Elective Induction Brochure

The Agency for Healthcare Research and Quality has recently issued a brochure on elective induction [ok, it looks like it went 404 on me, but here is a webpage with I think the same information on it, just not in brochure form]. The Family Way Publications has a good response about what’s wrong with the brochure. I would merely add that any time you choose an elective medical procedure, it only serves to introduce risk without a balancing or over-riding benefit. I agree with the rebuttal that the risks should be talked about in stronger terms, unless the brochure is not intending to dissuade women from an elective induction. I agree with being “fair and balanced” and trying to present both sides of the story, if that’s possible; but sometimes it’s not possible. What this brochure is doing is making it sound like a coin toss between waddling around for a few more days or weeks (which as far as I know, poses only mild and short-term discomfort for most women, and no long-term medical problem; if there is a medical problem necessitating induction, then that’s not elective), or choosing a medical procedure with known risks (including iatrogenic prematurity, more problems for both mother and baby during and after labor and birth, an increased risk of C-sections in first-time moms or those with unfavorable cervices) for no medical benefit. It shouldn’t be a coin toss. Weighing both sides of the issue in a balance, elective induction is a clear loser, and women should be dissuaded from that. The brochure does not seem to do that. It mildly mentions that women should wait until 39 weeks to be electively induced, but without a strong demonstration of the reasons why that is the best choice (certainly for the baby, who faces a doubled risk of NICU admissions, etc., at 38 weeks and a quadrupled risk at 37 weeks), women are left with the idea that the risks are about equal to the benefits, when that’s just not the case.

In fact, I wonder why they even put together this brochure at all. It seems to me that the only reason to do so would be to dissuade women from choosing an elective induction — after all, if the doctor suggests an induction, most women would think there would be some medical reason or benefit to doing it, and at the least would just be following the doctor’s lead. That may fit the definition of “elective” in that anything that is undertaken for no medical benefit is “elective”; but it doesn’t fit the narrower definition, of it being the mother’s choice, and I might add, the mother’s idea. Rather, it is the doctor’s idea, and the mother acquiesces. If I were to put together a brochure about elective induction, it would be with the idea of giving it out to women who are contemplating asking their doctor or midwife to end their pregnancy early, to dissuade them from so doing, not to leave them with the impression, “Six of one, half-dozen of the other.”

6 Responses

  1. Is it possible that the brochure was intended to make women *less* worried about elective induction? An attempt to normalize it, as just as valid a choice as remaining pregnant? I don’t know this organization that put the brochure out, are they reliable?

  2. This brochure sounds more like something to make the woman okay with the DOCTOR suggesting an elective induction. Many OBs today rutinely induce during the 39th week. I’ve even heard of practices that require women to be induced before they hit 40 weeks! (run, run, run for the hills!) If the doctor has this nifty little pamplet, published by a government organization, to hand out to his patient at 24 weeks (or whenever) when he first starts talking about ‘we like to induce everyone during their 39th week if labor doesn’t start on its own’, then the woman is less likely to put up a fight. After all an induction is far easier on the doctor, never mind harder on the baby and the mother. If they schedule the labor they can schedule it around times they will already be in the office and, hey, since your risk of c-section is doubled, they have twice the chance to cut and rush..home to dinner that is. After all, if they happen to be off and the baby needs extra hospital care, or if the mother happens to need additional care, it won’t be THEM that’s providing it. I bet we would see a lot less OBs wanting to induce/c-section if THEY had to follow their patients from admittance to discharge. I bet the first time they end up spending two weeks straight in the NICU, sleeping in a chair next to the crib and worried parents, because their elective induction at ’39’ weeks ended up being a 37 week baby who wasn’t quite ready, they would rethink the wisom (and convience!) of early inductions!
    And yes, I know I’m being wildly unfair, and painting all OBs who suggest inductions with the same brush…its called sarcasm. I’m sure somewhere out there there is an OB who has a perfectly legitimate reason, that is patient based not provider based, to suggest an elective induction at 39 weeks….And for those that say ‘the OB deserves a life too’, maybe they should refer some of (all of!) their low risk pregnancies over to midwives so they don’t end up with 20 patients all due during the same two week period (or even two day)! Their lack of life and personal time is in direct proportion to how many woman they choose to take on with delivery dates close to each other.

  3. Yes, I do think this brochure will increase the likelihood a woman will ask to be induced. Whether that is the *intent* or not, I couldn’t say. It seems to be something that a doctor or midwife can hand to a woman (perhaps so as not to cut into the valuable 5 minute prenatal visit?); but whether it is in-depth enough or accurate enough about the risks to be worthwhile is what bothers me.

    If the woman has not brought up elective induction, but for example, is handed the brochure (along with other brochures or hand-outs, just as a matter of course), then that may plant the seed in her mind to *ask* for an elective induction, when she otherwise might not have. Otherwise, would she even have known it was available? And then, “since the woman asked for it” the doctor just has to go along with it, to keep his patients happy!!

    If she brought up elective induction without having seen this brochure or anything else pro-induction (maybe just because all of her friends were induced, so she thinks it’s normal), then this will likely not dissuade her from choosing it… but the doctor (or midwife) could point to it, to say that “she was aware of the risks and consented.”

    Of course, as I stated in the post, [in my never-humble opinion ;-)], a medical procedure should only be done for medical reasons, and if the only reasons are “elective” then the person should be dissuaded from it. The fact that this brochure is not dissuasive bothers me.

  4. The AHRQ is set up like the Cochrane review. If you find Cochrane reliable the AHRQ is basically the same but done by Americans and Canadians. Their goal is to look at the literature and find evidence on how to best practice. So with induction of labor you would also have to look at iufd rates according to gestational age. We know that the IUFD rates go up after 40 weeks and they go up dramatically after 42. So you can sit around till 42 weeks then induce or you could try and induction at 41 weeks which would cut down on some chance of iufd. Iufd is a small risk but a risk nonetheless. And of course you have to look at bishop score.

    • Meta-analyses of studies are only as good as the studies themselves. If the studies are flawed, the meta-analysis will be as well. I read the link Yehudit put on your blog, and it seems pretty good and logical. I wonder if I’ve read it before, because it seemed somewhat familiar — maybe that’s where I got the objections or questions I had on your blog.

      It does seem somewhat bogus to include IUFDs from the 60s, when stillbirth rates were so high and obstetric knowledge and prenatal surveillance were quite poor compared to today’s standards. Plus the quadriplegic baby from the induction group whose injuries were not included in any of the studies much less the meta-analysis — and perhaps other babies as well? And the high crossover rate (1/3 from each group) is a bit of a confounding factor as well, I daresay.

      As I said, I’m still skeptical that these “good results” are going to be broadly applicable in routine elective inductions at 41 weeks — but since many women are being electively induced at 39 weeks or before, that is even more troubling, if doctors use this study to say that “elective inductions have good results with low problems.”

      But the main thing is that women are given true informed consent about all of their options. I’ve heard so many stories of women being pressured into an induction because “your baby could die” — which is true, but that doesn’t give a true picture of the risk (1/1000); or they’re offered an induction because, “aren’t you tired of being pregnant yet?” at 37-39 weeks, without being told of the greater risk of neonatal problems or increased risk of C/s. Sometimes the information can probably be overwhelming for women to consider, but it still should be offered them anyway, since it’s their decision to make, their bodies that are going to be induced and/or sectioned, and their babies that are going to be born. Some women may opt for an early induction out of a severe fear of IUFD; others may refuse even a post-term induction out of a severe fear of C/s for failed induction, or just a strong feeling that their bodies and/or babies are not ready yet despite what the calendar says.

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