OBJECTIVES: To examine the cost-effectiveness of planned caesarean section versus planned vaginal delivery in breech-presentation pregnancies at term. METHODS: An incremental cost-effectiveness analysis was performed using a Markov model for a hypothetical cohort of 25-year old pregnant women with a live singleton fetus in a frank or complete breech presentation at term. Caesarean section was compared with vaginal delivery from a societal perspective. The model operated over 25 years in 3-year cycles. The model integrated clinical and cost data from peer-reviewed studies and utilities to estimate cumulative quality-adjusted life years (QALYs) and costs for both the mother and infant. Effects and costs were discounted at 4%. Probabilistic sensitivity analyses were performed to determine key parameter uncertainty. RESULTS: If only maternal morbidity was taken into account, caesarean section was more costly and less effective (incremental cost-effectiveness ratio (ICER) -€54,000 per QALY), thus vaginal delivery was the dominated strategy. If only neonatal morbidity and mortality was considered, caesarean section was less costly and more effective (ICER -€2120 per QALY). However, if outcomes for both mother and child were considered, caesarean section was more costly but more effective (ICER €1275 per QALY). CONCLUSIONS: Caesarean section resulted to be cost-effective compared to vaginal delivery in breech presentation at term, if both maternal and neonatal outcomes were considered. If only maternal condition is considered, vaginal delivery appeared to be the best strategy.