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New York/Stuttgart – A highly significant study on the cost effectiveness of trial of labor following previous cesarean (TOLAC) has just been published in the “American Journal of Perinatology.” Sharon A. Gilbert from the George Washington University Biostatistics Center in Washington, D.C. along with her co-authors conducted this analysis for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Using rigorously collected data from a well-characterized cohort and a propensity score decision analysis model, the researchers compared the cost-effectiveness of TOLAC with an elective repeat cesarean delivery (ERCD) for a hypothetical cohort of 100,000 women at centers throughout the United States. 

Sharon Gilbert explains, “This is the first analysis to use propensity scores in this context. Different to previous analyses, our work was based on an observational study specifically devised to obtain maternal and perinatal outcome probabilities. We obtained these probabilities from a specifically designed model using propensity scores. This then allowed us to uniquely develop TOLAC and ERCD groups with well balanced covariates with minimal bias.”

Using this model, Gilbert and her colleagues estimate savings of $138.6 million per 100,000 women, and that 1,703 quality-adjusted life-years could be gained if TOLAC as a mode of delivery were chosen over ERCD. Unlike previous studies, the cost data for this analysis was obtained from several sources, including US national sources, the Agency for Healthcare Research and Quality and the American Medical Association.

Gibert continues, “In the future we would need to look at further aspects, for example the long-term maternal outcomes of fecal and urinary incontinence, which was not included in our analysis. Also the important long-term outcomes of placenta accreta and previa in subsequent pregnancies would need to be considered. The determination of the exact cost-effectiveness over the life course would require a separate more complex model taking into account uncertainties of future reproduction.”

Highlighting the timeliness of this study, George R. Saade, Editor-in-Chief of the “American Journal of Perinatology” comments, “This publication by Sharon Gilbert and her colleagues clearly demonstrates that it is much more cost-effective to attempt for vaginal delivery after a previous cesarean than repeating a cesarean in a subsequent pregnancy. The rise in cesarean delivery can be observed worldwide. Given the cost effectiveness, financial incentives for TOLAC seem reasonable and may be helpful in increasing the rates of TOLAC. I am delighted that this work is featured in our journal.”

About “American Journal of Perinatology”

The “American Journal of Perinatology” is an international, peer-reviewed, and indexed journal publishing 10 issues a year dealing with original research and topical reviews. It is the definitive forum for specialists in obstetrics, neonatology, perinatology, and maternal/fetal medicine, with emphasis on bridging the different fields.
The “American Journal of Perinatology” is accompanied by AJP Reports - an open access journal for case reports in neonatology and maternal/fetal medicine. All print subscriptions to American Journal of Perinatology include print copies of AJP Reports. For further information visit:

About Thieme

Thieme Publishing Group is a scientific and medical publishing house employing more than 950 people and maintaining offices in seven cities, including New York, Delhi, Stuttgart and three other locations in Germany. Founded in 1886, the Thieme name has become synonymous with high quality and excellence in medical and scientific publishing. Today, Thieme is the market leading publisher of neurosurgical content and holds strong market positions in orthopedics, radiology, anatomy and chemistry, among other specialties. Thieme publishes 137 peer-reviewed journals and over 500 new books annually. The company also has a rapidly growing array of web-based products in medicine and science. State-of-the-art online products include Thieme eJournals, Thieme Electronic Book Library, the medical student website and Thieme Teaching Assistant, an innovative web-based platform for faculty. For more information about Thieme, please visit

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