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Purpose: To reduce elective inductions among nulliparous women in a community hospital by adding standardized education regarding induction risks to prepared childbirth classes.
Study Design and Methods: Elective induction rates were compared between class attendees and nonattendees before and after the standardized content was added to prepared childbirth classes. A survey of nulliparous women's decisions regarding elective induction was conducted.
Results: Elective induction rates of 3,337 nulliparous women were evaluated over a 14-month period (n = 1,694, 7 months before adding content to classes; n = 1,643, 7 months after). Rates did not differ between class attendees (35.2%, n = 301) and nonattendees (37.2%, n = 312, p = .37) before the content was included. However, after standardized education was added, class attendees were less likely to have elective induction (27.9%, n = 239) than nonattendees (37%, n = 292, p < .00). Sixty-three percent of women who attended the classes and did not have elective induction indicated that the classes were influential in their decision. Physicians offered the option of elective induction to 69.5% (n = 937) of survey participants. This was a factor in women's decisions; 43.2% (n = 404) of those offered the option had elective induction, whereas 90.8% (n = 374) of those not offered the option did not have elective induction.
Clinical Implications: Education regarding elective induction offered during prepared childbirth classes was associated with a decreased rate among nulliparous women who attended classes when compared to those who did not attend. Patient education may be beneficial in reducing elective inductions.
Unnecessary procedures such as elective labor induction have risen sharply in the United States over the past two decades with associated increases in cesarean births and late preterm births (Martin, Hamilton et al., 2009; Martin, Kirmeyer, Osterman, & Shepherd, 2009). The reported rate of labor induction in the United States has more than doubled since 1990 from 9.5% to 22.5% in 2006 (most recent year for which induction data are available) (Martin, Hamilton et al.). During this same period, the cesarean birth rate increased 33% from 23.5% to 31.1% (Kozak & Lawrence, 1999; Martin, Hamilton et al.), and the percentage of late preterm vaginal births for which labor was induced increased 130%, from 7.5% to 17.3% (Martin, Kirmeyer et al.).
It has been estimated that approximately 10% of elective births are performed before 39 completed weeks of gestation (Clark et al., 2009), despite long-standing recommendations against this practice from the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (AAP & ACOG, 1983; ACOG 1999). These babies are more likely to suffer symptoms of iatrogenic prematurity requiring admission to a special care nursery or neonatal intensive care unit (Clark et al.). From 1992 to 2002, the mean gestational age for singleton births in the United States decreased from 40 weeks to 39 weeks, in part related to the rise in medical procedures such as labor induction and cesarean births (Davidoff et al., 2006). Although precise data are unknown due to inability to abstract indications for induction from certificates of live births, approximately one half to two thirds of labor inductions are performed for nonmedical indications (Clark et al.; Moore & Rayburn, 2006). The incidence of elective and medically indicated induction varies widely by institution (community or academic), area of the country (region, state, rural, or urban setting), and individual care providers (Glantz, 2005). The overall rate of induction is rising faster than the rate of pregnancy complications that would suggest a need for a medically indicated induction (Caughey et al., 2009; Martin, Hamilton et al., 2009).
There is evidence that elective labor induction significantly increases risk of cesarean birth for nulliparous women (Clark et al., 2009; Luthy, Malmgren, & Zingheim, 2004; Reisner, Wallin, Zingheim, & Luthy, 2009; Shin, Brubaker, & Ackerson, 2004; Vahratian, Zhang, Troendle, Sciscione, & Hoffman, 2005, Vrouenraets et al., 2005). Use of pharmacologic agents required for labor induction increases risk of complications related to excessive uterine activity, fetal heart rate abnormalities, and cesarean birth for failure to progress in labor and/or concern regarding fetal status (Bakker, Kurver, Kuik, & Van Geijn, 2007; Oscarsson, Amer-Wahlin, Rydhstroem, & Kallen, 2006; Simpson & James, 2008; Vahratian et al.; Vrouenraets et al.). Cesarean birth after labor is associated with increased maternal and neonatal morbidity and mortality, as well as an increase in inpatient length of stay and healthcare costs (Allen, O'Connell, & Baskett, 2006a, 2006b; Cheesman, Brady, Flood, & Li, 2009; Deneux-Tharaux, Carmona, Bouvier-Colle, & Breart, 2006; Getahun, Oyelese, Salihu, & Ananth, 2006; Lydon-Rochelle, Holt, Easterling, & Martin, 2001).
