Induction Rates and Delivery Outcomes After a Policy Limiting Elective Inductions

Abstract

The purpose of this study was to assess induction rates, maternal, and neonatal outcomes following adoption of a policy prohibiting elective inductions at less than 39 weeks gestation and inductions between 39 and 41 weeks with an unfavorable cervix. A retrospective cohort study of all deliveries greater than or equal to 37 weeks gestation was conducted 1 year prior to through 1 year after implementation of the induction policy. Induction rates before and after the policy were calculated as the primary outcome while maternal and neonatal conditions were assessed as secondary outcomes. Elective inductions (p = 0.016), elective inductions less than 39 weeks gestation (p = 0.020), and elective inductions 39-40 weeks and 6 days gestation with an unfavorable cervix (p = 0.031) decreased significantly following adoption of the policy. Maternal and neonatal outcomes, including rates of cesarean deliveries, postpartum hemorrhage, chorioamnionitis, and neonatal intensive care unit admissions remained unchanged, though this study was not adequately powered to detect differences in these outcomes. An institutional induction policy was associated with a reduction in elective inductions prior to 39 weeks and up to 40 weeks and 6 days with an unfavorable cervix. These reductions were not accompanied by change in maternal or neonatal outcomes at our institution.

A Systematic Review on the Effectiveness of Implementation Strategies to Postpone Elective Caesarean Sections to ≥39+(0-6) Week of Gestation.

“…(39,44) Additionally we added descriptive information on the "rationale for implementation strategy" if available. We found two studies stated, that the publication of a guideline (42,43) was their rationale for the strategy and a systematic review and recommendations from the Registered Nurses' Association of Ontario Toolkit was the rationale of the strategy in another study. (38,47) No other study reported any rationale for their idea of the implementation strategy.…”

“…According to the intervention types listed above we found an audit and feedback in Nicoll et al (40), continuous quality improvement in Dunn et al (38) and a multifaceted intervention in Nicholl et al (41) Moreover the local/regional policies are quality improvement projects without feedback and continuous learning. (37,42,43,45) The 2 studies assessing the impact of the publication of a guideline cannot be allocated to any of these strategies as there is no information if for example staff obtained written information about the guidelines or anything else. (39,44) Additionally we added descriptive information on the "rationale for implementation strategy" if available.…”

“…Only four studies reported how they measured WG. (40,42,43,45) We did not identify any risk of bias for selection of participants or classi cation of intervention as all included clinics/all health stuff received the intervention and all studies classi ed the groups before and after intervention clearly. We assessed 2 studies with serious risk of bias, (38,39), 3 studies did not report on adhering to the intervention (40-42) and we rated the others with low or moderate risk of bias depending on the potential confounding through co-interventions.…”

“…We rated serious risk of bias due to missing data in one study. (44) One study was rated with moderate (43) and one with low (37) risk of bias due to missing data, all others were rated with no information. We rated Snowden et al (37) with serious risk of bias in measurements of outcomes as the authors stated they assumed systematic errors in documentation due to the national attention through the implemented hard-stop policy.…”

Maternal Perceptions of the Experience of Attempted Labor Induction and Medically Elective Inductions: Analysis of Survey Results from Listening to Mothers in California

“…2 Recently published research 3,4 examining elective induction at 39 weeks has suggested multiple benefits of the intervention, including lower rates of hypertensive disorders and fewer cesareans. This research, in addition to other studies which focused on the relationship between induction and cesarean section, [5][6][7][8][9] has led to considerations of the possible wider use of elective induction to improve outcomes. 10 The multiple studies that have examined inductions in recent years have relied primarily on medical records or administrative data.…”