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Objective: To perform a health economic analysis of an intervention designed to increase rates of vaginal birth after caesarean, compared with usual care.Design: Economic analysis alongside the cluster-randomised OptiBIRTH trial (Optimising childbirth by increasing vaginal birth after caesarean section (VBAC) through enhanced women-centred care).Setting: Fifteen maternity units in three European countries - Germany (five), Ireland (five), and Italy (five) - with relatively low VBAC rates.Population: Pregnant women with a history of one previous lower-segment caesarean section; sites were randomised (3:2) to intervention or control.Methods: A cost-utility analysis from both societal and health-services perspectives, using a decision tree.Main Outcome Measures: Costs and resource use per woman and infant were compared between the control and intervention group by country, from pregnancy recognition until 3 months postpartum. Based on the caesarean section rates, and maternal and neonatal morbidities and mortality, the incremental cost-utility ratios were calculated per country.Results: The mean difference in costs per quality-adjusted life years (QALYs) gained from a societal perspective between the intervention and the control group, using a probabilistic sensitivity analysis, was: €263 (95% CI €258-268) and 0.008 QALYs (95% CI 0.008-0.009 QALYs) for Germany, €456 (95% CI €448-464) and 0.052 QALYs (95% CI 0.051-0.053 QALYs) for Ireland, and €1174 (95% CI €1170-1178) and 0.006 QALYs (95% CI 0.005-0.007 QALYs) for Italy. The incremental cost-utility ratios were €33,741/QALY for Germany, €8785/QALY for Ireland, and €214,318/QALY for Italy, with a 51% probability of being cost-effective for Germany, 92% for Ireland, and 15% for Italy.Conclusion: The OptiBIRTH intervention was likely to be cost-effective in Ireland and Germany.Tweetable Abstract: The OptiBIRTH intervention (to increase VBAC rates) is likely to be cost-effective in Germany and Ireland. [ABSTRACT FROM AUTHOR]