Economic implications of reducing caesarean section rates - Analysis of two health systems.

Deirdre Daly,Francesca Wuytack,Charles Normand,Cecily Begley,Michael Turner,Patrick S Moran,Patricia Gillen

doi:10.1371/journal.pone.0228309

Abstract

Caesarean section (CS) rates throughout Europe have risen significantly over the last two decades. As well as being an important clinical issue, these changes in mode of birth may have substantial resource implications. Policy initiatives to curb this rise have had to contend with the multiplier effect of women who had a CS for their first birth having a greater likelihood of requiring one during subsequent births, thus making it difficult to decrease CS rates in the short term. Our study examines the long-term resource implications of reducing CS rates among first-time mothers, as well as improving rates of vaginal birth after caesarean section (VBAC), among an annual cohort of women over the course of their most active childbearing years (18 to 44 years) in two public health systems in Europe. We found that the economic benefit of improvements in these two outcomes is considerable, with the net present value of the savings associated with a five-percentage-point change in nulliparous CS rates and VBAC rates being €1.1million and £9.8million per annual cohort of 18-year-olds in Ireland and England/Wales, respectively. Reductions in CS rates among first-time mothers are associated with a greater payoff than comparable increases in VBAC rates. The net present value of achieving CS rates comparable to those currently observed in the best performing Scandinavian countries was €3.5M and £23.0M per annual cohort in Ireland and England/Wales, respectively.

Highlights

The rate of caesarean section (CS) has been increasing worldwide for over two decades
Validation tests showing that the output of current standard of care models are consistent with observed data on the number of births in each cohort, overall national CS rates, and CS rates by parity are provided as supplementary material, along with kernel density plots showing the distribution of the sampled parameters
This shows that relatively modest changes in Parameter Probability of having a caesarean section for 1st baby Probability of having a CS after previous vaginal birth Probability of having a vaginal birth after previous CS (VBAC) Cost of uncomplicated CS Cost of vaginal birth Probability of having 0 children Probability of having 1 child Probability of having 2 children Probability of having 3 children Probability of having 4 or more children Mean (SD) age when having baby 1 Mean (SD) age when having baby 2 Mean (SD) age when having baby 3 Mean (SD) age when having baby 4 Cohort size

Summary

Introduction

The rate of caesarean section (CS) has been increasing worldwide for over two decades. In Western Europe, average CS rates rose from 19.6% in 2000 to 26.9% in 2015, representing an average increase of 2.1% per year. [1] This increasing trend has been replicated in both Ireland and England/Wales, with overall CS rates having reached 32.7% and 27.8%, respectively, in 2016. [2,3] While CS can be a life-saving intervention when medically indicated, once levels exceed 10% to 15% there is no evidence of a corresponding reduction in maternal or newborn mortality rates. [4] CS is, associated with a greater risk of experiencing health problems in later pregnancies such as uterine rupture, ectopic pregnancy, stillbirth, and preterm birth, compared with vaginal birth. Cost of caesarean section (European Cooperation in Science and Technology). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript

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