Download PDF
Am J Perinatol 2023; 40(03): 290-296
DOI: 10.1055/s-0041-1727213
Original Article

Twin Vaginal Deliveries in Labor Rooms: A Cost-Effectiveness Analysis

Jenny Y. Mei 
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
,
Divya Mallampati
2   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
,
Ilina D. Pluym
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
,
Christina S. Han 
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
,
Yalda Afshar 
1   Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles, California
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Objective Twin vaginal deliveries (VDs) are often performed in the operating room (OR) given the theoretical risk of conversion to cesarean delivery (CD) for the aftercoming twin. We aim to evaluate the cost-effectiveness of performing VDs for twin gestations in the labor and delivery room (LDR) versus OR.

Study Design We conducted a cost-effectiveness analysis using a decision-analysis model that compared the costs and effectiveness of two strategies of twin deliveries undergoing a trial of labor: (1) intended delivery in the LDR and 2) delivery in the OR. Sensitivity analyses were performed to assess strength and validity of the model. Primary outcome was incremental cost-effectiveness ratio (ICER) defined as cost needed to gain 1 quality-adjusted life year (QALY).

Results In the base-case scenario, where 7% of deliveries resulted in conversion to CD for twin B, attempting to deliver twins in the LDR was the most cost-effective strategy. For every QALY gained by delivering in the OR, 243,335 USD would need to be spent (ICER). In univariate sensitivity analyses, the most cost-effective strategy shifted to delivering in the OR when the following was true: (1) probability of successful VD was less than 86%, (2) probability of neonatal morbidity after emergent CD exceeded 3.5%, (3) cost of VD in an LDR exceeded 10,500 USD, (4) cost of CD was less than 10,000 USD, or (5) probability of neonatal death from emergent CD exceeded 2.8%. Assuming a willingness to pay of 100,000 USD per neonatal QALY gained, attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis.

Conclusion Twin VDs in the LDR are cost effective based on current neonatal outcome data, taking into account gestational age and associated morbidity. Further investigation is needed to elucidate impact of cost and outcomes on optimal utilization of resources.

Key Points

  • Cost effectiveness of twin VDs in the LDR versus OR was assessed.

  • Twin VDs in the LDR are cost effective based on current neonatal outcome data.

  • Attempted VD in the LDR was cost effective in 51% of simulations in the Monte Carlo analysis.

Keywords

twin vaginal deliveries - cost-effectiveness analysis - labor and delivery room

Note

This study was presented in poster format at Society of Maternal-Fetal Medicine's Annual Meeting, February 3–8, 2020, Grapevine, TX.


Supplementary Material



Publication History

Received: 29 August 2020

Accepted: 02 March 2021

Article published online:
20 April 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Jewell SE, Yip R. Increasing trends in plural births in the United States. Obstet Gynecol 1995; 85 (02) 229-232
    CrossrefPubMedGoogle Scholar
  • 2 Barrett JF, Hannah ME, Hutton EK. et al; Twin Birth Study Collaborative Group. A randomized trial of planned cesarean or vaginal delivery for twin pregnancy. N Engl J Med 2013; 369 (14) 1295-1305
    CrossrefPubMedGoogle Scholar
  • 3 Martin JA, Hamilton BE, Osterman MJK. Three decades of twin births in the United States, 1980–2009. NCHS Data Brief 2012; (80) 1-8
    PubMedGoogle Scholar
  • 4 MacKay AP, Berg CJ, King JC, Duran C, Chang J. Pregnancy-related mortality among women with multifetal pregnancies. Obstet Gynecol 2006; 107 (03) 563-568
    CrossrefPubMedGoogle Scholar
  • 5 Luke B, Brown MB, Alexandre PK. et al. The cost of twin pregnancy: maternal and neonatal factors. Am J Obstet Gynecol 2005; 192 (03) 909-915
    CrossrefPubMedGoogle Scholar
  • 6 Persad VL, Baskett TF, O'Connell CM, Scott HM. Combined vaginal-cesarean delivery of twin pregnancies. Obstet Gynecol 2001; 98 (06) 1032-1037
    PubMedGoogle Scholar
  • 7 Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000; 356 (9239): 1375-1383
    Google Scholar
  • 8 American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. ACOG practice bulletin no. 144: multifetal gestations: twin, triplet, and higher-order multifetal pregnancies. Obstet Gynecol 2014; 123 (05) 1118-1132
    CrossrefPubMedGoogle Scholar
  • 9 Schmitz T, Korb D, Battie C. et al; Jumeaux Mode d'Accouchement study group, Groupe de Recherche en Obstétrique et Gynécologie. Neonatal morbidity associated with vaginal delivery of noncephalic second twins. Am J Obstet Gynecol 2018; 218 (04) 449.e1-449.e13
    CrossrefPubMedGoogle Scholar
  • 10 Alexander JM, Leveno KJ, Rouse D. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Cesarean delivery for the second twin. Obstet Gynecol 2008; 112 (04) 748-752
    CrossrefPubMedGoogle Scholar
  • 11 American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics, Society for Maternal-Fetal Medicine, ACOG Joint Editorial Committee. ACOG practice bulletin #56: multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. Obstet Gynecol 2004; 104 (04) 869-883
    CrossrefPubMedGoogle Scholar
  • 12 Mei JY, Muñoz HE, Kim JS. et al. Rates of Cesarean conversion and associated predictors and outcomes in planned vaginal twin deliveries. Am J Perinatol 2020
    PubMedGoogle Scholar
  • 13 Aviram A, Lipworth H, Asztalos EV. et al. The worst of both worlds-combined deliveries in twin gestations: a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study. Am J Obstet Gynecol 2019; 221 (04) 353.e1-353.e7
    CrossrefPubMedGoogle Scholar
  • 14 Taylor M, Rebarber A, Saltzman DH, Klauser CK, Roman AS, Fox NS. Induction of labor in twin compared with singleton pregnancies. Obstet Gynecol 2012; 120 (2 Pt 1): 297-301
    CrossrefPubMedGoogle Scholar
  • 15 Mei-Dan E, Dougan C, Melamed N. et al. Planned cesarean or vaginal delivery for women in spontaneous labor with a twin pregnancy: A secondary analysis of the Twin Birth Study. Birth 2019; 46 (01) 193-200
    CrossrefPubMedGoogle Scholar
  • 16 Doss AE, Mancuso MS, Cliver SP, Jauk VC, Jenkins SM. Gestational age at delivery and perinatal outcomes of twin gestations. Am J Obstet Gynecol 2012; 207 (05) 410.e1-410.e6
    CrossrefPubMedGoogle Scholar
  • 17 Tavares MV, Domingues AP, Nunes F, Tavares M, Fonseca E, Moura P. Induction of labour vs. spontaneous vaginal delivery in twin pregnancy after 36 weeks of gestation. J Obstet Gynaecol 2017; 37 (01) 29-32
    CrossrefPubMedGoogle Scholar
  • 18 de Castro H, Haas J, Schiff E, Sivan E, Yinon Y, Barzilay E. Trial of labour in twin pregnancies: a retrospective cohort study. BJOG 2016; 123 (06) 940-945
    CrossrefPubMedGoogle Scholar
  • 19 Grobman WA, Bailit J, Sandoval G. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (MFMU) Network. The association of decision-to-incision time for cesarean delivery with maternal and neonatal outcomes. Am J Perinatol 2018; 35 (03) 247-253
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Vilchez G, Dai J, Kumar K, Lagos M, Sokol RJ. Contemporary analysis of maternal and neonatal morbidity after uterine rupture: a nationwide population-based study. J Obstet Gynaecol Res 2017; 43 (05) 834-838
    CrossrefPubMedGoogle Scholar
  • 21 Holmgren C, Scott JR, Porter TF, Esplin MS, Bardsley T. Uterine rupture with attempted vaginal birth after cesarean delivery: decision-to-delivery time and neonatal outcome. Obstet Gynecol 2012; 119 (04) 725-731
