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Inducing labor for convenience gets a second look

Rating

5 Star

Inducing labor for convenience gets a second look

Our Review Summary

This was an excellent story looking at practice variation and trends in medicine, namely, that of medically-managed birth which can potentially result in harms to patients and may increase healthcare costs. Cultural trends underpinning increased use are handled well: The story speculates that the increased practice of inducing labor may be influenced by obstetrician and patient schedules and the idea that it is equally safe to schedule a birth as it is to wait for a natural labor and delivery.

The story is quite balanced and notes ways to reduce practice variation by adhering to established guidelines.  The story also notes that requests for early labor induction may be restricted or denied by certain payers and at some healthcare settings, as the practice is not in accordance with most previously mentioned guidelines. The harms they include are well-described (if poorly supported by definitive evidence). 

The story addresses cost by implying there is an overall cost savings when labor is not induced early and the birth process is not medically managed if a mother and fetus are otherwise healthy. This story suggests that savings may be in the form of fewer birth complications, decreased risk of hemmorrhage and transfusion, less pain medication for longer labors, shorter hospital stays for infection or unplanned caesarean births and fewer days in neonatal intensive care for problems related to immature lungs and related respiratory problems.  It is optimistic to think that the sort of data they discuss is sound; actual evidence-based cost data is meager or absent. The article likely overstates the evidence, but it does directly address cost issues.

Overall, a solid piece of reporting that addresses some of the complex societal issues that may be driving the phenomenon of medically managing childbirth.  

Criteria

Does the story adequately discuss the costs of the intervention?

Satisfactory

The story addresses cost by implying there is an overall cost savings when labor is not induced early and the birth process is not medically managed if a mother and fetus are otherwise healthy. This story suggests that savings may be in the form of fewer birth complications, decreased risk of hemorrhage and transfusion, less pain medication for longer labors, shorter hospital stays for infection or unplanned caesarean births and fewer days in neonatal intensive care for problems related to immature lungs and related respiratory problems.  It is however, optimistic to think that the sort of data they discuss is sound; actual evidence-based cost data is meager or absent. The article likely overstates the evidence, but we give a satisfactory rating as they do directly address cost issues.

Does the story adequately quantify the benefits of the treatment/test/product/procedure?

Satisfactory

The story mentions that sometimes an induced labor is medically-appropriate for the safety of the mother and her infant.  The story also mentions recent data published in Annals of Family Medicine suggesting that even in healthy women, labor induction can be safe if women are appropriately selected.  However, the focus of the story is on the trend to induce labor for the sake of convenience in otherwise healthy women. The story makes  the strong case that adherence to evidence-based guidelines may reduce some of the harms of this practice. 

Regarding the title of Nicolson’s work and the concept of "preventive induction", indeed the title of the paper is somewhat insidious and not directly addressed by this article. The concept that retrospective cohort data can support the concept of finding an "optimal time" for medical intervention to prevent risks in normal, uncomplicated pregnancies that are not post dates deserves to be closely examined. The implication is that we will be able to determine through data when it is the best time to "prevent" normal onset of labor. A radical notion that was not much dealt with since we are so accustomed to the concept that aspects of prenatal and birth care can prevent many outcomes which in fact they cannot.

Does the story adequately explain/quantify the harms of the intervention?

Satisfactory

The harms they include are well-described (if poorly supported by definitive evidence). The risks may outweigh the benefits if labor is induced early without sufficient medical reason.  Among harms listed are potentially longer labors and related dehydration and infection; increased rates of unplanned caesarean births; longer hospital stays for both mother and baby; increased risk of birth injuries and more time spent in the neonatal in-hospital care for babies born with underdeveloped lungs or to heal birth injuries.

Does the story seem to grasp the quality of the evidence?

Satisfactory

In the interest of balance it is important to note that few trials are available to determine the risks/benefits and costs. The story presented an advocate, a nay-sayer, some commentators, and included the concept that more research is needed. However, they may have walked-by the fact that meta-analyses of trials to date do not find strong influence on cesearean rates and are underpowered for outcomes like neonatal death, NICU admission, fetal asphyxia, etc.   

Does the story commit disease-mongering?

Satisfactory

The story does not engage in disease mongering. The story is quite balanced and notes practice variation and ways to reduce the trend of medically-managed birth. The inclusion of details about the medicalization of birth and related cultural trends is a plus.

Does the story use independent sources and identify conflicts of interest?

Satisfactory

The story cites a new mother and several researchers and obstetricians who provide perspective on this issue and list pros and cons of the increasingly common practice of induced labor in the U.S.  All sources are appropriately identified by their practice, related research publications and university or medical center affiliation.

Does the story compare the new approach with existing alternatives?

Satisfactory

This story considers the "treatment option" of electively substituting a medical intervention for a physiologic process without specifically noting that it is an odd concept of "treatment" (except indirectly in Klein’s and the Intermountain representative).  The story does a good job of talking about how convenience and "consumer driven" the choice is but falls just short of really closing the loop that most normal things don’t require a treatment to replace them.

Does the story establish the availability of the treatment/test/product/procedure?

Satisfactory

The story notes the wide range of practice variation.  The story also notes that requests for early labor induction may be restricted or denied by certain payers and at some healthcare settings as the practice is not in accordance with most evidence-based guidelines.

Does the story establish the true novelty of the approach?

Satisfactory

The story notes that the practice of inducing labor and rates of caesarean births have increased.  The story speculates that this practice may be influenced by obstetrician and patient schedules and the idea that it is equally safe to schedule a birth as it is to wait for a natural labor and delivery. Novelty is not invoked though the cultural trends underpinning increased use are handled well.

Does the story appear to rely solely or largely on a news release?

Satisfactory

The story has an excellent variety of sources and there is balanced reporting on the trend to induce early labor in medical practices in the U.S.

Total Score: 10 of 10 Satisfactory

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