From the Journals

Disparate study results on elective labor costs fuel debate


Cost concerns have circulated regarding elective induction of labor, a method that’s become increasingly popular in the United States. Two studies in Obstetrics & Gynecology, however, offer no consensus on the cost burden of this method.

Young woman in labor dimarik/iStock/Getty Images

A retrospective analysis of a large cohort in California reported higher costs for induction, compared with spontaneous labor, after accounting for variables such as parity, mode of delivery, and gestational age. A prospective study of five Utah hospitals found no significant cost differences between induction and expectant management.

The ARRIVE trial (A Randomized Trial of Induction versus Expectant Management), a multicenter study that compared elective labor induction at 39 weeks of gestation with spontaneous labor in low-risk nulliparous women, suggests that induction may have some benefits. While its researchers found no differences in perinatal outcomes, induction cases had fewer cesareans, fewer hypertensive disorders, and fewer newborns requiring respiratory support.

One key question that remains following ARRIVE is whether this practice should be implemented universally, Alyssa R. Hersh, MD, MPH, lead author of the California study, said in an interview. Quantifying the costs associated with elective labor is important because “health care in the United States is already much more expensive than in other countries, and [elective labor] could have a dramatic impact on annual health care costs.”

In a retrospective analysis, Dr. Hersh, of the Oregon Health & Science University, Portland, and her colleagues examined data from more than 1.2 million women in California with singleton, nonanomalous births. They excluded for multiple factors such as medically indicated induction of labor, placenta previa, breech presentation, or planned cesarean delivery.

Estimating cost differences between elective induction and spontaneous labor for mothers and neonates, they stratified results by vaginal or cesarean delivery, parity, gestational age at delivery, and geographic location. Elective induced labor represented 15% of the overall cohort of 1.2 million women.

Among vaginal deliveries, median maternal hospitalization costs were $10,175 in the induction group and $9,462 in the spontaneous labor group. For cesarean deliveries, the median costs were $20,294 with induction of labor and $18,812 with spontaneous labor.

Costs of maternal hospitalization with elective induction of labor were significantly higher than that of spontaneous labor, regardless of parity, mode of delivery, and gestational age at delivery, the authors reported. Comparing costs at rural and urban areas, the induction group saw higher maternal hospitalization costs and longer lengths of stay regardless of scenario.

Neonatal care was the one metric that incurred lower costs and lengths of stay in the induction group. Fewer adverse outcomes in this group could explain this outlier. “However, because this is observational data, we cannot elucidate what exactly contributed to these decreased costs,” Dr. Hersh and colleagues noted.

Timeliness was another limitation. “It is important to note that our study was conducted between 2007 and 2011, and the patients undergoing elective induction of labor during those years may differ from women undergoing elective induction of labor currently,” the authors acknowledged.

Another study by Brett D. Einerson, MD, MPH, of the University of Utah Health, Salt Lake City, and associates evaluated the actual hospital costs of patients undergoing elective induction and expectant management in a subset of patients from the ARRIVE trial.

“If, medically speaking, induction is equal to expectant management or has some benefit, as the larger ARRIVE trial suggests, we wanted to know: At what cost?” Dr. Einerson said in an interview.

Study participants hailed from five Utah hospitals within two health systems: the University of Utah Health and Intermountain Healthcare. Taking available data for 1,231 enrollees, investigators randomized 608 to labor induction and 623 to spontaneous labor. They measured actual hospital costs using advanced value-based analytics platforms at the Utah hospitals, comparing cost means and reporting the relative difference between induction and expectant management.

Overall, they found no significant differences between the mean total cost of elective induction and expectant management (adjusted mean difference, +4.7%). This was the case for other metrics: Costs did not vary among the five health systems or in most phases of care, including maternal inpatient postpartum care, maternal outpatient care after discharge, neonatal hospital care, and neonatal care after discharge.

The induction group did incur higher maternal inpatient intrapartum and delivery care costs (17%). However, these were offset by savings achieved during outpatient antenatal care (–47%). The assumption was additional costs of time spent on the labor ward might overwhelm cost savings elsewhere (reduced cesarean deliveries, fewer prenatal appointments and tests). “But this was not the case,” Dr. Einerson said.

Ultimately, the study was not large enough to find smaller differences in cost, he noted. It was only large enough to say that cost didn’t differentiate between arms with a margin of +/–7%. “A cost increase (or cost savings) with induction of 7% is meaningful over time and on a national scale,” Dr. Einerson explained.

Taken together, the two studies show that cost is not an insurmountable barrier to elective induced labor, Jeffrey L. Ecker, MD, and Mark A. Clapp, MD, MPH, wrote in an accompanying editorial (Obstet Gynecol. 2020;136[1]:6-7).

“This will be especially true if we are innovative and creatively adapt our facilities and spaces, thinking about where and how some of the required care can be appropriately and more economically offered,” they noted.

“Specifically, strategies to safely reduce labor and delivery time for inductions of labor, including considering and studying outpatient cervical ripening, may make elective induction of labor at 39 weeks of gestation even less costly and even more feasible to offer to all women,” suggested Dr. Ecker and Dr. Clapp, both at Massachusetts General Hospital and Harvard Medical School, both in Boston.

Dr. Hersh and coauthors had no relevant financial disclosures, and there was no external funding for their study. Dr. Einerson and most coauthors reported no relevant financial disclosures; one coauthor reported receiving funds from GestVision as a consultant, and another coauthor reported funds paid to her or her institution from some pharmaceutical companies when she was primary investigator on various trials or a consultant. This study was supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Neither Dr. Ecker nor Dr Clapp had any relevant financial disclosures or received any funding.

SOURCES: Hersh AR et al. Obstet Gynecol. 2020. doi: 10.1097/AOG.0000000000003865; Einerson BD et al. Obstet Gynecol. 2020. doi: 10.1097/AOG.0000000000003930.

Next Article: