Labor induction rate variation in upstate New York: what is the difference?

Outpatient cervical ripening with balloon catheters: A Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

One in four labors are induced. The process of cervical ripening can be lengthy and pre-labor hospitalization is required. Outpatient cervical ripening can be an attractive alternative.

OBJECTIVES

To evaluate the efficacy and safety of outpatient cervical ripening with a balloon catheter compared with inpatient balloon catheter or prostaglandin E2 (PGE2).

SEARCH STRATEGY

The PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library databases were searched from their inception to October 15, 2022.

SELECTION CRITERIA

Randomized controlled trials comparing the outpatient balloon catheter with inpatient balloon catheter or inpatient PGE2 for term cervical ripening.

DATA COLLECTION AND ANALYSIS

Bayesian network meta-analysis was performed. The primary outcome was the cesarean delivery rate. The secondary outcomes included instrumental delivery, the time from intervention-to-birth, oxytocin augmentation, total hospital duration, and maternal/neonatal adverse events.

MAIN RESULTS

Twenty-nine randomized controlled trials with a total of 6004 participants were identified. No difference in the cesarean delivery rate was revealed among the three interventions. Compared with inpatient balloon catheter, outpatient balloon catheter had shorter total hospital duration (mean difference -8.58, 95% confidence interval -17.02 to -1.10). No differences were revealed in the time from intervention-to-birth, instrumental delivery, postpartum hemorrhage, 5-min Apgar score less than 7, umbilical cord arterial pH less than 7.1, and neonatal intensive care unit admission among the three interventions.

CONCLUSIONS

Outpatient balloon catheter in low-risk term pregnancies is an available option that could be considered for cervical ripening. The safety and effectiveness are comparable to inpatient cervical ripening methods.

Disruption of physiological labour; - A population register-based study among nulliparous women at term

OBJECTIVES

Current labour practices have seen an acceleration in interventions to either initiate, monitor, accelerate, or terminate the physiological process of pregnancy and childbirth. This study aimed to describe and analyse the use of interventions in childbirth in Denmark over almost two decades (2000-2017). We also examined the extent to which contemporary care adheres to current international recommendations towards restricted use of interventions.

STUDY DESIGN

A national retrospective Danish register-based cohort study including all nulliparous women with term births with singleton pregnancy and a foetus in cephalic between the years 2000 and 2017 (n = 380,326 births). Multivariate regression analyses with adjustment for change in population were performed.

MAIN OUTCOME MEASURES

Induction of labour, epidural analgesia, and augmentation of labour.

RESULTS

Between 2000/2001 and 2016/2017, the prevalence increased for induction of labour from 5.1% to 22.8%, AOR 4.84, 95% CI [4.61-5.10], epidural analgesia from 10.5% to 34.3% (AOR 4.10, 95% CI [3.95-4.26]), and augmentation of labour decreased slightly from 40.1% to 39.3% (AOR 0.84, 95% CI [0.81-0.86]). Having more than one of the three mentioned interventions increased from 12.8% in to 30.9%.

CONCLUSIONS

The number of interventions increased during the study period as well as the number of interventions in each woman. As interventions may interfere in physiological labour and carry the risk of potential short- and long-term consequences, the findings call for a careful re-evaluation of contemporary maternity care with a "first, do no harm" perspective.

Effects of induction of labor prior to post-term in low-risk pregnancies: a systematic review

OBJECTIVE

The objective of this review was to identify, assess and synthesize the best available evidence on the effects of induction prior to post-term on the mother and fetus. Maternal and fetal outcomes after routine labor induction in low-risk pregnancies at 41+0 to 41+6 gestational weeks (prior to post-term) were compared to routine labor induction at 42+0 to 42+6 gestational weeks (post-term).

INTRODUCTION

Induction of labor when a pregnancy exceeds 14 days past the estimated due date has long been used as an intervention to prevent adverse fetal and maternal outcomes. Over the last decade, clinical procedures have changed in many countries towards earlier induction. A shift towards earlier inductions may lead to 15-20% more inductions. Given the fact that induction as an intervention can cause harm to both mother and child, it is essential to ensure that the benefits of the change in clinical practice outweigh the harms.

INCLUSION CRITERIA

This review included studies with participants with expected low-risk deliveries, where both fetus and mother were considered healthy at inclusion and with no known risks besides the potential risk of the ongoing pregnancy. Included studies evaluated induction at 41+1-6 gestational weeks compared to 42+1-6 gestational weeks. Randomized control trials (n = 2), quasi-experimental trials (n = 2), and cohort studies (n = 3) were included. The primary outcomes of interest were cesarean section, instrumental vaginal delivery, low Apgar score (≤ 7/5 min.), and low pH (< 7.10). Secondary outcomes included additional indicators of fetal or maternal wellbeing related to prolonged pregnancy or induction.

METHODS

The following information sources were searched for published and unpublished studies: PubMed, CINAHL, Embase, Scopus, Swemed+, POPLINE; Cochrane, TRIP; Current Controlled Trials; Web of Science, and, for gray literature: MedNar; Google Scholar, ProQuest Nursing & Allied Health Source, and guidelines from the Royal College of Obstetricians and Gynaecologists, and American College of Obstetricians and Gynecologists, according to the published protocol. In addition, OpenGrey and guidelines from the National Institute for Health and Care Excellence, World Health Organization, and Society of Obstetricians and Gynaecologists of Canada were sought. Included papers were assessed by all three reviewers independently using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). The standardized data extraction tool from JBI SUMARI was used. Data were pooled in a statistical meta-analysis model using RevMan 5, when the criteria for meta-analysis were met. Non-pooled results were presented separately.

