Elective induction versus spontaneous labour in Latin America
Gláucia Virgínia Guerra a, José Guilherme Cecatti a, João Paulo Souza b, Aníbal Faúndes a, Sirlei Siani Morais a, Ahmet Metin Gülmezoglu b, Renato Passini a, Mary Angela Parpinelli a, Guillermo Carroli c, for the WHO Global Survey on Maternal & Perinatal Health in Latin America Study Group
a. Department of Obstetrics and Gynaecology, School of Medical Sciences, University of Campinas, PO Box 6030, 13083-881, Campinas, SP, Brazil.
b. Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
c. Centro Rosarino de Estudios Perinatales, Rosario, Argentina.
Correspondence to José Guilherme Cecatti (e-mail: email@example.com).
(Submitted: 05 November 2008 – Revised version received: 30 March 2011 – Accepted: 09 June 2011 – Published online: 05 July 2011.)
Bulletin of the World Health Organization 2011;89:657-665. doi: 10.2471/BLT.08.061226
Elective labour induction without any medical or obstetric indication has been increasing in recent years. In some countries, 10% of all deliveries are electively induced.1–4 This increase has been attributed to greater demand by mothers and to logistic factors such as distance from the maternal dwelling to the hospital or a history of precipitate delivery.4–6 In addition, elective induction to suit the obstetrician’s schedule has been a contributing factor since the first half of the 20th century.7
In places where caesarean section rates are high, inducing labour in situations in which termination of pregnancy is advisable may help to reduce these rates.8,9 Nevertheless, the same is not necessarily true when labour is induced without any medical indication. Elective induction may in fact alter normal physiology when delivery begins and increase the rate of caesarean section, irrespective of parity, especially among women with an unfavourable cervix (e.g. women with the cervix in a posterior position, firm, poorly effaced and dilated, and with the fetus in a high station).1,10–12 A caesarean section is usually performed after elective induction with an unripe cervix for the following indications: prolonged first stage of labour, fetal distress, failure to progress and intrapartum haemorrhage.13–15
Some adverse maternal outcomes have been associated with elective induction of labour. These include an increase in instrumental vaginal deliveries; greater need for epidural analgesia; postpartum haemorrhage; increased need for blood transfusion; longer hospital stays and higher hospital costs.12,14,16–19 In addition, the neonate requires immediate care and must sometimes be admitted to a neonatal intensive care unit (ICU), particularly when the cervix is unripe at delivery.15,17,19
Elective induction of labour is becoming increasingly common but is seldom directly reported in studies perhaps because of lack of consensus with respect to its definition. In some settings labour induction is reported as elective when it is performed without medical indication; in others, any pre-scheduled induction of labour, with or without medical indication, is considered elective. In the present analysis we use the term elective induction of labour when no medical indication for the procedure exists. Since this intervention may be associated with increased maternal and perinatal risks, knowing how frequently it is performed is important for taking steps towards preventing its associated problems and providing accurate information to both pregnant women and health-care professionals. The objectives of this study were to evaluate the frequency of elective induction of labour in Latin America; the procedure’s rate of success in achieving vaginal delivery; the factors determining its application and any associated unfavourable maternal and perinatal outcomes.
We performed a secondary analysis of data on elective labour induction in Latin America, as obtained from the 2004–2005 World Health Organization Global Survey on Maternal and Perinatal Health (WHOGS). The protocol and methods used in the original study have been described in other publications.20,21 Briefly, the WHOGS is a cross-sectional study in which data were collected from medical records in 120 randomly selected health facilities from eight randomly selected countries in Latin America. In each country data were collected on every single woman who gave birth in every selected facility (n = 97 095) during a data collection period lasting two or three months (depending on the number of deliveries in the facility) in 2004–2005. The protocol was approved by WHO’s Scientific and Ethical Review Group and Ethics Review Committee. Informed consent was not individually requested since the data were taken anonymously from medical charts.21
The database for this study included information from all the women in the 2004–2005 WHOGS. Although the original database indicated which inductions had been elective and/or performed at the mother’s request (totalling 3319 cases), we considered it fundamental for this analysis to select a low-risk population by excluding women who had risk factors that could have affected the delivery itself and its maternal and perinatal outcome. We therefore followed the steps in the flowchart shown in Fig. 1 to select a group of women with low-risk pregnancies who had undergone elective labour induction (at their own request or in the absence of any medical indication) as well as a group with spontaneous onset of labour. By using this strategy, we presumably excluded all inductions that were medically indicated and generated a low-risk sample of women undergoing induced labour. In this sample population we identified 1847 women with elective induction and compared them with the women with low-risk pregnancies (35 597) who went into labour spontaneously during the study period.
