Midwifery 60 (2018) 20–26

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Midwifery
journal homepage: www.elsevier.com/locate/midw

Budget impact of a program for safely reducing caesarean sections in MARK

Canada
⁎
Clara Bermúdez-Tamayo, MPH, PhD Professora,b,c, , Mira Johri, PhD Professord,e,
Nils Chaillet, PhD Professorf
a
Centre de recherche du CHUS, 12e Avenue Nord, Sherbrooke, QC, Canada J1H 5 N4
b
Andalusian School of Public Health, Cuesta del Observatorio 4, 18010 Granada, Spain
c
CIBERESP, Ciber de Epidemiologia y Salud Publica, Madrid, Spain
d
Division of Global Health, University of Montreal, Hospital Research Centre (CRCHUM), 900, rue Saint-Denis, Montreal, QC, Canada H2X 0A9
e
Department of Health Administration, School of Public Health, University of Montreal, Montreal, QC, Canada
f
Centre Hospitalier de l'Université Laval (CHUL), Québec, Canada

A R T I C L E I N F O A BS T RAC T

Keywords: Introduction: audits of indications for cesarean section (CS), feedback for health professionals, and
Caesarean section implementation of best practices, as compared with usual care (QUARISMA study), resulted in a small
Clinical practice guidelines reduction in the rate of CS in Quebec and important cost savings from a health care payer perspective.
Budget impact analysis Determining the budget impact would enable estimation of the financial consequences if the program is
extended nationwide.
Material and methods: a retrospective pre-post study design was used to estimate cost prior to and after the
implementation of QUARISMA in Quebec (105,351 subjects). A prospective analysis was performed to measure
the budget impact in Canada’s provinces. The primary analytic perspective was that of the Minister of Health,
for a 4-year time horizon. Data were taken from the trial for Quebec and extrapolated to Canada’s provinces. A
sensitivity analysis was conducted by varying more than one probability at a time.
Findings: over 4 years, there was a decrease of more than $7.8 million in CS burden in Quebec, $11.9 million in
vaginal birth and $9.8 million for neonatal complications. The impact on high-risk women was lower than that
on low-risk. In years 1 and 2, the provinces would have to cover the cost of program implementation.
Conclusions: QUARISMA led to savings of $27 million in Quebec over 4 years. In the short to medium term,
extending the QUARISMA program nationwide could lead to savings of $150.5 million.

Introduction in the rate of CS births without evidence of concomitant decreases in

Considering the increasing growth in health care costs, and the
budgetary constraints in many countries, it seems crucial to analyze
technologies or procedures with a probable margin of inefficiency that
may have a significant impact on budgets (Kneebone, 2016). Giving
birth is the most common reason for hospitalization in developed
countries (Torio and Andrews, 2006; Canadian Institute for Health
Information, 2017). In Canada, vaginal births and CS accounted for
15% of all inpatient hospitalizations, and represents, in the aggregate,
one of the most costly conditions for inpatient hospital care (Canadian
Institute for Health Information, 2017). In 2015, more than one in four
births in hospital was by CS, an increase of nearly 10% since 1995
(Canadian Institute for Health Information, 2015). The rapid increase
maternal or neonatal morbidity raises concerns that CS is overused
(Gregory et al., 2012). Because of potential harm to mother and baby
associated with medically unnecessary CS (Moore et al., 2014), and
given that CS can be up to 45% more expensive than a vaginal birth
(Halpern, 2009), improvements could be made to enhance efficiency.
In response to the rise in CS rates across Canada, in 2008 the
Society of Obstetricians and Gynaecologists (SOGC) released a joint
policy statement aimed at reducing unnecessary CS and promoting
normal childbirth whenever possible (OECD, 2014). However, these
recommendations have remained quite general and decisions to opt for
CS continue to be discretionary and often based on non-medical factors
(Chaillet et al., 2015). The QUARISMA project was designed to make
progress in this area (Johri et al., 2017). It was a randomised controlled

Abbreviations: CS, Caesarean section; BIA, Budget impact analysis

⁎
Corresponding author at: Andalusian School of Public Health, Cuesta del Observatorio 4, 18010 Granada, Spain.
E-mail address: clara.bermudez.easp@juntadeandalucia.es (C. Bermúdez-Tamayo).

https://doi.org/10.1016/j.midw.2018.01.022
Received 24 July 2017; Received in revised form 26 January 2018; Accepted 27 January 2018
0266-6138/ © 2018 Elsevier Ltd. All rights reserved.
C. Bermúdez-Tamayo et al. Midwifery 60 (2018) 20–26

trial to reduce the rate of CS with self-assessment of practice by peers.
The project hypothesises that poor adherence to clinical practice
guidelines (CPGs) plays a key role in the rising CS rate. The
QUARISMA program results suggest that a multifaceted intervention
with clinical audit, feedback activities and best practice implementation
may contribute to a small to moderate reduction in the overall cesarean
delivery rate, with a marked reduction in low-risk women, and an
overall improvement in neonatal outcomes (Garattini and van de
Vooren, 2011). Furthermore, the cost-effectiveness analysis showed
that the intervention resulted in important cost savings from a health
care payer perspective (Sullivan et al., 2014).
The potential implementation of such a program by the health care
system must be analyzed based on efficiency. Budget impact analysis
(BIA) would enable estimation of the financial consequences of
extending the program nationwide in Canada in the short to medium
term (Sullivan et al., 2014).
Intervention mix
QUARISMA program
The program combines the training of professionals and local
opinion leaders with best practices, as well as technical audit of CS
and the implementation of audit recommendations. The audit process
focuses on factors relating to structure (organizational factors affecting
adherence to CPGs), the care process (review of records of CS,
interviews with women) and outcomes (statistics for CS rates and
morbidity). The program phases and activities are described below and
schematised in Fig. 1.
Identification and training of opinion leaders, members of the audit
committee and data collectors. The program was implemented in
hospitals over a period of 6 months. A local audit committee and a local
team were identified in each of the centres receiving the intervention.

The members of the audit committee received 2 days of training on

Material and methods
A retrospective pre-post study design was used to estimate cost
prior to and after the implementation of the QUARISMA trial in
Quebec (Canada). We also performed a prospective analysis of the
potential economic impact of program implementation in Canada’s
other provinces. The methodology is described according to the
framework proposed by the BIA good practice guidelines (Canadian
Institute for Health Information CIHI, 2015).
Patient population
technical auditing and best practices in each hospital. A recertification
day was held at the beginning of year 3. The entire training program
was run by the SOGC. The training program focused on 4 main
indications for CS, based on: (1) SOGC CPGs on induction of labor at
term, monitoring of fetal well-being during labor, vaginal delivery and
operative vaginal delivery in women with a previous CS (1 day); (2) a
workshop dedicated to reviewing the studies on maternal and perinatal
morbidity associated with each mode of delivery (half day); and (3)
participant training in audit techniques (half day). The program also
raised awareness of the social, economic, cultural and legal factors
contributing to the increase in CS rates. The data collectors received 2
days of training on data collection and analysis of data necessary for the
audit process.

For the retrospective analysis for Quebec, we included 105,351
women enrolled in the QUARISMA study and treated in 32 centres.
47,872 were assigned to QUARISMA and 57,479 to standard care.
For the prospective analysis, we considered annual births in the
provinces and territories of Canada. We included Alberta, British
Columbia, Manitoba, New Brunswick, Newfoundland and Labrador,
Northwest Territories, Nova Scotia, Ontario, Prince Edward Island,
Saskatchewan and Yukon Territory (Table 1). The territory of Nunavut
was excluded because of demographic differences and differences in
clinical practice in comparison with Quebec. It had by far the lowest
cesarean section rate (less than 10% of all deliveries). This low rate can
be attributed at least partly to a much younger average age of mothers
at childbirth, reducing the risk of a cesarean section, as well as cultural
aspects of women and doctors (Chaillet et al., 2015).
Table 1
Population and mode of birth by province/territory, Canada, 2013.
Implementation of audit cycles. After the implementation period of 6
months, four 3-month audit cycles were set up for 1 year. Each cycle
was divided into 5 phases according to a standardised procedure: (1)
organise 4 audit cycles for a period of 3 months each; (2) complete
audit records for each case; (3) draw up recommendations; (4) ensure
their implementation; (5) write up a report summarizing the results.
During the post-intervention phase, continuing audits of CS cycles
(without supervision) were encouraged in each centre, to assess the
sustainability of the program. A meeting to present the results was held
at the end of the year post-procedure.
Control group
No external intervention was planned in this group. However,
internal evaluation activities and supervision are part of standard
practice in hospitals and were not an exclusion criterion.

