Midwives are panicking over a new study.
According to the Society for Maternal Fetal Medicine, where the data was presented last week:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Interventions improve birth outcomes and letting nature take its course in pregnancy is far from the best decision.[/pullquote]
In a study with more than 6,100 pregnant women across the country, researchers randomly assigned half of the women to an expectant management group (waiting for labor to begin on its own and intervening only if problems occur) and the other half to a group that would undergo an elective induction (inducing labor without a medical reason) at 39 weeks of gestation. Results include:
• Lower rates of cesarean birth among the elective induction group (19%) as compared to the expectant management group (22%)
• Lower rates of preeclampsia and gestational hypertension in the elective induction group (9%) as compared to the expectant management group (14%)
• Lower rates of respiratory support among newborns in the induction group (3%) as compared to the expectant management group (4%)“Safe reduction of the primary cesarean is an important strategy in improving birth outcomes,” said William Grobman, MD, MBA, who presented today’s findings and is professor in obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine. The research presented is part of, “A Randomized Trial of Induction Versus Expectant Management,” more commonly referred to as the ARRIVE Trial, which was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD).
You can read the brief presentation here:
…Women in the IOL [induction of labor] group delivered significantly earlier than those in the EM [expectant management] group (39.3 weeks (IQR 39.1 – 39.6) vs. 40.0 weeks (IQR 39.3 – 40.7), p<.001). The primary perinatal outcome occurred in 4.4% of the IOL group and 5.4% of the EM group (RR 0.81, 95% CI 0.64 – 1.01; p = .06). Need for neonatal respiratory support was significantly less frequent in the IOL group (Table). The frequency of CD was significantly lower in the IOL group (18.6% vs. 22.2%, RR 0.84, 95% CI 0.76 – 0.93), as was preeclampsia/gestational hypertension (Table). A priori baseline subgroup analyses showed no differences by race/ethnicity, maternal age > 34 years, BMI > 30 kg/m2, or modified Bishop score < 5 (all P-values for interaction > .05) for either the primary perinatal outcome or CD. IOL at 39 weeks in low-risk nulliparous women results in a lower frequency of CD without a statistically significant change in the frequency of a composite of adverse perinatal outcomes.
This is not surprising. It confirms a variety of studies that have been published in the last 6 years. The central reality of the timing of labor is this, which graphs the risk of stillbirth against the length of pregnancy.
Contrary to the claims of natural childbirth advocates that babies are “not library books due on a certain date,” there is an optimal time to be born and the death rate rises on both sides of that optimal time.
We’ve known that elective induction decreases perinatal mortality:
Stock, Sarah J., Evelyn Ferguson, Andrew Duffy, Ian Ford, James Chalmers, and Jane E. Norman. “Outcomes of elective induction of labour compared with expectant management: population based study.” BMJ 344 (2012): e2838.
Induction improves maternal and neonatal outcomes:
Gibson, Kelly S., Thaddeus P. Waters, and Jennifer L. Bailit. “Maternal and neonatal outcomes in electively induced low-risk term pregnancies.” American Journal of Obstetrics & Gynecology 211, no. 3 (2014): 249-e1.
Induction lowers the risk of C-section:
Mishanina, Ekaterina, Ewelina Rogozinska, Tej Thatthi, Rehan Uddin-Khan, Khalid S. Khan, and Catherine Meads. “Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis.” Canadian Medical Association Journal 186, no. 9 (2014): 665-673.
Obstetricians have been discussing the wisdom of recommending routine 39 week inductions for years. The issue was debated at the 2016 ACOG annual meeting, with Dr. Errol Norwitz recommending routine induction:
“Nature is a terrible obstetrician,” he said, referring to the “continuum” of pregnancy and birth: the large number of zygotes that never implant, the 75 percent lost before 20 weeks, and stillbirth.
And, he said, the risk of stillbirth and neurological injuries rises after 39 weeks. “Stillbirth is a hugely underappreciated problem,” he said. “There are anywhere between 25,000 to 30,000 stillbirths a year in the United States.”
And Dr. Grobman himself explored the issue in a 2016 commentary in The New England Journal of Medicine.
In this issue of the Journal, Walker et al. … report the results of a trial in which more than 600 women who were at least 35 years of age were randomly assigned to labor induction between 39 weeks 0 days and 39 weeks 6 days of gestation or to expectant management. This study was powered to detect at least a 36% relative difference between the two groups in the frequency of cesarean delivery. A total of 32% of the women assigned to the induction group, as compared with 33% of the women assigned to the expectant-management group, underwent a cesarean delivery (relative risk, 0.99; 95% confidence interval, 0.87 to 1.14). There were no significant differences between the groups in other adverse maternal or perinatal outcomes, but such outcomes were uncommon…
The authors note the need for “a larger trial to test the effects of induction on stillbirth and uncommon adverse neonatal outcomes.” I am the principal investigator of such a trial (ClinicalTrials.gov number, NCT01990612), which is currently under way …
It is this study that is being reported now.
Midwives are appalled and nurse midwives have rushed to reaffirm their support of “normal physiologic birth”:
ACNM President Lisa Kane Low, PhD, CNM, FACNM, FAAN cautioned against any rush to change practice … “ACNM has consistently noted there are a number of potentially negative implications when we disrupt the normal physiological processes of labor and birth,” Kane Low said. Research related to the longer-term effects of induction of labor is emerging, but is still insufficient to determine its full impact. Additionally, spontaneous labor offers substantial benefits to the mother and her infant, as ACNM has affirmed in its Consensus Statement on Physiological Birth.
She wrote on Facebook:
What’s missing is the focus on process …
Wait, what? Induction at 39 weeks improves multiple outcomes — lowers the C-section rate, lowers the rate of pre-eclampsia, lowers the need for newborn respiratory support — and Kane Low thinks we should focus on process instead of outcomes? Really?
I’m not surprised midwives are panicking about this study. It undermines the entire raison d’etre of contemporary midwifery theory, the belief that birth in nature is better than birth with interventions. This study shows in the clearest way possible that interventions improve birth outcomes and letting nature take its course in pregnancy is far from the best decision.
Of course, everyone except contemporary midwives have known that since the beginning of recorded history. Midwives were in charge of childbirth for more than 1,000 generations and the perinatal and maternal mortality rates were hideous throughout. It took modern obstetrics only 3 generations to drop the neonatal mortality rate by 90% and the maternal mortality rate by more than 90%.
Midwives did a terrible job when childbirth was midwife-led and childbirth is just as dangerous as it has ever been. Indeed, in every time, place and culture, childbirth has been a leading cause of death of young women and THE leading cause of death in the 18 years of childhood. No matter. Contemporary midwives believe that increasing their market share and profits depends of pretending that childbirth is safe and that obstetricians (the folks who reduced neonatal and maternal mortality by 90%) are the ones who made it dangerous. Many of them even believe it.
Midwives have proceeded to whip up a moral panic over the issue of C-sections and interventions. As I noted last week:
A moral panic is a widespread fear, most often an irrational one, that someone or something is a threat to the values, safety, and interests of a community or society at large…
This moral panic serves to reinforce and strengthen the social authority of midwives. They fear they are losing control of childbirth and they are desperate to gain it back.
It is too soon to change clinical practice based on these findings; we haven’t yet seem the complete paper. Moreover, extraordinary claims require extraordinary evidence.
I suspect that evidence will be forth coming. It makes sense considering what we know about pregnancy and about C-sections. The most common indications for a first C-section are a baby too big to fit or possible fetal distress. Babies are smaller at 39 weeks than anytime thereafter (they gain approximately a half pound a week at this stage) and the placenta is usually in optimal condition. It’s hardly surprising that babies are more likely to fit and less likely to experience fetal distress.
Given the amount of evidence that already exists, we should share this information with pregnant women so they can decide for themselves if they wish to be induced at 39 weeks. Medical ethics demands that we share what we know with our patients, not withhold the information in order to pressure women into a decision the provider might prefer. That goes for midwives as well as obstetricians.
I predict that going forward we will hear a lot from midwives about “nuance” and putting the findings “in perspective.” They are going to do everything they can to ignore the scientific evidence for as long as they can. Their profits depend on it, but more importantly, their fundamental beliefs depend on it and most people don’t give those up without a tremendous fight.
