SALT LAKE CITY — When Jessica Page, an OB-GYN doctor at University Hospital, was nearing the end of her pregnancy, she faced the same dilemma confronted by many her own patients: Whether or not to opt into an induction of labor at 39 weeks of gestation.
"I think all moms wonder, 'What's the right thing for me? What's the right thing for me and the best thing for my baby?'" Page said. "And I feel like I knew that my baby at 39 weeks was ready to come out, in regards to maturation, and … the decision to go ahead with an induction at that point felt like the right thing to do."
"Basically, there wasn't a lot to be gained by continuing pregnancy — I didn't feel strongly about going into spontaneous labor," she said, though she knows firsthand that many others feel differently.
Researchers hope that thanks to a new study about cesarean sections from the University of Utah, expectant mothers like Page and the patients she treats will have better data than ever to work with as they decide how to handle the question of whether or not to receive an induction — a medical treatment deliberately initiating the delivery.
Results from that research published for the first time Wednesday show that, contrary to a long-held popular perception among health providers, induction at 39 weeks does not increase a first-time mother's chances of needing an emergency C-section, said Dr. Robert Silver, co-author of the study and chairman of the Department of Obstetrics and Gynecology at the U.
In fact, Silver said, the findings now published in the peer-reviewed New England Journal of Medicine show a lower C-section rate among first-time mothers who participated in an elective induction at 39 weeks, compared to those who gave birth following spontaneous labor.
"If you would have told me this 10 years ago, I would have been flabbergasted," Silver said. "It's been treated as dogma, and in fact hospitals have had policies to not do inductions for fear of increasing the C-section rate. So this really does run contrary to dogma."
Some other recent research also "suggested that it decreased (chances of a cesarean section), but those studies weren't very scientifically robust," he said. "They were kind of retrospective studies."
Silver's clinical study, which began in 2014, enrolled 6,106 healthy first-time expectant mothers who indicated they were willing to commit to whichever course of action they would be randomly assigned: To receive an elective induction or not.
Roughly 3,000 women were in each group, cared for at 41 hospitals throughout the United States. About 1,200 of the subjects were from Utah.
The study found 18.6 percent of those who received an elective induction underwent a C-section, compared to 22.2 percent of those who did not receive such a procedure. The difference in rates was statistically significant, Silver said.
"The induction not only didn't increase the risk of a cesarean (section), but it actually decreased it. … I would conclude that delivery at 39 weeks is a reasonable option for patients who choose to do that and doctors who choose to do that," he said.
But Silver was also quick to add that the study's findings shouldn't imply that an elective induction at 39 weeks of pregnancy is a necessary course of action for every expectant mother.
"It's really a kind of personalized medicine thing — we can help people make the best choices for them, because both options are pretty reasonable," he said. "It's really important that people don't conclude that everybody should be induced at 39 weeks. It's that if that seems attractive to you, that's a reasonable option. If it doesn't seem attractive to you, it's not a necessary option."
Silver said the longstanding belief in the medical community that inductions increase risks for a C-section, combined with a steady increase in the use of C-section procedures overall, has led to an understandable suspicion in some women about the risks incurred by inducing labor deliberately.
"The rate of cesarean sections in this country is double what it used to be, without improving outcomes," he said. "The rate of cesarean sections is 32 percent and … one of the reasons why we're excited about this study is it's a potential way to reduce cesarean sections."
Data shows "medically unnecessary cesarean deliveries in healthy first-time mothers account for 80 percent" of all C-section procedures in the United States, Julie Kiefer, manager of U. science communications, said in a release.
"Although the procedure is generally safe, the major surgery increases risk for complications to both mother and baby," Kiefer said.
Other health effects
The study also tracked several severe negative outcomes among subjects, including stillbirth, neonatal death, brain damage and seizures, among other things, and in each group took a composite percentage of all those outcomes combined.
The combined percentage of the severely bad outcomes was 4.3 percent in those who had been induced, and 5.4 percent in those who were not induced, