{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,9]],"date-time":"2026-07-09T00:34:30Z","timestamp":1783557270240,"version":"3.55.0"},"reference-count":40,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,6,18]],"date-time":"2021-06-18T00:00:00Z","timestamp":1623974400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:p><jats:bold>Objective:<\/jats:bold> Out-of-hospital (outpatient) cervical ripening prior to induction of labor (IOL) is discussed for its potential to decrease the burden on hospital resources. We assessed the cost and clinical outcomes of adopting an outpatient strategy with a synthetic hygroscopic cervical dilator, which is indicated for use in preinduction cervical ripening.<\/jats:p><jats:p><jats:bold>Methods:<\/jats:bold> We developed a cost-consequence model from the hospital perspective with a time period from IOL to post-delivery discharge. A hypothetical cohort of women to undergo IOL at term with an unfavorable cervix (all risk levels) were assessed. As the standard of care (referred to as <jats:italic>IP-only<\/jats:italic>) all women were ripened as inpatients using the vaginal PGE2 insert or the single-balloon catheter. In the comparison (<jats:italic>OP-select<\/jats:italic>), 50.9% of low-risk women (41.4% of the study population) received outpatient cervical ripening using a synthetic hygroscopic cervical dilator and the remaining women were ripened as inpatients as in the standard of care. Model inputs were sourced from a structured literature review of peer-reviewed articles in PubMed. Testing of 2,000 feasible scenarios (probabilistic multivariate sensitivity analysis) ascertained the robustness of results. Outcomes are reported as the average over all women assessed, comparing OP-select to IP-only.<\/jats:p><jats:p><jats:bold>Results:<\/jats:bold> Implementing OP-select resulted in hospital savings of US$689 per delivery, with women spending 1.48 h less time in the labor and delivery unit and 0.91 h less in the postpartum recovery unit. The cesarean-section rate was decreased by 3.78 percentage points (23.28% decreased to 19.50%). In sensitivity testing, hospital costs and cesarean-section rate were reduced in 91% of all instances.<\/jats:p><jats:p><jats:bold>Conclusion:<\/jats:bold> Our model analysis projects that outpatient cervical ripening has the potential to reduce hospital costs, hospital stay, and the cesarean section rate. It may potentially allow for better infection-prevention control during the ongoing COVID-19 pandemic and to free up resources such that more women might be offered elective IOL at 39 weeks.<\/jats:p>","DOI":"10.3389\/fpubh.2021.689115","type":"journal-article","created":{"date-parts":[[2021,6,18]],"date-time":"2021-06-18T05:16:35Z","timestamp":1623993395000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":10,"title":["Out-of-Hospital Cervical Ripening With a Synthetic Hygroscopic Cervical Dilator May Reduce Hospital Costs and Cesarean Sections in the United States\u2014A Cost-Consequence Analysis"],"prefix":"10.3389","volume":"9","author":[{"given":"Sita J.","family":"Saunders","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rhodri","family":"Saunders","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tess","family":"Wong","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio F.","family":"Saad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2021,6,18]]},"reference":[{"key":"B1","unstructured":"National vital statistics reports births : final data for 2018147\n            MartinJA\n            HamiltonBE\n            SuttonPD\n            VenturaSJ\n            MenackerF\n            KirmeyerS\n          Natl Vital Statisctics Rep682019"},{"key":"B2","doi-asserted-by":"publisher","first-page":"513","DOI":"10.1056\/NEJMoa1800566","article-title":"Labor induction versus expectant management in low-risk nulliparous women","volume":"379","author":"Grobman","year":"2018","journal-title":"N Engl J Med"},{"key":"B3","doi-asserted-by":"publisher","first-page":"304","DOI":"10.1016\/j.ajog.2019.02.046","article-title":"Elective induction of labor at 39 weeks compared with expectant management: a meta-analysis of cohort studies","volume":"221","author":"Grobman","year":"2019","journal-title":"Am J Obstet Gynecol."},{"key":"B4","doi-asserted-by":"publisher","first-page":"212","DOI":"10.1055\/s-0040-1716711","article-title":"Labor induction at 39 weeks compared with expectant management in low-risk parous women","volume":"1","author":"Wagner","year":"2020","journal-title":"Am J Perinatol"},{"key":"B5","unstructured":"Clinical Guidance for Integration of the Findings of The ARRIVE Trial: Labor Induction Versus Expectant Management in Low-Risk Nulliparous Women | ACOG [Internet]"},{"key":"B6","doi-asserted-by":"publisher","first-page":"369.e1","DOI":"10.1016\/j.ajog.2020.01.002","article-title":"Health resource utilization of labor induction versus expectant management","volume":"222","author":"Grobman","year":"2020","journal-title":"Am J Obstet Gynecol"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s12884-020-03060-1","article-title":"Inpatient versus outpatient induction of labour: A systematic