Fig. 1. Steps used to identify women with low-risk pregnancies who had electively induced labour, as recorded in the 2004–2005 Global Survey for Latin America of the World Health Organization (WHO)
We first quantified successful elective labour inductions – i.e. inductions culminating in a vaginal delivery – as a function of the induction method used (i.e. oxytocin, misoprostol, another prostaglandin, artificial rupture of membranes, membrane sweeping, or a combination of methods). To assess maternal characteristics potentially predictive of elective labour induction (age, marital status, schooling, parity, type of delivery health-care facility, body mass index [BMI, expressed as kg/m2] and gestational age) we compared women whose labour was electively induced with women whose labour was spontaneous and calculated crude and adjusted odds ratios (ORs) and their respective 95% confidence intervals (CIs) using multiple logistic regression models.
We calculated crude relative risks (RR) and adjusted relative risks (RRadj) and their respective 95% CIs for the following maternal outcomes and complications potentially associated with labour induction: mode of delivery, postpartum haemorrhage with blood transfusion; a need for uterotonic agents in the postpartum period; blood transfusion; perineal laceration; hysterectomy; admission to the ICU; duration of postpartum stay in hospital; use of analgesia/anaesthesia, and maternal status at discharge. We then used a logistic regression model that included adjustment for mode of delivery and all other predictors (except BMI because of the large number of cases that were missing this information). We followed exactly the same procedures to assess the following perinatal outcomes: a low 5th minute Apgar score; low birth weight; admission to the neonatal ICU; neonatal deaths taking place in hospital within the first week of life (as a proxy for early neonatal death) and time of initiation of breastfeeding. All the analyses were performed with the Statistical Analysis System (SAS) software program, version 9.02 (SAS Institute, Cary, United States of America).
Of the 11 077 inductions registered in the database, 16.7% were elective as per the definition used in this study. These elective inductions occurred in 4.9% of women with low-risk pregnancies (37 444). Table 1 shows that vaginal delivery was attained in 88.2% of all elective inductions, with little variation among the different methods of induction used. Oxytocin administration was the single most frequently used induction method (65.9%), whereas misoprostol was used to induce only 8.9% of the deliveries. Other prostaglandins, membrane sweeping and artificial rupture of membranes were rarely used.
Table 1. Elective inductions of labour culminating in vaginal or Caesarean delivery, by method of induction, in women with low-risk pregnancies in selected Latin American countries, 2005
Table 2 shows that not having a partner was associated with a reduced risk of having an elective induction. On the other hand, nulliparity and giving birth in social security or private health-care institutes increased the risk of having an elective induction. A woman’s age and educational level showed no association with the risk of elective induction. Although a BMI > 30 was also associated with an increased likelihood of having an elective induction, it could not be determined from the logistic regression if obese women have an intrinsic risk of elective induction of labour because a substantial proportion of data were missing. All women were at term, between 37 and 40 weeks of gestational age.
