Sunday, October 11, 2009

Financial cost of vaginal delivery is high - and unaccounted for

I've just come across this letter, published in the BMJ back in 2006, titled: 'Consider the value of a functionally intact perineum', and written in response to the study, ''Caesarean delivery in the second stage of labour'.

It's written by Michelle J Thornton, a consultant colorectal surgeon at the Wishaw General Hospital in the UK, and in it, she talks about so many of the issues I've raised with respect to the unaccounted cost of a planned spontaneous vaginal delivery - specifically, when things don't go accoring to plan and an instrumental delivery is necessary.

This is what she has to say (with references listed below):

'Spencer et al say that instrumental delivery may reduce the caesarean section rate in the second stage of labour.1 Although this may be important for the 2006 NHS budget—saving anaesthetic, operating theatre, and hospital costs in the short term—the longer term health outcomes and costs of a high forceps delivery are concerning and go unmentioned.

Recognised third and fourth degree perineal tears occur in 0.5-6% of vaginal deliveries in the western world.2 3 A further 30-44% are estimated to be unrecognised.1 One of the most significant factors, clinically and statistically, to be associated with perineal injury is an instrumental delivery.2 3

Up to a quarter of women with a tear will experience faecal incontinence.3 Although perineal injury during childbirth may not be the sole factor for faecal incontinence, perineal damage increases its likelihood.3 The economic costs of faecal incontinence are large, lifetime cost estimates ranging from £7000 to £43000, depending on treatment.4 The social implications are immeasurable. In a questionnaire of their personal birthing choices even female obstetricians chose caesarean section over an instrumentally assisted delivery.5

To advocate obstetric management that has been declined by educated colleagues is worrying, particularly when the social and economic costs are so great and the idea of gaining valid informed consent is increasing.'

1. Spencer C, Murphy D, Bewley S. Caesarean delivery in the second stage of labour. BMJ 2006;333: 613-4. (23 September.)[Free Full Text]
2. Sultan AH, Kamm MA, Hudson NH, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329: 1905-11.[Abstract/Free Full Text]
3. Abramowitz L, Sobhani I, Ganasia R, Vuagnat A, Benifla JL, Darai E, et al. Are sphincter defects the cause of anal incontinence after vaginal delivery? Results of a prospective study. Dis Colon Rectum 2000;43: 590-6.[CrossRef][ISI][Medline]
4. Adang EM, Engel GL, Rutten FF, Geerdes BP, Baeten CG. Cost-effectiveness of dynamic graciloplasty in patients with faecal incontinence. Dis Colon Rectum 1998;41: 725-34.[CrossRef][ISI][Medline]
5. Al-Mufti R, McCarthy A, Fisk NM. Obstetrician's personal choice and mode of delivery. Lancet 1996;347: 544.[Medline]

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