Foley Catheter vs. Oral Misoprostol to Induce Labour among Hypertensive Women in India: A Cost-Consequence Analysis Alongside a Clinical Trial

BJOG; 2018 Dec; 125(13):1734-1742. doi:10.1111/1471-0528.15285

Objective: To determine the effectiveness and economic impact of two methods for induction of labour in hypertensive women, in low-resource settings.

Design: Cost-consequence analysis of a previously reported multicentre, parallel, open-label randomised trial.

Setting & population: A total of 602 women with a live fetus, aged ≥18 years requiring delivery for pre-eclampsia or hypertension, in two public hospitals in Nagpur, India.

Methods: We performed a formal economic evaluation alongside the INFORM clinical trial. Women were randomised to receive transcervical Foley catheterisation or oral misoprostol 25 mcg. Healthcare expenditure was calculated using a provider-side microcosting approach.

Main outcome measures: Rates of vaginal this delivery within 24 hours of induction, healthcare expenditure per completed treatment episode.

Results: Induction with oral misoprostol resulted in a (mean difference) $20.6USD reduction in healthcare expenditure [95% CI (-) $123.59 (-) $72.49], and improved achievement of vaginal delivery within 24 hours of induction, mean difference 10% [95% CI (-2 to 17.9%), P = 0.016]. Oxytocin administration time was reduced by 135.3 minutes [95% CI (84.4-186.2 minutes), P < 0.01] and caesarean sections by 9.1% [95% CI (1.1-17%), P = 0.025] for those receiving oral misoprostol. Following probabilistic sensitivity analysis, oral misoprostol was cost-saving in 63% of 5,000 bootstrap replications and achieved superior rates of vaginal delivery, delivery within 24 hours of induction and vaginal delivery within 24 hours of induction in 98.7%, 90.7%, and 99.4% of bootstrap simulations. Based on univariate threshold analysis, the unit price of oral misoprostol 25 mcg could feasibly increase 31-fold from $0.24 to $7.50 per 25 mcg tablet and remain cost-saving.

Conclusion: Compared to Foley catheterisation for the induction of high-risk hypertensive women, oral misoprostol improves rates of vaginal delivery within 24 hours of induction and may also reduce costs. Additional research performed in other low-resource settings is required to determine their relative cost-effectiveness.

Tweetable abstract: Oral misoprostol less costly and more effective than Foley catheter for labour induction in hypertension.

Keywords: Cost-consequence; economics; hypertension; labour induction; low-resource settings; preeclampsia.