Title: 662: Vacuum vs. forceps: A two-delivery cost-effectiveness analysis
Abstract: Operative vaginal delivery using forceps or vacuum is a common approach to the management of the prolonged second stage. Each method carries its own risks of neonatal and maternal morbidity. Our study examined the cost-effectiveness of forceps compared to vacuum in the context of two deliveries. A cost-effectiveness model was created using TreeAge 2018 software to compare neonatal and maternal outcomes of forceps delivery compared to vacuum delivery considering the impact on the subsequent pregnancy. We used a theoretical cohort of 100,000 women, the approximate number of nulliparous term births in the US annually affected by prolonged second stage of labor. We assumed all women proceeded to a second delivery, reflecting the average number of births per woman in the US. Outcomes included neonatal mortality, permanent brachial plexus injury (BPI), severe cerebral morbidity (CM), maternal mortality, severe perineal laceration, placenta previa, placenta accreta, uterine rupture, hysterectomy, cost, and quality-adjusted life years (QALY) of the woman and neonate. Probabilities, utilities, and costs were derived from the literature, and the willingness-to-pay (WTP) threshold was $100,000/QALY. Univariate sensitivity analysis was used to assess the robustness of the results. Comparing forceps to vacuum in a woman's first delivery, forceps was cost-effective (increased QALYs despite increased costs) when considering a primary and a subsequent delivery. In our theoretical cohort of 100,000 women, forceps delivery led to 10,163 fewer cesarean sections across two deliveries, 71 fewer placenta previas and 9 fewer hysterectomies with 34,233 additional QALYs, despite an additional 14,762 severe perineal lacerations (Table 1). Sensitivity analysis demonstrated that forceps remained the cost-effective strategy up to a failure rate of vacuum of 0.15 (with a baseline of 0.06) (Figure 1). The incremental cost-effectiveness ratio (ICER) was $1,345/QALY. In our theoretical cohort, utilizing forceps as compared to vacuum leads to fewer adverse outcomes, increased QALYs and increased costs during the first and second delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)