The Agency for Healthcare Research and Quality (AHRQ) has published a new consumer brochure on labor induction. Unfortunately, this brochure is poorly written and misleading. One would think from reading the brochure that elective induction is a completely innocuous procedure that is fine for any woman who is “uncomfortable” (their word!) towards the end of her pregnancy. Just recently the National Center for Health Statistics released released a report on the rise of late preterm births in the U.S. and placed part of the blame on obstetric interventions such as induction and scheduled cesarean surgery. When we all should be working together to reduce unnecessary inductions, I am shocked that AHRQ has published such a misleading brochure.
Here are my strong objections to this brochure:
1. Inside Front Cover: Fast Facts – The second fact, “A cesarean section (c-section) might be needed if there are problems with labor. This is true for labor that is induced and for labor that starts on its own” implies that there is no difference between risk of cesarean surgery for those who are induced and those who begin labor on its own. This is misleading.
2. Inside Front Cover: Fast Facts – The fourth fact, “The risk of C-section with elective induction depends on if you have ever had a baby before” is true. However, the more important fact for consumers is that the risk of C-section is doubled for first-time mothers if labor is induced. This fact is conveniently left out.
3. Page 2 – A consumer brochure published by a “scientific” agency of the government should include the fact that misoprostal (Cytotec) has not been approved by the FDA for use in labor and that, in fact, the FDA has issued a strong warning about its use in labor.
4. Page 3 – Under the reasons why someone might not want to induce labor, there should be more information about the risks of iatrogenic prematurity. This pamphlet is written at a low literacy level. Unfortunately, we know that women from lower socioeconomic groups are more likely to delay getting prenatal care. Without an early ultrasound to confirm the due date, there can easily be a 2 to 3 week error in calculating the due date.
There is also no mention of the possible benefits to the baby of allowing labor to begin on its own. Scientists at the University of Texas Southwestern Medical School believe that it is the baby who initiates labor once the lungs are fully mature. Neonatalogist Dr. Lucky Jain said at the NIH State-of-the-Science Conference: Cesarean Delivery on Maternal Request in March 2006 that:
“In summary, physiologic events in the last few days of pregnancy, coupled with the onset of spontaneous labor, play a critical role in fetal maturation and preparation of the fetus for neonatal transition.” (last paragraph on page 104 of the conference papers)
5. Page 5: Statement of bottom of page – “ Research can’t tell us if any one woman’s chance of having a C-section is different is she chooses to be induced rather than waiting labor to start on its own.” This statement infuriates me. Yes, it’s true (for any one woman), but it minimizes the increased risk of cesarean with an induced labor. Why include this statement unless the intent is to downplay the risks of induction?
6. Page 6 – The statement, “Research shows that inducing labor does not mean that babies have a higher chance for a newborn breathing problem…” is also misleading. According to Dr. Lucky Jain (see #4 above) there are important physiological benefits to the baby in allowing labor to begin on its own. And if the due date is off and the baby is born late pre-term, then there is compelling evidence that the baby is at higher risks for respiratory and other problems.
7. Page 6 – The statement “Research doesn’t have the answers about the effect inducing labor can have on the use of pain medications, length of hospital stay, breastfeeding problems, and problems for the baby during labor” is also misleading. Earlier in the brochure, the authors acknowledge that induced contractions may be stronger and more painful earlier in labor. I don’t think that there is any doubt among healthcare professionals that induced contractions are more painful and that women who are induced are more likely to request epidural analgesia. For the first-time mother whose risk for cesarean is doubled with induction, there is a greater risk for longer hospital stay, breastfeeding problems, and problems for the baby if cesarean surgery is required.
8. Page 8 – Things to Think About: Question: Am I more likely to have a C-section if I have my labor induced? The first line of the answer, “Research can’t tell us if inducing labor makes having a C-section more likely than waiting for labor to start on its own” is untrue for first-time mothers. The second line of the answer, “But your chances of a C-section are higher if you have never had a baby vaginally before” may be a little confusing for some readers and fails to include the important information that the risk for cesarean surgery is doubled for first-time mothers who are induced.
9. Page 8 – Fourth Question: The correct and appropriate answer to “How can I improve my chances of having a vaginal birth?” is to allow labor to begin on its own. This brochure addresses only elective induction!
10. Page 9: Questions to Ask Your Doctor or Midwife – Most of the questions do not provide the information needed to make a true informed decision. None deal with the potential risks of elective induction.
I certainly hope that you will not distribute this brochure in your childbirth classes and that you will consider voicing your own objections to this poor use of taxpayer dollars which has the potential of increasing requests for elective inductions; increasing the risks for unnecessary cesareans; and increasing medical complications for both mothers and babies.