Elliott Main, MD California Maternal Quality Care Collaborative, Stanford University, California Pacific Medical Center, Department of Obstetrics and Gynecology, San Francisco, California

REFERENCES 1. Gilbody S, Sheldon Y, House A. Screening and case-finding instruments for depression: a meta-analysis. CMAJ 2008;178:997–1003. 2. Screening for depression during and after pregnancy. Committee Opinion No. 453. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010; 115:394–5. 3. Kiely M, El-Mohandes A, AlKhorazaly MN, Ganz MG. An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial. Obstet Gynecol 2010; 115:1302–9.

altered because, at term, cesarean delivery rates are lower at earlier gestational ages. The fourth concern is that population results may or may not apply to individual women. A given pregnant woman’s choice is not necessarily between elective induction and indefinite expectant management. She may decide to be monitored for a week and then electively induced when her cervix is favorable. Reporting risk of cesarean delivery by week in the expectant group would have been helpful so that pregnant women could make choices based on more than “all or none” options. I am concerned that Darney’s results are presented in a way that will give rise to complacency about the safety of elective labor induction. Financial Disclosure: The author did not report any potential conflicts of interest.

J. Christopher Glantz, MD, MPH University of Rochester School of Medicine, Rochester, New York

4. Main EK, Menard MK. Maternal mortality: time for national action. Obstet Gynecol 2013;122:735–6.

Elective Induction of Labor at Term Compared With Expectant Management: Maternal and Neonatal Outcomes To the Editor: I have several concerns about the study by Darney et al.1 First is that the results may be biased to favor labor induction because the elective induction group ends at 40 6/7 weeks but the expectant group extends through 42 weeks, when risk of cesarean delivery is higher. The authors correctly state that good evidence supports 41-week inductions (the current standard of care), implying that the expectant group may include substandard management. The second concern is that electively inducing labor at 37 and 38 weeks is not consistent with current standards of care, thus elective inductions during these weeks are inappropriate. The third concern is that no data are shown for the sensitivity analysis of starting the expectant group at the same gestational week as the induction group. A statement is made that including “same-week” spontaneous labors did not alter outcome, but this is directly opposite of findings in upstate New York.2 It seems implausible that outcomes were not

REFERENCES 1. Darney BG, Snowden JM, Cheng YW, Jacob L, Nicholson JM, Kaimal A, et al. Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes. Obstet Gynecol 2013;122:761–9. 2. Glantz JC. Term labor induction compared with expectant management. Obstet Gynecol 2010;115:70–6.

In Reply: We thank Dr. Glantz for his interest in our study1 and respond to the issues he raises hereafter. Methodologically, recall that elective induction of labor is restricted to a single week of gestation but expectant management includes all management in future weeks of gestation. The expectant management group in our hospital discharge delivery data represents actual obstetric practice at a population level; continuing pregnancy through 42 weeks (albeit rare) is part of the risk of expectant management, and this is why we include these women in our expectant management group. We do not recommend early term (37 and 38 weeks) elective induction and agree that elective delivery before 39 weeks is not currently consistent with the standard of care. However, when conducting research, one is obligated to examine practices that range

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broadly. Because we were able to identify elective inductions before 39 weeks, we included their analyses in the study. When we included spontaneous births that occurred in the same week as the elective inductions in the expectant management group, our results were shifted toward the null. For example, the odds ratios for cesarean delivery in the elective induction group at 39 weeks were 0.79 (confidence interval 0.71–0.88) for nulliparous women and 0.42 (confidence interval 0.35–0.51) among women with prior vaginal deliveries compared with expectant management. Finally, we agree with Dr. Glantz that estimates of average treatment effects may not always apply to individual patients. We agree that it would be helpful to understand more about the week-by-week risk of cesarean delivery among women who are expectantly managed. A protocol such as the one he describes would be great to study as part of a prospective randomized controlled trial.2 Financial Disclosure: The authors did not report any potential conflicts of interest.

Blair G. Darney, PHD, MPH Aaron B. Caughey, MD, PhD Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon

REFERENCES 1. Darney BG, Snowden JM, Cheng YW, Jacob L, Nicholson JM, Kaimal A, et al. Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes. Obstet Gynecol 2013;122:761–9. 2. Caughey AB. Perinatal outcomes related to induction of labor: a call for randomized trials. Am J Obstet Gynecol 2013; 209:168–9.

Contemporary Labor Patterns and Maternal Age To the Editor:

I read the article by Dr. Zaki et al1 with great interest, but I have a reservation about their methodology and conclusion. The authors conclude that the first stage of labor progressed more quickly with increasing age for nulliparous women up to age 40 years—a conclusion based on labor patterns in women

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Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes.

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