Search

Objective: To compare hospitalization costs of pregnancies managed by elective induction of labor to those with spontaneous labor in a large cohort of pregnant women., Methods: We conducted a retrospective cohort study of women with singleton, nonanomalous births in California from 2007 to 2011. We excluded women with placenta previa, breech presentation, prior cesarean delivery, planned cesarean delivery, medically indicated induction of labor, gestational age less than 37 weeks or at or greater than 41 weeks, and stillbirths. We adjusted hospital charges using a cost-to-charge ratio and costs included hospitalization costs for admission for delivery only. We estimated the difference in costs between elective induction of labor (resulting in a vaginal or cesarean delivery) and spontaneous labor for both women and neonates, stratified by mode of delivery, parity, gestational age at delivery and geographic location. We conducted analyses using Kruskal-Wallis equality-of-populations rank tests with a significance level of 0.05., Results: In a California cohort of 1,278,151 women, 190,409 (15%) had an elective induction of labor. Median maternal hospitalization costs were $10,175 (interquartile range: $7,284-$14,144) with induction of labor and $9,462 (interquartile range: $6,667-$13,251) with spontaneous labor (P<.01) for women who had a vaginal delivery, and $20,294 (interquartile range: $15,367-$26,920) with induction of labor and $18,812 (interquartile range: $13,580-$25,197) with spontaneous labor (P<.01) for women who had a cesarean delivery. Maternal median hospitalization costs were significantly higher in the setting of elective induction of labor regardless of parity, mode of delivery, and gestational age at delivery. Alternatively, median hospitalization costs for neonates of women who had an elective induction of labor were significantly lower., Conclusion: Further research regarding approaches to induction of labor is necessary to determine whether strategies to reduce health care costs without affecting or even improving outcomes could help curb costs associated with induction of labor.

Objective: To compare the actual health-system cost of elective labor induction at 39 weeks of gestation with expectant management., Methods: This was an economic analysis of patients enrolled in the five Utah hospitals participating in a multicenter randomized trial of elective labor induction at 39 weeks of gestation compared with expectant management in low-risk nulliparous women. The entire trial enrolled more than 6,000 patients. For this subset, 1,201 had cost data available. The primary outcome was relative direct health care costs of maternal and neonatal care from a health system perspective. Secondary outcomes included the costs of each phase of maternal and neonatal care. Direct health system costs of maternal and neonatal care were measured using advanced costing analytics from the time of randomization at 38 weeks of gestation until exit from the study up to 8 weeks postpartum. Costs in each randomization arm were compared using generalized linear models and reported as the relative cost of induction compared with expectant management. With a fixed sample size, we had adequate power to detect a 7.3% or greater difference in overall costs., Results: The total cost of elective induction was no different than expectant management (mean difference +4.7%; 95% CI -2.1% to +12.0%; P=.18). Maternal outpatient antenatal care costs were 47.0% lower in the induction arm (95% CI -58.3% to -32.6%; P<.001). Maternal inpatient intrapartum and delivery care costs, conversely, were 16.9% higher among women undergoing labor induction (95% CI +5.5% to +29.5%; P=.003). Maternal inpatient postpartum care, maternal outpatient care after discharge, neonatal hospital care, and neonatal care after discharge did not differ between arms., Conclusion: Total costs of elective labor induction and expectant management did not differ significantly. These results challenge the assumption that elective induction of labor leads to significant cost escalation.

Background: The safety of anesthetic care provided during childbirth has improved during the past 2 decades in the United States, with a marked decrease in the rate of anesthesia-related adverse events (ARAEs). To date, there is little research on the costs of ARAEs in obstetrics. This study aims to assess the excess cost and cost per admission associated with ARAEs during labor and delivery., Methods: Data came from the New York State Inpatient Database 2010. Discharge records indicating labor and delivery and ARAEs were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. ARAEs were defined as minor if not associated with maternal death, cardiac arrest, or severe morbidity. Costs were calculated as the product of hospital charges and the group average all-payer inpatient charge-to-cost conversion ratio. Excess cost was calculated as the difference between the mean cost of discharges with and without ARAEs. The cost per admission was calculated as the product of the excess cost and ARAE incidence. Excess costs and cost per admission were also calculated for 2 pregnancy-related complications: postpartum hemorrhage and preeclampsia/eclampsia., Results: There were 228,104 delivery-related discharges in the study; of these, 1053 recorded at least 1 ARAE (4.6 per 1000), with 1034 (98.2%) of the ARAEs being minor. The adjusted excess cost associated with ARAEs was $1189 (95% confidence interval [CI], 1033-1350) and the cost per admission $5.49 (95% CI, 4.77-6.23). The incidence of postpartum hemorrhage and preeclamspia/eclampsia was 25.1 and 43.8 per 1000, respectively. The adjusted excess cost was $679 (95% CI, 608-748) and $1328 (95% CI, 1272-1378), respectively; the cost per admission was $17.07 (95% CI, 15.27-18.81) and $58.16 (95% CI, 55.72-60.34), respectively., Conclusions: ARAEs during labor and delivery are associated with significant excess cost. However, the excess cost per admission for ARAEs is significantly less compared with the excess cost per admission for preeclampsia/eclampsia and postpartum hemorrhage.

Elective labor induction is an increasingly common practice not only in high-income countries, but also in many low-income and middle-income countries. Many questions remain unanswered on the safety and cost-effectiveness of elective labor induction, particularly in resource-constrained settings where there may be a high unmet need for medically indicated inductions, as well as limited or no access to appropriate medications and equipment for induction and monitoring, comprehensive emergency obstetric care, safe and timely cesarean section, and appropriate supervision from health professionals. This article considers the global perspective on the epidemiology, practices, safety, and costs associated with elective labor induction.

