As Cases of Induced Labor Rise, So Do Experts' Concerns

-originally in the New York Times, 1/14/03

By JANE E. BRODY

A number of obstetrical experts are becoming increasingly concerned about the growing number of pregnant women whose labors are induced for no apparent medical reason. Since 1990, the proportion of births resulting from an induced labor has doubled: one baby in five is now born after the birth process has been started by a drug.

In about half of these cases, the reason for induction is not related to any medical problem in the woman or her unborn baby, said Dr. William F. Rayburn, an expert in maternal and fetal medicine at the University of New Mexico Health Sciences Center in Albuquerque.

Rather, a decision to induce labor is often reached for reasons of convenience to the mother, the family or the doctor. In some cases, women worried about the baby's health may exert pressure; in other cases, doctors may fear medical liability for waiting, Dr. Rayburn and his colleague, Dr. Jun Zhang, wrote this year in the journal Obstetrics and Gynecology, after reviewing the research on the topic.

"Now more than ever, obstetricians are concerned about anything going wrong," Dr. Rayburn said. Increasing numbers of lawsuits have so escalated the cost of malpractice insurance and the burdens of litigation that many obstetrician-gynecologists have abandoned obstetrics altogether.

In most hospitals, Dr. Rayburn and Dr. Zhang reported, the instances of induced labor now exceed the combined number of Caesarean deliveries, vaginal births after a previous Caesarean and vaginal deliveries requiring forceps. The numbers are even higher in many community hospitals, where more than 40 percent of births are induced, with as many as three of four done for no compelling medical reason, according to a review of 7,000 consecutive inductions published in 1999 in The American Journal of Obstetrics and Gynecology.

Induced labor greatly increases the costs and health risks of childbirth because time spent in labor in the hospital is longer, and the need for Caesarean deliveries is greater, Dr. Karen E. Kaufman, an expert in maternal and fetal medicine at Northwestern University Medical School, and her co-authors at Northwestern and the University of North Carolina reported in an analysis in October in The American Journal of Obstetrics and Gynecology.

"Induction increases the length of labor and often increases the need for pain relief because of the more prolonged labor," Dr. Rayburn said in an interview.

Induction results in Caesarean deliveries, he said, when the cervix fails to dilate or dilates very slowly or stops before full dilation, or when the woman becomes too fatigued to push the baby out or when the resulting contractions are too strong for the baby to tolerate them well. Caesareans after inductions are particularly common in first pregnancies, he said.

So why do so many women ask to be induced?

"Most women just want to get their pregnancies over with," said Dr. Deborah A. Wing of the University of Southern California. "They consider it abnormal if they go one day past their due date. They don't realize that the due date is merely a suggestion."

Dr. Kaufman cautioned, "Women should not be asking to be induced just for the sake of convenience."

In an uncomplicated single-birth pregnancy, it is more economical to wait up to two weeks past a woman's due date before trying to induce labor, the researchers from Northwestern and North Carolina wrote.

But, they noted, induction of labor has "potential tangible benefits" because delivery prevents the possibility that the fetus will die before birth, which occurs in 1 pregnancy in 1,000 among women past their due dates who wait for labor to start naturally.

The team acknowledged that the best way to deal with a pregnancy lasting beyond 40 weeks had never been clearly established.

Doctors who favor induction argue that waiting longer increases the risk of a Caesarean delivery because the fetus gets too big for a vaginal birth, and they also cite the risk of stillbirth and complications.

Those who favor waiting for labor to begin naturally point to studies showing that induction increases costs of childbirth and the need for Caesarean deliveries when induced labors fail to progress normally.

For women whose labor is induced before their due dates, or when a due date cannot be firmly established, Dr. Wing said, "there is a small increase in the number of newborns who must be placed in intensive care because of pulmonary complications" related to prematurity.

There are well-established medical reasons for inducing labor before a woman's due date, Dr. Rayburn said in an interview. They include medical problems in the pregnant woman, like diabetes or high blood pressure; pregnancy-related problems, like premature rupture of the membranes that encase the unborn baby, or a placenta that begins to detach from the uterine wall; and fetal problems, like an irregular heartbeat, retarded fetal growth or insufficient amniotic fluid bathing the fetus.

The current ability to detect fetal distress has raised the rates of both labor induction and Caesarean deliveries.

There are also "soft indications" for inducing labor, Dr. Rayburn said. These may include a woman who is overly anxious because of a previous pregnancy problem, a woman who lives very far from the hospital or a woman with a history of rapid delivery who is at risk of giving birth before reaching the hospital.

When there is a medical reason for inducing labor, the potential benefits greatly outweigh the risks, the experts said. The benefit-to-risk ratio is less clear when the reasons for induction are psychological or social. Some working women, for example, want the convenience of a planned delivery.

"Obstetrics has become very consumer-driven," Dr. Wing said. "When a woman can't get what she wants from one doctor, she'll go to another, so economics is driving the issue a bit." But she added: "Spontaneous labor is always preferable. The Caesarean section rates are doubled anytime you try to force the process along. You don't know what you will end up with."

Experts also condemned the practice of some doctors to administer an induction agent and send the woman home, telling her to return when labor is well established.

"Inductions should always be done in a hospital and the woman should be monitored continuously for uterine contractions and for the response of the fetal heart rate to those contractions," Dr. Wing said.

Some concern has also been raised about the use and abuse of certain induction agents. The drug most often used for cervical ripening — the process of softening the cervix that allows it to dilate — is misoprostol, a prostaglandin marketed as Cytotec. It is approved by the Food and Drug Administration for the treatment of ulcers, not for labor induction, and its use in obstetrics is considered "off label" but legal; once a drug is approved for one purpose, it can be used by doctors for other reasons.

Dr. Rayburn said misoprostol was "very inexpensive and effective, but requires close monitoring to detect changes in the cervix and excessive undesirable uterine activity." This drug sometimes causes uterine contractions that are more frequent and powerful than normal labor and has occasionally resulted in rupture of the uterus, particularly in women who have had previous Caesarean deliveries.

In August 2000, Searle, which markets Cytotec, cautioned doctors about administering the drug to pregnant women, noting that off-label use of the drug had resulted in reports of uterine rupture, hysterectomy and the death of women and babies. The warning prompted some hospitals to restrict the use of misoprostol for inductions.

Still, it is considered the drug of choice for labor induction, and when given in low doses and coupled with close monitoring, most obstetricians in this country believe it is safe, Dr. Rayburn said. Alternative agents, Cervidil and Prepidil, are much more expensive, he said.

Dr. Rayburn said that more research needed to be done on the circumstances under which inductions were performed and on the effects of induction on cost and long-term health of mothers and babies.

Meanwhile, he added: "There is nothing better than a natural spontaneous labor. Women should exercise patience and not be overly demanding about having their labor induced." When women are considering induction or when their doctors recommend it for nonmedical reasons, he suggested that women get second opinions.

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