Province Population (thousands)* Births* CS %*

Time horizon and perspective
AB 3735 51,685 30.2
BC 4550 43,781 29.8 – Retrospective analysis in Quebec. The time horizon included is
MB 1239 15,764 26.5 shown in Fig. 1. The first year was the ‘pre-intervention’ period, to
NB 754 7101 27.6
prepare and update the guidelines. There was then a 1.5-year
NL 511 446 23.9
NT 44 686 28.3 intervention period and a 1-year post-intervention period.
NS 946 8859 22.4 – Prospective analysis in Canada. The budget impact was calculated
ON 13,286 140,932 28.1 for a 3-year time horizon. We included the pre-intervention period
PE 144 1442 32.8 as part of the first year, prior to the intervention.
QU 7929 88,311 20.6
SK 1048 14,466 21.9
YT 35 434 23.7 The primary analytic perspective was that of the Minister of Health.
CA 34,254 378,762 27.2
Resource use and costing
AB: Alberta, BC: British Columbia, MB:Manitoba, NB: New Brunswick, NL: Newfound-
land and Labrador, NT: Northwest Territories, NS: Nova Scotia, ON: Ontario, PE: Prince
Edward Island, QC: Quebec, SK: Saskatchewan, YT: Yukon The resources used by women giving birth were taken from the trial
*
Canadian Institute for Health Information (CIHI). for Quebec (Chaillet et al., 2015) and extrapolated to Canada’s

21
C. Bermúdez-Tamayo et al.
Fig. 1. Program description.
provinces. We considered: (1) Cost of the program, including training,
audits and recertification; (2) Cost per woman giving birth and baby.
We studied only the resources where significant differences were found
in the trial (Chaillet et al., 2015).
The use of resources per patient (women giving birth and baby), is
divided into 3 categories: related to the intervention, to the birth and to
complications. The observation period of the post-intervention phase
begins at the women’s admission to hospital at onset of spontaneous
labour, and lasts until discharge.
Data sources
The source for the hospital unitary cost was the Patient Cost
Estimator, developed by the Canadian Institute for Health
Information (CIHI) (Canadian Institute for Health Information CIHI,
2013) to estimate the average cost of various services provided in
hospitals. It provides information by jurisdiction and by patient age
group. The cost estimates represent the estimated average cost of
services provided to the average patient. The fees were taken from the
National Physician Database (Chaudoir et al., 2013).
We used the following costs (taking into account mother age; < 18
years or > =18 years):
– Associated with caesarean section: primary CS with induction,
primary CS no induction, CS with uterine scar and no induction, CS
with uterine scar and induction, CS multiple birth.
– Vaginal birth (VB) after caesarean: VB with anaesthetic and non-
major obstetric/gynecological (OB/GYN) intervention, VB with
anaesthetic without non-major OB/GYN intervention, VB without
anaesthetic with non-major OB/GYN intervention, VB without
anaesthetic without non-major OB/GYN intervention.
– Assisted vaginal delivery: VB with anaesthetic with non-major OB/
GYN intervention, VB without anaesthetic with non-major OB/GYN
intervention.
– Labour induction.
– Procedures for the neonate: transient tachypnea; newborn major
respiratory complication, respiratory insufficiency or distress syn-
drome; newborn major respiratory complication, cardiopulmonary
resuscitation; newborn aspiration syndrome/fetal asphyxia; subdur-
al haematoma; newborn other major problem including intracer-
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Midwifery 60 (2018) 20–26
ebral or intraventricular haemorrhage, spinal cord injury, basal skull
fracture; newborn 2500+ grams, other moderate problem; brachial
plexus injury/palsy and peripheral nerve injury.
Supplementary Appendix shows the range of total unitary costs for
the different resources in Quebec and Canada used in the study.
Analysis
The budget impact was calculated by demonstrating the resulting
total costs for the QUARISMA program compared with the alternative
‘standard practice’ in Quebec. As a final result, savings or extra costs
were displayed for each year, separately according to the women’s risk
category. Risk status was considered on the basis of literature reviews
and the consensus of experts from the QUARISMA research team
(Chaillet et al., 2015). A pregnancy was considered at low-risk if the
woman gave birth to a single baby in cephalic presentation, with no
prior or current assisted reproductive technology, a maternal age ≥ 18
and < 40 yr, a gestational age ≥ 37 and < 42 weeks, a body mass index ≥
17 and < 30, and no prior cesarean delivery, no prior or current
stillbirth, no in utero transfer in another hospital, and no other
pathology or complication during current or prior pregnancy. A
pregnancy was considered at risk if any of the above conditions was
not met.
Pathology or complication during pregnancy: Non-cephalic pre-
sentation of the baby (including post-version cephalic presentation),
premature detachment of normally implanted placenta, myomectomy,
uterine rupture, pre-eclampsia, eclampsia, gravidic gestational hyper-
tension, cardiac, Crohn, thrombophilia or kidney disease, systemic
lupus erythematosus, pre-existing diabetes, gestational diabetes, in-
fectious disease (hepatitis, herpes, AIDS, malaria, pyelonephritis),
thyroid disorders, placenta previa, premature rupture of membranes
(women < 37 weeks), incompatibility Rh/ABO, intra uterine growth
restriction (IUGR), drugs abuse and birth defect (congenital anomalies
or malformation).
Those results were extrapolated to all the provinces of Canada to
calculate the potential savings or extra costs by year. The calculation
was replicated in a Microsoft Excel-based spreadsheet model, which
serves as a flexible analytic tool to examine the budgetary impact of
QUARISMA.
C. Bermúdez-Tamayo et al. Midwifery 60 (2018) 20–26