The primary purpose of this study was to test an educational intervention in the context of prepared childbirth classes to decrease the rate of elective labor induction among nulliparous women at our community hospital. The project was initiated after numerous discussions at department meetings where physicians indicated they often felt pressure from nulliparous women to induce their labor electively. In 2004, the medical center instituted a policy discouraging elective births before 39 completed weeks of gestation with requirements that a form with the indication for labor induction, gestational age, and cervical status be faxed to the unit before an elective induction could be scheduled. Mean gestational age for elective induction was 39.6 weeks (SD = .8) in 2007 and 2008, so the issue was not elective induction before 39 completed weeks, but rather elective induction specifically for nulliparous women. Physicians were concerned about the increased risk of cesarean birth for this patient population. Education about risks of elective labor induction during childbirth classes was identified as one possible way to minimize these types of requests. We hypothesized that women who were provided thorough information on risks of elective induction would be less likely to ask their physician for an induction of labor. A secondary aim was to explore reasons why nulliparous women choose to have an elective labor induction.
Although risks of elective induction have been studied, there are limited data as to whether patient education can be helpful in discouraging elective induction, and little is known about reasons nulliparas choose this method of labor. No studies of U.S. women's decisions regarding elective induction or educational interventions to assist women in the decision-making process were found searching the electronic databases PubMed, CINAHL, and the Cochrane Library from January 1988 to November 2009 using the terms elective labor induction, women's/patients' choices/decisions for labor/childbirth, patient education and prepared childbirth classes.
Given that there are known associated clinical, operational, and economic implications of elective induction, evaluation of efforts to discourage nulliparous women from choosing this method of labor is warranted. The childbearing woman is a key member of the perinatal team; providing as much accurate information as possible to assist with her decision-making regarding elective induction is consistent with patient advocacy as supported by the Association of Women's Health, Obstetric and Neonatal Nurses ([AWHONN], 2009) and ACOG (2008, 2009), and is a component of patient education standards from the Joint Commission (TJC, 2009).
Institutional review board approval was obtained at St. John's Mercy Medical Center in St. Louis, MO, which is a community teaching hospital with an average of over 8,000 births per year where private attending obstetricians are the primary care providers for 95% of childbearing women. Baseline data indicated that the elective induction rate for nulliparous women at our hospital was approximately 36%, with no difference between those who attended prepared childbirth classes (35%) and those who did not attend (37%; p = .37). Based on data that approximately 50% of nulliparous women at St. John's Mercy attend prepared childbirth classes, we developed a standardized 40-minute educational session regarding risks and benefits of elective induction for those who attend classes and then compared elective induction rates between class attendees who were exposed to the education and nonattendees who did not receive the education over a 7-month period. These rates were also compared for class attendees and nonattendees using the prior 7-month period as a baseline.
A power analysis determined that a sample size of 300 (n = 150 women per group) was necessary to achieve a power of .80 at the .05 level of significance to detect a difference of at least 10% in induction rates between class attendees and nonattendees. As there were four types of prepared childbirth classes in which the content was offered (traditional 6-week format, 6-week format for women who preferred minimal intervention during labor, 4-week format, and 1-day format), a sample of approximately 1,300 patients was desired in order to have at least 150 patients in each subgroup of class attendees to be able to further evaluate the rate of elective induction between types of classes. The Statistical Program for Social Sciences (SPSS 16.0 for Windows; SPSS, Chicago, IL) was used for data analysis. Descriptive data, paired t-tests, and [chi]2 analysis were used to evaluate data between the two groups.
Specific risks of elective induction presented during the class included cesarean birth with longer postpartum recovery, pain, and potential complications as well as other associated risks such as longer labor, use of pharmacologic agents and their effects on the mother and fetus, and neonatal morbidity. Benefits included advance planning and timing with personal schedules. Women were encouraged to discuss the labor induction process with their physician during their prenatal visits. As preparation for a discussion about elective induction if suggested by their physician, they were given cards with "talking points" listing potential questions they could ask including indication, what to expect during labor induction, potential methods, as well as risks, benefits, and alternatives such as waiting for spontaneous labor (Table 1).
The content of the slide presentation and written materials was based on current evidence and recommendations regarding appropriate candidates and timing for elective induction as well as associated risks of the procedure from ACOG (1999, 2001), AWHONN (2009; [Simpson] 2009), the National Institute of Child Health and Human Development (Raju, Higgins, Stark, & Leveno, 2005), and the March of Dimes (2008a, 2008b, 2008c, 2008d). A literacy expert assisted with development of the presentation. All but 6 of the 37 slides in final presentation were determined to be at or below the eighth-grade readability level. A decision was made to include these six slides based on the known level of education of the population served (mean years of education = at least some college).
The classes were provided by 15 Lamaze certified childbirth educators. A series of meetings were held with the childbirth educators before incorporating the education into the classes to review the content and emphasize importance of presenting the information in a standardized objective format. One of the investigators attended selected class sessions over the course of the 7 months to monitor consistency and objectivity in presentation of the information.
