“Except When Medically Necessary” : Making informed choices about induction of labor

by Amy Romano, CNM

This post was originally published on Science and Sensibility for Lamaze International.

It’s not hard for women to find advice and recommendations to avoid induction of labor “except when medically necessary.” But what do those words mean and who decides when an induction is medically necessary?

Lamaze’s Healthy Birth Practice Paper cites ACOG Guidelines that define medical induction of labor as necessary in the following circumstances:

• your water has broken and labor has not begun.
• your pregnancy is postterm (more than 42 weeks).
• you have high blood pressure caused by your pregnancy.
• you have health problems, such as diabetes, that could affect your baby.
• you have an infection in the uterus.
• your baby is growing too slowly.

Yet a systematic review of the highest quality research found evidence only to support the first three. Even in these three cases, differences in important health outcomes were small, study methodologies have been criticized, and some important questions remain unanswered.

For the rest of this list and other so-called “medical” reasons for induction, we simply lack scientific evidence that induction offers any clear health benefits, and for other conditions the available evidence suggests induction is more likely to harm than help.

When trade-offs are uncertain for a proposed course of treatment, that treatment is known as “preference-sensitive care.” According to the Dartmouth Atlas of Health Care, a leader in studying practice variation, “Decisions about these interventions — whether to have them or not, and which ones to have — should thus reflect patients’ personal values and preferences, and should be made only after patients have enough information to make an informed choice, in partnership with the physician.”

As the Dartmouth Atlas has demonstrated for many types of medical and surgical interventions, however, decisions are more likely to reflect local practice patterns and the preferences of individual providers than the preferences of patients themselves. While the Dartmouth Atlas does not track induction rates, a 2004 study in New York State found that risk factors (at least those documented in birth certificate records) explained just 12.6% of the four-fold variation in induction rates across hospitals.

But what of the variation in the use of interventions when clear evidence suggests is harmful? Shouldn’t rates of those interventions be stable at or near 0%? Take, for example, the rate of elective (non-medically indicated) deliveries before 39 weeks. In a landscape where clinical consensus is hard to come by, all of the major players from ACOG and ACNM to the March of Dimes, the National Quality Forum, and the Joint Commission, have gotten on the no elective deliveries before 39 weeks bandwagon. Yet this week a major hospital watchdog group, The Leapfrog Group, partnering with Childbirth Connection and the March of Dimes, released for the first time hospital rates of elective deliveries before 39 weeks and the results are all over the map (pun intended). Some hospitals are in the low single digits, rates we know are possible when quality improvement efforts are taken seriously, while others report up to half or more of all births between 37 and 39 weeks are electively delivered.

Women need individualized, evidence-based information about the likely benefits and harms when considering induction of labor in the face of complications or significant risk factors. Childbirth Connection has launched a new web resource dedicated to Induction of Labor to help fill this need. But evidence is just one piece of the puzzle. Women also need information about maternity care practice patterns in their communities, since this factor seems to affect their likelihood of induction more than any other. Leapfrog’s voluntary database of elective early delivery rates stands to drive significant quality improvement. Let’s hope it’s just the first step toward full transparency of maternity care quality.

Rigging the Election: When it comes to elective induction, are women asking for it?

by Amy Romano, CNM

This post was originally published on Science and Sensibility for Lamaze International.

There is a growing movement, backed up by evidence, practice guidelines, and efforts by agencies including the March of Dimes, the Institute for Healthcare Improvement and the Joint Commission, to reduce elective inductions, especially those occurring before 39 completed weeks of gestation.

Media coverage of these efforts tends to frame the problem as too many women asking for early delivery with no medical reason and the solution as hospitals “saying no” to these women. But this woman-blaming paradigm is simplistic and flawed. New research shows that, not only have maternity care providers failed to convey the risks of early delivery to women, they may be offering or recommending elective deliveries despite the risks, and telling women they have a medical reason for induction but documenting the inductions as “elective”.

First, the evidence that educating women does help.

