20: Induction of labor versus expectant management at 39 weeks: a cost-effectiveness analysis

Abstract

A recent study found that induction of labor at 39 weeks for low-risk women was not associated with an increased risk of adverse neonatal outcomes. We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks versus expectant management. A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks versus expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the US annually that are considered low risk. Outcomes included mode of delivery, preeclampsia, macrosomia, intrauterine fetal demise, permanent brachial plexus injury, cerebral palsy, and neonatal death, in addition to cost and quality-adjusted life years (QALY) for both the woman and neonate. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. In our theoretical cohort of 1.6 million women, induction of labor resulted in 49,449 fewer cesarean deliveries and 79,152 fewer cases of preeclampsia. Additionally, we found that induction of labor resulted in 795 fewer cases of intrauterine fetal demise and 49 fewer neonatal deaths, despite 50 more cases of brachial plexus injury and 54 cases of moderate cerebral palsy (Table 1). Induction of labor resulted in increased costs, but increased QALYs with an incremental cost-effectiveness ratio of $97,501 per QALY. Univariate sensitivity analysis demonstrated that induction of labor was cost-effective until the cost of induction exceeded $2000 (Figure 1). In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes, but increased costs. The cost-effectiveness ratio was marginally cost effective, but would lead to an additional $2.26 billion of health care costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity and patient preferences.View Large Image Figure ViewerDownload Hi-res image Download (PPT)