Active management of labor: a cost analysis of a randomized controlled trial

Objective To compare the costs of a protocol of active management of labor with those of traditional labor management. Design Cost analysis of a randomized controlled trial. Methods From August 1992 to April 1996, we randomly allocated 405 women whose infants were delivered at the University of New Mexico Health Sciences Center, Albuquerque, to an active management of labor protocol that had substantially reduced the duration of labor or a control protocol. We calculated the average cost for each delivery, using both actual costs and charges. Results The average cost for women assigned to the active management protocol was $2,480.79 compared with an average cost of $2,528.61 for women in the control group (P = 0.55). For women whose infant was delivered by cesarean section, the average cost was $4,771.54 for active management of labor and $4,468.89 for the control protocol (P = 0.16). Spontaneous vaginal deliveries cost an average of $27.00 more for actively managed patients compared with the cost for the control protocol. Conclusions The reduced duration of labor by active management did not translate into significant cost savings. Overall, an average cost saving of only $47.91, or 2%, was achieved for labors that were actively managed. This reduction in cost was due to a decrease in the rate of cesarean sections in women whose labor was actively managed and not to a decreased duration of labor.Many obstetricians are concerned about the increase in the rate of cesarean sections in the United States. In 1970, the overall incidence of cesarean section was 5%.¹ By 1983, the rate had increased to 21%; it peaked at 24.7% in 1988^2,3 and remains greater than 20% of all deliveries.⁴ Lowering the rate of cesarean delivery decreases maternal risk for associated morbidity and should, therefore, significantly decrease the costs of delivery.The active management of labor, first introduced by O''Driscoll et al in the 1960s at the National Maternity Hospital in Dublin, Ireland,⁵ is a group of interventions initially devised to ensure short labors in nulliparous women. In addition, active management of labor was noted to be associated with a lower cesarean section rate,^6,7 which was thought to be due to a decrease in the number of cesarean deliveries performed for dystocia. Three randomized studies have been done to evaluate the efficacy of active management of labor.^8,9,10 These studies have demonstrated significant decreases in the duration of labor and the incidence of infectious morbidity, as well as a trend toward lower cesarean section rates.Rogers et al¹⁰ reported their experience with a protocol of active management of labor at the University of New Mexico Health Sciences Center, Albuquerque. A randomized trial, carried out between August 1992 and April 1996, compared two protocols, one using an active management of labor and the other a standard management of labor. No significant differences between the patient populations, neonatal outcomes, the incidence of uterine hyperstimulation, the use of epidural analgesia, infectious morbidity, or cesarean delivery rates were observed. A significant reduction in the duration of labor and a trend toward fewer cesarean deliveries were observed in the group whose labor was actively managed. In the present study, we undertook to evaluate the differences in cost of the two protocols. We hypothesized that the reduction in the duration of labor for women whose labor was actively managed would translate to significant cost savings. This is a cost-minimization analysis of a prospective trial of a protocol of active management of labor.