RESULTS

Induction at 41+0-6 gestational weeks compared to 42+0-6 gestational weeks was found to be associated with an increased risk of overall cesarean section (relative risk [RR] = 1.11, 95% confidence interval [CI] 1.09-1.14), cesarean section due to failure to progress (RR = 1.43, 95% CI 1.01-2.01), chorioamnionitis (RR = 1.13, 95% CI 1.05-1.21), labor dystocia (RR = 1.29, 95% CI 1.22-1.37), precipitate labor (RR = 2.75, 95% CI 1.45-5.2), uterine rupture (RR = 1.97, 95% CI 1.54-2.52), pH < 7.10 (RR = 1.9, 95% CI 1.48-2.43), and a decreased risk of oligohydramnios (RR = 0.4, 95% CI 0.24-0.67) and meconium stained amniotic fluid (RR = 0.82, 95% CI 0.75-0.91). Data lacked statistical power to draw conclusions on perinatal death. No differences were seen for postpartum hemorrhage, shoulder dystocia, meconium aspiration, 5-minute Apgar score < 7, or admission to neonatal intensive care unit. A policy of awaiting spontaneous onset of labor until 42+0-6 gestational weeks showed, that approximately 70% went into spontaneous labor.

CONCLUSIONS

Induction prior to post-term was associated with few beneficial outcomes and several adverse outcomes. This draws attention to possible iatrogenic effects affecting large numbers of low-risk women in contemporary maternity care. According to the World Health Organization, expected benefits from a medical intervention must outweigh potential harms. Hence, our results do not support the widespread use of routine induction prior to post-term (41+0-6 gestational weeks).

Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California

OBJECTIVE

To assess hospital practices in obstetric quality management activities and identify institutional characteristics associated with utilization of evidence-supported practices.

METHODS

Data for this study came from a statewide survey of obstetric hospitals in California regarding their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that completed quality assurance sections of the survey to assess their practices in a broad spectrum of quality enhancement activities. The association between institutional characteristics and adoption of evidence-supported practices (ie, those supported by prior literature or recommended by professional organizations as beneficial for improving birth outcome or patient safety) was examined using bivariate analysis and appropriate statistical tests.

RESULTS

Most hospitals regularly audited adherence to written protocols regarding critical areas of care; however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest and management of abnormal fetal heart rate, respectively. Private nonprofit hospitals were more likely to have a written protocol for management of abnormal fetal heart rate (P=.002). One in 10 hospitals (9.7%) did not regularly review cases with significant morbidity or mortality, and only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%, and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia, shoulder dystocia, or postpartum hemorrhage, respectively. Teaching status was associated with more frequent simulations in these three areas (P≤.04 for all), while larger volume was associated with more frequent simulations for eclampsia (P=.04).

CONCLUSION

Hospitals in California engage in a wide range of practices to assure or improve quality of obstetric care, but substantial variation in practice exists among hospitals. There is opportunity for improvement in adoption of evidence-supported practices.

Characteristics Associated with Induction of Labor and Delivery Route Among Primiparous Women with Term Deliveries in the Listening to Mothers III Study

BACKGROUND

Induction of labor (IOL) is increasingly common in the United States, yet characteristics associated with IOL among primiparous women delivering at term are not well understood.

MATERIALS AND METHODS

Data from the Listening to Mothers III study, a survey of women aged 18-45 with singleton deliveries in U.S. hospitals in 2011-2012, were utilized. Weighted logistic regression models examined predictors of IOL among 924 primiparous women with term deliveries. Associations of maternal characteristics with delivery route (cesarean and vaginal delivery) were examined among primiparous women induced at term.

RESULTS

Four hundred twenty-three (45.8%) primiparous women with term deliveries underwent IOL; subjective reasons were reported by 53% of induced women. Women who were married (odds ratios [OR] = 1.8, 95% confidence intervals [CI] 1.2-2.9), felt pressure from a provider for IOL (OR = 3.5, 95% CI 2.0-6.2), and whose provider was concerned about the size of the baby (OR = 1.9, 95% CI 1.2-2.9) were significantly more likely to undergo IOL. Nearly 30% of primiparous women who underwent IOL at term had a cesarean delivery (CD). Among the induced women, those who were overweight/obese (OR = 4.9, 95% CI 2.5-10.0), felt pressure from a provider for CD (OR = 8.6, 95% CI 3.5-21.2), and whose provider suspected the baby might be getting large near end of pregnancy (OR = 2.7, 95% CI 1.1-7.0) were significantly more likely to have CD.

CONCLUSIONS

In this study, nearly half of the primiparous women with term deliveries underwent IOL, with a sizeable proportion reporting subjective reasons for induction. A better understanding of the characteristics associated with IOL at term may help reduce unnecessary interventions and, ultimately, primary CD.

Pharmacological and mechanical interventions for labour induction in outpatient settings

BACKGROUND

Induction of labour is carried out for a variety of indications and using a range of methods. For women at low risk of pregnancy complications, some methods of induction of labour or cervical ripening may be suitable for use in outpatient settings.

OBJECTIVES

To examine pharmacological and mechanical interventions to induce labour or ripen the cervix in outpatient settings in terms of effectiveness, maternal satisfaction, healthcare costs and, where information is available, safety.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials examining outpatient cervical ripening or induction of labour with pharmacological agents or mechanical methods. Cluster trials were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed evidence using the GRADE approach.

MAIN RESULTS

This updated review included 34 studies of 11 different methods for labour induction with 5003 randomised women, where women received treatment at home or were sent home after initial treatment and monitoring in hospital.Studies examined vaginal and intracervical prostaglandin E₂ (PGE₂), vaginal and oral misoprostol, isosorbide mononitrate, mifepristone, oestrogens, amniotomy and acupuncture, compared with placebo, no treatment, or routine care. Trials generally recruited healthy women with a term pregnancy. The risk of bias was mostly low or unclear, however, in 16 trials blinding was unclear or not attempted. In general, limited data were available on the review's main and additional outcomes. Evidence was graded low to moderate quality. 1. Vaginal PGE₂ versus expectant management or placebo (5 studies)Fewer women in the vaginal PGE₂ group needed additional induction agents to induce labour, however, confidence intervals were wide (risk ratio (RR) 0.52, 95% confidence interval (CI) 0.27 to 0.99; 150 women; 2 trials). There were no clear differences between groups in uterine hyperstimulation (with or without fetal heart rate (FHR) changes) (RR 3.76, 95% CI 0.64 to 22.24; 244 women; 4 studies; low-quality evidence), caesarean section (RR 0.80, 95% CI 0.49 to 1.31; 288 women; 4 studies; low-quality evidence), or admission to a neonatal intensive care unit (NICU) (RR 0.32, 95% CI 0.10 to 1.03; 230 infants; 3 studies; low-quality evidence).There was no information on vaginal birth within 24, 48 or 72 hours, length of hospital stay, use of emergency services or maternal or caregiver satisfaction. Serious maternal and neonatal morbidity or deaths were not reported. 2. Intracervical PGE₂ versus expectant management or placebo (7 studies) There was no clear difference between women receiving intracervical PGE₂ and no treatment or placebo in terms of need for additional induction agents (RR 0.98, 95% CI 0.74 to 1.32; 445 women; 3 studies), vaginal birth not achieved within 48 to 72 hours (RR 0.83, 95% CI 0.68 to 1.02; 43 women; 1 study; low-quality evidence), uterine hyperstimulation (with FHR changes) (RR 2.66, 95% CI 0.63 to 11.25; 488 women; 4 studies; low-quality evidence), caesarean section (RR 0.90, 95% CI 0.72 to 1.12; 674 women; 7 studies; moderate-quality evidence), or babies admitted to NICU (RR 1.61, 95% CI 0.43 to 6.05; 215 infants; 3 studies; low-quality evidence). There were no uterine ruptures in either the PGE₂ group or placebo group.There was no information on vaginal birth not achieved within 24 hours, length of hospital stay, use of emergency services, mother or caregiver satisfaction, or serious morbidity or neonatal morbidity or perinatal death. 3. Vaginal misoprostol versus placebo (4 studies)One small study reported on the rate of perinatal death with no clear differences between groups; there were no deaths in the treatment group compared with one stillbirth (reason not reported) in the control group (RR 0.34, 95% CI 0.01 to 8.14; 77 infants; 1 study; low-quality evidence).There was no clear difference between groups in rates of uterine hyperstimulation with FHR changes (RR 1.97, 95% CI 0.43 to 9.00; 265 women; 3 studies; low-quality evidence), caesarean section (RR 0.94, 95% CI 0.61 to 1.46; 325 women; 4 studies; low-quality evidence), and babies admitted to NICU (RR 0.89, 95% CI 0.54 to 1.47; 325 infants; 4 studies; low-quality evidence).There was no information on vaginal birth not achieved within 24, 48 or 72 hours, additional induction agents required, length of hospital stay, use of emergency services, mother or caregiver satisfaction, serious maternal, and other neonatal, morbidity or death.No substantive differences were found for other comparisons. One small study found that women who received oral misoprostol were more likely to give birth within 24 hours (RR 0.65, 95% CI 0.48 to 0.86; 87 women; 1 study) and were less likely to require additional induction agents (RR 0.60, 95% CI 0.37 to 0.97; 127 women; 2 studies). Women who received mifepristone were also less likely to require additional induction agents (average RR 0.59, 95% CI 0.37 to 0.95; 311 women; 4 studies; I² = 74%); however, this result should be interpreted with caution due to high heterogeneity. One trial each of acupuncture and outpatient amniotomy were included, but few review outcomes were reported.

AUTHORS' CONCLUSIONS

Induction of labour in outpatient settings appears feasible and important adverse events seem rare, however, in general there is insufficient evidence to detect differences. There was no strong evidence that agents used to induce labour in outpatient settings had an impact (positive or negative) on maternal or neonatal health. There was some evidence that compared to placebo or no treatment, induction agents administered on an outpatient basis reduced the need for further interventions to induce labour, and shortened the interval from intervention to birth.We do not have sufficient evidence to know which induction methods are preferred by women, the interventions that are most effective and safe to use in outpatient settings, or their cost effectiveness. Further studies where various women-friendly outpatient protocols are compared head-to-head are required. As part of such work, women should be consulted on what sort of management they would prefer.

Labor induction and cesarean delivery: A prospective cohort study of first births in Pennsylvania, USA

BACKGROUND

Mode of delivery at first childbirth largely determines mode of delivery at subsequent births, so it is particularly important to understand risk factors for cesarean delivery at first childbirth. In this study, we investigated risk factors for cesarean delivery among nulliparous women, with focus on the association between labor induction and cesarean delivery.

METHODS

A prospective cohort study of 2851 nulliparous women with singleton pregnancies who attempted vaginal delivery at hospitals in Pennsylvania, 2009-2011, was conducted. We used nested logistic regression models and multiple mediational analyses to investigate the role of three groups of variables in explaining the association between labor induction and unplanned cesarean delivery-the confounders of maternal characteristics and indications for induction, and the mediating (intrapartum) factors-including cervical dilatation, labor augmentation, epidural analgesia, dysfunctional labor, dystocia, fetal intolerance of labor, and maternal request of cesarean during labor.

RESULTS

More than a third of the women were induced (34.3%) and 24.8% underwent cesarean delivery. Induced women were more likely to deliver by cesarean (35.9%) than women in spontaneous labor (18.9%), unadjusted OR 2.35 (95% CI 1.97-2.79). The intrapartum factors significantly mediated the association between labor induction and cesarean delivery (explaining 76.7% of this association), particularly cervical dilatation <3 cm at hospital admission, fetal intolerance of labor, and dystocia. The indications for labor induction only explained 6.2%.

CONCLUSIONS

Increased risk of cesarean delivery after labor induction among nulliparous women is attributable mainly to lower cervical dilatation at hospital admission and higher rates of labor complications.

