Abstract
Objective: Out-of-hospital (outpatient) cervical ripening prior to induction of labor (IOL) is discussed for its potential to decrease the burden on hospital resources. We assessed the cost and clinical outcomes of adopting an outpatient strategy with a synthetic hygroscopic cervical dilator, which is indicated for use in preinduction cervical ripening.Methods: We developed a cost-consequence model from the hospital perspective with a time period from IOL to post-delivery discharge. A hypothetical cohort of women to undergo IOL at term with an unfavorable cervix (all risk levels) were assessed. As the standard of care (referred to as IP-only) all women were ripened as inpatients using the vaginal PGE2 insert or the single-balloon catheter. In the comparison (OP-select), 50.9% of low-risk women (41.4% of the study population) received outpatient cervical ripening using a synthetic hygroscopic cervical dilator and the remaining women were ripened as inpatients as in the standard of care. Model inputs were sourced from a structured literature review of peer-reviewed articles in PubMed. Testing of 2,000 feasible scenarios (probabilistic multivariate sensitivity analysis) ascertained the robustness of results. Outcomes are reported as the average over all women assessed, comparing OP-select to IP-only.Results: Implementing OP-select resulted in hospital savings of US$689 per delivery, with women spending 1.48 h less time in the labor and delivery unit and 0.91 h less in the postpartum recovery unit. The cesarean-section rate was decreased by 3.78 percentage points (23.28% decreased to 19.50%). In sensitivity testing, hospital costs and cesarean-section rate were reduced in 91% of all instances.Conclusion: Our model analysis projects that outpatient cervical ripening has the potential to reduce hospital costs, hospital stay, and the cesarean section rate. It may potentially allow for better infection-prevention control during the ongoing COVID-19 pandemic and to free up resources such that more women might be offered elective IOL at 39 weeks.
Highlights
National data indicate an induction of labor (IOL) rate of over one in four deliveries in the United States (US) (1)
In OP-select, 46.3 and 12.3% were ripened as inpatients with the PGE2 insert and the balloon catheter, respectively; and 41.4% of women were ripened as outpatients with the synthetic hygroscopic cervical dilator
Adopting outpatient cervical ripening for low-risk women is predicted to reduce average delivery costs even when only a small proportion of women are ripened by this route
Summary
National data indicate an induction of labor (IOL) rate of over one in four deliveries in the United States (US) (1). Elective IOL at 39 weeks is expected to add to medically indicated IOL in light of recent evidence (2–4). Inducing lowrisk women at 39 weeks was shown to reduce the risk of cesarean sections, hypertension during pregnancy, and neonatal respiratory morbidity in comparison to expectant management (2–4). Grobman et al reported that it might not increase healthcare resource utilization as expected, providing evidence for decreases in antepartum hospitalization, visits, treatments, and tests; the women in the IOL group spent 6 h longer in the labor and delivery (L&D) unit (6). Implementing an out-of-hospital (outpatient) strategy for cervical ripening has the potential to shorten the time spent in the L&D unit and significantly decrease cesarean sections (7, 8)
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