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Obstetric outcome in 100 women with severe anxiety over childbirth |
Sjogren B, Thomassen P |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology Use of psychological and obstetric support for the treatment of severe anxiety over childbirth in pregnant women.
Economic study type Cost-effectiveness analysis.
Study population Pregnant women, attending the Department of Obstetrics, Karolinska Hospital, Stockholm, Sweden.
Setting The practice setting was the outpatient department. The economic study was carried out in Stockholm, Sweden.
Dates to which data relate Effectiveness and resource use data related to the period September 1989-February 1992. The price date was not stated.
Source of effectiveness data Effectiveness data were derived from a single study.
Link between effectiveness and cost data Cost data were collected retrospectively from the same patient sample as that used for the effectiveness study.
Study sample 100 pregnant women, who were eligible and who attended the study hospital, were consecutively referred to a psychosomatic gynaecologist, to receive psychological and obstetric support.35% of the study patients were recommended for psychotherapy, but 29% (10/35) of those refused it. A reference group (n=100), matched for age, parity, gestational week and mode and date of delivery, was selected retrospectively from the delivery room register. The median age of the women in the study group was 32.8 years (SD 5.1), compared with 32.6 years (SD 4.8) in the reference group. Statistically significant differences between the two groups were found in three variables: the frequency of previous psychic problems (study group = 32%, control group = 4%); the frequency of previous voluntary abortions (study group = 38%, control group = 22%); and the proportion of patients with previous normal deliveries (study group = 15%, control group = 28%). The percentage of women who were excluded from, or who refused to participate in, the study was not stated. Power calculations were not used to determine sample size.
Study design The study was of a case-series design, conducted at a single centre. Patients were followed up until they had delivered.
Analysis of effectiveness The analysis was based on a complete set of patient records. The primary health outcomes used in the analysis were the proportion of patients undergoing an elective caesarean section (CS) for psychological reasons, the proportion of patients undergoing a CS for other reasons and the proportion of patients who had initially requested CS, but who, after counselling, changed their preference for a vaginal delivery (VD). The proportion of these patients whose pregnancy concluded in VD was also reported. At the time of analysis, groups were shown to be comparable in terms of psychosocial status and reproductive history.
Effectiveness results 43% of both groups were delivered by CS. In the study group, 30% of patients underwent an elective CS for psychological reasons. A further 13% of the study group were delivered by CS for other obstetrical reasons, and just under half reported that psychological reasons contributed to their choice of delivery.56% (38/68) of the study patients changed their preference for mode of delivery from CS to VD; 41% (28/68) of these study patients actually underwent VD. In the reference group, no CS was performed for psychological reasons: 26% of CS was for pelvic incompatibility, 26% for breech presentations and 19% because of previous CS. The statistical significance of these results was not reported. Changes in the reference patients' preferences for mode of delivery were not reported.
Clinical conclusions Psychosomatic support for women with severe anxiety over childbirth resulted in a 50% reduction of CS for psychosocial reasons and obstetric outcomes were similar to those of the reference group.
Measure of benefits used in the economic analysis Effectiveness estimates were not converted to a measure of health benefit. The estimate used in the economic analysis was the proportion of patients who changed their preference for mode of delivery from CS to VD.
Direct costs Costs were estimated from the perspective of the hospital and included the cost of a CS, the cost of a VD and the cost of psychological therapy from both the psychosomatic gynaecologist and from the psychotherapist. Prices were taken from an itemised price list from the local council but the price date was not stated. Prices and quantities were reported separately. Cost savings were estimated on the basis of the number of women who changed their preference for mode of delivery from CS to VD, rather than on the number who changed their preference and also gave birth by VD.
Statistical analysis of costs A statistical analysis of costs was not performed.
Indirect Costs Indirect costs were not included in the analysis.
Sensitivity analysis A sensitivity analysis was not performed.
Estimated benefits used in the economic analysis Estimated benefits were proxied by the effectiveness estimates.
Cost results Total per patient costs were not reported. The total cost of psychotherapeutic treatment was estimated to be SEK446,660. The cost savings from potentially averted CS deliveries was estimated to be SEK570,000. This implied an overall saving of SEK123,340.
Synthesis of costs and benefits A synthesis of costs and benefits was not performed.
Authors' conclusions Psychotherapeutic treatment reduces the rate of CS for psychosocial reasons. The cost of this treatment was compensated for by savings from this reduced rate. The intervention is therefore cost-saving.
CRD COMMENTARY - Selection of comparators The reason for the choice of comparator is clear, although the authors did not explicitly justify their choice. You, the user of this database, should decide if the absence of formal psychological or obstetric support is the usual practice in your own setting.
Validity of estimate of measure of benefit The reference group had a much higher rate of CS for non-psychological reasons, than did the study group. Although groups were matched for maternal age, other predictors of risk for CS, such as maternal height, smoking status and pregnancy weight gain, were not reported. This suggests that the groups were not comparable in important clinical characteristics. Moreover, the preferences for mode of delivery were not solicited from the reference group. Consequently, this was an uncontrolled study and the observed changes in the study group's preferences cannot be confidently attributed to the intervention. There was no formal measurement of health benefit. Quality of life improvements for patients undergoing VD rather than CS were addressed by the authors in a narrative fashion, but were not formally investigated.
Validity of estimate of costs Costs and quantities were reported separately, but insufficient detail of the composition of unit costs was given. Furthermore, the cost of other antenatal care was not included in the analysis, although this may have been affected by patients' use of psychosomatic therapy. The absence of statistical or sensitivity analyses of costings limits the generalisability of the results. In estimating cost savings for the intervention, the authors implicitly assumed that patients would not have changed the preferences for mode of delivery expressed at enrolment, which does not allow for women who may have changed their minds over the course of the pregnancy for other reasons. Moreover, the estimate was based on the proportion of patients who changed their preference for mode of delivery from CS to VD (38%), rather than on the proportion who changed their preference and also gave birth by VD (28%). Reworking costs based on the latter figure loses the cost saving advantage for psychosomatic treatment.
Other issues The availability of elective CS for psychological reasons may vary in other settings. It is unclear how 'severe anxiety' was defined, which further limits the applicability of the findings. Neither statistical nor sensitivity analyses of the findings were employed to investigate any areas of uncertainty. The authors' conclusions are therefore unlikely to be justified.
Implications of the study A randomised controlled study, in which the health benefits of psychotherapeutic treatment were estimated, could have given a more reliable assessment of the cost-effectiveness or cost-utility of the intervention.
Source of funding Supported by grants from The Karolinska Institute and the Swedish Society of Medicine.
Bibliographic details Sjogren B, Thomassen P. Obstetric outcome in 100 women with severe anxiety over childbirth. Acta Obstetricia et Gynecologica Scandinavica 1997; 76(10): 948-952 Indexing Status Subject indexing assigned by NLM MeSH Adult; Anxiety /psychology /therapy; Cesarean Section /economics; Cost-Benefit Analysis; Female; Humans; Labor, Induced /economics; Pregnancy; Pregnancy Complications /psychology /therapy; Pregnancy Outcome; Psychotherapy /economics AccessionNumber 21998000063 Date bibliographic record published 31/03/1999 Date abstract record published 31/03/1999 |
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