Obstructed Labor and Caesarean Delivery: The Cost and Benefit of Surgical Intervention

Background: Although advances in the reduction of maternal mortality have been made, up to 273,000 women will die this year from obstetric etiologies. Obstructed labor (OL), most commonly treated with Caesarean delivery, has been identified as a major contributor to global maternal morbidity and mortality. We used economic and epidemiological modeling to estimate the cost per disability-adjusted life-year (DALY) averted and benefit-cost ratio of treating OL with Caesarean delivery for 49 countries identified as providing an insufficient number of Caesarean deliveries to meet demand. Methods and Findings Using publicly available data and explicit economic assumptions, we estimated that the cost per DALY (3,0,0) averted for providing Caesarean delivery for OL ranged widely, from $251 per DALY averted in Madagascar to$3,462 in Oman. The median cost per DALY averted was $304. Benefit-cost ratios also varied, from 0.6 in Zimbabwe to 69.9 in Gabon. The median benefit-cost ratio calculated was 6.0. The main limitation of this study is an assumption that lack of surgical capacity is the main factor responsible for DALYs from OL. Conclusions: Using the World Health Organization's cost-effectiveness standards, investing in Caesarean delivery can be considered “highly cost-effective” for 48 of the 49 countries included in this study. Furthermore, in 46 of the 49 included countries, the benefit-cost ratio was greater than 1.0, implying that investment in Caesarean delivery is a viable economic proposition. While Caesarean delivery alone is not sufficient for combating OL, it is necessary, cost-effective by WHO standards, and ultimately economically favorable in the vast majority of countries included in this study

Estimated number of Caesarean deliveries required to prevent 90% of OL in each country, along with the total number of preventable obstetric fistulas and maternal mortality for each country in 2008.

a<p>Necessary to prevent 90% of OL;</p>b<p>Adjusted for mortality secondary to Caesarean delivery.</p

Cost per DALY (3,0,0) averted vs. cumulative DALYs (3,0,0) averted for the 49 countries included in the analysis.

<p>The vertical axis represents the average cost per DALY averted in a country, and the horizontal axis shows the cumulative number of DALYs averted as one moves from least-cost country to highest-cost country. To maximize the number of DALYs averted within their budgets, cost-conscious donors should first donate to countries at the left-most portion of curve and then move right until all funds are used.</p

Unit cost of Caesarean delivery, total cost (USD) of treating OL with Caesarean delivery (000 s), cost (USD) per DALY(3,0,0) averted by treating OL, gross economic benefit of addressing OL (in 000 s), and benefit-cost ratio for treating OL in 2008.

a<p>: Total cost to treat 90% of cases of neglected obstructed labor with Caesarean delivery.</p>b<p>: The cost per DALY averted using (3,0,0) assumptions, which is consistent with the DCPP approach.</p>c<p>: Estimated by valuing DALYs (3,1,) with value of a statistical life-year.</p>d<p>: Benefit-cost ratio calculated by dividing gross economic benefit by total cost.</p