Table 2 Table 3
Retrospective budget impact of QUARISMA intervention in Quebec ($CAN thousands). Retrospective budget impact of QUARISMA intervention by risk in Quebec ($CAN
thousands).
Intervention group Year 1 Year 2 Year 3 Year 4 Total
Year 1 Year 2 Year 3 Year 4 Total
All women Intervention group
Delivery 290,411 295,248 264,435 238,459 1,088,553 Women at low risk
Cesarean section 101,911 105,572 76,634 51,357 335,474
Vaginal birth 188,500 189,676 187,801 187,102 753,079 Delivery 145,218 149,454 132,567 119,916 547,155
Neonatal morbidity 47,210 50,361 38,036 30,861 166,468 Cesarean section 51,034 54,484 38,433 25,833 169,785
Major trauma 6915 6959 6660 6405 26,939 Vaginal birth 94,184 94,969 94,134 94,083 377,370
Cardiopulmonary 38,277 41,372 29,946 23,615 133,211 Neonatal morbidity 20,791 23,990 15,946 13,101 73,828
morbidity Major trauma 3765 3796 3509 3253 14,323
Non-invasive 2019 2030 1429 840 6318 Cardiopulmonary 16,241 19,401 11,751 9,261 56,654
mechanical ventilation morbidity
Total 337,621 345,609 302,470 269,319 1,255,020 Non-invasive mechanical 785 792 686 587 2,851
ventilation
Control group Total 166,010 173,443 148,513 133,017 620,983
Delivery 291,423 293,415 272,032 251,480 1,108,350
Cesarean section 101,454 101,614 80,947 59,279 343,294 Women at high risk
Vaginal birth 189,969 191,801 191,085 192,201 765,056 Delivery 145,192 145,795 131,868 118,543 541,397
Neonatal morbidity 47,378 50,642 41,875 36,372 176,267 Cesarean section 50,877 51,088 38,201 25,524 165,689
Major trauma 7080 7022 7595 8111 29,808 Vaginal birth 94,316 94,707 93,667 93,018 375,708
Cardiopulmonary 38,445 41,783 32,988 27,531 140,747 Neonatal morbidity 26,419 26,371 22,090 17,760 92,640
morbidity Major trauma 3150 3163 3151 3152 12,615
Non-invasive 1853 1838 1291 730 5712 Cardiopulmonary 22,036 21,970 18,196 14,355 76,557
mechanical ventilation morbidity
Total 338,801 344,057 313,907 287,852 1,284,617 Non-invasive mechanical 1233 1238 743 253 3468
ventilation
Incremental Total 171,612 172,166 153,957 136,303 634,037
(intervention-
control)* Control group
Delivery −1013 1833 −7597 −13,021 −19,798
Cesarean section 457 3958 −4313 −7922 −7,820 Women at low risk
Vaginal birth −1469 −2125 −3284 −5099 −11,978 Delivery 146,285 147,467 137,454 127,462 558,667
Neonatal morbidity −168 −281 −3839 −5511 −9799 Cesarean section 51,952 52,518 43,242 33,372 181,084
Major trauma −165 −63 −935 −1705 −2869 Vaginal birth 94,333 94,949 94,212 94,090 377,584
Cardiopulmonary −168 −411 −3042 −3916 −7537 Neonatal morbidity 20,867 24,497 18,371 15,876 79,611
morbidity Major trauma 3740 3710 3778 3816 15,044
Non-invasive 166 193 138 110 606 Cardiopulmonary 16,298 19,966 13,878 11,458 61,600
mechanical ventilation morbidity
Total −1180 1552 −11,436 −18,533 −29,597 Non-invasive mechanical 829 822 715 602 2,967
Intervention 240 968 711 628 2547 ventilation
Total (incremental- −1420 584 −10,726 −17,904 −27,049 Total 167,152 171,964 155,825 143,338 638,279
intervention cost)
Women at high risk
*
Negative values, meaning avoided costs comparing intervention group with control Delivery 145,138 145,948 134,578 124,019 549,683
group. Cesarean section 49,502 49,096 37,705 25,908 162,211
Vaginal birth 95,636 96,852 96,873 98,111 387,473
Neonatal morbidity 26,511 26,145 23,504 20,496 96,655
Uncertainty
Major trauma 3339 3312 3817 4295 14,764
Cardiopulmonary 22,148 21,817 19,110 16,072 79,147
To test the levels of uncertainty in the estimates, a sensitivity morbidity
analysis was conducted by varying more than one probability at a time. Non-invasive mechanical 1024 1016 576 128 2745
ventilation
The following factors were varied: program costs, CS cost, VB costs, CS
Total 171,649 172,093 158,082 144,514 646,339
rate, complications. The extreme scenario occurs when all the variables
have the highest value at a time.
It is assumed that the target population will hold stable over the vaginal birth burden ($753.1 million for intervention versus $765.1
time horizon for two reasons. Firstly, the birth rate has not shown a million for control group).
clear upward or downward trend over recent years. Secondly, we Regarding complications, spending decreased by $9.8 million in the
assumed there would not be any major lifestyle changes during the intervention group in comparison with the control group ($2.8 million
following 4 years. for major trauma, $7.5 million for cardiopulmonary morbidity and
$0.6 million for non-invasive mechanical ventilation).
Results The total cost by year of the QUARISMA intervention in Quebec is
shown in Supplementary Appendix 1. It includes pre-intervention costs
The 4-year results from the BIA in Quebec are shown in Table 2. of $29,594 in the first year (to prepare and update the clinical
Over 4 years, the savings to the Ministry of Health in Quebec were guidelines), an implementation cost of $198,498, for training in the
more than $27 million. first 2 years and recertification in the third year, as well as activities
The total cost of deliveries was $1,088.5 million for the intervention conducted over the entire period, including SOGC training ($502,106)
group and $1,108.3 million for the control group. This is a reduction of and local audit committees ($1.2 million). Finally, there were other
more than $19 million in the deliveries budget, attributable to the activities related to data collection and management, costing $627,910
QUARISMA program in Quebec. (surveillance and coordination, training of data gatherers and IT data
According to the mode of birth, there was a decrease of more than management). The total cost of the intervention was $2.5 million in
$7.8 million in cesarean burden ($335.4 million for intervention versus Quebec, for all of the 4 years considered.
$343.3 million for control group) and a decrease of $11.9 million in The 4-year results from the BIA in Quebec are shown in Table 3 for