Center Variation in the Delivery of Indicated Late Preterm Births

Objective Evidence for optimal timing of delivery for some pregnancy complications at late preterm gestation is limited. The purpose of this study was to identify center variation of indicated late preterm births. Study design We performed an analysis of singleton late preterm and term births from a large U.S. retrospective obstetrical cohort. Births associated with spontaneous preterm labor, major congenital anomalies, chorioamnionitis, and emergency cesarean were excluded. We used modified Poisson fixed effects logistic regression with interaction terms to assess center variation of indicated late preterm births associated with four medical/obstetric comorbidities after adjusting for socio-demographics, comorbidities, and hospital/provider characteristics. Results We identified 150,055 births from 16 hospitals; 9,218 were indicated late preterm births. We found wide variation of indicated late preterm births across hospitals. The extent of center variation was greater for births associated with preterm premature rupture of membranes (risk ratio [RR] across sites: 0.45-3.05), hypertensive disorders of pregnancy (RR across sites: 0.36-1.27), and placenta previa/abruption (RR across sites: 0.48-1.82). We found less center variation for births associated with diabetes (RR across sites: 0.65-1.39). Conclusion Practice variation in the management of indicated late preterm deliveries might be a source of preventable late preterm birth.

Variation in induction of labour rates across Irish hospitals; a cross-sectional study

BACKGROUND

In developed countries, rates of induction of labour (IOL) have increased and vary between hospitals. We aimed to identify whether national variations could be explained by sociodemographic, clinical and organisational differences.

METHODS

Two national databases in Ireland that routinely collect clinical and administrative data, the National Perinatal Reporting System and the Hospital Inpatient Enquiry Scheme, were used to analyse data for all women with singleton births weighing ≥500 g in 2009. We used logistic multilevel models to examine variation between hospitals, and to determine how much variation was due to individual level sociodemographic, clinical and organisational variables. Analyses were stratified for nulliparas, multiparas without prior caesarean section (CS) and multiparas with prior CS.

RESULTS

Of 69 304 eligible births, the rate of IOL nationally was 25.0% (range 14.5-33.2%).In nulliparas, the mean rate was 30.9% (range 18.6-45.7%). The rate was 24.8% (13.5-33.3%) and 3.8% (0.0-10.2%) for multiparas without and with prior CS, respectively. In nulliparas and multiparas without prior CS IOL was predicted by maternal birth in Ireland, increasing birthweight, antepartum complications, giving birth on a weekday and the model of obstetric care. Even after adjusting for known sociodemographic and clinical variables, variation between hospitals remained.

CONCLUSION

We found that clinical, sociodemographic and organisational factors all contributed to variation. However, unexplained variation persisted possibly due to organisational factors such as hospital-specific policies on IOL. The results indicate that the prevalence of antenatal complications, changing immigration patterns and policies on IOL after previous CS are factors likely to influence future IOL rates.

A retrospective population-based study of induction of labour trends and associated factors among aboriginal and non-aboriginal mothers in the northern territory between 2001 and 2012

Background

Induction of labour (IOL) has become more common among many populations, but the trends and drivers of IOL in the Northern Territory (NT) of Australia are not known. This study investigated trends in IOL and associated factors among NT Aboriginal and non-Aboriginal mothers between 2001 and 2012.

Methods

A retrospective analysis of all NT resident women who birthed in the NT between 2001 and 2012 at ≥32 weeks gestation. Demographic, medical and obstetric data were obtained from the NT Midwives’ Collection. The prevalence of IOL was calculated by Aboriginal status and parity of the mother and year of birth. The prevalence of each main indication for induction among women was compared for 2001–2003 and 2010–2012. Linear and logistic regression was used to test for association between predictive factors and IOL in bivariate and multivariate analysis, separately for Aboriginal and non-Aboriginal mothers.

Results

A total of 42,765 eligible births between 2001 and 2012 were included. IOL was less common for Aboriginal than non-Aboriginal mothers in 2001 (18.0 % and 25.1 %, respectively), but increased to be similar to non-Aboriginal mothers in 2012 (22.6 % and 24.8 %, respectively). Aboriginal primiparous mothers demonstrated the greatest increase in IOL. The most common indication for IOL for both groups was post-dates, which changed little over time. Medical and obstetric complications were more common for Aboriginal mothers except late-term pregnancy. Prevalence of diabetes in pregnancy increased considerably among both Aboriginal and non-Aboriginal mothers, but was responsible for only a small proportion of IOLs. Increasing prevalence of risk factors did not explain the increased IOL prevalence for Aboriginal mothers.

Conclusions

IOL is now as common for Aboriginal as non-Aboriginal mothers, though their demographic, medical and obstetric profiles are markedly different. Medical indications did not explain the recent increase in IOL among Aboriginal mothers; changes in maternal or clinical decision-making may have been involved.

Elective induction of labour and maternal request: a national population-based study

OBJECTIVE

To estimate the rate of elective inductions in France and the proportion of them that were maternally requested, and to study the factors associated with elective inductions that were or were not requested by women.

DESIGN

Cross-sectional population-based study.

SETTING

All maternity units in France.

POPULATION

About 14 681 women from the 2010 French National Perinatal Survey of a representative sample of births.

METHODS

Inductions were classified as elective based on their indications and maternal and fetal characteristics, collected from medical records. Elective inductions requested by women were identified from the mother's postpartum interviews. Polytomous logistic regression analysis was used to study the determinants of inductions that were or were not maternally requested. Women with spontaneous labour served as the comparison group.

MAIN OUTCOME MEASURE

Rate of elective inductions.

RESULTS

The induction rate was 22.6, 13.9% elective. Among elective inductions, 47.3% were requested by women. The characteristics of mothers, pregnancies, and maternity units were similar in both groups of elective inductions. The main associated factors were parity 2 or more [adjusted odds ratio (OR) 4.7, 95% confidence interval (CI) 3.1-7.2 for maternally requested inductions and aOR of 1.8 (95% CI1.2-2.7) for unrequested inductions, compared with parity 0] and private hospital status [aOR 4.5 95% (CI 3.3-6.0) for maternally requested inductions and aOR 3.7 (95% CI 2.8-4.9) for inductions not requested by the mother]. We found no association between maternal social characteristics and type of elective induction.

CONCLUSION

Parity and organisational factors appear to influence the decision about elective inductions. It would be interesting to determine how obstetricians and women make this decision and for what reasons.

