Introduction
In contrast to the UK’s NHS Resolution organisation, Australian health
care lacks an “arms length” institution to manage medico legal issues.
NHS Resolution’s 2021-2022 annual report (2) revealed that compensating
for harm caused by NHS maternity services costs almost three times what
the health service spends on maternity care (GBP 8.2 billion, compare to
GBP 3 billion spent on care). Cumulative maternity services’ liability
has reached GBP 41.5 billion. (GBP 38.8 billion relating to cerebral
palsy).
Continuous Electronic Fetal Monitoring (CEFM) (3) aims to identify
intrapartum hypoxic stress to avoid HIE and intrapartum-related
perinatal deaths. Meta-analysis of RCTS studying both high and low risk
women (4) shows show reduced neonatal seizures, but without significant
reduction in cerebral palsy. It has been argued that such meta-analyses
still lack the power to detect significant reductions in severe adverse
fetal outcomes, given the rarity of such outcomes among all risk women
(5). It is evident that the devastating impact of cerebral palsy,
frequently associated with inadequate utilisation of fetal monitoring or
substandard staff education, has created the unsustainable situation
described above (6) .
ST analysis (STan) is an adjunct to CTG, introduced at the study
institution as a standard of care in 2015, aiming to better identifying
hypoxic stress, thus to keep babies safer. It was also anticipated in
our RCT that STan as an adjunct to CTG (CTG+STan) would reduce the
proportion of emergency caesarean sections (EmCS) from false positive
diagnoses of fetal distress (7), relative to CTG alone. However,
clinical results of our RCT (1) did not demonstrate significant evidence
of a reduction in the proportion of EmCS in women requiring CEFM in
labour, but we did show a smaller proportion of poor neonatal outcomes
in the CTG+STan arm (relative to CTG alone), although the study was
underpowered to detect a decrease in metabolic acidosis or other adverse
neonatal outcomes.
With cost-effectiveness analysis of maternity interventions being
further recognised for the allocation of health resources and strategies
of clinical care, the lack of a published economic evaluation of CEFM
may be a barrier in the implementation and provision of appropriate
intrapartum fetal surveillance. The objective of this study was to
identify the cost minimising approach, by quantifying costs in the
context of clinical equivalence in each arm of the randomised controlled
trial. Thus, we have performed a cost minimisation study, as a specific
type of cost effectiveness study (8).