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C. Bermúdez-Tamayo et al. Midwifery 60 (2018) 20–26

the intervention and control group, separately for women at low/high nationwide is shown in Table 5. Over 4 years, the savings to Canada
risk. would be $150.5 million. In years 1 and 2, the provinces would have to
For women at low risk, the total cost of delivery for the intervention cover the cost of program implementation. In year 3, the intervention
group in Quebec was $547.1 million. The total cost of childbirth for the cost would be lower ($3 million), with savings of $37.9 million in
control group was higher ($558.7 million). The complications costs deliveries and $24.4 million in neonatal morbidity. In year 4, the
were lower for the intervention group in comparison with the control intervention cost would be lower than in year 3 ($2.6 million), with
group ($73.8 million versus $93.6 million), including major trauma savings of $65.1 million in deliveries, and $35.0 million in neonatal
($14.3 million versus $15.0 million), cardiopulmonary morbidity morbidity.
($56.6 million versus $61.6 million) and non-invasive mechanical The results of the sensitivity analyses are shown in Fig. 2. The
ventilation ($2.8 million versus $3 million). tornado diagram shows that the results of the model are particularly
For women at high risk, there were differences between the sensitive to VB cost. The absolute budget impact ranged from -$21
intervention and control groups, but these differences were smaller million to $42 million for Quebec in 4 years.
than those in low-risk women. The total cost of childbirth for the
intervention group in Quebec was $541.4 million. The cost for the Discussion
control group was higher ($549.7 million). The complications costs
were slightly lower for the intervention group in comparison with the One of the major debates in public funding of research is its overall
control group, including major trauma ($12.6 million versus $14.8 return to society (Rosbash, 2011; Department of Reproductive Health
million), cardiopulmonary morbidity ($76.6 million versus $77.3 and Research, 2015). Studies like this one, that link public-sponsored
million) and non-invasive mechanical ventilation ($ 3.5 million versus research to changes in clinical practice patterns, patient outcomes and
$2.7 million). costs, are uncommon. Our study findings suggest that public research
Table 4 shows the savings resulting from the QUARISMA program. investments can yield clinical and economic value when targeted to
Savings were higher in the low-risk group than in the high-risk group. address research questions with great clinical relevance and public
In the low-risk group, the program resulted in a spending decrease of health impact. Such information can inform the debate about the role
$16.0 million, of which $11.5 million were saved in deliveries (with a of publicly funded medical research in the nation’s portfolio of
decrease of $11.3 million in CS and $213,010 in VB), and $5.8 million provincial health spending.
were saved in neonatal morbidity ($721,024 for major trauma, $4.9 The current cesarean delivery rate puts increasing economic and
million for cardiopulmonary morbidity and $117,529 for non-invasive human resource demands on our already challenged system. This study
mechanical ventilation). shows that childbirth is a promising area to control part of the budget
In the high-risk group, the program led to savings of $11.0 million, of the Ministry of Health in Quebec and across Canada’s provinces,
of which $8.2 million were saved in deliveries (with an increase of $3.5 since there is a significant gap to bridge to achieve an acceptable CS
million in CS and a decrease of $11.7 million in VB) and $4.0 million rate. A World Health Organization study group suggested no additional
was saved in neonatal morbidity ($2.1 million in major trauma, $2.6 benefits were associated with rates higher than 10−15% and proposed
million in cardiopulmonary morbidity and $723,372 in non-invasive an empirical threshold in the intensity of use, suggesting that ‘countries
mechanical ventilation). with C-section rates above 15% were considered to show overuse’
The prospective budget impact of the QUARISMA intervention (World Health Organization, 1985; Lauer et al., 2010).
According to the literature (Heffner et al., 2003; Baicker et al.,
Table 4 2006; Chaillet et al., 2006; Hanley et al., 2010), drivers of the intensity
Retrospective net budget impact of QUARISMA intervention by risk in Quebec ($CAN of utilization might ostensibly lie on the supply side, relating to
thousands). provider density, the capacity of the local health care system, mal-
practice pressure, management of induced labour and quality of
Year 1 Year 2 Year 3 Year 4 Total
Incremental (intervention-control)
obstetric care. All of them are susceptible to intervention by decision-
makers in order to realign providers’ incentives to deliver value-based
Women at low risk care. According to systematic reviews, interventions related to guide-
Delivery −1067 1,987 −4886 −7546 −11,512 lines and addressed to doctors could be effective to decrease CS, as well
Cesarean section −918 1966 −4808 −7539 −11,299
as giving individualised information to women (Elovainio, 2010;
Vaginal birth −149 20 −78 −7 −213
Neonatal morbidity −76 −508 −2,425 −2,775 −5,784 Catling-Paull et al., 2011). A strategy to engage consumer-oriented
Major trauma 24 87 −269 −563 −721 media would contribute to better understanding and decision-making
Cardiopulmonary morbidity −57 −565 −2,127 −2,198 −4,947 by the public and could have an important budgetary impact, as this
Non-invasive mechanical −43 −30 −29 −15 −117 study does.
ventilation
Total −1142 1479 −7312 −10,321 −17,296
There is a clear need to generate tools and shape solid analytical
Intervention 120 484 355 314 1274 methods that could support decision-making in optimizing the use of
Total (incremental- −1,262 995 −6,956 −10,006 −16,022 available resources (Public Health Agency of Canada, 2012).
intervention cost) Reimbursement authorities increasingly utilise BIA not only to calcu-
Women at high risk
late affordability, but for advocacy and awareness among health
Delivery 54 −153 −2,711 −5,476 −8,286
Cesarean section 1375 1992 496 −383 3,479 decision-makers.
Vaginal birth −1320 −2145 −3206 −5093 −11,765 There are variations in professionals who attends births between
Neonatal morbidity −92 227 −1,414 −2,736 −4,016 provinces of Canada. The majority of births (72%) are attended by
Major trauma −190 −149 −666 −1,143 −2,148 obstetricians, 25% by family doctors, and 3% by midwives (Canadian
Cardiopulmonary morbidity −111 153 −914 −1,718 −2,590
Non-invasive mechanical 209 222 167 125 723
Institute for Health Information, 2017). Because QUARISMA inter-
ventilation vention was addressed to obstetricians and family doctors, impact of
Total −38 73 −4125 −8212 −12,301 intervention and budget impact was more limited in those provinces as
Intervention 120 484 355 314 1274 British Columbia or Ontario, where midwives attend births in 21% and
Total (incremental- −158 −411 −3769 −7898 −11,028
15 %, respectively.
intervention cost)
As with all models, the main limitation of this budget impact model
*
Negative values, meaning avoided costs comparing intervention group with control was the simplification of assumptions required to compare the
group QUARISMA intervention with standard practice. First, we considered

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Table 5
Prospective budget impact of QUARISMA Intervention in Canada ($CAN thousands).

