Cost-effectiveness analysis of natural birth and elective C-section in supplemental health

Entringer, Aline Piovezan; Pinto, Márcia; Gomes, Maria Auxiliadora de Souza Mendes

doi:10.11606/S1518-8787.2018052000373

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Sumário

Original Article • Rev. Saúde Pública 52 • 2018 • https://doi.org/10.11606/S1518-8787.2018052000373 copy

Cost-effectiveness analysis of natural birth and elective C-section in supplemental health

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To conduct a cost-effectiveness analysis of natural childbirth and elective C-section for normal risk pregnant women.

METHODS

The study was conducted from the perspective of supplemental health, a health subsystem that finances private obstetric care, represented in Brazil by health plan operators. The reference populations were normal risk pregnant women, who could undergo natural childbirth or elective C-section, subdivided into primiparous and multiparous women with previous uterine scar. A decision analysis model was constructed including choice of delivery types and health consequences for mother and newborn, from admission for delivery to maternity hospital discharge. Effectiveness measures were identified from the scientific literature, and cost data obtained by consultation with health professionals, health plan operators’ pricing tables, and pricing reference publications of health resources.

RESULTS

Natural childbirth was dominant compared with elective C-section for primiparous normal risk pregnant women, presenting lower cost (R$5,210.96 versus R$5,753.54) and better or equal effectiveness for all evaluated outcomes. For multiparous women with previous uterine scar, C-section presented lower cost (R$5,364.07) than natural childbirth (R$5,632.24), and better or equal effectiveness; therefore, C-section is more efficient for this population.

CONCLUSIONS

It is necessary to control and audit C-sections without clinical indication, especially with regard to primiparous women, contributing to the management of perinatal care.

Natural Childbirth, economics; Cesarean Section, economics; Cost-Effectiveness Evaluation; Supplemental Health

Variable	Reference case	Variation (minimum-maximum)		Source
Primiparous women

Natural childbirth (labor)
Emergency C-section	0.113	0.082	0.154	^8,14,9
Hemorrhage with blood transfusion	0.004	0.0032	0.019	^10,6,8
Thrombosis/Embolism	0.003	-	-	¹⁴
Uterine rupture	0.00029	-	-	¹⁴
Hysterectomy	0.001	0.0001	0.002	^6,10,14
Maternal death	0.0002	0	-	^14,10
Admission to NICU	0.063	-	-	³
Neonatal death	0.0007	-	-	⁴
Elective C-section
Hemorrhage with blood transfusion	0.003	0.0029	0.017	^8,10,6
Thrombosis/Embolism	0.006	-	-	¹⁴
Uterine rupture	0.00015	-	-	¹⁴
Hysterectomy	0.006	0.001	0.006	^14,10,6
Maternal death	0	0		^14.10
Admission to NICU	0.139	-	-	³
Neonatal death	0.0017	-	-	⁴

Multiparous women

Natural childbirth (labor)
Emergency C-sector	0.26	0.08	0.28	^7.18
Hemorrhage with blood transfusion	0.0066	0.002	0.022	⁷
Thrombosis/Embolism	0.04	-	-	⁷
Uterine rupture	0.0071	0.0052	0.0097	⁷
Hysterectomy	0.0014	0.0008	0.0022	⁷
Maternal death	0.000019	0.000004	0.000095	⁷
Admission to NICU	0.088	-	-	⁵
Neonatal death	0.0011	0.0006	0.002	⁷
Elective C-section
Hemorrhage with blood transfusion needed	0.0046	0.0016	0.013	⁷
Thrombosis/Embolism	0.1	-	-	⁷
Uterine rupture	0.0002	0.00003	0.0018	⁷
Hysterectomy	0.0016	0.0007	0.0036	⁷
Maternal death	0.000096	0.000021	0.0004	⁷
Admission to NICU	0.083	-	-	⁵
Neonatal death	0.0006	0.0002	0.0015	⁷