TWEETABLE ABSTRACT

About 13.9% of inductions of labour were elective in France, 47.3% of these requested by women.

Patient-Perceived Pressure from Clinicians for Labor Induction and Cesarean Delivery: A Population-Based Survey of U.S. Women

OBJECTIVE

To determine whether patient-perceived pressure from clinicians for labor induction or cesarean delivery is significantly associated with having these procedures.

DATA SOURCES/STUDY SETTING

Listening to Mothers III, a nationally representative survey of women 18-45 years who delivered a singleton infant in a U.S. hospital July 2011-June 2012 (N = 2,400).

STUDY DESIGN

Multivariate logistic regression analysis of factors associated with perceived pressure and estimation of odds of induction and cesarean given perceived pressure.

PRINCIPAL FINDINGS

Overall, 14.8 percent of respondents perceived pressure from a clinician for labor induction and 13.3 percent for cesarean delivery. Women who perceived pressure for labor induction had higher odds of induction overall (adjusted odds ratio [aOR]: 3.51; 95 percent confidence interval [CI]: 2.5-5.0) and without medical reason (aOR: 2.13; 95 percent CI: 1.3-3.4) compared with women who did not perceive pressure. Those perceiving pressure for cesarean delivery had higher odds of cesarean overall (aOR: 5.17; 95 percent CI: 3.2-8.4), without medical reason (aOR: 6.13; 95 percent CI: 3.4-11.1), and unplanned cesarean (aOR: 6.70; 95 percent CI: 4.0-11.3).

CONCLUSIONS

Patient-perceived pressure from clinicians significantly predicts labor induction and cesarean delivery. Efforts to reduce provider-patient miscommunication and minimize potentially unnecessary procedures may be warranted.

Sonographically accessed funneling of the uterine cervix as a predictor of successful labor induction

OBJECTIVE

The Bishop score and length of the uterine cervix are good predictors of successful labor induction. However, little is known about the association between the funneling of the uterine cervix and successful labor induction. The study aimed to evaluate cervical funneling as a predictor of successful labor induction.

METHODS

This study was designed as a prospective observational study. Subjects who delivered a baby by labor induction were enrolled in the study from July 2011 to August 2013. Cervical funneling and length were examined with transvaginal ultrasonography. The Bishop score was rated by digital pelvic examination.

RESULTS

A total of 163 primigravida women were recruited for the study. Of these, 137 participants (84.0%) delivered vaginally by labor induction. Cervical funneling was observed in 93 women (57.1%). Successful labor induction was significantly higher in patients with cervical funneling than those without it (91.4% vs. 74.3%, P<0.01), and was significantly associated with cervical funneling, as well as the Bishop score and cervical length. In a multivariate analysis, cervical funneling was an independent predictor for successful vaginal delivery by labor induction ( odd ratio, 2.70; 95% confidence interval, 1.02 to 7.10; P=0.04). However, the Bishop score and cervical length had no association with successful vaginal delivery.

CONCLUSION

This study showed that cervical funneling could be a predictive marker for vaginal delivery during labor induction.

Risk of caesarean section after induced labour: do hospitals make a difference?

Background

There is a well-known relationship between induced labour and caesarean rates. However, it remains unknown whether this relationship reflects the impact of more complex obstetric conditions or the variability in obstetric practices. We sought to quantify the independent role of the hospital as a variable that can influence the occurrence of caesarean section after induced labour.

Methods

As part of the Portuguese Generation XXI birth cohort, we evaluated 2041 consecutive women who underwent singleton pregnancies with labour induction, at five public level III obstetric units (April 2005-August 2006). The indications for induction were classified according to the guidelines of the American and the Royal Colleges of Obstetricians and Gynaecologists. Poisson regression models were adjusted to estimate the association between the hospital and surgical delivery after induction. Crude and adjusted prevalence ratios (PR) and a 95% confidence interval (95% CI) were computed.

Results

The proportion of women who were induced without formal clinical indications varied among hospitals from 20.3% to 45.5% (p < 0.001). After adjusting for confounders, the risk of undergoing a caesarean section after induced labour remained significantly different between the hospitals, for the cases in which there was no evident indication for induction [the highest PR reaching 1.86 (95% CI, 1.23–2.82)] and also when at least one such indication was present [1.53 (95% CI, 1.12–2.10)]. This pattern was also observed among the primiparous cephalic term induced women [the highest PR reaching 2.06 (95% CI, 1.23–2.82) when there was no evident indication for induction and 1.61 (95% CI, 1.11–2.34) when at least one such indication was present].

Conclusions

Caesarean section after induced labour varied significantly across hospitals where similar outcomes were expected. The effect was more evident when the induction was not based on the unequivocal presence of commonly accepted indications.

Regional variation in late preterm births in North Carolina

Late preterm (LPT) neonates (34 0/7th-36 6/7th weeks' gestation) account for 70% of all premature births in the United States. LPT neonates have a higher morbidity and mortality risk than term neonates. LPT birth rates vary across geographic regions. Unwarranted variation is variation in medical care that cannot be explained by sociodemographic or medical risk factors; it represents differences in health system performance, including provider practice variation. The purpose of this study is to identify regional variation in LPT births in North Carolina that cannot be explained by sociodemographic or medical/obstetric risk factors. We searched the NC State Center for Health Statistics linked birth-death certificate database for all singleton term and LPT neonates born between 1999 and 2006. We used multivariable logistic regression analysis to control for socio-demographic and medical/obstetric risk factors. The main outcome was the percent of LPT birth in each of the six perinatal regions in North Carolina. We identified 884,304 neonates; 66,218 (7.5%) were LPT. After multivariable logistic regression, regions 2 (7.0%) and 6 (6.6%) had the highest adjusted percent of LPT birth. Analysis of a statewide birth cohort demonstrates regional variation in the incidence of LPT births among NC's perinatal regions after adjustment for sociodemographic and medical risk factors. We speculate that provider practice variation might explain some of the remaining difference. This is an area where policy changes and quality improvement efforts can help reduce variation, and potentially decrease LPT births.

