Tuesday, June 19, 2007

What if a Cesarean section costs less?

It is conventional wisdom that a C-section costs more than a vaginal delivery, but conventional wisdom may be wrong. The reason is that conventional comparisons are restricted to the costs of the procedures themselves whereas a more accurate measure of economic impact is to compare total charges (mother and baby) for vaginal deliveries vs. total charges for C-sections. Much to the surprise of many people, including the researchers, C-sections may actually cost less.

The economic analysis is done by comparing different intentions to treat. In other words, instead of comparing vaginal deliveries to C-sections, researchers compared the costs for women who intended to have a vaginal delivery with the costs for women who intended to have a C-section. The study Does a Cesarean section delivery always cost more than a vaginal delivery? undertaken by healthcare economists was done in just this way. According to the authors:
There is evidence that average total charges per episode of child birth depend on maternal plus child length of stay, neonatal intensive care unit (NICU) utilization, maternal race and mode of delivery. In particular, when maternal and child records are linked, this study suggests that when adjusted for maternal characteristics, the cost of vaginal deliveries followed by NICU utilization may be higher than the cost of Cesarean sections and NICU utilization.

... Much of the current Cesarean section literature focuses on reporting geographic and hospital-specific variations, but little has been published about the clinical and demographic characteristics of the patients, and even less about the economic consequences of a Cesarean section delivery compared with a vaginal delivery [e.g. the total hospital charges and length of neonatal intensive care unit-NICU stay] of a birth episode. To examine these relationships further, three urban Baltimore hospitals volunteered in 2004 to participate in a retrospective chart review that linked mother and child hospital records.
The authors found that when total costs were compared, C-section actually cost less than vaginal delivery:
Average total charges for vaginal deliveries [maternal plus total baby charges that includes NICU utilization (X = $17 624.38)] may be higher than average total charges for Cesarean sections [maternal plus total baby charges that includes NICU utilization (X = $13 805.47)]. Specifically, maternal race – being African American – was indirectly associated with overall charges through its association with mode of delivery and NICU utilization patterns. The presence of maternal co-morbidities – Herpes Simplex Virus, hypertension and diabetes – most probably influenced babies’ hospital stay charges as well as NICU charges when transferred to NICU following both vaginal and Cesarean section deliveries. Thus, prenatal care targeting co-morbidities management may reduce the odds of a newborn’s transfer to NICU thus avoiding greater lengths of stay, medical care and charges. Recommendations for obstetrical practices as well as health care policy on their charges should not assume that Cesarean section deliveries are always costlier than vaginal deliveries.
Similarly, when the authors of the Term Breech Trial went back and looked at the economic data for planned vaginal deliveries vs. planned C-sections, they also found that planned C-sections were less expensive.
The estimated mean cost of a planned cesarean was significantly lower than that of a planned vaginal birth ($7165 v. $8042 per mother and infant; mean difference –$877, 95% credible interval –$1286 to –$473). The estimated mean cost of a planned cesarean was lower than that of a planned vaginal birth for both women having a first birth ($7255 v. $8440) and women having had at least one prior birth ($7071 v. $7559)...

Interpretation: Planned cesarean section was found to be less costly than planned vaginal birth for the singleton fetus in a breech presentation at term in the Term Breech Trial. From The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial:
The commentary by Henderson and Stavrou explains the apparent paradox:
The difference in costs between the 2 groups was largely related to the relatively high physician fees for carrying out a vaginal breech delivery as well as to the higher costs of epidural analgesia, in-hospital costs of labour and delivery and costs of neonatal intermediate and intensive care. It is worth noting that 43% of women allocated to vaginal delivery subsequently delivered by cesarean section, 36% after labour began. Costs incurred by this group therefore included both the higher labour costs as well as the operating theatre costs associated with a cesarean section...
Based on this research, it is possible that a maternal request C-sections could actually cost less than a planned vaginal deliveries because planned C-sections obviate the need for the most expensive option, labor followed by a C-section. This is not an argument for planned C-sections, but it does demonstrate the economic benefits of vaginal delivery may be much less than commonly supposed.


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