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Exclusion criteria were: inability for counselling, previous uterine surgery, known menstrual disorder, placenta increta or percreta, pregnant with three or more fetuses. 1144\u2009women were assigned to single-layer and 1148 to double-layer closure. We included 1620 women with a menstrual cycle in the main analysis.<\/jats:p><\/jats:sec><jats:sec><jats:title>Interventions<\/jats:title><jats:p>Single-layer unlocked uterine closure and double-layer unlocked uterine closure with the second layer imbricating the first.<\/jats:p><\/jats:sec><jats:sec><jats:title>Main outcome measures<\/jats:title><jats:p>Spotting days, quality-adjusted life-years (QALYs), and societal costs at 9\u2009months of follow-up. Missing data were imputed using multiple imputation.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>No significant differences were found between single-layer versus double-layer closure in mean spotting days (1.44 and 1.39\u2009days; mean difference (md) \u22120.056, 95%\u2009CI \u22120.374 to 0.263), QALYs (0.663 and 0.658; md \u22120.005, 95%\u2009CI \u22120.015 to 0.005), total healthcare costs (\u20ac744 and \u20ac727; md \u20ac\u221217, 95%\u2009CI \u2212273 to 143), and total societal costs (\u20ac5689 and \u20ac5927; md \u20ac238, 95%\u2009CI \u2212624 to 1108). The probability of the intervention being cost-effective at willingness-to-pay of \u20ac0, \u20ac10\u2009000 and \u20ac20 000\/QALY gained was 0.30, 0.27 and 0.25, respectively, (societal perspective), and 0.55, 0.41 and 0.32, respectively, (healthcare perspective).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Double-layer uterine closure is not cost-effective compared with single-layer uterine closure from both perspectives. If this is confirmed by our long-term reproductive follow-up, we suggest to adjust uterine closure technique guidelines.<\/jats:p><\/jats:sec><jats:sec><jats:title>Trial registration number<\/jats:title><jats:p>NTR5480\/NL5380.<\/jats:p><\/jats:sec>","DOI":"10.1136\/bmjopen-2020-044340","type":"journal-article","created":{"date-parts":[[2021,7,2]],"date-time":"2021-07-02T16:34:29Z","timestamp":1625243669000},"page":"e044340","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":5,"title":["Cost-effectiveness of single-layer versus double-layer uterine closure during caesarean section on postmenstrual spotting: economic evaluation alongside a randomised controlled trial"],"prefix":"10.1136","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1353-5576","authenticated-orcid":false,"given":"Sanne I.","family":"Stegwee","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4793-9026","authenticated-orcid":false,"given":"\u00c2ngela J.","family":"Ben","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6341-7976","authenticated-orcid":false,"given":"Mohamed","family":"El Alili","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5389-646X","authenticated-orcid":false,"given":"Lucet F.","family":"van der Voet","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3277-2542","authenticated-orcid":false,"given":"Christianne J.M.","family":"de Groot","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1443-1026","authenticated-orcid":false,"given":"Judith E.","family":"Bosmans","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8248-2677","authenticated-orcid":false,"given":"Judith A.F.","family":"Huirne","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,7,2]]},"reference":[{"key":"2021070209101754000_11.7.e044340.1","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)31928-7"},{"key":"2021070209101754000_11.7.e044340.2"},{"key":"2021070209101754000_11.7.e044340.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajog.2011.06.035"},{"key":"2021070209101754000_11.7.e044340.4","doi-asserted-by":"publisher","DOI":"10.1002\/uog.6405"},{"key":"2021070209101754000_11.7.e044340.5","doi-asserted-by":"publisher","DOI":"10.1002\/uog.8864"},{"key":"2021070209101754000_11.7.e044340.6","doi-asserted-by":"publisher","DOI":"10.1111\/1471-0528.12542"},{"key":"2021070209101754000_11.7.e044340.7","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1055\/s-0032-1304829","article-title":"Systematic review of cesarean scar assessment in the nonpregnant state: imaging techniques and uterine scar defect","volume":"29","author":"Roberge","year":"2012","journal-title":"Am J Perinatol"},{"key":"2021070209101754000_11.7.e044340.8","doi-asserted-by":"publisher","DOI":"10.1002\/uog.13199"},{"key":"2021070209101754000_11.7.e044340.9","doi-asserted-by":"publisher","DOI":"10.1111\/1471-0528.12537"},{"key":"2021070209101754000_11.7.e044340.10","unstructured":"Eurostat . 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