ORIGINAL ARTICLE Patrick J. Culligan Æ John A. Myers Roger P. Goldberg Æ Linda Blackwell Stephan F. Gohmann Æ Troy D. Abell Elective cesarean section to prevent anal incontinence and brachial plexus injuries associated with macrosomia— a decision analysis Received: 15 April 2004 / Accepted: 16 June 2004 / Published online: 29 July 2004 Ó International Urogynecological Association 2004 Abstract Our aim was to determine the cost-effectiveness of a policy of elective C-section for macrosomic infants to prevent maternal anal incontinence, urinary inconti- nence, and newborn brachial plexus injuries. We used a decision analytic model to compare the standard of care with a policy whereby all primigravid patients in the United States would undergo an ultrasound at 39 weeks gestation, followed by an elective C-section for any fetus estimated at ‡4500 g. The following clinical conse- quences were considered crucial to the analysis: brachial plexus injury to the newborn; maternal anal and urinary incontinence; emergency hysterectomy; hemorrhage requiring blood transfusion; and maternal mortality. Our outcome measures included (1) number of brachial plexus injuries or cases of incontinence averted, (2) incremental monetary cost per 100,000 deliveries, (3) expected quality of life of the mother and her child, and (4) ‘‘quality-adjusted life years’’ (QALY) associated with the two policies. For every 100,000 deliveries, the policy of elective C-section resulted in 16.6 fewer permanent brachial plexus injuries, 185.7 fewer cases of anal incontinence, and cost savings of $3,211,000. Therefore, this policy would prevent one case of anal incontinence for every 539 elective C-sections performed. The ex- pected quality of life associated with the elective C-sec- tion policy was also greater (quality of life score 0.923 vs 0.917 on a scale from 0.0 to 1.0 and 53.6 QALY vs 53.2). A policy whereby primigravid patients in the United States have a 39 week ultrasound-estimated fetal weight followed by C-section for any fetuses ‡4500 g appears cost effective. However, the monetary costs in our anal- ysis were sensitive to the probability estimates of urinary incontinence following C-section and vaginal delivery and the cost estimates for urinary incontinence, vaginal delivery, and C-section. Keywords Elective cesarean section Æ Anal incontinence Æ Brachial plexus injuries Æ Macrosomia Introduction As maternal and fetal mortality rates have steadily de- clined within the developed world [1], defining a ‘‘suc- cessful’’ childbirth has become increasingly centered upon issues of morbidity and quality of life from both the maternal and neonatal standpoints. Especially with cases involving macrosomia, vaginal deliveries can result in significant injuries to both the mother and baby. Difficult vaginal childbirth has been implicated as the primary etiologic factor leading to pelvic floor disorders such as anal incontinence, urinary incontinence, and pelvic organ prolapse in the mother [2] as well as permanent brachial plexus injuries in the newborn [3]. Delivery via C-section (especially when the C-sections are performed in the P. J. Culligan (&) Æ L. Blackwell Department of Obstetrics, Gynecology and Women’s Health, Division of Urogynecology and Reconstructive Pelvic Surgery, University of Louisville Health Sciences Center, 315 East Broadway M-18, Louisville, KY 40202, USA E-mail: culligan@mybladderMD.com Tel.: +1-502-6292452 Fax: +1-502-6292444 J. A. Myers School of Public Health and Health Informatics, Biostatistics—Decision Science Program, University of Louisville Health Sciences Center, Louisville, KY, USA R. P. Goldberg Evanston Continence Center, Northwestern University Medical School, Evanston, IL, USA S. F. Gohmann Department of Economics, University of Louisville College of Business and Public Administration, Louisville, KY, USA T. D. Abell Abell Research Consulting, Ouray, CO, USA Int Urogynecol J (2005) 16: 19–28 DOI 10.1007/s00192-004-1203-3