The Agency for Healthcare Research and Quality (AHRQ) has published a new consumer brochure on labor induction. Unfortunately, this brochure is poorly written and misleading. One would think from reading the brochure that elective induction is a completely innocuous procedure that is fine for any woman who is “uncomfortable” (their word!) towards the end of her pregnancy. Just recently the National Center for Health Statistics released released a report on the rise of late preterm births in the U.S. and placed part of the blame on obstetric interventions such as induction and scheduled cesarean surgery. When we all should be working together to reduce unnecessary inductions, I am shocked that AHRQ has published such a misleading brochure.

Here are my strong objections to this brochure:

1. Inside Front Cover: Fast Facts – The second fact, “A cesarean section (c-section) might be needed if there are problems with labor. This is true for labor that is induced and for labor that starts on its own” implies that there is no difference between risk of cesarean surgery for those who are induced and those who begin labor on its own. This is misleading.

2. Inside Front Cover: Fast Facts – The fourth fact, “The risk of C-section with elective induction depends on if you have ever had a baby before” is true. However, the more important fact for consumers is that the risk of C-section is doubled for first-time mothers if labor is induced. This fact is conveniently left out.

3. Page 2 – A consumer brochure published by a “scientific” agency of the government should include the fact that misoprostal (Cytotec) has not been approved by the FDA for use in labor and that, in fact, the FDA has issued a strong warning about its use in labor.

4. Page 3 – Under the reasons why someone might not want to induce labor, there should be more information about the risks of iatrogenic prematurity. This pamphlet is written at a low literacy level. Unfortunately, we know that women from lower socioeconomic groups are more likely to delay getting prenatal care. Without an early ultrasound to confirm the due date, there can easily be a 2 to 3 week error in calculating the due date.

There is also no mention of the possible benefits to the baby of allowing labor to begin on its own. Scientists at the University of Texas Southwestern Medical School believe that it is the baby who initiates labor once the lungs are fully mature. Neonatalogist Dr. Lucky Jain said at the NIH State-of-the-Science Conference: Cesarean Delivery on Maternal Request in March 2006 that:

“In summary, physiologic events in the last few days of pregnancy, coupled with the onset of spontaneous labor, play a critical role in fetal maturation and preparation of the fetus for neonatal transition.” (last paragraph on page 104 of the conference papers)

5. Page 5: Statement of bottom of page – “ Research can’t tell us if any one woman’s chance of having a C-section is different is she chooses to be induced rather than waiting labor to start on its own.” This statement infuriates me. Yes, it’s true (for any one woman), but it minimizes the increased risk of cesarean with an induced labor. Why include this statement unless the intent is to downplay the risks of induction?

6. Page 6 – The statement, “Research shows that inducing labor does not mean that babies have a higher chance for a newborn breathing problem…” is also misleading. According to Dr. Lucky Jain (see #4 above) there are important physiological benefits to the baby in allowing labor to begin on its own. And if the due date is off and the baby is born late pre-term, then there is compelling evidence that the baby is at higher risks for respiratory and other problems.

7. Page 6 – The statement “Research doesn’t have the answers about the effect inducing labor can have on the use of pain medications, length of hospital stay, breastfeeding problems, and problems for the baby during labor” is also misleading. Earlier in the brochure, the authors acknowledge that induced contractions may be stronger and more painful earlier in labor. I don’t think that there is any doubt among healthcare professionals that induced contractions are more painful and that women who are induced are more likely to request epidural analgesia. For the first-time mother whose risk for cesarean is doubled with induction, there is a greater risk for longer hospital stay, breastfeeding problems, and problems for the baby if cesarean surgery is required.

8. Page 8 – Things to Think About: Question: Am I more likely to have a C-section if I have my labor induced? The first line of the answer, “Research can’t tell us if inducing labor makes having a C-section more likely than waiting for labor to start on its own” is untrue for first-time mothers. The second line of the answer, “But your chances of a C-section are higher if you have never had a baby vaginally before” may be a little confusing for some readers and fails to include the important information that the risk for cesarean surgery is doubled for first-time mothers who are induced.

9. Page 8 – Fourth Question: The correct and appropriate answer to “How can I improve my chances of having a vaginal birth?” is to allow labor to begin on its own. This brochure addresses only elective induction!

10. Page 9: Questions to Ask Your Doctor or Midwife – Most of the questions do not provide the information needed to make a true informed decision. None deal with the potential risks of elective induction.

