Induction of labour and caesarean delivery rates: The need for a
national and international consensus
In high- and middle-income countries (HMIC), induction of labour are
common obstetric interventions often based on guidelines and hospital
protocols aimed at starting the labor for specific medical circumstances
or initiate it in post-term pregnancy. In low-income countries (LIC),
inductions are rarely available to pregnant patients due to lack of
maternity resources. By contrast, cesarean delivery (CD) rates are more
volatile and continue to increase in most HMIC with little improvement
in perinatal outcomes (Betran et al., BJOG; 206;123:667-70) whereas CD
rates have remained low in most sub-Saharan African countries (Boatin et
al., BMJ, 2018;360:k55) but maternal and perinatal deaths following CD
are disproportionately high (Sobhy et al., Lancet, 2019;393:1973-82) due
to inadequate access to emergency obstetric care facilities.
There is little controversy regarding induction of labour at any
gestational age to prevent perinatal morbidity and mortality in case of
pregnancy complications. Conversely, the timing of induction for
post-term pregnancies has been recently challenged. A large trial from
the United States, found no significant difference in perinatal outcome
in nulliparous patients induced between 39 weeks+0 and 39 weeks+4 days
compared to expectant management up to 41 weeks+0 days but reported a
significantly lower incidence of CD in the early induction group
(Grobman et al., NEJM, 2018;379:513-230). A Swedish trial comparing
induction at 41 versus 42 weeks was stopped due to a significantly
higher rate of perinatal mortality in the expectant management group
(Wennerholm et al., BMJ,2019;367:I6131).
Overall, CD rates have increased by 400% between 1966 and 1997 in most
HICs (Glantz and McNamley, Obstet Gynecol Surv. 1997;52:497505). This
trend expends even more rapidly in MICs where attempt at stemming it
have so far failed (Hussein et al., BJOG, 2021;128:807). A recent
analysis of the 2010-2018 world data from 154 countries covering 94.5%
of live births shows that 21.1% of pregnant patients gave birth by CD
(Betran et al., BMJ Glob Health. 2021;6:e005671). The authors estimate
that by 2030, 28.5% of patients worldwide will be delivered by
caesarean section with the greatest increase predicted to be in Eastern
Asia.
The recent publication of a national review of maternity safety has
identified a “culture to keep CD rates low at all costs” in some UK
maternities with poor perinatal outcomes
(www.gov.uk/publications/Okenden
review/2022). In this issue of the journal, Gurol-Urganci et al
(BJOG,2022: in press) report on rates of induction of labour and
emergency CD in the English National Health Service (NHS) between April
2015 and March 2017. The authors found considerable in between-hospital
variation in the use of both procedures and hospitals with a higher
induction rate presented with a lower risk of adverse birth outcomes but
no similar association was found for CD rates. The UK has a unique
national system of evidence-based guidelines for clinical care
(www.nice.org.uk/guidance). The
recommendations proposed in these guidelines are intended to decrease
variations in clinical practice to optimize patients care and are
developed involving patients. Their implementation should focus on
patient needs and preferences and not be influenced by local
socio-economic, medico-legal or cultural factors.
Word count : 500