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

Sleep disturbances in late pregnancy: associations with induction of labor

PURPOSE

Sleep disturbances, which are common during pregnancy, may compromise labor. Nevertheless, little is known about associations between sleep disturbances and the likelihood of ending up induction of labor (IOL). Accordingly, we aimed to evaluate the connections between sleep disturbances during pregnancy and IOL.

METHODS

Altogether 1778 women from the FinnBrain Birth Cohort Study with gestation weeks over 37 + 6 were enrolled in the study. The women were divided into IOL (n = 331) and spontaneous onset of labor (SOL, n = 1447) groups. Sleep disturbances in late pregnancy were evaluated using the Basic Nordic Sleep Questionnaire. Logistic regression analyses were conducted with adjustments for age, body mass index, parity, smoking, and depressive symptoms.

RESULTS

Sleep disturbances were frequent in both IOL and SOL groups. In the IOL group 43.0% and in the SOL group 39.0% had poor general sleep quality (P = 0.186). Nocturnal awakenings occurred most commonly, in 94.0% and 93.9%, respectively (P = 0.653). In the IOL group, more women (22.7%) were habitual snorers than in the SOL group (17.0%, P = 0.017), however, the difference lost the statistical significance in adjusted analysis (P = 0.848). Women in the IOL group were more likely to be short sleepers (< 7 h) compared to those in the SOL group (20.2% and 15.4%, respectively, P = 0.034) with no difference after adjustment (P = 0.133). The two groups showed no differences in sleep loss (P = 0.252).

CONCLUSIONS

Deterioration in sleep quality was noticeable in pregnant women, but it was unconnected with IOL. As the frequency of IOL is increasing, more research for related risk factors is needed.

Early-term birth and its association with universal two-child policy: a national cross-sectional study in China

OBJECTIVE

To describe the epidemiology of early-term birth (ETB) at the national level in China, and explore the association and mediating factors between ETB and policy between universal two-child policy and ETB, so as to explain the potential reason for such a relationship and provide evidence for future ETB interventions in the era of the new birth control policy.

DESIGN

Cross-sectional study.

PARTICIPANTS

The cross-sectional study used data from China Labour and Delivery Survey between 2015 and 2016. A total of 75 132 survey data collected from 89 hospitals in 25 provinces were included in the analysis. We further explored the association between the universal two-child policy and ETB.

RESULTS

The weighted incidence of ETB was 30.1 per 100 all births (95% CI 30.06% to 30.14%) or 29.88 per 100 live births (95% CI 29.97% to 30.05%) between 2015 and 2016 in China. There was an association between the universal two-child policy and ETB (relative risk, RR 1.19, 95% CI 1.15 to 1.23), which was not mediated by maternal age (RR 1.17, 95% CI 1.13 to 1.22), previous uterine scars (RR 1.18, 95% CI 1.14 to 1.22), parity (RR 1.19, 95% CI 1.15 to 1.24) and other measured conditions (each p<0.05). Stratified analysis showed that the association between universal two-child policy and ETB were the strongest in multiparous young women or women without previous uterine scars (each p<0.05), and disappeared in all women of advanced maternal age (each p>0.05).

CONCLUSION

The incidence of ETB was high in China when compared with most of reported countries, and there might be a link between two-child policy and ETB. Obstetric practice such as selective induced labour and caesarean section should be revised with ETB risks in mind, when ETB is more likely to happen under the universal two-child policy. Preventing ETB should not be neglected in multiparous young women or those without previous uterine scars under the new policy.

Induction of labour as compared with spontaneous labour in low-risk women: A multicenter study in Catalonia

OBJECTIVE

To compare birth and neonatal outcomes in low-risk women undergoing induced labour with those undergoing spontaneous onset.

METHODS

This retrospective multicentre study included 30 public maternity hospitals in Catalonia between 2016 and 2017. The study population consisted of 5,717 women.

RESULTS

Of the 5,717 births, 75.8% had spontaneous onset and 24.2% had an induction. Induced labour was more likely at week 41 of gestation and in nulliparous women. Induced labour increased the likelihood of undergoing caesarean section (adjusted OR [ORa], 2.59; 95% confidence interval [CI], 2.11-3.16), assisted vaginal birth (ORa, 1.70; 95% CI, 1.46-1.98), epidural analgesia (ORa, 2.64; CI, 2.14-3.27), postpartum haemorrhage (ORa, 1.56; 95% CI, 1.14-2.15) and episiotomy (ORa, 1.26; 95% CI, 1.08-1.47). Induced labour was also associated with not performing skin-to-skin contact with the mother (ORa, 0.47; 95% CI, 0.39-0.58) and with not performing early breastfeeding (ORa, 0.49; 95% CI, 0.39-0.61).

