Examining the Evidence
The economics of an elective cesarean delivery policy
To determine the true cost differences between vaginal delivery and elective cesarean and to assess the economic impact of a “cesarean on demand” policy.
Methods and Results
Using data on direct costs (those that can be directly attributed to the care of mother and neonate) from a community-based hospital over a 12-month period, the author calculated the average perpatient costs of both vaginal delivery and elective cesarean.
He found that, compared with elective cesarean delivery ($918), multiparous vaginal delivery costs 7.1% less ($853) but nulliparous vaginal delivery costs 5.9% more ($972), on average.
Who may be affected by these findings?
Women who would prefer cesarean delivery, payers of health-care costs (including patients), health plans, and society.
For 2 decades the merits and drawbacks of elective cesarean delivery have been debated in the medical literature.1 This practice is seen in Brazil, Chile, and Taiwan, among other countries, where physicians seem to encourage delivery by cesarean section.2 In the United States, no formal guidelines exist. However, with approximately 4 million births per year, this country needs a clear policy concerning elective cesarean that considers
- risks and benefits,
- effects on the provision of care, and
- costs to patients and society.
It is this last item that the current study examines.
Other costs must be considered. Dr. Bost’s analysis of the short-term direct costs of attempted vaginal and elective cesarean delivery finds little difference between the 2 modes of delivery. The strength of this study is its use of estimated costs from supplies, labor, and amortization of equipment. However, the author does not consider any of the indirect costs, the expenditures related to rare but expensive complications, and, notably, future costs these patients might incur in later pregnancies or subsequent medical care.
Health-care expenditures accounted for 13% of the gross domestic product in the United States for 2002 ($1.3 trillion),3 and are projected to outstrip the economy’s growth at even higher rates during the next few decades.4 Thus, when considering a new policy regarding clinical care, cost is clearly a crucial factor—but it is not the only issue for us to weigh.
Evidence sparse on clinical outcomes. In a recent commentary, Minkoff and Chervenak5 support “a physician’s decision to accede to an informed patient’s request for [elective cesarean] delivery.” The authors discuss the risks and benefits of elective cesarean to both mother and fetus. These include protecting the pelvic floor, a slightly reduced rate of neonatal complications at term, and increased risks to the mother from surgery and anesthesia. They advise that these data should be used to counsel patients considering elective cesarean, but concede that there is no overwhelming evidence on either side to guide a clear decision.
The issue of consent. There also is the concern of how well women can be counseled regarding complications. It is unclear whether patients are able to truly understand6 and incorporate7 small risks of rare complications into the decision-making process. Certainly, psychologists, economists, and sociologists have found that there are many ways in which individuals are unable to make well-informed decisions based on the proper use of probabilities; these limitations have been designated as “bounded rationality.”8 This observation raises the issue of patient autonomy versus paternalism.
While we as clinicians endeavor to consistently achieve informed consent by educating patients about the range of possible outcomes, bounded rationality may prevent us from always reaching this goal. Further, many clinical situations call for shared decision-making between patients, families, and physicians. Thus, we must exercise at least some paternalism in order to optimize the medical care we provide to our patients. This balance is particularly relevant when establishing practice standards, guidelines, and other such policies.
This investigation found a slightly increasing trend in the short-term direct costs of successful vaginal delivery (least costly), cesarean delivery, and unsuccessful attempted vaginal delivery (most costly). However, indirect, long-term costs may have larger variation, and clinical outcomes also must be considered. Both require further examination in prospective studies.
1. Feldman GB, Freiman JA. Prophylactic cesarean section at term? N Engl J Med. 1985;312:1264-1267.
2. Behague DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. BMJ. 2002;324:942-945.
3. Heffler S, Smith S, Won G, et al. Health spending projections for 2001-2011: the latest outlook. Faster health spending growth and a slowing economy drive the health spending projection for 2001 up sharply. Health Aff. 2002;21(2):207-218.
4. Chernew ME, Hirth RA, Cutler DM. Increased spending on health care: how much can the United States afford? Health Aff. 2003;22(4):15-25.
5. Minkoff HL, Chervenak FA. Elective primary cesarean delivery. N Engl J Med. 2003;348:946-950.
6. Caughey AB, Washington AE, Kuppermann M. Pregnant patients’ perception of their risk for Down syndrome and complications from invasive prenatal diagnosis. Obstet Gynecol. 2002;99:93S.-
7. Musci TJ, Caughey AB, Main D, Belluomini J, Goldberg J. Nuchal translucency screening: how is it used by women over 35 years of age? Am J Obstet Gynecol. 2003;187:S161.-
8. Simon HA. Theories of decision making in economics and behavioral science. Am Econ Rev. 1959;49:253-283.