This site began in April 2012 as a way for me to document the evidence I found about various birth practices. In June 2012, this site became widely read on an international level. Based on the sheer numbers of people who were reading my articles, I became motivated to increase my standards for evidence-based birth articles. I began using this article-writing process formally in August 2012. This article about inductions was written before August 2012 and may not meet my current quality standards for peer review and eliminating bias from my writing.
In my previous post, I talked about what evidence-based practice is, and why it is important for you to receive (if you are the patient) or provide (if you are the practitioner) evidence-based care.
However, did you know there are no hard and fast rules about evidence based practice?
It’s important for you to understand that evidence by itself is never a good enough reason to do something. This is because you have to know the quality of the evidence.
To make my point, I am going to present a case study, like I do with my students in Pathopharm class. I will call this the “If you don’t have this baby by 42 weeks (and sometimes by 41) we have to induce” case study.
So, a first-time mom has made it to 40 weeks and shows up for her weekly doctor’s appointment. Mom is tired but doing well, and baby is great. That’s why mom is surprised when she hears the doctor say, “Well, if you are still here next week at 41 weeks, we will have you come in for an induction.” Mom is disappointed, because she really, really wants to have a vaginal birth, and she is worried that induction may increase her risks for a C-section.
Mom makes it through to 41 weeks and shows up at the doctor’s office. The doctor says, “Alright, we need to talk about induction now. I’m going to have you check into the hospital tonight. I know you didn’t want to have an induction, but you have to. Unfortunately, you don’t have a very good Bishop score, and so this induction is going to increase your risk of a C-section by quite a bit. But this is the route you should take.” Mom asks if induction is really necessary– can’t we please, pretty please just wait a little longer? She is persistent enough and finally talks the doctor into waiting one more week, as long as she goes to every other day ultrasounds and fetal non-stress tests to make sure baby is fine.
Forty-two weeks arrive and mom is having lots of pre-labor (cramping and intermittent, irregular contractions). Mom is fine, and all the tests show that baby is fine. However, her OB is insistent. “I will not budge on this. You need to be induced today, because you are increasing your risks of your baby being stillborn.” What is mom supposed to say to this? “No, I want to increase my risks of stillbirth.” Of course not. She cries, but she listens to her doctor and checks in for the induction, because the doctor told her the baby was at risk. And to some extent, her physician has a point– there is evidence out there– from the Cochrane library no less– that HAS shown an increased risk of stillbirth after 41 weeks.
What is this evidence you are talking about, you might ask? Is it really more dangerous to wait for baby to be born spontaneously than to induce labor?
Well, the evidence that this doctor is using to talk her patient into a medical induction comes from an often-quoted Cochrane review. In this review, researchers pooled data from 19 trials with 7,984 low-risk women who were randomized to either “watchful waiting” or induction. There were protocol violations in both groups: 30% of women assigned to induction ended up delivering spontaneously, and some women (# not reported) in the watchful waiting group ended up being medically induced (usually for unsatisfactory fetal test results).
The number of perinatal deaths was statistically significant between the 2 groups– 1 death out of 3285 births in the labor induction group vs. 11 deaths out of 3238 births in the watchful waiting group. However, it is important to note that the majority of these studies were carried out more than 20 years ago—between 1969 and 1992. Furthermore, many of these studies were conducted in India and Thailand. In the 7 studies that were conducted more recently (after 1992), there was only 1 stillbirth at all (in the watchful waiting group) reported out of 1817 women. There are 10 newer trials that were not included in this Cochrane review but are “awaiting assessment,” and the authors caution that when these results are included in the next review, it could change the overall conclusions.
So, do you see the problem here? We have evidence, and it comes from a reputable source (the Cochrane library, famous for its reviews), but the evidence is outdated. Don’t you think that maternity and birth care has improved just a little bit since the 1960′s, 70′s, and even 80′s? And don’t you think modern maternity care in the U.S. right now is just a little bit different from it was in Bangkok and Calcutta back then? It is amazing to me that people quote this Cochrane review all the time to pressure women into inductions, when the quality of the evidence is not as high as you might think it is. In fact, you really have to dig into the actual text of the whole 58-page article to come to the conclusions that I just did. You can’t just read the summary.
In the end, this mom’s overall risk of having anything go wrong with “watchful waiting” is EXTREMELY remote (even the Cochrane reviewers admit this in their conclusions). That risk– I believe– becomes almost non-existent when you only consider the recent data, like from the last 20 years.
Anyways, I hope you guys find this interesting. This blog post only scratches the surface on the evidence about inductions, but I thought it was a good place as any to start.