs, health systems, and epidemiologic profiles of the countries,21 it is necessary to conduct an economic evaluation that compares delivery alternatives in the Colombian context. These results would allow an efficient comparison with other countries of the Organization for Economic Cooperation and Development. We hypothesize that our results will not only be useful for guiding clinicians, but also provide decision makers with valuable information to guarantee the efficient use of resources and welfare for the population.
Materials and Methods
Reference population, setting and comparators
A cost-effectiveness analysis was performed to compare elective cesarean delivery (ECD) and spontaneous vaginal delivery (SVD) in low-risk obstetrical population in Colombia during 2019. The reference population comprised women with a low-risk pregnancy who delivered at term, either by an SVD or ECD under medical or nonmedical indications. Low-risk pregnancy was defined as one that evolves without risk factors22, and term pregnancy as the one with a gestational age between 37 to 42 weeks.23
Study perspective
The study uses a healthcare-system perspective, which includes direct medical costs associated with birth-route alternatives, as well as maternal outcomes. Nonmedical costs assumed by patients or families (out-of-pocket payments and indirect costs of productivity lost) were not included.
Time horizon and discount rate
The time horizon was 42 days postpartum where short-term complications of delivery are evident, based on the time frame considered by WHO for maternal morbidity and mortality.24,25 As the time horizon was <1 year, it was unnecessary to apply a discount rate on costs and health outcomes.
Decision model and assumptions
An analytical decision model (decision tree) was designed (Figure 1), which included delivery alternatives, their respective courses of action represented in the different branches of the tree, and the outcomes of interest. It was assumed that women did not have an absolute indication for a cesarean delivery or a contraindication for vaginal delivery. Thus, patients could have either of the 2 alternatives of childbirth, and women with ECD had 39 gestational weeks or more at delivery time. In addition, it was assumed that women with a scheduled cesarean delivery, delivered only by cesarean delivery, whereas women with spontaneous vaginal labor had the option to have an assisted vaginal delivery, an intrapartum cesarean delivery, or an unassisted vaginal delivery.
Figure 1.
Decision tree
Sarmiento. Cost-effectiveness analysis of childbirth. Am J Obstet Gynecol Glob Rep 2023.
Choice of health outcomes
A review of systematic reviews and meta-analysis was conducted to define maternal outcomes and their probabilities on each of the birth alternatives (ECD and SVD). We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines; PROSPERO, Cochrane, and PubMed databases were reviewed searching the following terms: “low-risk pregnancies,” “Vaginal delivery,” “Cesarean section,” “maternal outcomes,” “systematic review,” “meta-analysis.” Studies that compared vaginal birth with cesarean delivery were reviewed considering the following inclusion criteria: analyzing a similar population to the one included in this article (women with a low-risk pregnancy who delivered at term) and aiming to describe short-term complications arising from childbirth. We included retrospective and prospective cohort studies published between 2007 and 2017.
A national external committee formed by obstetricians validated the information on health outcomes (maternal outcomes and their probabilities) found in the literature review. An online questionnaire was used to validate their level of agreement. Finally, we defined maternal complications with the following outcomes: hemorrhage requiring blood transfusion, hemorrhage requiring surgical intervention, anesthesia complications, postpartum infection, wound complication, venous thromboembolism, pelvic tissue damage, and maternal death (Table 1).
Table 1.
Probabilities of the maternal decision tree
| Variable | Reference case | Minimum | Maximum | Source |
|---|---|---|---|---|
| Elective cesarean delivery | ||||
| Maternal complications | 0.0208 | 0.0016 | 0.0789 | Restrepo et al18, 2017. Banco de la República B et al28, 2019. The World Bank et al29, 2023. Villar et al30, 2007. Gonzales et al31, 2013. Kamilya et al32, 2010. Koroukian et al33, 2004. Dahlgren et al34, 2009. Allen et al35, 2003. Geller et al36, 2010. |
| Assisted vaginal delivery | 0.0714 | 0.0195 | 0.2197 | Gonzales et al31, 2013. Kamilya et al32, 2010. Koroukian et al33, 2004. |
| Maternal complications | 0.0170 | 0.0002 | 0.0815 | Borghi et al10, 2003. Kamilya et al32, 2010. Koroukian et al33, 2004. |
| Intrapartum cesarean delivery | 0.0961 | 0.08350 | 0.2068 | Kamilya et al32, 2010. Koroukian et al33, 2004. Dahlgren et al34, 2009. Allen et al35, 2003. |
| Maternal complications | 0.0166 | 0.0005 | 0.0480 | Banco de la República B et al28, 2019. Kamilya et al32, 2010. Koroukian et al33, 2004. Dahlgren et al34, 2009. Allen et al35, 2003. |
| Unassisted vaginal delivery | ||||
| Maternal complications | 0.0078 | 0.0002 | 0.0459 | Restrepo et al18, 2017. Banco de la República B et al28, 2019. The World Bank et al29, 2023. Villar et al30, 2007. Gonzales et al31, 2013. Kamilya et al32, 2010. Koroukian et al33, 2004. Dahlgren et al34, 2009. Allen et al35, 2003. Geller et al36, 2010 |
Sarmiento. Cost-effectiveness analysis of childbirth. Am J Obstet Gynecol Glob Rep 2023.
Measurement of effectiveness
Quality-adjusted life years (QALYs) were used as effectiveness measurements. We extracted utilities and disutilities from the literature, given that in Colombia, this information was not available, to the best of our knowledge. In addition, the duration of utility and disutility was adjusted according to clinical judgment (Table 2). QALYs were calculated with the multiplication of the utility of the condition with its duration, according to the 42 days’ time horizon.
Table 2.
Utilities for delivery alternative and disutilities for maternal outcomes
| Variable | Utility (per d) | Duration (d) | Reference |
|---|---|---|---|
| Unassisted vaginal delivery | 0.9975 | 42 | Kor-Anantakul et al37, 2008 |
| Elective cesarean delivery | 0.9655 | 42 | Kor-Anantakul et al37, 2008 |
| Intrapartum cesarean delivery | 0.9670 | 42 | Kor-Anantakul et al37, 2008 |
| Assisted vaginal delivery | 0.9525 | 42 | Kor-Anantakul et al37, 2008 |
| Disutility (per d) | |||
| Maternal death | 1 | 42 | Assumption |
| Hemorrhage requiring blood transfusion | 0.41 | 7 | Entringer et al15, 2018 |
| Hemorrhage requiring surgical intervention | 0.58 | 7 | Entringer et al15, 2018 |
| Postpartum infection | 0.38 | 14 | Entringer et al15, 2018 |
| Wound complication | 0.53 | 14 | Entringer et al15, 2018 |
| Pelvic tissue damage | 0.53 | 14 | Entringer et al15, 2018 |
| Venous thromboembolism | 0.41 | 14 | Entringer et al15, 2018 |
| Anesthesia complications | 0.2 | 7 | Assumption |
| Without complications | 0 | 42 | Assumption |
Sarmiento. Cost-effectiveness analysis of childbirth. Am J Obstet Gynecol Glob Rep 2023.
Estimation of costs
A top-down analysis was conducted to estimate the costs associated with each delivery option and its outcomes. This analysis followed 3 steps: identification, quantification, and valuation. The identification step consisted of identifying all cost-generating events; in the quantification step, quantities were assigned to each of the cost-generating events, and in the valuation phase, the research team gave a unit price to the amounts of each of the previous resources.26
For the identification and quantification of resources, we used the Individual Registry of Provision of Health Services Records (RIPS in Spanish), the Colombian clinical practice guidelines, and the management protocols.27 In addition, this information was verified with nurses and obstetrics experts. For cost definition, we used the Per-capita Payment Units (UPC) sufficiency databases and the reference fee manual in Colombia for healthcare institutions (ISS + 30% of adjustment). For medications, we obtained the information through the Medicines Price Information System (SISMED in Spanish).21 Costs are presented in United States dollars (USD), according to the average exchange rate for 2019 ($3281.09 Colombian Peso (COP) = 1 USD)28 (Table 3).
