Journal of Midwifery & Women’s Health
www.jmwh.org
Commentary
Midwives and Nonmedically Indicated Induction of Labor Catherine Ruhl, CNM, MS, Debra Bingham, DrPH, RN
INTRODUCTION
Midwives, leaders among maternal health professionals in promoting physiologic labor and birth and the appropriate use of interventions, have a significant role to play in addressing one of the most pressing maternal health problems of our time: the rise in nonmedically indicated inductions of labor and the decrease in the number of women experiencing spontaneous labor. Midwives, working in many roles and settings, can champion the elimination of all nonmedically indicated inductions through empowering women to make informed decisions and facilitating conversations about change among women, physicians, nurses, hospital administrators, public health officials, insurers, and other maternity care stakeholders. NATIONAL STATISTICS ON INDUCTION
Nonmedically indicated induction is widespread. The National Center for Health Statistics1 reported that in 2010 the rate of labor induction was 23.4% of all US births, and this rate would be higher if only the total number of women who could have had inductions (ie, excluding women having planned cesareans) was used as the denominator in calculating this percentage. A significant number of inductions seem to be scheduled without medical indications because the rate of induction is rising faster than the rate of pregnancy complications that would result in a medically indicated induction.2 The induction rate of 23.4% in 2010 has more than doubled in 20 years,1,3 and the rate of cesarean birth has increased by 50%.1 In 2000, the largest proportion of births occurred at 40 to 41 weeks’ gestation, but by 2009 the largest proportion occurred at 39 weeks’ gestation.4 The contribution of nonmedically indicated inductions to the primary cesarean rate is a matter of increasing concern because cesarean is associated with an increased risk for severe maternal morbidity and mortality compared to vaginal birth.5 Nulliparous women who have their labors induced also have been shown to have higher rates of cesarean compared to women who have spontaneous onset of labor.6–8 Clark et al reviewed 6562 births resulting from induction of labor, 71% of which were nonmedically indicated, and found that the cesarean rate was 50% for nulliparous women who began induction with a closed cervix.6 The Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal Fetal Medicine (SMFM), and the American College of Obstetricians and Gynecologists (ACOG) convened a workshop in
2012 to discuss how to prevent the first cesarean birth. One of the group’s consensus “Key Points” is that “Labor induction should be performed only for medical indication; if done for nonmedical indications, the gestational age should be 39 weeks or more, and the cervix should be favorable (Bishop score more than 8), especially in the nulliparous patient.”9 ACOG and SMFM published a joint statement on safe prevention of primary cesareans in 2014 that made a number of recommendations, including allowing more time for first- and second-stage labor than conventional obstetric practice has previously dictated and not inducing before 41 0/7 weeks’ gestation unless there are maternal or fetal indications.5 Spong et al identify failed induction of labor as one of the main contributors to the United States’ recent increase in cesarean births.10 The most recently reported cesarean rate, which was in 2011, was 32.8%. Long-term health consequences of cesarean birth include repeated cesareans for future births, either by choice or due to lack of availability of trial of labor after cesarean in some regions, with associated increases in placental complications and neonatal morbidity. Other adverse effects that affect long-term health include adhesions, surgical complications, and hysterectomy.11 Cesarean is not the only outcome of concern when considering risks of induction. Induction with oxytocin has been shown to increase the risk for severe postpartum hemorrhage (PPH) due to uterine atony, which is a dose-related association.12 Bateman et al found that uterine atony is the cause of 79% of cases of PPH and that the 27.5% increase in the rates of PPH from 1995 to 2004 was primarily due to increased rates of uterine atony.13 Furthermore, PPH is a leading cause of rising rates of severe maternal morbidity and mortality in the United States.14,15 Callaghan et al found a 183% increase in blood transfusions and a 100% increase in shock during childbirth hospitalizations that occurred in 2008 to 2009 compared to those that occurred in 1998 to 1999.14 THE ECONOMIC PERSPECTIVE
Address correspondence to Catherine Ruhl, CNM, MS, Association of Women’s Health, Obstetric and Neonatal Nurses, 2000 L St, NW, Suite 740, Washington, DC 20036. Email: [email protected].
