Systematic review on repeat cesareans find procedure costlier, less effective

Cesarean deliveries make up for 32 percent of the four million annual births in the U.S., but do these procedures have negative side effects when chosen over vaginal births? A review conducted by the University of Alabama and published in Value in Health found women who have a trial of labor after cesarean (TOLAC) or an elective repeat cesarean delivery (ERCD) face higher rates of morbidity.

Researchers complied searched EMBASE, MEDLINE, CINAHL, Cochrane Library, EconLit, and the Cost-Effectiveness Analysis Registry and analyzed the cost-effectiveness of the choices for women who have a TOLAC and an ERCD with low-risk, singleton gestation pregnancies.

The review included seven studies and found the following:

• Four studies found TOLAC was more effective and less costly than ERCD.
• One study concluded that ERCD was more effective and less costly.
• Two studies found that ERCD was slightly more effective for a larger cost but most patients were unwilling to pay the higher price for slightly better benefits.
• Cost-effectiveness corresponded with a high likelihood of TOLAC success, low risk of uterine rupture and a low TOLAC cost when compare to ERCD.

"The conventional wisdom is 'once a cesarean, always a cesarean,'" said Anna Joy Rogers, MD, DrPH candidate in the UAB School of Public Health Department of Health Care Organization and Policy. "Older C-section incision techniques posed a higher risk of uterine rupture during future attempts at a vaginal delivery, so patients and physicians often felt more comfortable with a planned C-section. Our study found that, when we look at the big picture, routinely choosing a C-section may actually come at a higher cost and result in more women having poorer outcomes. This is especially true for women who plan to have several children after the primary C-section."

For women capable of having successful vaginal delivery, an ERCD increases risk of morbidly and costs. These results show that the characteristics of each women, like the ability to deliver vaginally and history of failing to progress to labor, must be taken into account to calculate their TOLAC eligibility.