Time Source Province

AB BC MB NB NL NS NT ON PE QC SK YT Total

Year 1 Delivery −866 −617 −220 −98 −7 −9 −123 −1862 −20 −1,013 −218 −9 −5063
Neonatal morbidity −221 −136 −45 −25 −2 −2 −28 −397 −5 −168 −36 −1 −1066
Intervention 140 119 43 19 1 2 24 383 4 240 39 1 1,016
Total −946 −634 −223 −104 −8 −10 −127 −1876 −21 −940 −214 −9 −5112
Year 2 Delivery 1568 1,117 399 178 13 17 223 3372 35 1833 395 17 9168
Neonatal morbidity −370 −228 −76 −42 −3 −4 −47 −666 −9 −281 −60 −2 −1,789
Intervention 567 480 173 78 5 8 97 1545 16 968 159 5 4100
Total 1765 1369 496 213 15 20 273 4251 42 2520 493 20 11,479
Year 3 Delivery −6,498 −4,629 −1,654 −737 −53 −70 −925 −13,973 −146 −7,597 −1,635 −69 −37,986
Neonatal morbidity −5,051 −3,112 −1,035 −579 −39 −57 −643 −9,094 −119 −3,839 −818 −24 −24,409
Intervention 416 352 127 57 4 6 71 1,134 12 711 116 3 3,009
Total −11,133 −7,388 −2,562 −1,259 −88 −121 −1,497 −21,933 −254 −10,726 −2,336 −89 −59,386
Year 5 Delivery −11,138 −7933 −2834 −1264 −91 −119 −1586 −23,950 −251 −13,021 −2802 −118 −65,109
Neonatal morbidity −7251 −4467 −1486 −831 −55 −81 −923 −13,053 −171 −5511 −1174 −34 −35,038
Intervention 368 312 112 51 3 5 63 1,003 10 628 103 3 2,661
Total −18,021 −12,089 −4,208 −2,044 −144 −196 −2,446 −36,001 −412 −17,904 −3,873 −149 −97,485
Total Delivery −16,933 −12,062 −4,309 −1,922 −139 −181 −2,411 −36,413 −381 −19,798 −4,260 −179 −98,989
Neonatal morbidity −12,893 −7,943 −2,642 −1,477 −99 −145 −1,641 −23,211 −304 −9,799 −2,088 −60 −62,301
Intervention 1491 1263 455 205 13 20 256 4065 42 2547 417 13 10,786
Total −28,335 −18,742 −6,497 −3,194 −225 −306 −3,797 −55,558 −644 −27,049 −5,931 −227 −150,504

AB: Alberta, BC: British Columbia, MB:Manitoba, NB: New Brunswick, NL: Newfoundland and Labrador, NT: Northwest Territories, NS: Nova Scotia, ON: Ontario, PE: Prince Edward
Island, QC: Quebec, SK: Saskatchewan, YT: Yukon

labour to discharge. According to the American College of Obstetricians

Fig. 2. Sensitivity analysis.* The extreme scenario occurs when all the variables have the
highest value at a time.
that the program would ensure the same results in different contexts.
Research in Canada has shown that CS rates vary considerably between
regions (Heffner et al., 2003; Hanley et al., 2010), and this could
suggest that there are certain differences in practices and that some of
the variation may be attributable to providers and/or women prefer-
ences. According to the Canadian Hospitals Maternity Policies and
Practices Survey (American College of Obstetricians and Gynecologists
College, 2014), there are certain similarities in hospital policies and
directives that should allow implementation of the program. For
example, most hospitals have policies specifying routine initial electro-
nic fetal heart rate monitoring on all women (74%), a policy regarding
induction of labour (89%), ambulation available for pain control (99%)
and epidural anesthesia available for pain control (87%). Furthermore,
most hospitals in Canada (84%) have a perinatal committee that
reviews obstetrical policies and approves guidelines.
The second limitation is related to the costs included in our
analysis. The estimation of costs has been conservative. For example,
we only considered the observation period of the post-intervention
phase, from the women’s admission to hospital at onset of spontaneous
and Gynecologists (Fagerberg et al., 2013), in most cases the complica-
tions associated with childbirth occur before discharge. We excluded
any complications that occurred in mother and baby after discharge, as
well as the health problems derived from previous complications. This
probably influences the results for the group with a higher CS rate, i.e.
the control group. We also did not include the cost of subsequent CS.
Even if a previous CS is no longer considered an indication per se to
perform a planned cesarean in the second pregnancy, it is well known
that women with a first CS are at increased likelihood of a repeat
cesarean (Essex et al., 2013). In this case, our results are also biased
against the intervention.
Thirdly, the cost savings need to be interpreted with caution,
because existing infrastructure and personnel cannot immediately be
reduced if CS and complication rates decrease.
Finally, the alternative scenarios chosen (‘standard practice’) may
not totally reflect the real-world situation in Canada as many of the
measures analyzed may already have been implemented in some cases,
such as the provincial perinatal programs: Perinatal Program of
Newfoundland and Labrador, British Columbia Perinatal Health
Program, Child Health Network - Greater Toronto Area, Champlain
Maternal Newborn Regional Program (CMNRP), Reproductive Care
Program of Nova Scotia, Alberta Perinatal, Southwestern Ontario
Maternal, Newborn, Child and Youth Program, and Saskatchewan
Perinatal Education Program. This influences the results in two
directions.
In keeping with the theory of change for the QUARISMA interven-
tion, which attempted to optimise medical practice by reducing
unnecessary caesareans, our study found evidence of improved quality
along the continuum of care. Cost reductions were driven principally by
lower rates of neonatal complications and corresponding lower use of
resources within the intervention group. These changes are consistent
with improvements in the quality of care in intervention group
hospitals (Johri et al., 2017). Findings from our study provide new
evidence concerning a safe and possibly sustainable strategy to reduce
unnecessary caesarean sections at wider scale and cost savings over
time.