    CrossrefPubMedGoogle Scholar
  • 22 The World Bank. Indicators. Accessed March 17, 2021 at: https://data.worldbank.org/indicator
    PubMedGoogle Scholar
  • 23 Mokdad AH, Ballestros K, Echko M. et al; US Burden of Disease Collaborators. The state of US health, 1990-2016: burden of diseases, injuries, and risk factors among US States. JAMA 2018; 319 (14) 1444-1472
    CrossrefPubMedGoogle Scholar
  • 24 Eunson P. The long-term health, social, and financial burden of hypoxic-ischaemic encephalopathy. Dev Med Child Neurol 2015; 57 (Suppl. 03) 48-50
    CrossrefPubMedGoogle Scholar
  • 25 Mei JY, Muñoz HE, Szlachta-McGinn AC, Rao R, Pluym I, Afshar Y. Rates of Cesarean Conversion in Planned Vaginal Twin Deliveries: Do We Need the Operating Room? Poster presented at: The Annual Clinical and Scientific Meeting of the American Congress of Obstetricians and Gynecologists; May 3–6, 2019; Nashville, TN
    PubMed
  • 26 Lagrew DC, Bush MC, McKeown AM, Lagrew NG. Emergent (crash) cesarean delivery: indications and outcomes. Am J Obstet Gynecol 2006; 194 (06) 1638-1643 , discussion 1643
    CrossrefPubMedGoogle Scholar
  • 27 Refuerzo JS, Momirova V, Peaceman AM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Neonatal outcomes in twin pregnancies delivered moderately preterm, late preterm, and term. Am J Perinatol 2010; 27 (07) 537-542
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Swanson K, Grobman WA, Miller ES. The Association between the Intertwin Interval and Adverse Neonatal Outcomes. Am J Perinatol 2017; 34 (01) 70-73
    PubMedGoogle Scholar
  • 29 Yang Q, Wen SW, Chen Y, Krewski D, Fung Kee Fung K, Walker M. Neonatal death and morbidity in vertex-nonvertex second twins according to mode of delivery and birth weight. Am J Obstet Gynecol 2005; 192 (03) 840-847
    CrossrefPubMedGoogle Scholar
  • 30 Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Accessed March 17, 2021 at: https://www.ahrq.gov/data/hcup/index.html
    PubMedGoogle Scholar
  • 31 Childers CP, Maggard-Gibbons M. Understanding costs of care in the operating room. JAMA Surg 2018; 153 (04) e176233
    CrossrefPubMedGoogle Scholar
  • 32 Executive Summary ACOG. American Collge of Obstetricians and Gynecologists (ACOG). Neonatal encephalopathy and cerebral palsy: executive summary. Obstet Gynecol 2004; 103 (04) 780-781
    CrossrefPubMedGoogle Scholar
  • 33 Werner EF, Hamel MS, Orzechowski K, Berghella V, Thung SF. Cost-effectiveness of transvaginal ultrasound cervical length screening in singletons without a prior preterm birth: an update. Am J Obstet Gynecol 2015; 213 (04) 554.e1-554.e6
    CrossrefPubMedGoogle Scholar
  • 34 Tengs TO, Wallace A. One thousand health-related quality-of-life estimates. Med Care 2000; 38 (06) 583-637
    CrossrefPubMedGoogle Scholar
  • 35 Yang Q, Wen SW, Chen Y, Krewski D, Fung Kee Fung K, Walker M. Occurrence and clinical predictors of operative delivery for the vertex second twin after normal vaginal delivery of the first twin. Am J Obstet Gynecol 2005; 192 (01) 178-184
    CrossrefPubMedGoogle Scholar
  • 36 Goossens SM, Hukkelhoven CW, de Vries L, Mol BW, Nijhuis JG, Roumen FJ. Clinical indicators associated with the mode of twin delivery: an analysis of 22,712 twin pairs. Eur J Obstet Gynecol Reprod Biol 2015; 195: 133-140
    CrossrefPubMedGoogle Scholar
  • 37 Aviram A, Weiser I, Ashwal E, Bar J, Wiznitzer A, Yogev Y. Combined vaginal-cesarean delivery of twins: risk factors and neonatal outcome--a single center experience. J Matern Fetal Neonatal Med 2015; 28 (05) 509-514
    CrossrefPubMedGoogle Scholar
  • 38 Mauldin JG, Newman RB, Mauldin PD. Cost-effective delivery management of the vertex and nonvertex twin gestation. Am J Obstet Gynecol 1998; 179 (04) 864-869
    CrossrefPubMedGoogle Scholar
  • 39 Braithwaite RS, Meltzer DO, King Jr. JT, Leslie D, Roberts MS. What does the value of modern medicine say about the $50,000 per quality-adjusted life-year decision rule?. Med Care 2008; 46 (04) 349-356
    CrossrefPubMedGoogle Scholar
  • 40 Neumann PJ, Cohen JT, Weinstein MC. Updating cost-effectiveness--the curious resilience of the $50,000-per-QALY threshold. N Engl J Med 2014; 371 (09) 796-797
    CrossrefPubMedGoogle Scholar
  • 41 Callahan TL, Hall JE, Ettner SL, Christiansen CL, Greene MF, Crowley Jr WF. The economic impact of multiple-gestation pregnancies and the contribution of assisted-reproduction techniques to their incidence. N Engl J Med 1994; 331 (04) 244-249
    CrossrefPubMedGoogle Scholar
  • 42 Carvalho B, Saxena A, Butwick A, Macario A. Vaginal twin delivery: a survey and review of location, anesthesia coverage and interventions. Int J Obstet Anesth 2008; 17 (03) 212-216
    CrossrefPubMedGoogle Scholar