Cost of Elective Labor Induction Compared With Expectant Management in Nulliparous Women.
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ABSTRACT: 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.
SUBMITTER: Einerson BD
PROVIDER: S-EPMC7323797 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:The perinatal and maternal consequences of induction of labor at 39 weeks among low-risk nulliparous women are uncertain. METHODS:In this multicenter trial, we randomly assigned low-risk nulliparous women who were at 38 weeks 0 days to 38 weeks 6 days of gestation to labor induction at 39 weeks 0 days to 39 weeks 4 days or to expectant management. The primary outcome was a composite of perinatal death or severe neonatal complications; the principal secondary outcome was cesarean delivery. RESULTS:A total of 3062 women were assigned to labor induction, and 3044 were assigned to expectant management. The primary outcome occurred in 4.3% of neonates in the induction group and in 5.4% in the expectant-management group (relative risk, 0.80; 95% confidence interval [CI], 0.64 to 1.00). The frequency of cesarean delivery was significantly lower in the induction group than in the expectant-management group (18.6% vs. 22.2%; relative risk, 0.84; 95% CI, 0.76 to 0.93). CONCLUSIONS:Induction of labor at 39 weeks in low-risk nulliparous women did not result in a significantly lower frequency of a composite adverse perinatal outcome, but it did result in a significantly lower frequency of cesarean delivery. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ARRIVE ClinicalTrials.gov number, NCT01990612 .).
| S-EPMC6186292 | biostudies-literature
Project description:ObjectiveTo evaluate characteristics associated with adverse outcomes in low-risk nulliparous women randomized to elective labor induction at 39 weeks of gestation or expectant management.MethodsWe conducted a secondary analysis of women randomized during the 38th week to induction at 39 weeks of gestation or expectant management. Deliveries before 39 weeks of gestation and those not adherent to study protocol or with fetal anomalies were excluded. A composite of adverse outcomes (perinatal death or severe neonatal complications), third- or fourth-degree lacerations, and postpartum hemorrhage were evaluated. Log binomial regression models estimated relative risks and 95% CIs for associations of outcomes with patient characteristics including randomly assigned treatment group. Interactions between patient characteristics and treatment group were tested.ResultsOf 6,096 women with outcome data, 5,007 (82.1%) met criteria for inclusion in this analysis. Frequency of the perinatal composite was 252 (5.0%), 166 (3.3%) for third- or fourth-degree perineal laceration, and 237 (4.7%) for postpartum hemorrhage. In multivariable analysis, intended labor induction at 39 weeks of gestation was associated with a reduced perinatal composite outcome (4.1% vs 6.0%; adjusted relative risk [aRR] 0.71; 95% CI 0.55-0.90), whereas increasing body mass index (BMI) was associated with an increased perinatal composite outcome (aRR 1.04/unit increase; 95% CI 1.02-1.05). Decreased risk of third- or fourth-degree perineal laceration was observed with increasing BMI (aRR 0.96/unit increase; 95% CI 0.93-0.98) and in Black women compared with White women (1.2% vs 3.9%; aRR 0.34; 95% CI 0.19-0.60). Increased risk of postpartum hemorrhage was observed in Hispanic women compared with White women (6.3% vs 4.0%; aRR 1.64; 95% CI 1.18-2.29). Patient characteristics associated with adverse outcomes were similar between treatment groups (P for interaction >.05).ConclusionCompared with expectant management, intended induction at 39 weeks of gestation was associated with reduced risk of adverse perinatal outcome. Patient characteristics associated with adverse outcomes were few and similar between groups.Clinical trial registrationClinicalTrials.gov, NCT01990612.
| S-EPMC7529933 | biostudies-literature
Project description:To test the association of elective induction of labor at term compared with expectant management and maternal and neonatal outcomes.This was a retrospective cohort study of all deliveries without prior cesarean delivery in California in 2006 using linked hospital discharge and vital statistics data. We compared elective induction at each term gestational age (37-40 weeks) as defined by The Joint Commission with expectant management in vertex, nonanomalous, singleton deliveries. We used multivariable logistic regression to test the association of elective induction and cesarean delivery, operative vaginal delivery, maternal third- or fourth-degree lacerations, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, hyperbilirubinemia, and macrosomia (birth weight greater than 4,000 g) at each gestational week, stratified by parity.The cesarean delivery rate was 16%, perinatal mortality was 0.2%, and neonatal intensive care unit admission was 6.2% (N=362,154). The odds of cesarean delivery were lower among women with elective induction compared with expectant management across all gestational ages and parity (37 weeks [odds ratio (OR) 0.44, 95% confidence interval (CI) 0.34-0.57], 38 weeks [OR 0.43, 95% CI 0.38-0.50], 39 weeks [OR 0.46, 95% CI 0.41-0.52], 40 weeks [OR 0.57, CI 0.50-0.65]). Elective induction was not associated with increased odds of severe lacerations, operative vaginal delivery, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, or macrosomia at any term gestational age. Elective induction was associated with increased odds of hyperbilirubinemia at 37 and 38 weeks of gestation and shoulder dystocia at 39 weeks of gestation.Elective induction of labor is associated with decreased odds of cesarean delivery when compared with expectant management.: II.