25
C. Bermúdez-Tamayo et al.
Funding statement
Supported by grants from the Canadian Institutes of Health
Research (200702MCT−171307-RFA-CFCF−153236 and MOP
81275), and the Spanish Ministry of Health and Consumer Affairs
(FIS Exp. PI13/01340).
Conflicts of interest notification
None declared.
Ethical approval statement
The economic evaluation plan was pre-specified in the trial protocol
and updated to reflect recent advances in analytic methods and
reporting. On behalf of the 32 participating hospital centres, the
following 32 local institutional review boards granted research ethics
approval for the QUARISMA trial: (1) Comité d’éthique de la recherche
du Centre intégré de santé et de services sociaux du Bas-Saint-Laurent;
(2) Comité d’éthique de la recherche du Centre intégré universitaire de
santé et de services sociaux du Saguenay-Lac-Saint-Jean (Hôtel-Dieu
de Roberval); (3) Directeur des services professionnels du Hôtel-Dieu
d’Alma; (4) Comité d’éthique de la recherche, Centre de santé et de
services sociaux de Chicoutimi; (5) Comité d’éthique de la recherche du
Centre hospitalier universitaire de Québec - Université Laval; (6)
Comité d’éthique mixte du Centre Hospitalier du Centre-de-la-
Mauricie; (7) Comité d’éthique de la recherche multiclientèle du
Centre intégré universitaire de santé et de services sociaux de la
Mauricie-et-du-Centre-du-Québec; (8) Comité d’éthique de la re-
cherche du Centre Hospitalier Universitaire de Sherbrooke; (9)
Comité d’éthique de la recherche Centre Hospitalier de St. Mary;
(10) Directeur des services professionnels, Hôpital général du
Lakeshore; (11) Directeur des services professionnels, Hôpital St-Luc
(Centre hospitalier de l’Université de Montréal); (12) Comité d’éthique
de la recherche du Centre hospitalier universitaire Sainte-Justine; (13)
Comité d’éthique de la recherche du Centre intégré universitaire de
santé et de services sociaux de l’Est-de-l’Île-de-Montréal (Hôpital
Maisonneuve-Rosemont); (14) Directeur des services professionnels,
Centre hospitalier de Val d’Or; (15) Centre de santé et de services
sociaux les Eskers de l’Abitibi; (16) Directeur des services profession-
nels, Centre hospitalier Rouyn-Noranda; (17) Directeur des services
professionnels, Centre hospitalier régional de Sept-îles; (18) Centre de
santé et services de Manicougan (Centre hospitalier régional Baie-
Comeau); (19) Comité de bioéthique, Hôtel-Dieu de Lévis; (20) Centre
hospitalier Beauce-Etchemin; (21) Comité d’éthique de la recherche,
Centre de santé et de services sociaux de Laval, Hôpital de la Cité-de-la-
Santé; (22) Directeur des services professionnels, Centre hospitalier
régional de Lanaudière; (23) Comité d’éthique de la recherche, Centre
hospitalier Pierre-Le Gardeur; (24) Directeur des services profession-
nels, Centre hospitalier Mont-Laurier; (25) Directeur des services
professionnels, Centre hospitalier St-Eustache; (26) Comité d’éthique
de la recherche, Centre de santé et de services sociaux de Saint-Jérôme;
(27) Directeur des services professionnels, Hôpital Brôme-Missisquoi-
Perkins; (28) Directeur des services professionnels, Centre hospitalier
Pierre-Boucher; (29) Directeur des services professionnels, Centre de
santé et de services sociaux Richelieu-Yamaska (Hôpital Honoré-
Mercier); (30) Comité d’éthique, Centre de santé et de services sociaux
de la Haute-Yamaska (Centre hospitalier de Granby); (31) Comité
d’éthique de la recherche, Hôtel-Dieu de Sorel; (32) Comité d’éthique
du Centre de santé et de services sociaux Drummond (Hôpital Ste.
Croix).
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.midw.2018.01.022.
26
Midwifery 60 (2018) 20–26
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