review and meta-analysis","volume":"20","author":"Dong","year":"2020","journal-title":"BMC Pregnancy Childbirth"},{"key":"B8","doi-asserted-by":"publisher","first-page":"101823","DOI":"10.1016\/j.jogoh.2020.101823","article-title":"Outpatient versus inpatient balloon catheter insertion for labor induction: a systematic review and meta-analysis of randomized controlled trials","volume":"2019","author":"Abdelhakim","year":"2020","journal-title":"J Gynecol Obstet Hum Reprod"},{"key":"B9","doi-asserted-by":"publisher","first-page":"231","DOI":"10.1016\/j.jval.2013.02.002","article-title":"Consolidated Health Economic Evaluation Reporting Standards (CHEERS)-explanation and elaboration: a report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force","volume":"16","author":"Husereau","year":"2013","journal-title":"Value Heal"},{"key":"B10","doi-asserted-by":"publisher","first-page":"796","DOI":"10.1016\/j.jval.2012.06.012","article-title":"Modeling good research practices - Overview: A report of the ISPOR-SMDM modeling good research practices task force-1","volume":"15","author":"Caro","year":"2012","journal-title":"Value Heal"},{"key":"B11","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1016\/j.jval.2013.08.2291","article-title":"Budget impact analysis - principles of good practice: report of the ISPOR 2012 budget impact analysis good practice II task force","volume":"17","author":"Sullivan","year":"2014","journal-title":"Value Heal"},{"key":"B12","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1016\/j.ajog.2018.04.012","article-title":"Cesarean delivery in the United States 2005 through 2014: a population-based analysis using the Robson Ten Group Classification System","volume":"219","author":"Hehir","year":"2018","journal-title":"Am J Obstet Gynecol"},{"key":"B13","doi-asserted-by":"publisher","first-page":"1657","DOI":"10.1517\/14656566.2015.1060960","article-title":"Pharmacotherapy options for labor induction","volume":"16","author":"Wing","year":"2015","journal-title":"Expert Opin Pharmacother"},{"key":"B14","doi-asserted-by":"publisher","first-page":"151216","DOI":"10.1016\/j.semperi.2019.151216","article-title":"Cervical ripening: why we do what we do","volume":"44","author":"Levine","year":"2020","journal-title":"Semin Perinatol"},{"key":"B15","doi-asserted-by":"publisher","first-page":"70","DOI":"10.1016\/j.ejogrb.2018.08.004","article-title":"Synthetic osmotic dilators in the induction of labour-An international multicentre observational study","volume":"229","author":"Gupta","year":"2018","journal-title":"Eur J Obstet Gynecol Reprod Biol"},{"key":"B16","doi-asserted-by":"publisher","first-page":"245","DOI":"10.1055\/s-0039-1694791","article-title":"Outpatient cervical ripening: a cost-minimization and threshold analysis","volume":"37","author":"Son","year":"2020","journal-title":"Am J Perinatol"},{"key":"B17","first-page":"477","article-title":"Kim A. Current Trends in Cervical Ripening and Labor Induction","volume":"60","author":"Harman","year":"1999","journal-title":"Am Fam Physician"},{"key":"B18","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1007\/s10995-019-02819-z","article-title":"Costs of severe maternal morbidity during pregnancy in us commercially insured and medicaid populations: an observational study","volume":"24","author":"Vesco","year":"2020","journal-title":"Matern Child Health J"},{"key":"B19","doi-asserted-by":"publisher","first-page":"328","DOI":"10.1097\/ALN.0000000000001981","article-title":"Cost-effectiveness analysis of intraoperative cell salvage for obstetric hemorrhage","volume":"128","author":"Lim","year":"2018","journal-title":"Anesthesiology"},{"key":"B20","doi-asserted-by":"publisher","first-page":"632","DOI":"10.1016\/j.ajog.2010.03.045","article-title":"Timing of elective repeat cesarean delivery at term and neonatal outcomes: a cost analysis","volume":"202","author":"Robinson","year":"2010","journal-title":"Am J Obstet Gynecol"},{"key":"B21","doi-asserted-by":"publisher","first-page":"1227","DOI":"10.1097\/AOG.0000000000003581","article-title":"Maternal and infant health care costs related to preeclampsia","volume":"134","author":"Hao","year":"2019"},{"key":"B22","doi-asserted-by":"publisher","first-page":"1197","DOI":"10.1038\/jp.2017.122","article-title":"Time-to-delivery and delivery outcomes comparing three methods of labor induction in 7551 nulliparous women: a population-based cohort study","volume":"37","author":"Lindblad Wollmann","year":"2017","journal-title":"J Perinatol"},{"key":"B23","doi-asserted-by":"publisher","first-page":"13251","DOI":"10.1097\/MD.0000000000013251","article-title":"Intracervical Foley catheter balloon versus dinoprostone insert for induction cervical ripening: A systematic review and meta-analysis of randomized controlled trials","volume":"97","author":"Zhu","year":"2018","journal-title":"Med (United States)"},{"key":"B24","doi-asserted-by":"publisher","first-page":"275.e1","DOI":"10.1016\/j.ajog.2019.01.008","article-title":"A randomized controlled trial of Dilapan-S vs Foley balloon for preinduction cervical ripening (DILAFOL trial)","volume":"220","author":"Saad","year":"2019","journal-title":"Am