Table 2. Crude odds ratios (OR) and adjusted odds ratios (ORadj) of elective labour induction in women with low-risk pregnancies, by demographic and other characteristics, in selected Latin American countries, 2005
Caesarean sections were performed in 11.8% of women with low-risk pregnancies who underwent elective labour induction, as opposed to 8.6% of women who went into labour spontaneously. Despite the fact that higher caesarean section rates were observed among women undergoing elective induction of labour (crude RR: 1.36; 95% CI: 1.19–1.55), the intrinsic risk of this procedure was only marginally associated with caesarean section (RRadj: 1.16; 95% CI: 1.00–1.35). The maternal complications most associated with elective induction of labour among women with low-risk pregnancies, confirmed by multiple logistic regression analysis, were: postpartum need for uterotonic drugs (a 1.5-fold greater risk); hysterectomy (a 5.2-fold greater risk, although this figure comes from only 4 cases among women with elective induction); admission to the ICU (a 3-fold greater risk), and a greater need for anaesthetic and analgesic procedures. On the other hand, elective induction was not associated with an increased risk of perineal laceration or postpartum haemorrhage, lengthened hospital stay or a greater need for blood transfusion (Table 3).
Table 3. Crude relative risk (RR) and adjusted relative risk (RRadj) of specific maternal outcomes in women with low-risk pregnancies who underwent elective labour induction in selected Latin American countries, 2005
Four women who had elective induction of labour had a hysterectomy; two of them were nulliparas and all had been induced with oxytocin. Two of the four women required uterotonics in the postpartum period and received blood transfusions. None had to be admitted to the ICU. Thirteen hysterectomies occurred among women who had spontaneous labour. Of these 13 women, 10 were multiparas, 4 had postpartum haemorrhage, 8 required uterotonics postpartum, 7 required blood transfusions and 4 were admitted to the ICU. Ten of these women had vaginal deliveries. Only one of the women whose labour was spontaneous died. This was a 20-year old primigravida at full term who had received appropriate prenatal care and in whom no risk factors had been identified. She had a vaginal delivery of a full-term, healthy infant with good vital signs (data not shown).
Finally, Table 4 shows that elective induction among women with low-risk pregnancies was not significantly associated with an increased risk of most neonatal complications, including a low 5th minute Apgar score, low birth weight, admission to a neonatal ICU or early neonatal death. Nevertheless, delayed initiation of breastfeeding (i.e. initiation between one hour and seven days postpartum) was more common among women who had an elective induction of labour, with a mean 22% higher risk (RR: 1.22; 95% CI: 1.12–1.34). In addition, the mean birth weight of neonates did not significantly vary between groups (elective induction group: 3259.6 g [standard deviation, SD: ± 417.3]; spontaneous onset of labour group: 3254.6 g [SD: ± 430.1]) (P = 0.63, data not shown).
Table 4. Crude relative risk (RR) and adjusted relative risk (RRadj) of adverse perinatal outcomes in women with low-risk pregnancies who underwent elective labour induction in selected Latin American countries, 2005
In this study, a substantial proportion of labour inductions were performed without medical indication or at the mother’s request. Women with low-risk pregnancies who underwent elective induction of labour had an increased risk of adverse outcomes. In fact, we were surprised to find that in 30% of all cases of induced labour contained in the database, “elective” and “by request” were the terms used for the indication, even in some cases that were medically justified. Countries varied, however, in the extent to which they used these terms. We then restricted the sample to women with low-risk pregnancies by excluding all inductions that were medically indicated or that were performed in women with a pathological condition during pregnancy or delivery or with a history of uterine scarring, breech presentation or any other obstetric complication. In this way we obtained a smaller sample and the fraction of elective inductions decreased. This approach, also used by other authors,3,22 is considered the only acceptable method for comparing pregnant women whose induction was genuinely elective with other women with low-risk pregnancies delivering spontaneously.
The success of elective induction
The mean caesarean section rate in the elective inductions was 11.7%, well below the caesarean rate of 29.5% for the sum of all inductions in this same population. This rate of caesarean section is low considering current standards, perhaps because elective induction was performed only in the presence of a favourable cervix, as recommended by Bishop;23 however, this aspect was not evaluated in the present study. We believe this may have been the case because oxytocin is generally effective only when the cervix is favourable for induction and in this study oxytocin, alone or in combination with another method, was the agent most commonly used to induce labour. However, we are unable to exclude the possibility that misoprostol was less available or that practitioners felt less confident in using it. Misoprostol, which is most frequently indicated when the cervix needs to be prepared, was used alone in only 8.9% of the pregnant women, and the caesarean section rate among women given misoprostol was 21.8%, twice as high as the rate after induction with oxytocin. These results indirectly corroborate findings from other studies to the effect that elective induction in the presence of an unripe cervix constitutes a risk factor for caesarean section.19,24–26
In this sample of women with low-risk pregnancies, maternal age was not associated with elective induction, contrary to findings published by other investigators who reported that age below 19 years was a protective factor.3,8,10,27 Not having a partner was a factor associated with a reduced risk of elective induction, and this corroborates the findings of Coonrod et al.8 On the other hand, maternal educational level was not associated with elective induction in our study population, a finding in agreement with the findings of Boulvain et al.10 and Le Ray et al.26 but in disagreement with those of Coonrod et al.,8 who reported a greater risk of elective induction in women with more than 12 years of schooling. However, only 9% of the women in our study fell into this category.
Nulliparity was an independent risk factor for elective labour induction. This finding conflicts with reports from other authors who found a protective effect.3,10,26 Giving birth in a private or social security institution was associated with a double or triple risk of elective induction, a finding also in agreement with reports from other studies.3,26,28
Higher rates of caesarean section were observed among women who underwent elective induction of labour. After adjustment for other risk factors, elective induction of labour remained marginally associated with an intrinsic risk of caesarean section. Uterotonic agents in the postpartum period were more often needed after elective inductions than after spontaneous initiation of labour. This last finding should be interpreted with caution, however, because elective induction was not associated with an increased risk of puerperal haemorrhage requiring blood transfusion. Moreover, the same uterotonic drugs can continue to be used through the third and fourth stages of labour prophylactically, not necessarily to control new haemorrhage.
The most important finding of this study is perhaps the fivefold increase in hysterectomies among women who underwent elective labour induction. Although hysterectomy was infrequent both in absolute and in relative terms, this finding is worrisome because labour induction was theoretically not medically indicated in these cases and culminated in a procedure with high morbidity that puts an end to a woman’s reproductive life. In fact, some authors have reported a higher risk of hysterectomy during labour induced inappropriately with misoprostol and a higher risk of uterine rupture in association with the induction itself.29–32 The four women who underwent elective induction followed by a hysterectomy were all induced with oxytocin. This reinforces some authors’ views that uterotonics have to be used with caution.31,32 This finding should be cautiously interpreted in light of the very small number of hysterectomies (i.e. the finding may be unstable)
Elective induction of labour has also been associated with a greater need for anaesthesia, which interferes with the natural process of delivery even in the absence of maternal complications or other adverse situations, and also carries inherent risks and increased costs.14,17,18
There was no difference between the two groups with respect to the 5th minute Apgar score, even after adjustment for all predictor variables. This finding corroborates reports from various other authors.10,13,24,33 In the current study, elective induction did not show a significant association with low birth weight. Finally, elective induction in this study was associated with late initiation of breastfeeding.
In this study, elective induction was practised at a rate similar to the rates reported in developed countries, around 10%.1,2,4 Although perinatal outcomes were similar among women who underwent elective induction of labour and those whose labour was spontaneous, women who had induced labour had increased rates of caesarean section and, more importantly, of hysterectomy. Therefore, caution should be exercised when inducing labour without any medical indication, since no clear benefits outweigh the associated risk of an adverse maternal outcome.
We thank all those people who were involved in the planning, implementation, data collection, analysis and reporting of the 2004–2005 WHO Global Survey on Maternal and Perinatal Health in Latin America.
The original study was funded by the Joint United Nations Programme on HIV/AIDS and WHO’s Department of Reproductive Health and Research. The current analysis was sponsored by the University of Campinas, Brazil.
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