Examining Labor in the Upright Positioning with a Low-Dose Epidural: A Cost-Effectiveness Analysis

Abstract Purpose: To estimate the outcomes, costs, and cost-effectiveness associated with birthing in the upright position compared to the recumbent position in patients with a low-dose epidural. Methods: We designed a decision-analytic model using TreeAge Pro software to compare the outcomes and cost-effectiveness of employing the upright versus recumbent position during the first delivery with a low-dose epidural, incorporating the impact of mode of delivery on a subsequent delivery. We used a theoretical cohort of 756,000 patients, representing the approximate number of nulliparous individuals who have a term birth in the United States annually and are given an epidural. Probabilities and costs were derived from the literature. Results: In our theoretical cohort of 756,000 nulliparous individuals with a low-dose epidural, the recumbent positioning strategy was associated with 18,652 fewer cesarean deliveries in the first pregnancy (66,210 vs 84,862), which would lead to 11,228 fewer cesarean deliveries in the second pregnancy (135,787 vs 147,015), 4 fewer uterine ruptures (15 vs 19) and 1 fewer hysterectomy (4 vs 5) in the second pregnancy, 2 fewer maternal deaths (23 vs 25) in the first delivery, and 1 fewer maternal death in the second delivery (26 vs 27). Laboring in the recumbent position saved $157 million ($15.526 billion vs $15.683 billion) and increased QALYs by 2,141 QALYs (19.846 million vs 19.844 million). Conclusion: Our results show that in a theoretical cohort of 756,000 patients, laboring in the recumbent position may save $157 million annually and improve maternal outcomes.