Economic Evaluation of Elective Cesarean Section on Maternal Request Compared With Planned Vaginal Birth—Application to Swedish Setting Using National Registry Data

There is a lack of consensus around the definition of delivery by cesarean section (CS) on maternal request, and clinical practice varies across and within countries. Previous economic evaluations have focused on specific populations and selected complications. Our aim was to evaluate the cost-effectiveness of CS on maternal request compared with planned vaginal birth in a Swedish context, based on a systematic review of benefits and drawbacks and national registry data on costs. We used the results from a systematic literature review of somatic risks for long- and short-term complications for mother and child, in which certainty was rated low, moderate, or high using the Grading of Recommendations Assessment, Development and Evaluation. Swedish national registry data were used for healthcare costs of delivery and complications. Utilities for long-term complications were based on a focused literature review. We constructed a decision tree and conducted separate analyses for primi- and multiparous women. Costs and effects were discounted by 3% and the time horizon was varied between 1 and 20 years. Planned vaginal birth leads to lower healthcare costs and somatic health gains compared with elective CS without medical indication over up to 20 years. Although there is uncertainty around, for example, quality-of-life effects, results remain stable across sensitivity analyses. CS on maternal request leads to increased hospitalization costs in a Swedish setting, taking into account short- and long-term consequences for both mother and child. Future research needs to study the psychological consequences related to different delivery methods, costs in outpatient care, and productivity losses. •Over- and underuse of cesarean section (CS) may be associated with increased risks of complications. A lack of consensus on the definition of CS on maternal request and binding guidelines leaves room for practice variations.•Previous economic evaluations have mostly focused on countries with high rates of CS or have used specific assumptions. This is an applied cost-effectiveness analysis of CS on maternal request compared with planned vaginal birth using national Swedish data.•In Sweden, planned vaginal birth leads to lower healthcare costs and somatic health gains compared with elective CS without medical indication.