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).