Wednesday, January 4, 2012

Deconstructing the Cost of Planned Cesarean Delivery

Some people claim that women should not be free to plan a cesarean delivery because cesarean deliveries cost more than vaginal deliveries, and in a publicly run health system (like in Canada), that is unacceptable as it places an unneccessary strain on the system. As a result, the violation of patient autonomy and charter rights is "justified".

This claim needs to be deconstructed because such a violation should only happen when it can be demonstrably justified in a free and democratic society.

I believe this claim can be clearly deconstructed using data from the the Canadian Institute for Health Information's Patient Cost Estimator
I note that all data is for the province of British Columbia.

For convenience, I will assume that all repeat c-sections are planned c-sections, even though many of them will include failed vaginal birth after cesarean attempts (which would be at a higher cost as they would be emergent procedures). The average cost of these in 2008/09 was $3,410. Also for convenience, I will assume that all other births were 'planned vaginal' births regardless of whether or not they resulted in an 'actual vaginal delivery'. I note that some primary c-sections would have been lower cost planned c-sections for bonefide medical reasons, however, the vast majority of them are likely emergent/urgent c-sections done as a result of complications that emerged during labour. Weighing these births by volume, the weighted average of planned vaginal delivery in BC in 2008/09 was: $2,938.45. I note that this is likely an underestimate of the cost of planned vaginal delivery.

So, according to this back-of-the-envelope calcuation, how much does the health system 'save' by denying a women the right to choose a cesarean delivery based on these rough estimations:

That's right ladies and gentlemen - violating a patient's autonomy in BC in 2008/09 saved the health system an estimated $471.55. Assuming that 2 percent of all 'planned vaginal deliveries' would have choosen a cesarean (approximately 721 women in 2008/09), the health system saved $340,091.44. That's less than 0.3% of the money spent on deliveries in the health system in 2008/09 and less than 0.0025% of the total $15 Billion health budget in 2008/09. In 2008/09, to allow all women in British Columbia who would have choosen cesarean delivery to do so would have cost less than the amount that was paid to Vancouver Island Health Authority's CEO in salary and benefits ($417,425) in 2007/08.

I note at my therapist's rate of $160 bucks per hour is less than 3 hours worth of therapy. I'm reasonably convinced that my birth experience will need more than 3 hours of therapy to deal with - so in my particular case, denying my right to choose how my child was born will likely cost the system MORE than if the pre-labour cesarean had been granted.

I also must note that this cost difference does not include the costs that are associated with correcting the impact of vaginal delivery on the pelvic floor, the cost of caring for permanently disabled children who were injured during their mothers' planned vaginal deliveries, or the cost of birth related litigation.

So to those who say that planned elective cesarean is not a valid birth choice on the basis of cost - I would say that they need to take a long, hard look at some real numbers. I would further hope that preservation of one's charter rights should be worth more than $471.55 - which is likely a gross overestimate of the actual cost difference between thes modes of delivery.


  1. Are you nuts? Put aside the cost; the risk of maternal mortality is 2-4 times higher than that of vaginal birth (some studies claim as high as 12 times). Have you met women who had permanent nerve damage in the area in the site of catheter, loss of bladder and bowel function, loss of sexual function, seizures,
    permanent paralysis, cardiac arrest?

    And you are talking about choice?

    With Cesarean the baby is at higher risk of mortality and morbidity.

    Delayed neurodevelopmental

    Mild to severe respiratory

    Difficulty/delay initiating

    Asthma in childhood and

    Future pregnancies are at risk too:

    Ectopic pregnancy (out of uterine
    Placenta previa (placenta covering
    the cervix)
    Placenta accreta (abnormally deep
    attachment of placenta into the
    wall of the uterine)
    Placental abruption (early
    separation of placental lining)
    Maternal death
    Increased risk of stillbirth and

    I am a childbirth educator and I feel that your blog is misleading the parents to be.

  2. Haikproject - No I am not nuts - nor is any other woman who decides that cesarean is a better birth plan for herself, in the context of her own situation. How a woman decides to give birth, is her choice - it is one that should be based on the information available and her own personal assessment of the relative risks and benefits to herself in the context of her own aspirations and needs. I would beg you to assess your sources of information regarding the relative risks of cesareans and would strongly urge you to separate the risks of emergent cesarean sections from elective cesarean sections. I would also urge you to put aside your own biases with respect to vaginal birth - as it is apparent you have a few.

    This blog is not a substitute for medical advice (nor does it purport to be) - the decision of how a woman decides to birth her baby is between her, the babies father and her doctor. That decision should be respected.

  3. Haikproject - if your interested in some actual research on the relative risks, I'd suggest you look at the following study (warning: it won't say what you want it to say) -
    You might be interested in a Canadian study ( of almost 40,000 term deliveries, 1994-2002, comparing outcomes of planned cesarean delivery for breech presentation with spontaneous labour with anticipated vaginal delivery (i.e. planned vaginal delivery) at term in pregnancies with a cephalic-presenting singleton. Life-threatening maternal morbidity was similar in each group. Life-threatening neonatal morbidity was decreased in the cesarean group. It concluded that ‘elective pre-labour Caesarean full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery.' (Dahlgren et al, 2009).

  4. I'm sorry to see childbirth educators such as haikuproject above take such a biased and harsh tone against choices that some women might make. This post answers a very specific question regarding cost of RCS vs. vaginal birth in British Columbia. I find it very informative.

  5. I would like to see the break down of costs for this estimate...because it doesn't make sense to me. Elective c/s are quicker, but they involve way more resources:

    1. More health care providers (~triple the amount)
    2. More medical equipment
    3. More clean up equipment
    4. Longer hospital stay (postpartum)
    5. More costly medication (antibiotics, pain control, sedation, etc).

  6. For verifiable information go here:

    Costs for maternal professional fees:
    vaginal, complicated or uncomplicated: $516 OB, $1032
    cesarean, emergent: $442 daytime, $685 nighttime, $605 eve/weekend
    cesarean, complicated: $546 surcharge
    elective cesarean: $395

    All other costs:
    vaginal, uncomplicated: $2700
    vaginal, complicated: $3200
    cesarean (elective or unplanned): $4200
    complicated cesarean (elective or unplanned): $5200

    Cost to care for infant born by section: $1400
    Cost to care for infant born vaginally: $800

    ADDITIONAL COSTS for sections:
    pediatric consult mandatory at sections
    OR nursing costs
    NICU/special care nursery observation/treatment (increased risk with section babies)

    Vaginal births:$4016-$5032
    Emergent/unplanned Cesareans: $6042-$7831 +additional costs
    Elective cesarean with no complications: $5995 +additional costs
    Elective cesarean with complications: $6559 +additional costs

  7. Cassie - the difficulty is that a planned vaginal birth does not always result in a vaginal delivery. Many vaginal births result in emergent c-sections, as such the costs of those emergent c-sections should be attributable to vaginal births. Further, there are costs associated with longer term sequalae such as surgical correction of urinary/fecal incontinence or adddressing the costs associated with a variety of birth traumas some of which may be severe. As such your cost break down is incomplete and does not provide an accurate picture of the cost difference between planned vaginal and planned cesarean births.