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Background: Clinical interventions known to reduce the risk of caesarean delivery include routine induction of labour at 39 weeks, caseload midwifery and chart audit, but they have not been compared for cost-effectiveness., Objective: To assesses the cost-effectiveness of three different interventions known to reduce caesarean delivery rates compared to standard care; and conduct a budget impact analysis., Methods: A Markov microsimulation model was constructed to compare the costs and outcomes produced by the different interventions. Costs included all costs to the health system, and outcomes were quality-adjusted life years (QALY) gained. A budget impact analysis was undertaken using this model to quantify the costs (in Australian dollars) over three years for government health system funders., Results: All interventions, plus standard care, produced similar health outcomes (mean of 1.84 QALYs gained over 105 weeks). Caseload midwifery was the lowest cost option at $15 587 (95% confidence interval [CI] 15 269, 15 905), followed by routine induction of labour ($16 257, 95% CI 15 989, 16 536), and chart audit ($16 325, 95% CI 15 979, 16 671). All produced lower costs on average than standard care ($16 905, 95% CI 16 551, 17 259). Caseload midwifery would produce the greatest savings of $172.6 million over three years if implemented for all low-risk nulliparous women in Australia., Conclusions: Caseload midwifery presents the best value for reducing caesarean delivery rates of the options considered. Routine induction of labour at 39 weeks and chart audit would also reduce costs compared to standard care., (© 2019 John Wiley & Sons Ltd.)

Objective: To compare the impact upon maternity unit resources and finances of two protocols for induction of labour using prostaglandins., Design: A prospective randomised trial comparing a single dose of prostaglandin E2 (2 mg) in the evening with two doses of prostaglandin E2 (2 mg), the second being given after six hours if labour had not started or the cervix was still unripe, followed if necessary by formal induction of labour by amniotomy and oxytocin infusion 14 to 20 hours after the initial prostaglandin E2 dose. Outcome for nulliparae and multiparae were analysed separately, by treatment intention., Setting: A maternity unit in a district general hospital delivering > 6000 women annually., Participants: Nine hundred and fifty-five women with viable singleton pregnancies and cephalic presentation at term without previous history of caesarean section who were advised to have labour induced with prostaglandins., Main Outcome Measures: Costs incurred in managing all aspects of labour, including time spent on the antenatal ward and, in the delivery unit; costs associated with formal induction, augmentation of labour and epidural analgesia; costs of intrapartum maternal morbidity, mode of delivery and immediate neonatal care. Costs of postpartum hospital stay were estimated from unit statistics., Results: The overall mean cost of induction of labour was Pounds 5.00 and Pounds 7.22 less per woman for nulliparae and multiparae, respectively, if the two dose regimen was used. The main reason for the differences was due to delivery suite costs from the slightly greater rate of assisted deliveries in the single treatment groups. In contrast, costs for neonatal care were marginally lower if only one prostaglandin dose was used., Conclusions: The increased drug costs providing two prostaglandin E2 doses when required were off-set by reductions in the costs of other intrapartum interventions for both nulliparae and multiparae. The advantages of less time spent on the antenatal ward for multiparae when two prostaglandin E2 doses were used may be eliminated if amniotomy and oxytocin infusion was commenced six hours after the initial prostaglandin dose had been given if labour had not started.

Objective: To compare the effectiveness of extra-amniotic saline with intra-amniotic prostaglandin F2 alpha in inducing labour in pregnancies with intrauterine fetal death., Design: A randomised controlled trial., Participants: One hundred and twenty-one women in the extra-amniotic saline group and 123 women in the intra-amniotic prostaglandin group, performed at Harare Maternity Hospital, Zimbabwe during the period October 1994 to February 1996., Results: The two methods were equally effective in achieving delivery. The number of women not delivering within 48 hours of recruitment was 6% for the extra-amniotic saline group compared with 11% for the intra-amniotic prostaglandin group (relative risk [RR] 0.51, 95% CI 0.21-1.22). The extra-amniotic saline group required augmentation with Syntocinon more frequently than the intra-amniotic prostaglandin group: 22% compared with 7% (RR 3.1, 95% CI 1.5-6.2). There were more complications associated with the intra-amniotic prostaglandin group: five women developed hypertonic contractions compared with none in the extra-amniotic saline group. In addition 23% of women in the intra-amniotic prostaglandin group developed acute vasovagal-like symptoms lasting for about 10 to 15 minutes which were distressing for the women. There was no evidence of any increase in febrile morbidity from extra-amniotic saline (RR 0.8, 95% CI 0.75-1.1)., Conclusion: Extra-amniotic saline infusion in successful in inducing labour in antepartum fetal deaths after 20 weeks of gestation. This method has been shown to be safe and well tolerated by the women and should be considered in areas with limited resources. This method should be evaluated further for inductions of labour with a live fetus.