Multiple authors have documented that maternal outcomes differ depending on whether labor is spontaneous or electively induced. Correspondingly, there is evidence that women who are electively induced generate more costs than those in spontaneous labor. However, to determine the resource utilization of women who are electively induced, one must compare them to women who experience the actual alternative to induction, namely, expectant management. Observational studies using these comparison groups have not replicated many of the findings that lead to elective inductions being more costly. Moreover, there is little information about the contribution of outpatient costs from expectant management.

Purpose of Review: The prevalence and impact of elective deliveries occurring prior to 39 weeks' gestation has been the focus of several important studies published in recent medical literature. Defined as scheduled deliveries in the absence of medical or obstetrical indications, concern has been raised that many of these procedures are not performed within the parameters of existing clinical guidelines., Recent Findings: The American College of Obstetricians and Gynecologists (ACOG) recommends that no elective delivery should be performed before the gestational age of 39 weeks; however, studies report rates of 28-35.8% of elective deliveries occurring before 39 weeks and reveal that they also contribute to increased rates of late-preterm births (34 0/7-36 6/7 weeks). These deliveries are associated with increased neonatal morbidity, neonatal intensive care unit admissions, and associated hospital costs compared to deliveries (37 0/7-38 6/7 weeks) occurring at 39-40 weeks. Prevention of early-term elective deliveries has not demonstrated an increased risk for stillbirth. The implementation of hospital quality improvement programs has successfully reduced the occurrence of elective early-term and late-preterm deliveries, as well as associated neonatal morbidity and mortality., Summary: Improved compliance with ACOG recommendations and a reduction in elective deliveries before 39 weeks can be achieved through the use of quality improvement processes involving education, tracking of data, and strict enforcement of clinical practice policies.

The frequency of labor induction has increased significantly in recent years. Although medically indicated inductions comprise a portion of this increase, elective inductions have increased in frequency as well. Given that elective inductions, by definition, provide no benefit from a strictly medical standpoint, it is particularly important to evaluate whether women who undergo these inductions incur greater risks than those who labor spontaneously. This article will assess whether elective inductions are associated with changes in pregnancy outcomes, and evaluate how these associations are influenced by parity and cervical ripeness.

Objective: To examine the cumulative costs of hospital care in the first and subsequent pregnancies associated with different methods in the initial delivery of nulliparous women., Methods: An 18-year population-based cohort study (1985-2002) using the Nova Scotia Atlee Perinatal Database compared cumulative delivery costs in the first and subsequent pregnancies. Women were identified by initial method of delivery for nulliparous women with singleton cephalic presentation at term undergoing spontaneous or induced labor for planned vaginal delivery, and for nulliparous women undergoing cesarean delivery without labor. Costs that were assessed included nursing hours in antepartum, labor and delivery, postpartum and neonatal intensive care units, physician costs, labor induction agents, consumables, and costs for postpartum hysterectomy, tubal ligation, and dilatation and curettage., Results: A total of 27,613 pregnancies satisfied inclusion and exclusion criteria. When cumulative costs by type of labor at first delivery were considered, induction of labor (7,220 dollars) was more costly than spontaneous onset of labor (6,919 dollars, P = .006). The cumulative costs of assisted vaginal delivery at first delivery (7,288 dollars) and cesarean delivery in labor at first delivery (9,524 dollars) were similar in magnitude and were higher than spontaneous vaginal delivery at first delivery (P < .001). Cesarean delivery in labor in the first delivery was the most costly type of delivery (9,524 dollars), and the differences in cost increased with increasing number of deliveries (P < .05)., Conclusion: Cesarean delivery in labor in the first delivery is associated with increased cumulative costs compared with other methods of delivery, regardless of the number or type of subsequent deliveries.

Objective: To compare the safety and efficacy of misoprostol and oxytocin for induction of labor., Methods: One hundred thirty women requiring induction of labor were randomized to receive either intravenous oxytocin or 100 micrograms misoprostol, administered intravaginally every 4 hours until labor was established., Results: Compared with women receiving oxytocin, a greater percentage of women in the misoprostol group had Bishop scores of 3 or less (58 versus 38%, P < .05). Nonetheless, the median induction-to-delivery interval was significantly shorter (585 versus 885 minutes, P < .001) in the misoprostol group. Women in the misoprostol group were more likely to deliver vaginally within 24 hours of the start of induction (77 versus 55%, P < .002). Epidural analgesia was used more frequently in women receiving oxytocin than in those receiving misoprostol (73 versus 50%, P = .025). The total percentage of cesarean deliveries was not significantly different, although the percentage of cesarean deliveries for dystocia was lower in the misoprostol group (8 versus 21%, P = .02). Uterine tachysystole was significantly more common (70 versus 11%, P < .001) and hospital charges significantly less with misoprostol., Conclusion: Compared with oxytocin for labor induction, misoprostol results in a shorter induction-to-delivery interval, a reduction in the rate of cesarean delivery for dystocia, and a decreased use of epidural analgesia. Uterine tachysystole is significantly more common with the use of misoprostol.

To evaluate the economic effects of an increased oxytocin dosage for labor stimulation at a large urban hospital, a cost analysis of a before and after cohort, analytic clinical trial was performed. Delivery outcomes for two different oxytocin dosages were evaluated from the perspective of provider and consumer costs attributable to the oxytocin regimen. The high-dose oxytocin regimen resulted in an estimated provider and consumer cost savings of approximately $350,000 per year. We conclude that a small change in health care, such as an increased infusion rate of a single drug, can have economic advantages.