I certainly hope that you will not distribute this brochure in your childbirth classes and that you will consider voicing your own objections to this poor use of taxpayer dollars which has the potential of increasing requests for elective inductions; increasing the risks for unnecessary cesareans; and increasing medical complications for both mothers and babies.

H means HELP! And now in many hospitals, a patient or visitor is provided with the phone number for a “hot line” to use to voice urgent concerns if they arise.

Along with the recognition of patient’s rights and responsibilities to Speak Up and be heard, as well as the desire to improve the quality of health care, many hospitals have implemented the use of “Condition H.” Upon admission, patients are given information about this service and the number for them to call if needed. It enables patients and their visitors to call for immediate help from a rapid-response team if:
• a noticeable change in the patient’s condition occurs and the health care team is not present or not responding to the patient’s or visitors’                 concerns,

• there is a breakdown in how care is being given or confusion about the care plan,

• they become concerned about what is happening and need an urgent response from other health professionals.

Traditionally, condition codes have been used only by health care providers. “Condition H” differs in that patients and visitors are asked to alert caregivers to clinical changes. Every Condition H call brings a rapid response team immediately to the patient’s bedside so the concern can be heard and an evaluation made.
To read about how the program was developed following the experience of one family, go to the Josie King Foundation. Or gather more information from the Institute for Healthcare Improvement.
I like the idea of inviting patients and their loved ones to be part of the health care team. What about you? I am proud to say this is used successfully by the hospital where I teach.

It’s been almost 20 months since I sat in as a guest at the meeting of the Steering Committee on National Voluntary Consensus Standards for Perinatal Care for the National Quality Forum. (That is a lot of words for the name of that meeting.) The discussions and sometimes heated debates that day led finally to the adoption last summer of a new voluntary perinatal measure set for hospitals which will go into effect in April 2010. MSNBC got it wrong – the new measures are not required, BUT hospital administrators will want to impress the Joint Commission by implementing this newest measure set. Here is an excerpt from the new Joint Commission measure set on elective delivery:

“Rationale: For almost 3 decades, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have had in place a standard requiring 39 completed weeks gestation prior to ELECTIVE delivery, either vaginal or operative (ACOG, 1996). A survey conducted in 2007 of almost 20,000 births in HCA hospitals throughout the U.S. carried out in conjunction with the March of Dimes at the request of ACOG revealed that almost 1/3 of all babies delivered in the United States are electively delivered with 5% of all deliveries in the U.S. delivered in a manner violating ACOG/AAP guidelines. Most of these are for convenience, and result in significant short term neonatal morbidity (neonatal intensive care unit admission rates of 13- 21%) (Clark et al., 2009).

According to Glantz (2005), compared to spontaneous labor, elective inductions result in more cesarean deliveries and longer maternal length of stay. The American Academy of Family Physicians (2000) also notes that elective induction doubles the cesarean delivery rate. Repeat elective cesarean sections before 39 weeks gestation also result in higher rates of adverse respiratory outcomes, mechanical ventilation, sepsis and hypoglycemia for the newborns (Tita et al., 2009).

Type of Measure: Process

Improvement Noted As: Decrease in the rate”

Decrease in the rate! It will take a while, but eventually we will see a decrease in the number of elective inductions. As childbirth educators, we will play an important role in decreasing the number of elective inductions. In some communities, almost all women are scheduled for induction. Some physicians and pregnant women may resist giving up the convenience of scheduling the birth, but the evidence is strong to support the wisdom of letting labor begin on its own. If you are not already doing so, work with others at your hospital to create a plan for reducing the number of elective deliveries. Present evidence-based information in your childbirth classes about the risks to the baby and to the mother with elective induction and planned early cesarean section. Include information from the March of Dimes on why the last weeks of pregnancy matter and especially on the growth of the brain between 35 and 40 weeks. Provide time for small group discussions so that students can explore their own rationales for wanting to schedule their births, and hopefully measure those rationales against best evidence.

As a childbirth educator with more than 25 years experience (don’t ask!), it has been encouraging to have witnessed the process of development and eventual adoption of the new perinatal measures. Just as I have seen the acknowledgement that routine episiotomy is harmful and the slow decline of episiotomy, I hope to see a rapid decline in the number of elective inductions.

Note: If you’d like to read the other new perinatal measures, go to the link, Joint Commission measure set on elective delivery, and click on “Perinatal Care” in the first line.

What can hospitals do to create an environment where clients actually do have freedom of choice?  At the ICEA convention Val Lincoln told wondrous stories of an exemplary model of holistic care offered at the Woodwinds Hospital in Minnesota.