| S-EPMC3905733 | biostudies-literature
Project description:BackgroundThere is no apparent consensus on obstetric management, i.e., induction of labor or expectant management of women with suspected large-for-gestational-age (LGA)-fetuses.Methods and findingsTo further examine the subject, a nationwide population-based cohort study from the Swedish Medical Birth Register in nulliparous non-diabetic women with singleton, vertex LGA (>90th centile) births, 1992-2013, was performed. Delivery of a live-born LGA infant induced at 38 completed weeks of gestation in non-preeclamptic pregnancies, was compared to those of expectant management, with delivery at 39, 40, 41, or 42 completed weeks of gestation and beyond, either by labor induction or via spontaneous labor. Primary outcome was mode of delivery. Secondary outcomes included obstetric anal sphincter injury, 5-minute Apgar<7 and birth injury. Multivariable logistic regression analysis was performed to control for potential confounding. We found that among the 722 women induced at week 38, there was a significantly increased risk of cesarean delivery (aOR = 1.44 95% CI:1.20-1.72), compared to those with expectant management (n = 44 081). There was no significant difference between the groups in regards to risk of instrumental vaginal delivery (aOR = 1.05, 95% CI:0.85-1.30), obstetric anal sphincter injury (aOR = 0.81, 95% CI:0.55-1.19), nor 5-minute Apgar<7 (aOR = 1.06, 95% CI:0.58-1.94) or birth injury (aOR = 0.82, 95% CI:0.49-1.38). Similar comparisons for induction of labor at 39, 40 or 41 weeks compared to expectant management with delivery at a later gestational age, showed increased rates of cesarean delivery for induced women.ConclusionsIn women with LGA infants, induction of labor at 38 weeks gestation is associated with increased risk of cesarean delivery compared to expectant management, with no difference in neonatal morbidity.
| S-EPMC5519027 | biostudies-literature
Project description:ObjectiveTo develop models to predict vaginal delivery in low-risk, nulliparous women contemplating elective induction of labor or expectant management at 39 weeks of gestation.MethodsWe conducted a secondary analysis of a randomized controlled trial of planned elective induction of labor at 39 weeks of gestation compared with expectant management for low-risk nulliparous women. Two groups were included for this analysis: 1) women who were randomized to the induction of labor group and underwent elective induction at 39 0/7-39 4/7 weeks of gestation and 2) women who were randomized to the expectant management group who experienced spontaneous labor or medically indicated delivery (including postterm). Multivariable logistic regression models were developed for each group using patient characteristics that would be available at the time of counseling. Model selection was based on k-fold cross-validation using backward elimination and variables that remained significant at P<.05 were retained. To compare estimated with observed rates, the elective induction of labor model was then applied to each woman in both groups to estimate individualized predicted probabilities of vaginal delivery with elective induction of labor.ResultsOf 6,106 women enrolled in the trial, 4,661 met criteria for this analysis. Vaginal delivery occurred in 80.6% of the 2,153 women in the elective induction of labor group and 77.2% of the 2,508 women in the expectant management group (P=.005). The final elective induction of labor model included age, height, weight, and modified Bishop score (area under the receiver operating characteristic curve [AUROC] 0.72, 95% CI 0.70-0.75). The same variables were included in the final expectant management model (AUROC 0.70, 95% CI 0.67-0.72). Across the range of predicted probability deciles derived from the elective induction of labor model, almost all women who underwent elective induction of labor at 39 weeks of gestation had a higher observed chance of vaginal delivery than expectant management.ConclusionIrrespective of the individual predicted chance of vaginal delivery from elective induction of labor at 39 weeks of gestation, vaginal delivery is generally more frequent if elective induction of labor is undertaken rather than expectant management. These data can be used to counsel nulliparous women regarding their "customized" chances of vaginal delivery as they choose between elective induction of labor or expectant management at 39 weeks of gestation.Clinical trial registrationClinicalTrials.gov, NCT01990612.