As reported in the July/August issue of the American Journal of Maternal/Child Nursing, researchers at St. John’s Mercy Medical Center in St. Louis, MO, studied the effect of a 40-minute educational intervention given in the context of hospital-based Lamaze classes. The intervention was an educational module about elective induction incorporating evidence and professional practice guidelines, taught along with the otherwise-unchanged Lamaze class curriculum. Researchers compared the elective induction rates between attendees and nonattendees in the 7-month period following the introduction of the new module. The content of the educational model was straightforward:

Specific risks of elective induction presented during the class included cesarean birth with longer postpartum recovery, pain, and potential complications as well as other associated risks such as longer labor, use of pharmacologic agents and their effects on the mother and fetus, and neonatal morbidity. Benefits included advance planning and timing with personal schedules. (p. 190)

Women were also given “talking points” to discuss with their provider if induction was recommended.

The intervention appeared to be very effective. The elective induction rate was about 37% in both attendees and nonattendees before the intervention and in nonattendees after the intervention. But 28% of women who attended the classes that included the educational content had elective inductions, a significant reduction indicating that the hospital would only need to educate about 11 first-time mothers to prevent one elective induction.

But, you might say, that still leaves more than 1 in 4 first-time mothers having elective inductions. What else might be driving this besides lack of education? Well, it might be this: the researchers also discovered that nearly 70% of women were offered elective induction by their doctors. And, not surprisingly, women whose doctors offered them elective induction were far more likely to choose elective induction, whether or not they were exposed to the educational intervention. In fact, the magnitude of the difference was much greater than with educational content. Roughly speaking, doctors would have to refrain from offering elective induction to just three first-time mothers to prevent one elective induction.

Prior to the educational intervention, when the hospital leadership were considering how to decrease the use of elective induction, most doctors believed that the problem was that uninformed women were asking for it, an assumption turned on its head by the research findings. In postpartum surveys, three-quarters of women who had “elective” inductions indicated that the physician suggested the option compared with only 25% of women who indicated that they initiated the request themselves. Class attendance had an influence on whether women chose to act on the option of elective induction, but the difference wasn’t huge. About 38% of women who attended the class and whose doctors offered elective induction chose the option, compared with 50% of those who were offered elective induction but didn’t attend the class.

The researchers conclude:

Although education provided in prepared childbirth classes can be helpful for women in making the choice of whether or not to have their labor electively induced, the physician is a powerful influence…It is possible that patients perceive the offer of the option for elective induction as a recommendation that they actually have the procedure, particularly if they are told they are due now, overdue, or their baby is getting too big. (p. 193)

And therein lies the problem: it turns out many women having “elective” inductions think they’re having medically indicated inductions. In a follow-up study by the same research team, published in the current issue of the Journal of Perinatal Education (full-text available to Lamaze members), the researchers report more of their findings from postpartum surveys as well as data gleaned from reviewing the medical records of each woman after delivery. They write:

The most significant discrepancy between the medical record and patient perception was related to macrosomia as an indication. For example, based on the medical record, macrosomia was the indication for 26.7% of inductions; however, 39.9 of patients noted that their physician told them they needed to be induced because “my baby was too big.” The next most common reason women believed they had an induction was that they were “due now or overdue” (20.3%), yet only 35 women (6.4%) who had an elective induction were 41 completed weeks of gestation and none were more than 41 3/7 weeks. The majority of women who indicated they were induced for being “overdue” were only 1 to 4 days past their estimated due date. (p. 28)

So what’s the take-home of all of this? How do we rein in the overuse of elective induction? Clearly, childbirth education that specifically addresses the risks, benefits, and evidence-based indications for induction helps. As we have seen, fewer women exposed to this educational content will choose induction. Researchers also found that women who had inductions were more likely to have reported feeling prepared and having the reality match up with their expectations if they had taken the classes. They were also less likely to report not knowing why they were induced compared with women who were induced but didn’t take the class. In other words, the class helped women have more fruitful conversations with their care providers.

But it is clear from this research – the first to explore these issues in depth with a combination of qualitative and quantitative approaches – that we have to change provider beliefs and practices to have a meaningful impact on induction rates. It’s time for more research on what happens behind the closed doors of prenatal visits, and for clear standards that tell doctors it is not okay to offer a major medical (often turned surgical) procedure to women as if it was benign or beneficial.