Obstetric variation, intervention, and outcomes: doing more but accomplishing less

Obstetric interventions, particularly induction of labor and cesarean section, are done more and more commonly, although there is a wide variation between hospitals and practitioners in specific rates. This degree of variation implies imprecision and uncertainty about diagnoses and indicated management. Although the net result of this variation has been a "more is better" approach leading to increasing use of obstetric interventions, little evidence of commensurate improvements in outcome is available. A combined package of using currently available evidence, formulating best practices, instituting regular review and feedback to hospitals and practitioners about intervention rates, and a public health approach to educate women has the potential to achieve an acceptable balance between when intervention in the labor and delivery process is warranted and when it is unnecessary.

Factors that influence the practice of elective induction of labor: what does the evidence tell us?

Elective induction of labor has been linked to increased rates of prematurity and rising rates of cesarean birth. The purpose of this investigation was to evaluate current trends in induction of labor scholarship focusing on evidence-based factors that influence the practice of elective induction. A key word search was conducted to identify studies on the practice of elective induction of labor. Analysis of the findings included clustering and identification of recurrent themes among the articles with 3 categories being identified. Under each category, the words/phrases were further clustered until a construct could be named. A total of 49 articles met inclusion criteria: 7 patient, 6 maternity care provider, and 4 organization factors emerged. Only 4 of the articles identified were evidence based. Patient factors were divided into preferences/convenience, communication, fear, pressure/influence, trust, external influences, and technology. Provider factors were then divided into practice preferences/convenience, lack of information, financial incentives, fear, patient desire/demand, and technology. Organization factors were divided into lack of enforcement/accountability, hospital culture, scheduling of staff, and market share issues. Currently, there is limited data-based information focused on factors that influence elective induction of labor. Despite patient and provider convenience/preferences being cited in the literature, the evidence does not support this practice.

Ethnicity and newborn outcomes: the case of African American women

PURPOSE

Although previous studies have confirmed the relationship between socioeconomic status, ethnicity, education, and occupation on birth outcomes, less is known about the relationship of providers influence or hospital characteristics on birth outcomes for minority women. It is not well understood whether hospital or physician characteristics exert an equal or greater affect compared with maternal sociodemographic factors, particularly for Black childbearing women known to be at particular risk for adverse birth outcomes.

DESIGN

This retrospective descriptive study sought to determine whether variation in neonatal birth outcomes for Black women was attributable to hospital characteristics, physician influence, or patient sociodemographics.

METHODS

Fixed and random effects were conducted to empirically determine the relative importance of hospital, physician, and patient characteristics (partitioning the variation of differences in birth outcome to each component) using a large administrative dataset.

FINDINGS

Considerable variability existed among hospitals over and above hospital ownership or number of hospital beds.

CONCLUSIONS

Ethnicity was a statistically significant predictor of adverse outcomes, as was the number of prenatal visits and maternal education. There is a significant relationship between adverse newborn outcomes and ethnicity after controlling for hospital and physician characteristics.

CLINICAL RELEVANCE

Ongoing birth disparities in African American childbearing women are a significant public policy issue with important research and clinical implications. This research adds to nursing knowledge by helping eliminate some factors previously thought to have contributed to the high incidence of perinatal complications for African American women and their newborns.

Rates of labor induction and primary cesarean delivery do not correlate with rates of adverse neonatal outcome in level I hospitals

OBJECTIVE

To determine whether variation in rates of labor induction (IOL) and primary cesarean delivery (PCD) among level I hospitals is associated with differences in neonatal outcomes.

METHODS

A birth certificate database was used to calculate crude and adjusted rates of IOL and PCD among 10 regional hospitals. Adjustment via logistic regression controlled for differences in medical and demographic factors. Linear regression assessed the relationship of crude and adjusted IOL and PCD rates to rates of three neonatal outcomes.

RESULTS

IOL and PCD rates varied widely among hospitals (1.79- and 1.72-fold, respectively); variation increased following adjustment (1.93- and 1.86-fold, respectively). Rates of adverse neonatal outcomes varied by year and hospital, but not by IOL or PCD rates (p ≥ 0.05).

CONCLUSIONS

Crude and adjusted rates of labor induction and PCD vary among level I hospitals, but with no consistent effect on neonatal outcome.

Different methods for the induction of labour in outpatient settings

BACKGROUND

Induction of labour is carried out for a variety of indications and using a range of pharmacological, mechanical and other methods. For women at low risk, some methods of induction of labour may be suitable for use in outpatient settings.

OBJECTIVES

To examine pharmacological and mechanical interventions to induce labour in outpatient settings in terms of feasibility, effectiveness, maternal satisfaction, healthcare costs and, where information is available, safety. The review complements existing reviews on labour induction examining effectiveness and safety.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2009) and reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials examining outpatient cervical ripening or induction of labour with pharmacological agents or mechanical methods.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed eligible papers for risk of bias. We checked all data after entry into review manager software.

MAIN RESULTS

We included 28 studies with 2616 women examining different methods of induction of labour where women received treatment at home or were sent home after initial treatment and monitoring in hospital.Studies examined vaginal and intracervical PGE(2), vaginal and oral misoprostol, isosorbide mononitrate, mifepristone, oestrogens, and acupuncture. Overall, the results demonstrate that outpatient induction of labour is feasible and that important adverse events are rare. There was no strong evidence that agents used to induce labour in outpatient settings had an impact (positive or negative) on maternal or neonatal health. There was some evidence that, compared to placebo or no treatment, induction agents reduced the need for further interventions to induce labour, and shortened the interval from intervention to birth. We were unable to pool results on outcomes relating to progress in labour as studies tended to measure a very broad range of outcomes.There was no evidence that induction agents increased interventions in labour such as operative deliveries. Only two studies provided information on women's views about the induction process, and overall there was very little information on the costs to health service providers of different methods of labour induction in outpatient settings.

AUTHORS' CONCLUSIONS

Induction of labour in outpatient settings appears feasible. We do not have sufficient evidence to know which induction methods are preferred by women, or the interventions that are most effective and safe to use in outpatient settings.