J Obstet Gynecol"},{"key":"B25","doi-asserted-by":"publisher","first-page":"e1001972","DOI":"10.1371\/journal.pmed.1001972","article-title":"Length of stay after childbirth in 92 countries and associated factors in 30 low- and middle- income countries : compilation of reported data and a cross-sectional analysis from nationally representative surveys","volume":"13","author":"Campbell","year":"2016","journal-title":"PLoS Med"},{"key":"B26","doi-asserted-by":"publisher","first-page":"197863","DOI":"10.1001\/jamanetworkopen.2019.7863","article-title":"Rates of new persistent opioid use after vaginal or cesarean birth among US women","volume":"2","author":"Peahl","year":"2019","journal-title":"JAMA Netw Open"},{"key":"B27","doi-asserted-by":"publisher","first-page":"CD001233","DOI":"10.1002\/14651858.CD001233.pub3","article-title":"Mechanical methods for induction of labour","volume":"10","author":"de Vaan","year":"2019","journal-title":"Cochrane Database Syst Rev"},{"key":"B28","unstructured":"Recent trends in vaginal birth after cesarean delivery: United States, 2016-201818\n            OstermanMJK\n          32487289NCHS Data Brief3592020"},{"key":"B29","doi-asserted-by":"publisher","first-page":"299","DOI":"10.1515\/jpm-2017-0029","article-title":"Induction of labor in patients with an unfavorable cervix after a cesarean using an osmotic dilator versus vaginal prostaglandin","volume":"46","author":"Maier","year":"2018","journal-title":"J Perinat Med"},{"key":"B30","doi-asserted-by":"publisher","first-page":"44","DOI":"10.1016\/j.ejogrb.2016.07.505","article-title":"Balloon catheters for induction of labor at term after previous cesarean section: a systematic review","volume":"204","author":"Kehl","year":"2016","journal-title":"Eur J Obstet Gynecol Reprod Biol"},{"key":"B31","article-title":"Ferring Pharmaceuticals Inc","year":""},{"key":"B32","doi-asserted-by":"publisher","first-page":"205","DOI":"10.1055\/s-2008-1064933","article-title":"Duration of labor induction in nulliparous women at term: How long is long enough?","volume":"25","author":"Blackwell","year":"2008","journal-title":"Am J Perinatol"},{"key":"B33","doi-asserted-by":"publisher","first-page":"4880","DOI":"10.1097\/AOG.0b013e3182704880","article-title":"Preventing the first cesarean delivery: summary of a joint eunice kennedy shriver national institute of child health and human development, society for maternal-fetal medicine, and American college of obstetricians and gynecologists workshop","volume":"120","author":"Spong","year":"2012","journal-title":"Obstet Gynecol"},{"key":"B34","doi-asserted-by":"publisher","first-page":"145","DOI":"10.1016\/j.ogc.2005.01.001","article-title":"Normal labor: Mechanism and duration","volume":"32","author":"Liao","year":"2005","journal-title":"Obstet Gynecol Clin North Am"},{"key":"B35","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1080\/14767058.2020.1811665","article-title":"Outpatient management of pre-induction cervical ripening","volume":"26","author":"Chen","year":"2020","journal-title":"J Matern Neonatal Med"},{"key":"B36","doi-asserted-by":"publisher","first-page":"597","DOI":"10.1097\/AOG.0000000000004041","article-title":"Outpatient foley catheter for induction of labor in nulliparous women: a randomized controlled trial","volume":"136","author":"Ausbeck","year":"2020","journal-title":"Obstet Gynecol"},{"key":"B37","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1186\/s40814-020-00661-7","article-title":"Prostaglandin insert dinoprostone versus trans-cervical balloon catheter for outpatient labour induction: A randomised controlled trial of feasibility (PROBIT-F)","volume":"6","author":"Bhide","year":"2020","journal-title":"Pilot Feasibility Stud"},{"key":"B38","doi-asserted-by":"publisher","first-page":"CD007372","DOI":"10.1002\/14651858.CD007372.pub4","article-title":"Home versus inpatient induction of labour for improving birth outcomes","volume":"8","author":"Alfirevic","year":"2020","journal-title":"Cochrane Database of Syst Rev."},{"key":"B39","doi-asserted-by":"publisher","DOI":"10.1016\/j.wombi.2020.07.006","article-title":"Women's experiences of outpatient induction of labour with double balloon catheter or prostaglandin pessary: a qualitative study","author":"Coates","year":"2020","journal-title":"Women Birth"},{"key":"B40","doi-asserted-by":"publisher","first-page":"440","DOI":"10.1111\/ajo.12348","article-title":"Cost-effectiveness of term induction of labour using inpatient prostaglandin gel versus outpatient Foley catheter","volume":"55","author":"Austin","year":"2015","journal-title":"Aust New Zeal J Obstet Gynaecol"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2021.689115\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,6,18]],"date-time":"2021-06-18T05:16:40Z","timestamp":1623993400000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2021.689115\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6,18]]},"references-count":40,"alternative-id":["10.3389\/fpubh.2021.689115"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2021.689115","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6,18]]},"article-number":"689115"}}