The “Patient Push” for Early Birth: A Dangerous Concept or Valid Point?

by Melissa Garvey, ACNM Writer and Editor

Last summer, ACOG officially revised its recommendations on elective labor induction, raising the “safe” gestational age to induce from 37 to 39 weeks. Now a study in the December 2009 issue of Obstetrics & Gynecology examines women’s perceptions of the definition of full term and the safety of birth at various gestational ages. Long study short, nearly half of the 650 women surveyed believe it is safe to give birth at 37 weeks, and almost all believe it is safe to give birth before 39 weeks. (Note: All women were insured and had recently given birth.)

While there are numerous discussion-worthy topics nestled in the article, one in particular piques my interest as an informed consumer. Remember ACNM President Melissa Avery’s post about the startling rise in rates of preterm birth in the US? The number-one reason is labor induction. With that in mind, check out this statement from the Discussion section of the article:

Misinformation about the safety of early deliveries, especially those that are perceived to be “only a little early,” combined with the desire for the pregnancy to be over, likely contributes to a patient “push” for early delivery.

The authors say that recent educational efforts aimed toward providers have been promising in reducing the rate of elective preterm or early term birth, but the role of the patient has not yet been studied. So, my question is should we start looking at women’s role in elective induction or does this sound eerily similar to blaming women for the rise in cesarean section rates?

Bonus Discussion
To fully appreciate the survey results, it’s worth looking at the actual questions that researchers asked women:

1. “At what gestational age do you believe the baby is considered full term?” (Possible responses ranged from 34 to 40 weeks.)
2. “What is the earliest point in the pregnancy that it is safe to deliver the baby, should there be no other medical complications requiring early delivery?” (Again, possible responses ranged from 34 to 40 weeks.)
   

These questions measure the women’s knowledge base, but not where they’re getting that knowledge. Perhaps they’re getting it from the media, the Internet, or their care provider? It’s also worth noting, as the authors point out, these questions do not control for women’s varying interpretations of “full term” and “safe,” nor do they distinguish between spontaneous preterm labor and elective labor induction.

The Real Risk of Late Prematurity

A study in the August 2009 issue of Obstetrics and Gynecology shows that late prematurity is an independent risk factor for neonatal morbidity. For those of us who aren’t women’s health experts, that means babies born between 34 and 37 weeks of pregnancy are at greater risk for health problems than babies born on or after week 37.

Midwives already know that late prematurity puts babies at risk for complications, but this retrospective study involving nearly 10,000 low-risk pregnancies singles out late prematurity as an independent risk factor. After adjusting for potential confounders, including maternal age, birth weight, and mode of delivery, researchers found a 30-fold increase in complications like respiratory problems, hypoglycemia, and hypothermia in babies who were born at 34 weeks. Researchers also observed a “gradual and consistent decrease” in risk of neonatal morbidity as gestational age increased with risks leveling off at about 39 weeks.

Study authors note that late prematurity has increased dramatically over the past two decades to about 8% of all deliveries and 75% of preterm deliveries. Interestingly, ACOG recently revised their labor induction guidelines, encouraging avoidance of induction before 39 weeks of pregnancy (the previous recommendation was 37 weeks). Do you think this study had anything to do with this?

ACOG Revises Labor Induction Guidelines

Midwives are applauding the American College of Obstetricians and Gynecologists (ACOG) latest revision to their labor induction guidelines. The new ACOG practice bulletin recommends avoiding labor induction before week 39 of pregnancy—an improvement over the previous 37-week recommendation.

This comes on the heels of more good news: a recent study at Brigham and Women’s Hospital in Boston found that 10-year episiotomy rates have steeply declined, thanks to peer pressure to stop performing the procedure as well as significant research on the topic. A Medscape article also says that researchers acknowledge "several other contributing factors, including long-standing CNM service in hospital-based practice, and the addition of CNMs to Harvard Vanguard Medical Associates in 1990."

Midwives may be blue in the face from their decades of trumpeting the need for judicious use of interventions, but it looks like their music has not fallen on deaf ears.