| S-EPMC7899015 | biostudies-literature
Project description:ObjectiveTo determine neonatal outcomes (perinatal mortality and special care unit admission) and maternal outcomes (mode of delivery, delivery complications) of elective induction of labour compared with expectant management.DesignRetrospective cohort study using an unselected population database.SettingConsultant and midwife led obstetric units in Scotland 1981-2007.Participants1,271,549 women with singleton pregnancies of 37 weeks or more gestation.InterventionsOutcomes of elective induction of labour (induction of labour with no recognised medical indication) at 37, 38, 39, 40, and 41 weeks' gestation compared with those of expectant management (continuation of pregnancy to either spontaneous labour, induction of labour or caesarean section at a later gestation).Main outcome measuresExtended perinatal mortality, mode of delivery, postpartum haemorrhage, obstetric anal sphincter injury, and admission to a neonatal or special care baby unit. Outcomes were adjusted for age at delivery, parity, year of birth, birth weight, deprivation category, and, where appropriate, mode of delivery.ResultsAt each gestation between 37 and 41 completed weeks, elective induction of labour was associated with a decreased odds of perinatal mortality compared with expectant management (at 40 weeks' gestation 0.08% (37/44,764) in the induction of labour group versus 0.18% (627/350,643) in the expectant management group; adjusted odds ratio 0.39, 99% confidence interval 0.24 to 0.63), without a reduction in the odds of spontaneous vertex delivery (at 40 weeks' gestation 79.9% (35,775/44,778) in the induction of labour group versus 73.7% (258,665/350,791) in the expectant management group; adjusted odds ratio 1.26, 1.22 to 1.31). Admission to a neonatal unit was, however, increased in association with elective induction of labour at all gestations before 41 weeks (at 40 weeks' gestation 8.0% (3605/44,778) in the induction of labour group compared with 7.3% (25,572/350,791) in the expectant management group; adjusted odds ratio 1.14, 1.09 to 1.20).ConclusionAlthough residual confounding may remain, our findings indicate that elective induction of labour at term gestation can reduce perinatal mortality in developed countries without increasing the risk of operative delivery.
| S-EPMC3349781 | biostudies-literature
Project description:BackgroundAlthough induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.ObjectiveThe objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.Study designThis is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.ResultsOf 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).ConclusionWomen randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.
| S-EPMC7141954 | biostudies-literature
Project description:ObjectiveOptimal management of pregnancies at 39 weeks gestational age is unknown. Therefore, we sought to perform a comparative effectiveness analysis of elective induction of labor (eIOL) at 39 weeks among nulliparous women with non-anomalous singleton, vertex fetuses as compared to expectant management (EM) which included IOL for medical or obstetric indications or at 41 weeks in undelivered mothers.Materials and methodsA Monte Carlo micro-simulation model was constructed modeling two mutually exclusive health states: eIOL at 39 weeks, or EM with IOL for standard medical or obstetrical indications or at 41 weeks if undelivered. Health state distribution probabilities included maternal and perinatal outcomes and were informed by a review of the literature and data derived from the Consortium of Safe Labor. Analyses investigating preferences for maternal versus infant health were performed using weighted utilities. Primary outcome was determining which management strategy posed less maternal and neonatal risk. Secondary outcomes were rates of cesarean deliveries, maternal morbidity and mortality, stillbirth, neonatal morbidity and mortality, and preferences regarding the importance of maternal and perinatal health.ResultsA management strategy of eIOL at 39 weeks resulted in less maternal and neonatal risk as compared to EM with IOL at 41 weeks among undelivered patients. Cesarean section rates were higher in the EM arm (35.9% versus 13.9%, p<0.01). When analysis was performed only on patients with an unfavorable cervix, 39 week eIOL still resulted in fewer cesarean deliveries as compared to EM (8.0% versus 26.1%, p<0.01). There was no statistical difference in maternal mortality (eIOL 0% versus EM 0.01%, p = 0.32) but there was an increase in maternal morbidity among the EM arm (21.2% versus 16.5, p<0.01). There were more stillbirths (0.13% versus 0%, p<0.0003), neonatal deaths (0.25% versus 0.12%, p< 0.03), and neonatal morbidity (12.1% versus 9.4%, p<0.01) in the EM arm as compared to the eIOL arm. Preference modeling revealed that 39 week eIOL was favored over EM.Conclusions and relevanceMathematical modeling revealed that eIOL at 39 weeks resulted in lower population risks as compared to EM with induction of labor at 41 weeks. Specifically, eIOL at 39 weeks resulted in a lower cesarean section rate, lower rates of maternal morbidity, fewer stillbirths and neonatal deaths, and lower rates of neonatal morbidity.