Nulliparous women who gave birth in the 7-month period after the content was added to the classes were invited to participate in a survey to explore the genesis of the decision to related to an elective induction of labor (Table 2 for selected items from the survey). Potential responses to structured survey items were derived from common reasons nulliparous women at our hospital indicate that they choose to have an elective induction as noted via review of medical records (indication for induction per patient) and discussions with clinicians. Content validity of the survey was determined through a review and revision process by obstetricians, childbirth educators, labor nurses, and patients. The survey was pilot tested during the first week, and minor changes were made to several items based on patient and research nurse feedback. The survey can be obtained via e-mail to the primary author.
Our data indicated that mean gestational age of women in the first prepared childbirth class was approximately 32 weeks; therefore, the second 7-month comparison group and survey period began 9 weeks after the standardized labor induction education content was added to prepared childbirth classes to ensure that all potential survey participants were exposed to the intervention. Inclusion criteria were nulliparity, singleton pregnancy, gestation <=37 weeks, live birth, and English speaking. Eligible patients were identified from the daily log. During the inpatient postpartum stay, eligible patients were approached by a research nurse, provided information about the survey, and invited to participate. If they agreed, the survey was provided, selected clinical data including indication for induction were collected from the medical record, and the completed survey was obtained during the inpatient stay. Indications for induction (elective vs. medically indicated) in the medical record were coded based on those listed in the ACOG (1999) practice bulletin Induction of Labor.
Baseline data on elective induction rates of those who attended prepared childbirth classes and those who did not attend were obtained from a review of the birth log, prepared childbirth class rosters, and medical records of all women meeting inclusion criteria in the 7 months immediately before the survey period, before the standardized educational content on elective induction was added to the childbirth classes. From November 1, 2006 to May 31, 2007 there were 5,309 births, 1,694 of which met inclusion criteria. Women were invited to participate in the survey from June 1, 2007 to January 31, 2008 during which there were 5,274 births, 1,643 of which met inclusion criteria. Eighty-two percent (n = 1,349) of eligible women completed the survey. Various reasons patients offered for not participating were postoperative pain, fatigue, breastfeeding difficulties, multiple visitors, and time constraints.
During the first and second 7-month periods, 51% (n = 856) and 52% (n = 854), respectively, of women who met inclusion criteria attended hospital-sponsored prepared childbirth classes. Fifty-five percent (n = 741) of women who participated in the survey attended classes. Survey participants who attended classes were significantly older (M = 27.2 years) than those who did not attend (M = 24.8 years; p < .00) and had significantly more years of education (attended class = 89% some college; did not attend class = 40% some college; p < .00). Sixty-seven percent and 25% of class attendees completed college and had a graduate or professional degree, respectively, compared to 25% and 11% for the same education levels in the group that did not attend classes (p < .00).
Elective induction rates based on class attendance for the first 7 months before the content was added to the prepared childbirth classes and the next 7 months after are presented in Table 3. In the 7 months before adding the content to the classes, there was no significant difference in the elective induction rates of women who attended prepared childbirth classes (35.2%; n = 301) and those that did not attend (37.2%; n = 312, p = .37). However, after the content was added, elective induction rates differed significantly based on class attendance. Women who attended prepared childbirth classes that included the standardized content related to elective induction were less likely to have an elective induction (27.9%; n = 239) than women who did not attend classes (37%; n = 292, p < .00). Sixty-three percent (n = 289) of women who attended classes, participated in the survey, and did not have elective induction indicated that the classes in some way influenced their decision not to have their labor electively induced. Labor inductions decreased 20.7% from 35.2% to 27.9% (p = .01) among class attendees comparing the 7 months before adding the standardized content and the 7 months after. The decrease in the rate of elective induction among class attendees resulted in an overall 10.7% decrease in elective inductions of nulliparous women meeting inclusion criteria from 36.2% to 32.3% (p = .05) comparing the two 7-month periods.
Although a majority of survey participants noted that the class content was helpful in their decision-making process regarding elective induction, a significant factor was whether the physician offered the option (p < .00). Physicians offered the option of elective induction to 69.5% (n = 937) of survey participants; 33% (n = 311) ranging from early in the pregnancy to several weeks before the estimated date of delivery (EDD). Forty-seven percent (n = 436) were offered the option around the EDD and 20% (n = 190) were offered the option after their EDD. There was no difference in physicians offering the option for elective induction between class attendees (70.4%; n = 522) and nonattendees (68.2%; n = 415, p = .38) who completed the survey; however, class attendees who were offered the option chose elective induction less (37.7%; n = 195) than non attendees who were offered the option (50%; n = 209, p < .00). Forty-three percent (n = 404) of all women offered the option had elective induction, whereas 90.8% (n = 374) of all women who were not offered the option did not have elective induction (p < .00).