The result of using financial and human resources for nonmedically indicated inductions can result in the availability of fewer resources, especially nursing resources, to put toward the other needs of laboring women. With rising maternity care costs and predicted shortages of obstetricians, midwives, and nurses in coming years, the wise use of resources is critical. The recommended nurse-to-patient ratio for use of oxytocin (Pitocin), designated a high-alert medication by the Institute for Safe Medication Practices, is a ratio of 1:1.16 This is necessary to provide the necessary surveillance of the woman and fetus, which includes assessments every 15 minutes—as recommended in the Guidelines for Perinatal Care 17 —as well as comfort measures and education for the woman and her family. When more women have oxytocin for induction or
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augmentation during labor, more nurses are needed to provide quality care and promote maternal and fetal safety. Therefore, the cost of adequate nursing staff must be factored into the significant costs of nonmedically indicated inductions. In 2001, when an integrated health system in Utah, Intermountain Health Care, implemented a multi year quality improvement initiative aimed at improving processes and managing variation in clinician practices, one of their first focus areas was to standardize their criteria for medical indications for the induction of labor. In 2011, the leaders of this initiative reported that they reduced all elective inductions, defined as those that did not have “strong indications for clinical appropriateness,” regardless of gestational age, from 28% to 2% and estimated that this saved the state of Utah about $50 million per year.18 The annual cost savings was attributed to fewer neonatal intensive care unit (NICU) admissions, less nursing time needed because women spent fewer days in labor, and fewer unplanned cesareans. Intermountain Health’s overall cesarean rate at this time was 21% versus 32.8% nationally; the US Intermountain Health’s quality experts projected that there would be a cost savings of $3.5 billion annually if their initiative was applied nationally.18 Perinatal quality collaboratives in Ohio and North Carolina have also been successful in reducing early elective births occurring from elective inductions or planned cesareans before 39 weeks’ gestation. Annual cost savings, related to fewer cesareans and NICU admissions, are estimated at $10 million for Ohio and $2.4 million for North Carolina. Medicaid finances about 45% of all births in the United States; thus, if similar efforts to reduce nonmedically indicated births at all gestational ages, not just before 39 weeks’ gestation were applied in all states, the savings for Medicaid would be expected to be substantial.19
INDUCTION OF LABOR: AMERICAN COLLEGE OF NURSE-MIDWIVES AND AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS STATEMENTS
Avoiding cesarean and other complications is one aspect of the discussion about induction of labor for women and their providers to consider. The other aspect to consider is what is at stake if a woman misses out on spontaneous labor. The American College of Nurse-Midwives (ACNM) position statement on induction of labor begins with: “Spontaneous labor offers substantial benefit to the mother and her newborn. Disruption of this process without an evidence-based medical indication represents a risk for potential harm.”20 Both the ACNM and ACOG official statements on induction of labor describe the induction decision as one based on weighing the benefits and risks to a woman and her fetus of continuing a pregnancy versus ending it through induction.20,21 But they differ in important ways. ACOG states that there may be psychosocial reasons for an induction. ACOG’s recommendations do not include explaining the benefits of spontaneous labor to women who choose, or agree to, nonmedically indicated inductions. ACNM’s statement cites the importance of education about normal labor, as well as the benefits and risks of induction. 234
INDUCTION OF LABOR: WOMEN’S PERCEPTIONS
The reasons why women choose nonmedically indicated induction, as well as the extent to which women feel that they are making informed decisions about induction, has not been extensively studied, nor has women’s perceptions of the experience and its outcomes been explored. The Listening to Mothers III survey found that 15% of women reported feeling pressured to have an induction of labor, and close to twothirds were unaware or unclear about how induction might influence their chance of having a cesarean, or about cesarean complications such as newborn respiratory problems or placental problems in future pregnancies.22 The qualitative research of Moore et al. examined women’s decisions, perceptions, and experiences with the induction of labor process.23 A key finding was that women reported agreeing with their provider’s recommendation to induce labor, but they did not feel that agreeing to have an induction was the same as deciding to be induced; women said that they had insufficient information to make an informed decision. There is also a dearth of studies assessing whether education about elective induction will impact women’s choices. Simpson et al tested the effect of a standardized childbirth education curriculum about risks and benefits of elective induction of labor on women’s decisions to have elective induction. Data were obtained via surveying the women and medical record review. Before the education was added, there were no significant differences in the rates of elective induction between childbirth class attendees (35.2%) and nonattendees (37.2%). After the education was added, the attendees had a 27.9% rate of elective induction, and the nonattendees had a 37% rate.24 Women who received the education were less likely to chose elective induction. The limited research thus far performed indicates that maternity care is an area in need of effective decision aids for professionals and women to promote shared decision making; such aids are currently in development.25 Effective decision making has promising potential to improve women’s knowledge of choices, expectations, and satisfaction with care.26 INSPIRING CHANGE THROUGH QUALITY INITIATIVES
The local and national efforts to end nonmedically indicated inductions prior to 39 weeks’ gestation, which have met with success in many regions of the United States, are laudable but do not go far enough. Improving neonatal outcomes was the main motivation for these initiatives because it was recognized that those neonates who were born after nonmedically indicated inductions and planned cesareans that occurred before 39 0/7 weeks’ gestation suffered higher rates of morbidity than did those born after 39 0/7 weeks’ gestation. The collaboration in the past decade of maternity care stakeholders to decrease nonmedically indicated inductions before 39 weeks’ gestation serves as an example of how clinical practices that have become widespread but lack evidence of benefit can be changed. These stakeholders, including the Joint Commission, the Centers for Medicaid and Medicare Services, the March of Dimes, and state-based collaboratives, have led successful nation wide, state wide, or systems-wide quality improvement initiatives.27 Volume 59, No. 3, May/June 2014
Since January 2014, all hospitals with 1100 or more births annually are required by the Joint Commission to report data on 5 perinatal care core measures.28 The Joint Commission, a not-for-profit organization accrediting more than 17,000 US health care organizations, develops performance measure sets that identify target areas for performance improvement. The core measures do not have specific goals to achieve; rather, they allow the Joint Commission to measure hospital improvement over time and compare performance to similar institutions.29 The perinatal core measure set includes 5 measures: 1) elective birth before 39 weeks’ gestation; 2) administration of antenatal steroids to women at risk of preterm birth between 24 and 34 weeks’ gestation; 3) health care associated bloodstream infections in newborns; 4) exclusive breast milk feeding; and 5) the nulliparous, term, singleton, vertex (NTSV) cesarean rate. The selection of these measures emphasizes their importance as indicators of high quality care and high priority areas for change, if we are to make progress toward meeting national health goals. The perinatal core measures on elective induction and cesareans have the potential to increase the number of women who experience spontaneous labor and decrease the NTSV cesarean rates. Both of these measures can be used to push for the increased scrutiny of routine intrapartum care practices that are used without the careful examination of medical need and to inspire institutional policies that promote physiologic labor and birth. CALL TO ACTION: WHAT CAN MIDWIVES DO?
As experts on normal labor and birth, midwives must more effectively promote the benefits of spontaneous labor through formal and informal education of other health professionals, health care executives, risk management and quality improvement professionals, public health leaders, health insurers and purchasers, and community organizations. This education should include the contribution of the overuse of interventions in labor and birth to cascading obstetric costs and the lack of evidence for certain common obstetric interventions such as nonmedically indicated induction of labor. Midwives’ influence as mentors to nurses, physicians, residents, and medical students in labor and birth settings cannot be underestimated. Modeling care that promotes and supports physiologic labor and birth, individualized to a woman’s needs and desires, can be an insightful learning experience for colleagues and a powerful influence on the birth environment. Midwives have the obligation to clearly explain the benefits of spontaneous labor to women—not just the risks of induction. This will help them understand and value the profound physiologic changes leading up to spontaneous labor, during spontaneous labor, and immediately after birth.30 This powerful hormonal cascade results in the woman and her fetus being physically and psychologically ready for labor, birth, and maternal–infant attachment in ways that go far beyond a ripe cervix or the presence of biochemical indicators of fetal lung maturity. Spontaneous labor at term, the initiation of which has yet to be entirely explicated, is the signal of maternal and fetal readiness. We do women a disservice if they do not hear about the beneficial effects of the endogenous hormones of spontaneous labor that may be overridden or Journal of Midwifery & Women’s Health r www.jmwh.org
adversely affected by the exogenous hormones used for induction. These hormones include endorphins to relieve labor pain; catecholamines to inspire final pushing efforts and euphoria at birth; prolactin to promote uterine involution, infant attachment, and the initiation of successful lactation; and of course oxytocin, which produces efficient contractions without undue fetal stress and also has multiple roles in supporting the maternal–infant relationship.31,32 A recent public education campaign about the benefits of spontaneous labor and the harms of nonmedically indicated induction is the Association of Women’s Health, Obstetric and Neonatal Nurses’ Don’t Rush Me . . . Go the Full 40 campaign.33 The campaign gives women 40 serious and lighthearted reasons to wait for labor to start on its own when all is well and provides tools for maternity care professionals to use to inspire productive dialogues about benefits and harms of spontaneous and induced labor. ACNM’s Our Moment of Truth campaign has addressed the discrepancies in the information that women want from their providers and what they are receiving related to contraception and reproductive health care.34 The campaign will examine spontaneous labor and birth in the future to add to our knowledge of women’s experiences with nonmedically indicated inductions. ACNM’s physiologic birth initiative for clinicians provides midwives and other maternity care professionals with practical resources for promoting informed decision making and implementing care practices that promote and sustain spontaneous labor and birth.35 Midwives using these resources can collaborate with their maternity care colleagues and the women who they serve to revise or create institutional policies and protocols about induction, informed consent, and practices that promote spontaneous labor. They can partner with their colleagues to establish what will be the acceptable maternal and fetal indications for the induction of labor in their settings. Midwives can lead efforts to examine reasons for all nonmedically indicated inductions in peer review and monitor the performance of their setting on the Joint Commission’s perinatal core measures. Midwives can collaborate with other champions of spontaneous labor and birth in their communities and pregnancy and birth care settings to ensure that all women have a full range of options for achieving healthy and satisfying labor and birth outcomes. Those committed to promoting and protecting physiologic labor and birth should take every opportunity to ensure that women and all maternity care stakeholders understand the benefits of waiting for spontaneous labor. All women with healthy pregnancies should have the option, and full support and access, to wait for their bodies and their babies to be optimally ready for labor and birth. AUTHORS
Catherine Ruhl, MS, CNM, is Director of Women’s Health Programs at the Association of Women’s Health, Obstetric and Neonatal Nurses and a staff nurse-midwife at Providence Hospital in Washington, DC. Debra Bingham, DrPH, RN, is Vice President for Research, Education and Publications at the Association of Women’s Health, Obstetric and Neonatal Nurses in Washington, DC. 235
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. REFERENCES 1.Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final data for 2010. Natl Vital Stat Rep. 2012; 61(1). http://www.cdc.gov/nchs/ Accessed September 28, data/nvsr/nvsr61/nvsr61 01.pdf. 2013. 2.Caughey AB, Sundaram V, Kaimal AJ, et al. Maternal and neonatal outcomes of elective induction of labor. Evid Rep Technol Assess (Full Rep). 2009;(176):1-257. 3.Zhang J, Yancey MK, Henderson CE. U.S. national trends in labor induction, 1989-1998. J Reprod Med. 2002; 47(2):120-124. 4.Martin J.A., Hamilton, B.E., Ventura, S.J. et al. Births: Final data for 2009. Natl Vital Stat Rep. 2011; 60(1). http://www.cdc.gov/nchs/ data/nvsr/nvsr60/nvsr60 01.pdf. Accessed September 28, 2013. 5.American College of Obstetricians and Gynecologists (the College) and the Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, GRouseuise DJ. Safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014 123(3):693-711. http://www. acog.org/Resources And Publications/Obstetric Care Consensus Series/Safe Prevention of the Primary Cesarean Delivery Accessed February 20, 2014. 6.Clark SL, Miller DD, Belfort MA, Dildy GA, Frye DK, Meyers JA. Neonatal and maternal outcomes associated with elective term delivery. Am J Obstet Gynecol. 2009;200(2):156.e1-4. 7.Coonrod DV1, Drachman D, Hobson P, Manriquez M. Nulliparous term singleton vertex cesarean delivery rates: institutional and individual level predictors. Am J Obstet Gynecol. 2008;198(6): 694. 8.Ehrenthal DB, Jiang X, Strobino DM. Labor induction and the risk of a cesarean delivery among nulliparous women at term. Obstet Gynecol. 2010 116(1):35-42. 9.Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: Summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol. 2012;120(5):1181-1193. 10.Hamilton BE. Births: Preliminary data for 2011. Natl Vital Stat Rep. 2012; 61(5). http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61 05. pdf. Accessed September 28, 2013. 11.Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: A systematic review. Am J Obstet Gynecol 2011; 205:262.e1-e8. 12.Belghiti J, Kayem G, Dupont C, Rudigoz RC, Bouvier-Colle MH, Deneux-Tharaux C. Oxytocin during labour and risk of severe postpartum haemorrhage: A population-based, cohort-nested case-control study. BMJ Open. 2011;1(2):e000514. 13.Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg. 2010;110(5):1368-1373. 14.Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012;120(5):1029-1036. 15.Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancyrelated mortality in the United States, 1998 to 2005. Obstet Gynecol. 2010;116(6):1302-1309. 16.Association of Women’s Health, Obstetric and Neonatal Nurses. Guidelines for Professional Registered Nurse Staffing for Perinatal Units. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses; 2010. 17.American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 7th
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edition. Elk Grove Village, IL: American Academy of Pediatrics; 2012. 18.James, BC, Savitz, LA. How Intermountain trimmed health care costs through robust quality improvement efforts. Health Aff. 2011; 30(6):1185-1191. 19.Centers for Medicare and Medicaid Services, Reducing early elective deliveries in Medicaid and CHIP. Last modified November 2012. http://www.medicaid.gov/Medicaid-CHIP-ProgramInformation/By-Topics/Quality-of-Care/Downloads/EED-Brief.pdf Accessed February 17, 2014. 20.American College of Nurse-Midwives. Induction of Labor. Silver Spring, MD: American College of Nurse-Midwives; 2010. 21.American College of Obstetricians and Gynecologists. Induction of Labor, Practice Bulletin Number 107. Washington, DC: American College of Obstetricians and Gynecologists; 2009. 22.Childbirth Connection. Listening to mothers III: pregnancy and birth. 2013. http://transform.childbirthconnection.org/wp-content/ uploads/2013/06/LTM-III MajorSurveyFindings PregnancyAndBirth.pdf. Accessed September 28, 2013. 23.Moore, JE., Kane Low, L, Titler, MG, Dalton, VK, Sampselle, CM. Moving toward patient-centered care: Women’s decisions, perceptions, and experiences of the induction of labor process. Birth. 2014:41(4): in press. 24.Simpson KR, Newman G, Chirino OR. Patient education to reduce elective inductions. MCN Am J Matern Child Nurs.2010;35(4):188194. 25.Romano, A. The First National Maternity Care Shared Decision Making Initiative. 2013. http://informedmedicaldecisions.org/wpcontent/uploads/2012/05/First Natl Maternity SDM.pdf. Accessed February 17, 2014. 26.Dugas M, Shorten A, Dub´e E, Wassef M, Bujold E, Chaillet N. Decision aid tools to support women’s decision making in pregnancy and birth: A systematic review and meta-analysis. Soc Sci Med. 2012;74(2012):1968-1978. 27.Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, Kowalewski L. Elimination of non-medically indicated (elective) deliveries before 39 weeks gestational age. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #08–85012 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; March of Dimes; 2010. 28.The Joint Commission. Clarification: 2014 perinatal core measure reporting requirements for hospitals. 2013. http://www. jointcommission.org/issues/article.aspx?Article=%2FNm2cIJcBIUvzQTGxhp3pW2kJ7ntpLWaW1Dimh7G9l4%3D. Accessed September 28, 2013. 29.The Joint Commission. The Joint Commission FAQ page. http:// www.jointcommission.org/about/jointcommissionfaqs.aspx. Accessed February 14, 2014. 30.Romano AM, Lothian JA. Promoting, protecting and supporting normal birth: A look at the evidence. J Obstet Gynecol Neonatal Nurs. 2008; 37(1):94-104; quiz 104-105. 31.Lothian, JA. Saying “no” to induction. J Perinat Educ. 2006; 15(2): 43-45. 32.American College of Nurse-Midwives, Midwives Alliance of North America and the National Association of Certified Professional Midwives. Supporting Healthy and Normal Physiologic Childbirth: A Consensus Statement. Silver Spring, MD: American College of NurseMidwives; 2012. 33.Association of Women’s Health, Obstetric and Neonatal Nurses’ Health4mom. Don’t rush me...go the full 40. www.gothefull40.com. Accessed September 28, 2013. 34.American College of Nurse-Midwives. Our moment of truth. http://ourmomentoftruth.midwife.org/. Accessed February 17, 2014. 35.American College of Nurse-Midwives. Physiological birth initiative. http://www.midwife.org/Physiologic-Birth-Initiative. Accessed February 17, 2014.
Volume 59, No. 3, May/June 2014
www.jmwh.org
Commentary
Midwives and Nonmedically Indicated Induction of Labor Catherine Ruhl, CNM, MS, Debra Bingham, DrPH, RN
INTRODUCTION
Midwives, leaders among maternal health professionals in promoting physiologic labor and birth and the appropriate use of interventions, have a significant role to play in addressing one of the most pressing maternal health problems of our time: the rise in nonmedically indicated inductions of labor and the decrease in the number of women experiencing spontaneous labor. Midwives, working in many roles and settings, can champion the elimination of all nonmedically indicated inductions through empowering women to make informed decisions and facilitating conversations about change among women, physicians, nurses, hospital administrators, public health officials, insurers, and other maternity care stakeholders. NATIONAL STATISTICS ON INDUCTION
Nonmedically indicated induction is widespread. The National Center for Health Statistics1 reported that in 2010 the rate of labor induction was 23.4% of all US births, and this rate would be higher if only the total number of women who could have had inductions (ie, excluding women having planned cesareans) was used as the denominator in calculating this percentage. A significant number of inductions seem to be scheduled without medical indications because the rate of induction is rising faster than the rate of pregnancy complications that would result in a medically indicated induction.2 The induction rate of 23.4% in 2010 has more than doubled in 20 years,1,3 and the rate of cesarean birth has increased by 50%.1 In 2000, the largest proportion of births occurred at 40 to 41 weeks’ gestation, but by 2009 the largest proportion occurred at 39 weeks’ gestation.4 The contribution of nonmedically indicated inductions to the primary cesarean rate is a matter of increasing concern because cesarean is associated with an increased risk for severe maternal morbidity and mortality compared to vaginal birth.5 Nulliparous women who have their labors induced also have been shown to have higher rates of cesarean compared to women who have spontaneous onset of labor.6–8 Clark et al reviewed 6562 births resulting from induction of labor, 71% of which were nonmedically indicated, and found that the cesarean rate was 50% for nulliparous women who began induction with a closed cervix.6 The Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal Fetal Medicine (SMFM), and the American College of Obstetricians and Gynecologists (ACOG) convened a workshop in
2012 to discuss how to prevent the first cesarean birth. One of the group’s consensus “Key Points” is that “Labor induction should be performed only for medical indication; if done for nonmedical indications, the gestational age should be 39 weeks or more, and the cervix should be favorable (Bishop score more than 8), especially in the nulliparous patient.”9 ACOG and SMFM published a joint statement on safe prevention of primary cesareans in 2014 that made a number of recommendations, including allowing more time for first- and second-stage labor than conventional obstetric practice has previously dictated and not inducing before 41 0/7 weeks’ gestation unless there are maternal or fetal indications.5 Spong et al identify failed induction of labor as one of the main contributors to the United States’ recent increase in cesarean births.10 The most recently reported cesarean rate, which was in 2011, was 32.8%. Long-term health consequences of cesarean birth include repeated cesareans for future births, either by choice or due to lack of availability of trial of labor after cesarean in some regions, with associated increases in placental complications and neonatal morbidity. Other adverse effects that affect long-term health include adhesions, surgical complications, and hysterectomy.11 Cesarean is not the only outcome of concern when considering risks of induction. Induction with oxytocin has been shown to increase the risk for severe postpartum hemorrhage (PPH) due to uterine atony, which is a dose-related association.12 Bateman et al found that uterine atony is the cause of 79% of cases of PPH and that the 27.5% increase in the rates of PPH from 1995 to 2004 was primarily due to increased rates of uterine atony.13 Furthermore, PPH is a leading cause of rising rates of severe maternal morbidity and mortality in the United States.14,15 Callaghan et al found a 183% increase in blood transfusions and a 100% increase in shock during childbirth hospitalizations that occurred in 2008 to 2009 compared to those that occurred in 1998 to 1999.14 THE ECONOMIC PERSPECTIVE
Address correspondence to Catherine Ruhl, CNM, MS, Association of Women’s Health, Obstetric and Neonatal Nurses, 2000 L St, NW, Suite 740, Washington, DC 20036. Email: [email protected].
The result of using financial and human resources for nonmedically indicated inductions can result in the availability of fewer resources, especially nursing resources, to put toward the other needs of laboring women. With rising maternity care costs and predicted shortages of obstetricians, midwives, and nurses in coming years, the wise use of resources is critical. The recommended nurse-to-patient ratio for use of oxytocin (Pitocin), designated a high-alert medication by the Institute for Safe Medication Practices, is a ratio of 1:1.16 This is necessary to provide the necessary surveillance of the woman and fetus, which includes assessments every 15 minutes—as recommended in the Guidelines for Perinatal Care 17 —as well as comfort measures and education for the woman and her family. When more women have oxytocin for induction or
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c 2014 by the American College of Nurse-Midwives
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augmentation during labor, more nurses are needed to provide quality care and promote maternal and fetal safety. Therefore, the cost of adequate nursing staff must be factored into the significant costs of nonmedically indicated inductions. In 2001, when an integrated health system in Utah, Intermountain Health Care, implemented a multi year quality improvement initiative aimed at improving processes and managing variation in clinician practices, one of their first focus areas was to standardize their criteria for medical indications for the induction of labor. In 2011, the leaders of this initiative reported that they reduced all elective inductions, defined as those that did not have “strong indications for clinical appropriateness,” regardless of gestational age, from 28% to 2% and estimated that this saved the state of Utah about $50 million per year.18 The annual cost savings was attributed to fewer neonatal intensive care unit (NICU) admissions, less nursing time needed because women spent fewer days in labor, and fewer unplanned cesareans. Intermountain Health’s overall cesarean rate at this time was 21% versus 32.8% nationally; the US Intermountain Health’s quality experts projected that there would be a cost savings of $3.5 billion annually if their initiative was applied nationally.18 Perinatal quality collaboratives in Ohio and North Carolina have also been successful in reducing early elective births occurring from elective inductions or planned cesareans before 39 weeks’ gestation. Annual cost savings, related to fewer cesareans and NICU admissions, are estimated at $10 million for Ohio and $2.4 million for North Carolina. Medicaid finances about 45% of all births in the United States; thus, if similar efforts to reduce nonmedically indicated births at all gestational ages, not just before 39 weeks’ gestation were applied in all states, the savings for Medicaid would be expected to be substantial.19
INDUCTION OF LABOR: AMERICAN COLLEGE OF NURSE-MIDWIVES AND AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS STATEMENTS
Avoiding cesarean and other complications is one aspect of the discussion about induction of labor for women and their providers to consider. The other aspect to consider is what is at stake if a woman misses out on spontaneous labor. The American College of Nurse-Midwives (ACNM) position statement on induction of labor begins with: “Spontaneous labor offers substantial benefit to the mother and her newborn. Disruption of this process without an evidence-based medical indication represents a risk for potential harm.”20 Both the ACNM and ACOG official statements on induction of labor describe the induction decision as one based on weighing the benefits and risks to a woman and her fetus of continuing a pregnancy versus ending it through induction.20,21 But they differ in important ways. ACOG states that there may be psychosocial reasons for an induction. ACOG’s recommendations do not include explaining the benefits of spontaneous labor to women who choose, or agree to, nonmedically indicated inductions. ACNM’s statement cites the importance of education about normal labor, as well as the benefits and risks of induction. 234
INDUCTION OF LABOR: WOMEN’S PERCEPTIONS
The reasons why women choose nonmedically indicated induction, as well as the extent to which women feel that they are making informed decisions about induction, has not been extensively studied, nor has women’s perceptions of the experience and its outcomes been explored. The Listening to Mothers III survey found that 15% of women reported feeling pressured to have an induction of labor, and close to twothirds were unaware or unclear about how induction might influence their chance of having a cesarean, or about cesarean complications such as newborn respiratory problems or placental problems in future pregnancies.22 The qualitative research of Moore et al. examined women’s decisions, perceptions, and experiences with the induction of labor process.23 A key finding was that women reported agreeing with their provider’s recommendation to induce labor, but they did not feel that agreeing to have an induction was the same as deciding to be induced; women said that they had insufficient information to make an informed decision. There is also a dearth of studies assessing whether education about elective induction will impact women’s choices. Simpson et al tested the effect of a standardized childbirth education curriculum about risks and benefits of elective induction of labor on women’s decisions to have elective induction. Data were obtained via surveying the women and medical record review. Before the education was added, there were no significant differences in the rates of elective induction between childbirth class attendees (35.2%) and nonattendees (37.2%). After the education was added, the attendees had a 27.9% rate of elective induction, and the nonattendees had a 37% rate.24 Women who received the education were less likely to chose elective induction. The limited research thus far performed indicates that maternity care is an area in need of effective decision aids for professionals and women to promote shared decision making; such aids are currently in development.25 Effective decision making has promising potential to improve women’s knowledge of choices, expectations, and satisfaction with care.26 INSPIRING CHANGE THROUGH QUALITY INITIATIVES
The local and national efforts to end nonmedically indicated inductions prior to 39 weeks’ gestation, which have met with success in many regions of the United States, are laudable but do not go far enough. Improving neonatal outcomes was the main motivation for these initiatives because it was recognized that those neonates who were born after nonmedically indicated inductions and planned cesareans that occurred before 39 0/7 weeks’ gestation suffered higher rates of morbidity than did those born after 39 0/7 weeks’ gestation. The collaboration in the past decade of maternity care stakeholders to decrease nonmedically indicated inductions before 39 weeks’ gestation serves as an example of how clinical practices that have become widespread but lack evidence of benefit can be changed. These stakeholders, including the Joint Commission, the Centers for Medicaid and Medicare Services, the March of Dimes, and state-based collaboratives, have led successful nation wide, state wide, or systems-wide quality improvement initiatives.27 Volume 59, No. 3, May/June 2014
Since January 2014, all hospitals with 1100 or more births annually are required by the Joint Commission to report data on 5 perinatal care core measures.28 The Joint Commission, a not-for-profit organization accrediting more than 17,000 US health care organizations, develops performance measure sets that identify target areas for performance improvement. The core measures do not have specific goals to achieve; rather, they allow the Joint Commission to measure hospital improvement over time and compare performance to similar institutions.29 The perinatal core measure set includes 5 measures: 1) elective birth before 39 weeks’ gestation; 2) administration of antenatal steroids to women at risk of preterm birth between 24 and 34 weeks’ gestation; 3) health care associated bloodstream infections in newborns; 4) exclusive breast milk feeding; and 5) the nulliparous, term, singleton, vertex (NTSV) cesarean rate. The selection of these measures emphasizes their importance as indicators of high quality care and high priority areas for change, if we are to make progress toward meeting national health goals. The perinatal core measures on elective induction and cesareans have the potential to increase the number of women who experience spontaneous labor and decrease the NTSV cesarean rates. Both of these measures can be used to push for the increased scrutiny of routine intrapartum care practices that are used without the careful examination of medical need and to inspire institutional policies that promote physiologic labor and birth. CALL TO ACTION: WHAT CAN MIDWIVES DO?
As experts on normal labor and birth, midwives must more effectively promote the benefits of spontaneous labor through formal and informal education of other health professionals, health care executives, risk management and quality improvement professionals, public health leaders, health insurers and purchasers, and community organizations. This education should include the contribution of the overuse of interventions in labor and birth to cascading obstetric costs and the lack of evidence for certain common obstetric interventions such as nonmedically indicated induction of labor. Midwives’ influence as mentors to nurses, physicians, residents, and medical students in labor and birth settings cannot be underestimated. Modeling care that promotes and supports physiologic labor and birth, individualized to a woman’s needs and desires, can be an insightful learning experience for colleagues and a powerful influence on the birth environment. Midwives have the obligation to clearly explain the benefits of spontaneous labor to women—not just the risks of induction. This will help them understand and value the profound physiologic changes leading up to spontaneous labor, during spontaneous labor, and immediately after birth.30 This powerful hormonal cascade results in the woman and her fetus being physically and psychologically ready for labor, birth, and maternal–infant attachment in ways that go far beyond a ripe cervix or the presence of biochemical indicators of fetal lung maturity. Spontaneous labor at term, the initiation of which has yet to be entirely explicated, is the signal of maternal and fetal readiness. We do women a disservice if they do not hear about the beneficial effects of the endogenous hormones of spontaneous labor that may be overridden or Journal of Midwifery & Women’s Health r www.jmwh.org
adversely affected by the exogenous hormones used for induction. These hormones include endorphins to relieve labor pain; catecholamines to inspire final pushing efforts and euphoria at birth; prolactin to promote uterine involution, infant attachment, and the initiation of successful lactation; and of course oxytocin, which produces efficient contractions without undue fetal stress and also has multiple roles in supporting the maternal–infant relationship.31,32 A recent public education campaign about the benefits of spontaneous labor and the harms of nonmedically indicated induction is the Association of Women’s Health, Obstetric and Neonatal Nurses’ Don’t Rush Me . . . Go the Full 40 campaign.33 The campaign gives women 40 serious and lighthearted reasons to wait for labor to start on its own when all is well and provides tools for maternity care professionals to use to inspire productive dialogues about benefits and harms of spontaneous and induced labor. ACNM’s Our Moment of Truth campaign has addressed the discrepancies in the information that women want from their providers and what they are receiving related to contraception and reproductive health care.34 The campaign will examine spontaneous labor and birth in the future to add to our knowledge of women’s experiences with nonmedically indicated inductions. ACNM’s physiologic birth initiative for clinicians provides midwives and other maternity care professionals with practical resources for promoting informed decision making and implementing care practices that promote and sustain spontaneous labor and birth.35 Midwives using these resources can collaborate with their maternity care colleagues and the women who they serve to revise or create institutional policies and protocols about induction, informed consent, and practices that promote spontaneous labor. They can partner with their colleagues to establish what will be the acceptable maternal and fetal indications for the induction of labor in their settings. Midwives can lead efforts to examine reasons for all nonmedically indicated inductions in peer review and monitor the performance of their setting on the Joint Commission’s perinatal core measures. Midwives can collaborate with other champions of spontaneous labor and birth in their communities and pregnancy and birth care settings to ensure that all women have a full range of options for achieving healthy and satisfying labor and birth outcomes. Those committed to promoting and protecting physiologic labor and birth should take every opportunity to ensure that women and all maternity care stakeholders understand the benefits of waiting for spontaneous labor. All women with healthy pregnancies should have the option, and full support and access, to wait for their bodies and their babies to be optimally ready for labor and birth. AUTHORS
Catherine Ruhl, MS, CNM, is Director of Women’s Health Programs at the Association of Women’s Health, Obstetric and Neonatal Nurses and a staff nurse-midwife at Providence Hospital in Washington, DC. Debra Bingham, DrPH, RN, is Vice President for Research, Education and Publications at the Association of Women’s Health, Obstetric and Neonatal Nurses in Washington, DC. 235
CONFLICT OF INTEREST
The authors have no conflicts of interest to disclose. REFERENCES 1.Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final data for 2010. Natl Vital Stat Rep. 2012; 61(1). http://www.cdc.gov/nchs/ Accessed September 28, data/nvsr/nvsr61/nvsr61 01.pdf. 2013. 2.Caughey AB, Sundaram V, Kaimal AJ, et al. Maternal and neonatal outcomes of elective induction of labor. Evid Rep Technol Assess (Full Rep). 2009;(176):1-257. 3.Zhang J, Yancey MK, Henderson CE. U.S. national trends in labor induction, 1989-1998. J Reprod Med. 2002; 47(2):120-124. 4.Martin J.A., Hamilton, B.E., Ventura, S.J. et al. Births: Final data for 2009. Natl Vital Stat Rep. 2011; 60(1). http://www.cdc.gov/nchs/ data/nvsr/nvsr60/nvsr60 01.pdf. Accessed September 28, 2013. 5.American College of Obstetricians and Gynecologists (the College) and the Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, GRouseuise DJ. Safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014 123(3):693-711. http://www. acog.org/Resources And Publications/Obstetric Care Consensus Series/Safe Prevention of the Primary Cesarean Delivery Accessed February 20, 2014. 6.Clark SL, Miller DD, Belfort MA, Dildy GA, Frye DK, Meyers JA. Neonatal and maternal outcomes associated with elective term delivery. Am J Obstet Gynecol. 2009;200(2):156.e1-4. 7.Coonrod DV1, Drachman D, Hobson P, Manriquez M. Nulliparous term singleton vertex cesarean delivery rates: institutional and individual level predictors. Am J Obstet Gynecol. 2008;198(6): 694. 8.Ehrenthal DB, Jiang X, Strobino DM. Labor induction and the risk of a cesarean delivery among nulliparous women at term. Obstet Gynecol. 2010 116(1):35-42. 9.Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR. Preventing the first cesarean delivery: Summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol. 2012;120(5):1181-1193. 10.Hamilton BE. Births: Preliminary data for 2011. Natl Vital Stat Rep. 2012; 61(5). http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61 05. pdf. Accessed September 28, 2013. 11.Marshall NE, Fu R, Guise JM. Impact of multiple cesarean deliveries on maternal morbidity: A systematic review. Am J Obstet Gynecol 2011; 205:262.e1-e8. 12.Belghiti J, Kayem G, Dupont C, Rudigoz RC, Bouvier-Colle MH, Deneux-Tharaux C. Oxytocin during labour and risk of severe postpartum haemorrhage: A population-based, cohort-nested case-control study. BMJ Open. 2011;1(2):e000514. 13.Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesth Analg. 2010;110(5):1368-1373. 14.Callaghan WM, Creanga AA, Kuklina EV. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States. Obstet Gynecol. 2012;120(5):1029-1036. 15.Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancyrelated mortality in the United States, 1998 to 2005. Obstet Gynecol. 2010;116(6):1302-1309. 16.Association of Women’s Health, Obstetric and Neonatal Nurses. Guidelines for Professional Registered Nurse Staffing for Perinatal Units. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses; 2010. 17.American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care, 7th
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