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OFFERING BREECH VERSION BY ACUMOXA AT 33 WEEKS GESTATION: A DECISION ANALYSIS ON EFFECTIVENESS AND COSTS

• Ineke van den Berg MSc, BSc, Guido C. Kaandorp, MSc, Johanna L. Bosch, PhD, Johannes J. Duvekot, MD, PhD, M.G.Myriam Hunink M.D., PhD

Department of Epidemiology and Biostatistics, Radiology, Obstetrics and Gynecology, Erasmus University MC Rotterdam, Rotterdam, The Netherlands

Clinic for Complementary Medicine, Praktijk Rodenrijs, Berkel en Rodenrijs, The Netherlands

BACKGROUNDIn pregnancies at term, about 3-5% of singleton fetuses presents in breech position at delivery, and caesa-rian section have become common practice in many Western Countries for term breech deliveries. Caesarian sections, however, do have disadvantages. Next to the estimated perinatal mortality as addi-tional risk of a caesarian section (i.e. 0.2%), the-re is a risk of adverse effects of a caesarian sec-tion on subsequent pregnancies. Furthermore, distinct disadvantages including an increased risk of maternal urinary tract infection, hemor-rhage, wound infection, and scar dehiscence or uterine rupture during subsequent labor are described. In addition, the increased rate of cae-sarian section for breech delivery will lead to higher societal costs in a time of budget cons-traints. Therefore, from various perspectives it is impor-tant to find methods that can be used to correct breech presentation before delivery, so that the number of caesarian sections can be reduced.

OBJECTIVETo evaluate the effectiveness and costs of the strategies Breech Version by Acu-moxa (Moxa) and Standard Care (SC) for women with a fetus in breech presenta-tion at 33 weeks gestation.

OUTCOMES For both strategies the percentage of breech presentations at term, percentage of Caesarean sections, and total costs were calculated. In addition, we calculated Odds Ratios (OR) of Moxa versus SC of the effectiveness outco-mes. Associated events, treatment compliance, and costs were included in the model. The analysis was perfor-med from the third-party payer perspective. Costs were expressed in 2006 Euros. Extensive sensitivity analyses were performed.

RESULTSThe percentage of breech presentations after Moxa compared to SC was 32% vs. 53%, (OR 0.61, 95%CI 0.43, 0.83). The percentage of Caesarian sections was 37% vs. 50% Moxa compared to SC (OR 0.73, 95%CI 0.59, 0.88). The mean total costs per woman were €4595 for Acumoxa vs. € 5046 for SC (Cost difference €451, 95%CI €109, €775). Sensitivity analysis showed that if 16% or more of women offered Acumoxa complied, offering Acumoxa was more effective and less costly than SC. To prevent one Caesarean section, 7 women with a fetus in breech presentation at 33 weeks gestation have to be treated with Acumoxa.

CONCLUSIONSOur results suggest that offering Acumoxa to women with a fetus in breech position at 33 weeks gestation reduces the number of breech presentations at term reduces the number of Caesarean sections, and is less costly compared to standard care.

ACKNOWLEDGEMENTSThe authors thank the Dutch Association for Acupuncture (N.V.A.) who, in part, suppor-ted this study.

Moxa = Breech version by AcumoxaSC = Standard CareECV = External Cephalic VersionCS = Cesarean Section

Percentage breech presentation at delivery

Analysis- No ECV performed Mean (%) OR (95% CI) Probability SC preferred

Moxa 32.0 0.61 (0.43, 0.83) 0.0008

Standard Care 52.9

Analysis- ECV performed

Moxa 11.6 0.62 (0.45, 0.84) 0.001

Standard Care 18.8

Percentage cesarean section

Analysis- No ECV performed Mean (%) OR (95% CI) Probability SC preferred

Nrs. to treat to prevent one CS

Moxa 36.6 0.73 (0.59, 0.88) 0.0008 7.3

Standard Care 50.3

Analysis- ECV performed

Moxa 23.1 0.83 (0.67, 0.98) 0.001 21.0

Standard Care 27.8

Total costs (2006 Euros)

Analysis- No ECV performed Mean (€) Difference (95% CI) Probability SC preferred

Moxa 4595 451 (109,775) 0.0052

Standard Care 5046

Analysis- ECV performed

Moxa 4523 404 (72,864) 0.0073

Standard Care 4927

RESULTSOutcomes of Moxa and standard care strategies for women at 33 gestation with a fetus in breech presentation.

METHODSA decision tree was developed to compa-re the strategies Acumoxa with standard care to correct breech presentation. In the decision tree, two strategies were modeled: “Moxa” and ”Standard care” (Figure 1).Moxa implied two visits by the acupuncturist at 33 weeks gestation, and followed by one week daily treatment performed at home by the partner of the pregnant woman.Standard Care implied wait and observe by midwife till 36 weeks gestational age. Possible events and interven-tions were included in the tree. In both strategies, the option to perform ECV at 36 weeks gestation was inclu-ded.