Monday, May 14, 2012

Cost Studies on Cesarean Birth versus Vaginal Birth Short-Changes Mothers and Babies

As an economist, I am often dismayed by the existing studies that compare the costs of vaginal birth with the costs of caesarean birth - and then come to the conclusion that a great deal of money could be saved by promoting "normal birth". I am further dismayed, when without question or critical thought the media then goes on to parrot the cost difference, as being $4,863 versus $2,486, as in this recent Toronto Star article . The problem with most existing cost studies and a simple parroting of cost statistics is that it over simplifies the issue of cost as it pertains to childbirth.

The first flaw in the basic statistics on the cost of mode of delivery, is that they are retrospective in nature. This means that they do not reflect the planned mode of birth but rather are the result of the actual mode of birth.

As such, the statistics on the costs of caesarean sections include the costs of both elective or planned cesarean sections as well as the costs of emergent caesarean sections. The vast majority of emergent cesarean sections are the result of planned vaginal births that do not go as expected. Emergent caesarean sections cost significantly more than their planned counterparts as many of these births involve the interventions (and their costs) that are common to vaginal births as well as the costs of caesarean births and may also involve increased costs associated with a substantially increased risk of complications. This artificially inflates the reported cost of cesarean birth.

While the basic statistics inflate the cost of caesarean birth, they also diminish the cost of vaginal birth. A "straight forward" vaginal delivery - is a delivery that does not involve the use of an epidural or augmentation, and does not involve the use of forceps or vacuum to assist with the delivery of the child. This is the type of delivery that those who subscribe to the philosophy of natural childbirth aspire to achieve. The reality is that for many women achieving this kind of delivery is simply either not possible or not desireable (it could be done, but at a great risk of harm to either the mother or the child). Many women elect or need epidural pain relief. Some women have fetuses that are simply too large or are not ideally positioned for their bodies to safely accommodate a natural delivery. Many women and babies need help with the delivery process and will require assistance by way of either forceps or vacuum (which in the absence of an epidural can be excruciatingly painful). Some who planned on a "straight forward" vaginal delivery will ultimately need an urgent or emergent caesarean. Yet, the costs associated with epidurals, forceps, vacuum, or emergent caesareans are conveniently left out of the tally associated with "straight-forward" vaginal birth - and as such do not even reflect the reality of the "average vaginal birth".

As a result, readers are erroneously left comparing the discounted costs of vaginal birth with the inflated costs of caesarean births.

If that wasn't bad enough, it should also be noted that the vast majority of existing cost studies completely ignore longer-run costs that may be associated with the mode of delivery. If the delivery results in a cost that is incurred more than 42 days after the birth, the costs are frequently not allocated to the mode of delivery. A child born with a life-long disability as a result of mode of delivery - will not have the life-long costs allocated to that mode of delivery. A mother with urinary or fecal incontinence attributable to the mode of delivery that needs to be repaired (through surgery or physiotherapy) months or years later will not have those costs allocated to the mode of delivery. A mother with PTSD or PPD associated with her mode of delivery will not have the costs of those mental health issues allocated to the mode of delivery.

Furthermore, the costs that occur as a result of mode of delivery that are incurred privately are never accounted for in cost-studies of different modes of birth. There are private costs associated with either mode of delivery - including time off work, costs of preparing for the birth, and costs of recuperating after the birth.

Lastly, the costs that are "expected" by planned mode of delivery are likely to be very different on a case-by-case basis. There are many women for whom the "expected" total cost of a planned vaginal delivery is likely to be lower than the "expected" total cost of a planned caesarean delivery. There are other women (particularly in a time when mothers are getting older, heavier and having fewer children) for whom the "expected" total cost of delivery would be cheaper by planning an elective caesarean delivery.

As a health system, the goal should be to encourage women to discuss their circumstance and options with their healthcare providers and to choose the mode of delivery that is most efficient for them in their individual circumstances with an objective to reduce unnecessary morbidity and reduce unnecessary mortality for mothers and and babies. If this were done, a reduction in the overall healthcare costs would likely follow, even if a reduction in the rates of caesarean sections did not.

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