Table 3.
Costs for the maternal decision treea
| Variable | Reference case | Minimum | Maximum |
|---|---|---|---|
| Elective cesarean delivery | 722 | 552 | 1066 |
| Assisted vaginal delivery | 364 | 287 | 527 |
| Intrapartum cesarean delivery | 818 | 628 | 1205 |
| Unassisted vaginal delivery | 353 | 278 | 512 |
| Maternal death | 0 | 0 | 0 |
| Hemorrhage requiring blood transfusion | 366 | 277 | 549 |
| Hemorrhage requiring surgical intervention | 797 | 602 | 1191 |
| Anesthesia complications | 86 | 65 | 130 |
| Postpartum infection | 557 | 428 | 821 |
| Wound complication | 220 | 168 | 325 |
| Venous thromboembolism | 282 | 210 | 426 |
| Pelvic tissue damage | 70 | 58 | 96 |
USD, United States dollar.
USD average exchange rate for 2019.
Sarmiento. Cost-effectiveness analysis of childbirth. Am J Obstet Gynecol Glob Rep 2023.
The incremental cost-effectiveness ratio (ICER) was estimated; the numerator represents the incremental cost of an ECD, and the denominator the incremental effectiveness. The defined threshold was 1 and 3 gross domestic product (GDP) per capita, as suggested by WHO.21 The information on GDP per capita for 2019 was obtained from the reports of The World Bank (1 GDP per capita = 6428 USD).29
In addition, to evaluate uncertainty, a univariate deterministic sensitivity analysis was performed, and it is presented in a tornado graph. We estimated a probabilistic sensitivity analysis through Monte-Carlo simulation (1000 iterations), using beta distribution for probabilities and gamma distribution for costs. Results are shown in the scatter plot. All the analyses were performed using TreeAge Pro Healthcare 2021, R1. (TreeAge Software, Williamstown, MA).
Results
Based on the data obtained from the literature review and the validation with the experts, probabilities for the decision tree were calculated (Table 1). It was found that the highest likelihood of maternal complications comes from ECD, whereas the probability of maternal complications after uncomplicated vaginal delivery was the lowest.
Cost estimation (Table 3) from the decision tree evidenced that the most expensive birth-route alternative was intrapartum cesarean delivery (818 USD), and the least expensive was the uncomplicated vaginal delivery (353 USD). From the maternal complications included in the study, the highest expenses came from hemorrhage that required surgical intervention (797 USD), followed by postpartum infection (557 USD).
The base-case analysis is summarized in Table 4. ECD, including its possible outcomes, represented an incremental cost of USD 324 compared with SVD. However, ECD effectiveness was 0.03 lower than SVD. The results suggest that ECD is more expensive and less effective for low-risk women in Colombia, meaning that ECD is overshadowed by SVD. The ICER was below the defined threshold, so the generation of 1 additional QALY would imply a saving of 12,145 USD.
Table 4.
Incremental cost-effectiveness analysis
| Alternative | Cost | Incremental cost | Effectiveness | Incremental effectiveness | Incremental cost-effectiveness ratio |
|---|---|---|---|---|---|
| Spontaneous vaginal delivery | 398.90 | 0.99 | |||
| Elective cesarean delivery | 722.98 | 324.08 | 0.96 | −0.03 | −12.145 |
Sarmiento. Cost-effectiveness analysis of childbirth. Am J Obstet Gynecol Glob Rep 2023.
Sensitivity analysis
The tornado analysis (Figure 2) shows that ICER is mainly affected by the costs of uncomplicated ECD, costs of uncomplicated unassisted vaginal delivery, the probability of assisted vaginal delivery, and the likelihood of maternal complications after ECD. Therefore, these are the variables that contribute the most to the uncertainty of the model.