CONCLUSIONS

The frequency of labour inductions among low-risk women exceeds the level recommended by scientific organisations in Catalonia and Spain, and is associated with adverse birth outcomes such as increased caesarean section rates, assisted vaginal births, and episiotomy rates. It is also associated with the failure to perform early skin-to-skin contact with the mother and failure to initiate early breastfeeding.

Recent advances in the induction of labor

The rate of labor induction is steadily increasing and, in industrialized countries, approximately one out of four pregnant women has their labor induced. Induction of labor should be considered when the benefits of prompt vaginal delivery outweigh the maternal and/or fetal risks of waiting for the spontaneous onset of labor. However, this procedure is not free of risks, which include an increase in operative vaginal or caesarean delivery and excessive uterine activity with risk of fetal heart rate abnormalities. A search for "Induction of Labor" retrieves more than 18,000 citations from 1844 to the present day. The aim of this review is to summarize the controversies concerning the indications, the methods, and the tools for evaluating the success of the procedure, with an emphasis on the scientific evidence behind each.

Induction of labor and postpartum blood loss

BACKGROUND

To analyze blood loss after delivery in women with induction of labor compared to women with spontaneous onset of labor.

METHODS

In this secondary analysis of a prospective cohort study investigating postpartum hemorrhage, 965 deliveries were analyzed including 380 women with induction of labor (39%) between 2015 and 2016. Primary outcome parameters were rate of postpartum hemorrhage, estimated blood loss and post-partum decrease in hemoglobin.

RESULTS

Rates of postpartum hemorrhage and estimated blood loss were not significantly different in women with induction of labor. Women with induction of labor had a significantly reduced decrease in hemoglobin after delivery. In the multivariate linear regression analysis, induction of labor remained associated with reduced decrease in hemoglobin. Secondary maternal and neonatal outcomes were unaffected.

CONCLUSIONS

Induction of labor is not associated with increased blood loss after delivery and should not be regarded as a risk factor for postpartum hemorrhage.

Evidence-based Birth Attendance in Spain: Private versus Public Centers

The type of hospital (public or private) has been associated with the type of clinical practice carried out. The purpose of this study was to determine the association between the type of hospital (public or private) and delivery attendance with practices based on the recommendations by the World Health Organization (WHO). A cross-sectional study with puerperal women (n = 2906) was conducted in Spain during 2017. The crude Odds Ratios (OR), adjusted (aOR) and their 95% confidence intervals (CI) were calculated through binary logistic regression. For multiparous women in private centers, a higher rate of induced labor was observed (aOR: 1.49; 95% CI: 1.11⁻2.00), fewer natural methods were used to relieve pain (aOR: 0.51; 95% CI: 0.35⁻0.73), and increased odds of cesarean section (aOR: 2.50; 95% CI: 1.81⁻3.46) were found as compared to public hospitals. For primiparous women in private centers, a greater use of the epidural was observed (aOR: 1.57; 95% CI: 1.03⁻1.40), as well as an increased likelihood of instrumental birth (aOR: 1.53; 95% CI: 1.09⁻2.15) and of cesarean section (aOR: 1.77; 95% CI: 1.33⁻2.37) than in public hospitals. No differences were found in hospitalization times among women giving birth in public and private centers (p > 0.05). The World Health Organization birth attendance recommendations are more strictly followed in public hospitals than in private settings.

Travel Time to Hospital for Childbirth: Comparing Calculated Versus Reported Travel Times in France

Objectives Timely access to health care is critical in obstetrics. Yet obtaining reliable estimates of travel times to hospital for childbirth poses methodological challenges. We compared two measures of travel time, self-reported and calculated, to assess concordance and to identify determinants of long travel time to hospital for childbirth. Methods Data came from the 2010 French National Perinatal Survey, a national representative sample of births (N = 14 681). We compared both travel time measures by maternal, maternity unit and geographic characteristics in rural, peri-urban and urban areas. Logistic regression models were used to study factors associated with reported and calculated times ≥30 min. Cohen's kappa coefficients were also calculated to estimate the agreement between reported and calculated times according to women's characteristics. Results In urban areas, the proportion of women with travel times ≥30 min was higher when reported rather than calculated times were used (11.0 vs. 3.6%). Longer reported times were associated with non-French nationality [adjusted odds ratio (aOR) 1.3 (95% CI 1.0-1.7)] and inadequate prenatal care [aOR 1.5 (95% CI 1.2-2.0)], but not for calculated times. Concordance between the two measures was higher in peri-urban and rural areas (52.4 vs. 52.3% for rural areas). Delivery in a specialised level 2 or 3 maternity unit was a principal determinant of long reported and measured times in peri-urban and rural areas. Conclusions for Practice The level of agreement between reported and calculated times varies according to geographic context. Poor measurement of travel time in urban areas may mask problems in accessibility.