Hospital stay days

Shared room after C-section	2.6	2	4	^a,b
Shared room after natural childbirth	2.1	1	3	^a,b
Maternal ICU after clinical event	2	1	5	^b
Maternal ICU after surgical event	3	2	5	^b
Neonatal ICU	3	2	5	^b
Shared room after clinical event	4	3	5	^b
Shared room after surgical event	4	3	5	^b
Days before maternal or neonatal death	5	2	10	^b

Variable	Reference case		Variation

	R$	%	Minimum	Maximum
Natural childbirth
Medical fees	2,727.63	78	2,182.10	3,727.32
Supplies and medicines	254.83	7	202.64	384.75
Room rate	526.40	15	421.12	631.68
Total	3,508.85	100	2,805.86	4,743.76
C-section
Medical fees	2,123.81	62	1,699.05	2,548.57
Supplies and medicines	723.06	21	581.17	812.95
Surgical and post-anesthetic room rate	582.40	17	465.92	698.88
Total	3,429.27	100	2,746.13	4,060.40
Intrapartum C-section
Medical fees	3,425.33	72	2,740.26	4,110.39
Supplies and medicines	760.63	16	610.79	856.36
Surgical and post-anesthetic room rate	582.40	12	465.92	698.88
Total	4,768.36	100	3,816.98	5,665.64
Mother/baby apartment
Medical fees	72.31	13	57.85	86.77
Supplies and medicines	104.14	19	80.80	119.67
Apartment daily fee	368.20	68	294.56	441.84
Total	544.65	100	433.20	648.28
Neonatal ICU
Medical fees	525.49	29	420.39	630.59
Supplies and medicines	353.00	19	229.95	332.56
Daily rate	951.00	52	760.80	1,141.20
Total	1,829.49	100	1,411.15	2,104.35
Adult ICU
Medical fees	525.49	27	420.39	630.59
Supplies and medicines	608.43	31	523.20	705.11
Daily rate	827.54	42	662.03	993.05
Total	1,961.46	100	1,605.62	2,328.75
Surgical event
Medical fees	2,300.29	59	1,840.23	2,760.35
Supplies and medicines	825.38	21	859.75	1,215.74
Room rate	789.69	20	631.75	947.63
Total	3,915.36	100	3,331.74	4,923.71
Clinical event
Medical fees	343.70	66	274.96	412.44
Supplies and medicines	175.80	34	143.99	199.72
Total	519.50	100	418.95	612.16

Variable	Total cost (R$)	Additional cost (R$)	Effectiveness	Incremental effectiveness	Incremental cost-effectiveness ratio
Primiparous women

Outcome: Maternal death avoided
C-section	5,753.54	524.58	0.98	-	Dominated
Natural childbirth	5,210.96	-	0.99	0.01	Dominant
Outcome: maternal death avoided
C-section	5,753.54	524.58	1	-	Dominated
Natural childbirth	5,210.96	-	1	-	Dominant
Outcome: admission to NICU avoided
C-section	5,753.54	524.58	0.86		Dominated
Natural childbirth	5,210.96	-	0.94	0.08	Dominant
Outcome: neonatal death avoided
C-section	5,753.54	524.58	1	-	Dominated
Natural childbirth	5,210.96	-	1	-	Dominant

Multiparous women (one previous scar)

Outcome: maternal death avoided
C-section	5,364.07		0.99	0.01	Dominant
Natural childbirth	5,632.24	268.17	0.98		Dominated
Outcome: neonatal death avoided
C-section	5,364.07		1		Dominant
Natural childbirth	5,632.24	268.17	1		Dominated
Outcome: uterine rupture avoided
C-section	5,364.07		1	0.01	Dominant
Natural childbirth	5,632.24	268.17	0.99		Dominated
Outcome: admission to NICU avoided
C-section	5,364.07		0.92	0.01	Dominant
Natural childbirth	5,632.24	268.17	0.91		Dominated
Outcome: neonatal death avoided
C-section	5,364.07		1		Dominant
Natural childbirth	5,632.24	268.17	1		Dominated

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[1] Correspondence: Aline Piovezan Entringer. Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira – IFF/Fiocruz Neonatologia. Avenida Rui Barbosa, 716 3º andar. 20021-140 Rio de Janeiro, RJ, Brasil. E-mail: aline.entringer@iff.fiocruz.br