An online tool for investigating clinical decision making

BACKGROUND

Induction of labour is a common clinical intervention. There has been a recent rise in rates of induction of labour and wide variation between published hospital rates without obvious explanation. Clinician variation has been suggested as a reason.

OBJECTIVE

The study described aimed to examine clinical decision making, whilst removing individual patient bias. To achieve this clinical behaviour was studied by the use of imaginary clinical scenarios presented to clinicians by computer. Unlike retrospective audit, the rates thus generated are unaffected by differences in casemix, pressure of time, work or other factors and allow direct comparison between clinicians and comparison with clinical guidelines.

METHODS

Data about 15 imaginary pregnant women are presented to the clinician, each may have symptoms or signs of hypertensive disorders, intrauterine growth restriction (IUGR) and/or postdates. From the decision made in each scenario, and the information revealed about each scenario, a set of 'decision rules' is created for each clinician, describing in what circumstances they would induce labour. Data from the National Women's Hospital (Auckland, New Zealand) is then examined using these rules and the induction of labour rate thus generated presented to the clinician.

RESULTS

Sixteen clinicians were interviewed. Their induction of labour rate ranged from 10-31%.

CONCLUSIONS

Clinician variation in decision making is evident about the intervention when to induce labour. The system is available on the WWW at http://csrs2.aut.ac.nz/scenario

Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system

OBJECTIVE

The American College of Obstetricians and Gynecologists has recommended that elective deliveries not be performed before 39 weeks of gestation, to minimize prematurity-related neonatal complications. Because a worrisome number of elective deliveries were occurring before 39 weeks of gestation in our system, we developed and implemented a program to decrease the number of these early term elective deliveries. Secondary objectives were to monitor relevant clinical outcomes.

METHODS

The electronic medical records of an integrated health care system involving nine labor and delivery units in Utah were queried to establish the incidence of patients admitted for elective induction of labor or planned elective cesarean delivery. These facilities have open staff models with obstetricians, family practitioners, and certified nurse midwives. Guidelines were developed and implemented to discourage early term elective deliveries. The prevalence of early term elective deliveries was tracked and reported back regularly to the obstetric leadership and obstetric departments at each facility.

RESULTS

The baseline prevalence of early term elective deliveries was 28% of all elective deliveries before the initiation of the program. Within 6 months of initiating the program, the incidence of near-term elective deliveries decreased to less than 10% and after 6 years continues to be less than 3%. A reduced length of stay in labor and delivery occurred with the introduction of the program, and there were no adverse effects on secondary clinical outcomes.

CONCLUSION

With institutional commitment, it is possible to substantially reduce and sustain a decline in the incidence of elective deliveries before 39 weeks of gestation.

LEVEL OF EVIDENCE

III.

Does distance matter? Increased induction rates for rural women who have to travel for intrapartum care

OBJECTIVES

Although there has been a devolution of local rural maternity services across Canada in the past 10 years in favour of regional centralization, little is known about the health outcomes of women who must travel for care. The objective of this study was to compare intervention rates and outcomes between women who live adjacent to maternity service with specialist (surgical) services and women who have to travel for this care.

METHODS

The BC Perinatal Database Registry provided data for maternal and newborn outcomes by delivery hospital for 14 referral hospitals (selected across a range of 250-2500 annual deliveries) between 2000 and 2004. Three hospitals were selected for sub-analysis on the basis of almost complete capture of the satellite community population (greater than 90%) to avoid referral bias.

RESULTS

Women from outside the hospital local health area (LHA) had an increased rate of induction of labour compared with women who lived within the hospital LHA. Sub-analysis by parity demonstrated that multiparous women had increased rates of induction for logistical reasons.

CONCLUSION

Rural parturient women who have to travel for care are 1.3 times more likely to undergo induction of labour than women who do not have to travel. Further research is required to determine why this is the case. If it is a strategy to mitigate stress incurred due to separation from home and community, either a clinical protocol to support geographic inductions or an alternative strategy to mitigate stress is needed.

Trajetória das mulheres na definição pelo parto cesáreo: estudo de caso em duas unidades do sistema de saúde suplementar do estado do Rio de Janeiro

No Brasil, as taxas de cesariana são bastante elevadas, principalmente nos serviços privados, estando provavelmente associadas a fatores socioeconômicos e culturais. O objetivo deste estudo foi descrever as características socioeconômicas, demográficas, culturais e reprodutivas de puérperas e os determinantes da decisão por parto cesáreo em duas unidades do sistema de saúde suplementar do Estado do Rio de Janeiro. A população foi composta por 437 puérperas que tiverem partos vaginais ou cesarianos nas duas unidades selecionadas. Os dados foram coletados por meio de entrevistas com as mães e consulta aos prontuários. Através de regressão logística não condicional, avaliaram-se os fatores associados à decisão por cesariana como via de parto, seguindo os modelos hierárquicos estabelecidos em três momentos definidos: no início, ao longo da gestação e no momento do parto. Observou-se que, embora 70% das entrevistadas não relatassem preferência inicial pela cesariana, 90% apresentaram esse tipo de parto. Verificou-se que, independente do desejo inicial da gestante, a interação com o serviço de saúde resultou na cesariana como via final de parto. Trabalhos educativos direcionados às gestantes e à população geral e mudanças no modelo de assistência ao parto podem ser estratégias promissoras para a reversão desse quadro.

Sonographic cervical assessment to predict the success of labor induction: a systematic review with metaanalysis

OBJECTIVE

The purpose of this investigation was to review the literature that evaluates sonographic cervical assessment to predict successful induction of labor.

STUDY DESIGN

Published prospective trials that measured sonographic cervical length before labor induction was initiated were evaluated. Trials were excluded if they contained data presented in later articles or did not contain extractable data. The total analysis included 20 trials with 3101 aggregate participants.