| S-EPMC5918610 | biostudies-literature
Project description:ImportanceElective induction of labor at 39 weeks of gestation is common. Thus, there is a need to assess maternal labor-related complications and neonatal outcomes associated with elective induction of labor.ObjectiveTo examine maternal labor-related complications and neonatal outcomes following elective induction of labor at 39 weeks compared with expectant management.Data sourcesA systematic review of the literature was conducted using the MEDLINE (Ovid), Embase (Ovid), Cochrane Central Library, World Health Organization, and ClinicalTrials.gov databases and registries to search for articles published between database inception and December 8, 2022.Study selectionThis systematic review and meta-analysis included randomized clinical trials, cohort studies, and cross-sectional studies reporting perinatal outcomes following induction of labor at 39 weeks vs expectant management.Data extraction and synthesisTwo reviewers independently assessed study eligibility, extracted data, and assessed studies for bias. Pooled odds ratios (ORs) and 95% CIs were calculated using a random-effects model. This study is reported per the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guideline, and the protocol was prospectively registered with PROSPERO.Main outcomes and measuresMaternal outcomes of interest included emergency cesarean section, perineal injury, postpartum hemorrhage, and operative vaginal birth. Neonatal outcomes of interest included admission to the neonatal intensive care unit, low 5-minute Apgar score (<7) after birth, macrosomia, and shoulder dystocia.ResultsOf the 5827 records identified in the search, 14 studies were eligible for inclusion in this review. These studies reported outcomes for 1 625 899 women birthing a singleton pregnancy. Induction of labor at 39 weeks of gestation was associated with a 37% reduced likelihood of third- or fourth-degree perineal injury (OR, 0.63 [95% CI, 0.49-0.81]), in addition to reductions in operative vaginal birth (OR, 0.87 [95% CI, 0.79-0.97]), macrosomia (OR, 0.66 [95% CI, 0.48-0.91]), and low 5-minute Apgar score (OR, 0.62 [95% CI, 0.40-0.96]). Results were similar when confined to multiparous women only, with the addition of a substantial reduction in the likelihood of emergency cesarean section (OR, 0.61 [95% CI, 0.38-0.98]) and no difference in operative vaginal birth (OR, 1.01 [95% CI, 0.84-1.21]). However, among nulliparous women only, induction of labor was associated with an increased likelihood of shoulder dystocia (OR, 1.22 [95% CI, 1.02-1.46]) compared with expectant management.Conclusions and relevanceIn this study, induction of labor at 39 weeks was associated with improved maternal labor-related and neonatal outcomes. However, among nulliparous women, induction of labor was associated with shoulder dystocia. These results suggest that elective induction of labor at 39 weeks may be safe and beneficial for some women; however, potential risks should be discussed with nulliparous women.
| S-EPMC10182428 | biostudies-literature
Project description:A recent randomised controlled trial (RCT) demonstrated that induction of labour at 39 weeks of gestational age has no short-term adverse effect on the mother or infant among nulliparous women aged ?35 years. However, the trial was underpowered to address the effect of routine induction of labour on the risk of perinatal death. We aimed to determine the association between induction of labour at ?39 weeks and the risk of perinatal mortality among nulliparous women aged ?35 years.We used English Hospital Episode Statistics (HES) data collected between April 2009 and March 2014 to compare perinatal mortality between induction of labour at 39, 40, and 41 weeks of gestation and expectant management (continuation of pregnancy to either spontaneous labour, induction of labour, or caesarean section at a later gestation). Analysis was by multivariable Poisson regression with adjustment for maternal characteristics and pregnancy-related conditions. Among the cohort of 77,327 nulliparous women aged 35 to 50 years delivering a singleton infant, 33.1% had labour induced: these women tended to be older and more likely to have medical complications of pregnancy, and the infants were more likely to be small for gestational age. Induction of labour at 40 weeks (compared with expectant management) was associated with a lower risk of in-hospital perinatal death (0.08% versus 0.26%; adjusted risk ratio [adjRR] 0.33; 95% CI 0.13-0.80, P = 0.015) and meconium aspiration syndrome (0.44% versus 0.86%; adjRR 0.52; 95% CI 0.35-0.78, P = 0.002). Induction at 40 weeks was also associated with a slightly increased risk of instrumental vaginal delivery (adjRR 1.06; 95% CI 1.01-1.11, P = 0.020) and emergency caesarean section (adjRR 1.05; 95% CI 1.01-1.09, P = 0.019). The number needed to treat (NNT) analysis indicated that 562 (95% CI 366-1,210) inductions of labour at 40 weeks would be required to prevent 1 perinatal death. Limitations of the study include the reliance on observational data in which gestational age is recorded in weeks rather than days. There is also the potential for unmeasured confounders and under-recording of induction of labour or perinatal death in the dataset.Bringing forward the routine offer of induction of labour from the current recommendation of 41-42 weeks to 40 weeks of gestation in nulliparous women aged ?35 years may reduce overall rates of perinatal death.
| S-EPMC5685438 | biostudies-literature