Ninety-one percent (n = 275) of women who completed the survey and did not have an elective induction indicated that it was their decision ("did not ask physician"; "did not want an induction"), whereas 9% (n = 27) indicated it was their physician's decision ("asked, but physician said no"). Seventy-five percent (n = 320) of women who completed the survey and had an elective induction indicated that the physician suggested the option compared to 25% (n = 104) who indicated that they asked the physician to perform an elective induction. These data are consistent with the various reasons women noted why they chose elective induction. Seventy-two percent (n = 317) indicated that chose to be induced after their physician suggested elective induction due to a large baby or being due now or overdue, whereas 20% of women (n = 88) chose elective induction for personal reasons such as wanting relief from pregnancy discomforts, specific timing of birth, or to have their own physician deliver their baby rather than another physician in the group practice (Table 4).
Standardized information based on current evidence and recommendations from professional organizations regarding risks and benefits of elective induction presented during prepared childbirth classes was beneficial in discouraging some women from choosing this option for labor in this study and may be applicable to other settings where prepared childbirth classes are offered (Table 5). Patient education before clinical procedures is important to promote informed consent (TJC, 2009). Before induction, ACOG (2009) and AWHONN (Simpson, 2009) recommend counseling women regarding indications, pharmacologic agents and methods, and possible need for repeat induction or cesarean birth. Nulliparous women with an unfavorable cervix should be counseled about a twofold increased risk of cesarean birth (ACOG). Women who participated in the recent Listening to Mothers Survey II (Declercq, Sakala, Corry, & Applebaum, 2006) overwhelmingly expressed a desire for information regarding potential risks of elective induction; nearly all first time mothers surveyed wanted to know every complication (74.7%) or most complications (24%) of labor induction. Standardized evidence-based information provided in prepared childbirth classes can meet these desires and serve as a foundation for the discussion between the physician/nurse midwife and the patient regarding elective induction recommended by ACOG and AWHONN (Simpson). Nurses working in the prenatal clinic or office setting can reinforce this information and follow up with patients who have additional questions.
Although education provided in prepared childbirth classes can be helpful for women in making the choice of whether or not to have their labor electively induced, the physician is a powerful influence. Contrary to the initial perceptions of our physicians that most elective inductions are performed based on requests from patients, physicians offered the option to nearly 70% of women who participated in the survey. It is possible that patients perceive the offer of the option for elective induction as a recommendation that they actually have the procedure, particularly if they are told they are due now, overdue, or their baby is getting too big. When the option for elective induction was offered by their physician, women were significantly more likely to choose elective induction than when the option was not offered. Offering the option in the absence of patient request, especially before cervical readiness has been achieved, may lead to unnecessary elective inductions with the associated increased risk of cesarean birth and increased healthcare costs (Allen et al., 2006b; Clark et al., 2009; Reisner et al., 2009). With the ongoing decline in the vaginal birth after cesarean birth rate (Martin, Hamilton et al., 2009; Menacker, 2005), subsequent births are most likely to be via cesarean as well.
There are several limitations to this study. Patients were not randomly selected for prepared childbirth class attendance; rather class attendance was per patient choice. Among patients who participated in the survey, class attendees were slightly older and had a higher level of education than those who did not attend. However, although the elective induction rate was essentially the same between class attendees and nonattendees before the study intervention, a significant difference in elective induction rates was noted between these two groups after the standardized educational content on elective induction was added to the classes.
The potential of patient education to reduce elective induction rates has not been well studied. Despite availability of prepared childbirth classes in many settings, the high percentage of women who receive prenatal care (Martin, Hamilton et al., 2009) with the opportunity for education, and patient information materials from the March of Dimes (2008a, 2008b, 2008c, 2008d), ACOG (2001), and Lamaze International (2007) delineating the risks of elective induction, until now none of these mediums have been tested for efficacy in discouraging women from choosing to have an elective induction. Much more data are needed on effective patient education methods, settings, and materials to help women make informed decisions. Further there are limited data based on direct feedback from women who undergo labor induction that can assist clinicians in offering effective guidance in patients' decision-making regarding method of labor. Future research involving discussions with women as they are making the decision about whether or not to have an elective induction may be useful in gaining more insight on this topic. Based on results of this study, pregnant women who are provided standardized evidence-based education regarding specific risks and benefits of elective induction in the context of prepared childbirth classes may be less likely to choose this method of labor and thereby decrease their exposure to the potential associated risks of this elective procedure. Patient education may be an effective tool in decreasing elective inductions among nulliparous women.
Standardized evidence-based information regarding risks of elective labor induction provided in prepared childbirth classes may be helpful in discouraging nulliparous women from choosing to have an elective induction.
Physicians offering the option of elective labor induction to nulliparous women in the absence of patient requests may be associated with an increased likelihood of women having an elective induction.
Hearing from their physicians that they are due now or overdue or that their baby is getting too big may be associated with womens choices to have an elective induction.
Patient education may be one method to decrease the rate of elective induction for nulliparous women.
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