RESULTS

Cervical length predicted successful induction (likelihood ratio of positive test, 1.66; 95% confidence interval [CI], 1.20-2.31) and failed induction (likelihood ratio of negative test, 0.51; 95% CI, 0.39-0.67). Cervical length did not predict any specific outcome (eg, mode of delivery). The assessment of cervical wedging proved to be a useful diagnostic test, with a likelihood ratio of a positive test result of 2.64 and a likelihood ratio of a negative test result of 0.64.

CONCLUSION

Sonographic cervical length was not an effective predictor of successful labor induction. Further evaluation of cervical wedging in the prediction of labor induction appears warranted.

Induction of labor in the absence of standard medical indications: incidence and correlates

BACKGROUND

Induction of labor is an increasingly common obstetrical procedure, with approximately 20-34% of women undergoing labor induction in the United States annually.

OBJECTIVE

To determine the extent of labor induction in the absence of standard medical indications and to assess possible associations with maternal and infant characteristics and hospital factors.

METHODS

We ascertained induction of labor and associated details as part of a medical record validation study of 4541 women with live, singleton births in 2000 in Washington State using medical record, birth certificate, and hospital discharge data. In this analysis, we report findings for the 1473 women (33% of original cohort) whose medical records indicated that their labors were induced.

RESULTS

Among women with induced labor, 7.9% had no clinical information providing an indication for the induction, and 6.4% had only "nonstandard" indications recorded. Compared with women delivering in moderate volume hospitals, women who delivered at lower volume (odds ratios [OR] 3.9; 95% confidence intervals [CI] 1.8-8.6) or higher volume hospitals (OR 4.2; 95% CI 2.4-7.2) had significantly increased risk for undocumented indication of labor. Women who had undocumented indication for induction were at significantly decreased risk of giving birth at a teaching hospital and a public nonfederally owned hospital, and were at greater risk to give birth at a private religious hospital. Factors that remained independently associated with nonstandard indication for induction of labor were primiparas (OR 2.4; 95% CI 1.3-4.2); multiparas (OR 4.3; 95% CI 2.5-7.4), pregnancy-induced hypertension (OR 0.2; 95% CI 0.1-0.4), hospital volume >or=2000 births annually (OR 19.9; 95% CI 6.7-58.6), primary (OR 11.7; 95% CI 4.1-33.6), and tertiary level hospital (OR 0.4; 95% CI 0.2-0.7).

CONCLUSIONS

Our findings suggest that nearly 15% of inductions either were not clinically indicated according to standard protocols or indications were incompletely documented. At minimum, further studies are needed to explore how best to improve documentation of indications of labor because accurately describing, among other things, the process of labor induction, is a basic benchmark of care.

What happens when a private hospital comes to town? The impact of the 'public' to 'private' hospital shift on regional birthing outcomes

PURPOSE

To examine the regional impact of a shift from public to private hospital care on birthing outcomes.

PROCEDURES

A retrospective regional cohort study analysed the birth outcomes for 20,826 live singleton births of gestation >or=37 weeks, within one regional area in New South Wales between 1 January 1997 and 31 December 2003. Rates of intervention for induction of labour (IOL), epidural pain relief and operative mode of birth were established and analysed according to hospital type. A cascade model was then constructed for total births by hospital type.

FINDINGS

Regional birthing outcomes were significantly affected by a shift from public to private hospital care. The introduction of a new private hospital birth facility in the region studied, led to 90% of all privately insured births within the region shifting to the private hospital. During the period 1997-2003, overall regional rates for IOL increased from 38 to 45%, epidural use in labour increased from 10.4 to 21.1% and the caesarean section rate increased from 14.1 to 24.75%.

PRINCIPAL CONCLUSIONS

The introduction of a new private hospital birthing facility into the regional health area studied and the shift from public to private hospital birth had a profound impact on the overall birthing experiences of women in the region. This suggests that private hospital services are not a direct substitute for public hospital birthing services. The cascade effect was present for women regardless of risk category and more pronounced in the private hospital. Women who are privately insured require better information to assist them in choosing their birthing environment, rather than assuming that they are simply buying a comparable product through private insurance.

Clinical and Ultrasound Parameters to Predict the Risk of Cesarean Delivery After Induction of Labor

OBJECTIVE

To evaluate whether factors in the maternal history and/or ultrasound parameters are useful in predicting the risk of cesarean delivery after induction of labor.

METHODS

Maternal age, height, body mass index, parity, gestational age, Bishop score, ultrasonic amniotic fluid volume, fetal head position, estimated fetal weight, and transvaginal cervical length were studied prospectively in 267 women at 36 or more weeks of gestation immediately before induction of labor. Logistic regression analysis was used to determine which factors best predicted the risk of cesarean delivery. Receiver operating characteristic curves and a resampling technique were used to evaluate the model's performance.

RESULTS

Eighty (30%) of these 267 women had cesarean delivery. Logistic regression was performed and a final model chosen, which included parity (odds ratio [OR] 20.56, 95% confidence interval [CI] 7.97-53.05, P < .001), body mass index (OR 6.17, 95% CI 2.10-18.13, P < .001), height (OR 0.94, 95% CI 0.89-0.98, P = .005), and ultrasonic transvaginal cervical length (OR 1.07, 95% CI 1.04-1.11, P < .001) as the best predictors of cesarean delivery. A risk score was calculated containing these 4 parameters, which predicted reasonably accurately the risk of cesarean delivery.

CONCLUSION

Parity, body mass index, height, and ultrasonic transvaginal cervical length are the most accurate parameters in predicting the risk of cesarean delivery after induction of labor. A predictive model using these would allow more accurate counseling and better informed consent in the decision-making process regarding induction of labor

LEVEL OF EVIDENCE

II-2.

Trends in labor induction in the United States: is it true that what goes up must come down?

Three recent studies examined the national trend in labor induction in the United States. All show a doubling in the rate of induction during the 1990s, although vital statistics data show a consistently higher trend than that obtained from national hospital discharge data. Neither data source adequately documents the full range of indications for induction, its timing, hospital staffing considerations, and other factors that may play a role. Although rates of induction of labor may be leveling off, despite a lack of scientific evidence for its widespread use, rates are likely to remain at current levels for the next few years.