Elective induction of labor: A prospective observational study

The aim of the present study was to assess indications for induction and describe the characteristics and delivery outcome in medical compared to non-medical/elective inductions. During a three-month period, 1663 term inductions were registered in 24 delivery units in Norway. Inclusion criteria were singleton pregnancies with cephalic presentation at gestational age 37⁺⁰ and beyond. Indications, pre-induction Bishop scores, mode of delivery and adverse maternal and fetal outcomes were registered, and compared between the medically indicated and elective induction groups. Ten percent of the inductions were elective, and the four most common indications were maternal request (35%), a previous negative delivery experience or difficult obstetric history (19%), maternal fatigue/tiredness (17%) and anxiety (15%). Nearly half of these inductions were performed at 39⁺⁰–40⁺⁶ weeks. There were fewer nulliparous women in the elective compared to the medically indicated induction group, 16% vs. 52% (p<0.05). The cesarean section rate in the elective induction group was 14% and 17% in the medically indicated group (14% vs. 17%, OR = 0.8, 95% CI 0.5–1.3). We found that one in ten inductions in Norway is performed without a strict medical indication and 86% of these inductions resulted in vaginal delivery.

Less or more? Maternal requests that go against medical advice

PROBLEM AND BACKGROUND

This study explores the experiences of Dutch midwives and gynaecologists with pregnant women who request more, less or no care during pregnancy and/or childbirth.

METHODS

All Dutch midwives and (trainee) gynaecologists were invited to fill out a questionnaire specifically designed for the purposes of this study. Holistic midwives were analysed separately from regular community midwives.

FINDINGS

Most maternity care providers in the Netherlands receive requests for less care than recommended at least once a year. The most frequently maternal requests were declining testing for gestational diabetes (66.3%), opting for a home birth in case of a high risk pregnancy (65.3%), and declining foetal monitoring during labour (39.6%). Holistic midwives are more convinced of an increasing demand for less care than community midwives (73.1% vs. 35.2%, p=<0.001). More community midwives than hospital staff reported to have declined one or more request for less care than recommended (48.6% vs. 27.9%, p=<0.001). The majority of hospital staff also receive at least one request for an elective caesarean section every year.

DISCUSSION AND CONCLUSION

Requests for more and less care than indicated during pregnancy and childbirth are equally prevalent in this study. However, a request for less care is more likely to be declined than a request for more care. Counselling women who disagree with their care provider demands time. In case of requests for less care, second best care should be considered.

Are risk factors for preterm and early-term live singleton birth the same? A population-based study in France

OBJECTIVES

To investigate whether risk factors for preterm (<37 weeks gestation) and early-term birth (37 and 38 weeks gestation) are similar.

DESIGN

Nationally representative cross-sectional study of births.

SETTING

France in 2010.

PARTICIPANTS

Live singleton births (n=14 326).

PRIMARY AND SECONDARY OUTCOME MEASURES

Preterm and early-term birth rates overall and by mode of delivery (spontaneous and indicated). Risk factors were maternal sociodemographic characteristics, previous preterm birth, height, prepregnancy body mass index (BMI) and smoking, assessed using multinomial regression models with full-term births 39 weeks and over as the reference group.

RESULTS

There were 5.5% preterm and 22.5% early-term births. Common risk factors were: a previous preterm delivery (adjusted relative risk ratio (aRRR) 8.2 (95% CI 6.2 to 10.7) and aRRR 2.4 (95% CI 2.0 to 3.0), respectively), short stature, underweight (overall and in spontaneous deliveries), obesity (in indicated deliveries only), a low educational level and Sub-Saharan African origin. In contrast, primiparity was a risk factor only for preterm birth, aRRR 1.8 (95% CI 1.5 to 2.2), while higher parity was associated with greater risk of early-term birth.

CONCLUSIONS

Most population-level risk factors were common to both preterm and early-term birth with the exception of primiparity, and BMI which differed by mode of onset of delivery. Our results suggest that preterm and early-term birth share similar aetiologies and thus potentially common strategies for prevention.