Figure 2.
Tornado analysis
AVD, assisted vaginal delivery; C, costs; IPCS, intrapartum cesarean section; P, probability; UAVD, unassisted vaginal delivery.
Sarmiento. Cost-effectiveness analysis of childbirth. Am J Obstet Gynecol Glob Rep 2023.
Discussion
Principal findings
This study found that within a 42-day time frame and considering health gain as QALYs, SVD is the best cost-effective delivery route alternative for Colombia.
Results in the context of what is known
According to the results of our analysis, ECD represents a higher expensive birth alternative compared with vaginal delivery. These results are similar to the ones found in the cost analysis study performed at Medellín, Colombia, in 2016. The authors found through a microcosting analysis that cesarean delivery is more expensive when compared with vaginal delivery in 4 different health institutions.18 Therefore, this evidence suggests that with a reduction in the cesarean delivery rates, Colombia's healthcare system may benefit from a reduction in expenditures on obstetrical care.
In accordance with our findings, our literature review evidenced that in other countries, vaginal birth represents the dominant childbirth alternative as a public health issue. In Ireland, Fawsitt et al17 conducted an economic evaluation comparing a trial of labor after a previous cesarean (TOLAC) with elective repeat cesarean delivery of short-term maternal health consequences. The authors found that on a 6-week time horizon, TOLAC represents the dominant delivery alternative with a slightly incremental effect of 0.14 QALYs.17 Finally, a cost-effectiveness analysis performed by the National Institute for Health and Clinical Excellence (NICE) in England and Wales found that in primiparous women, planned vaginal delivery could be cost-effective compared with cesarean delivery because it implies lower costs and shows a smaller loss of QALYs; however, this could be modified by the inclusion of other outcomes in the model.16
Clinical and research implications
According to our analysis, one of the parameters that impact the decision model the most is the probability of maternal complications after an ECD. Thus, to guarantee the cost-effectiveness of SVD, it is crucial to implement interventions that consider not only the reduction of cesarean delivery but also maternal morbidity and mortality. As stated by the Cochrane review on nonclinical interventions to reduce unnecessary cesarean delivery, high-quality evidence showed that some strategies that reduce cesarean delivery rates without adverse effects were focused on healthcare professionals, as the application of clinical guidelines combined with a second opinion or feedback and education to healthcare professionals.9
Strengths and limitations
This study is a health economic evaluation comparing 2 alternatives of childbirth in Colombia. Although the results are significant for analyzing the obstetrical-care model in the country, the study has some limitations. First, a subgroup analysis was not performed according to the parity of pregnant women. This gap is an opportunity for future research. Second, the evidence on the effectiveness of the different delivery alternatives in Colombia is limited. Thus, we used evidence from other countries and regions that might not represent the effectiveness of these delivery alternatives in our country. Finally, this study did not consider a social perspective, therefore information related to out-of-pocket payments and other social costs was not included in the analysis.
Conclusions
According to our analysis, in Colombia, SVD represents the dominant alternative in terms of cost-effectiveness compared with ECD. Considering that Colombia currently presents a high cesarean rate and efforts are being focused on its reduction, this analysis provides valuable information for clinicians and for decision makers to design and implement protocols that guarantee the maximization of health welfare and the efficient use of resources.
Footnotes
The authors report no conflict of interest.
This research was supported with financial sources from Hospital Universitario Fundación Santa Fe de Bogotá and Universidad de los Andes.
Patient consent was not required because no personal information or details are included.
Cite this article as: Sarmiento A, Ayala N, Rojas KK, et al. Cost-effectiveness analysis of spontaneous vaginal delivery vs elective cesarean delivery for maternal outcomes in Colombia. Am J Obstet Gynecol Glob Rep 2023;XX:x.ex–x.ex.
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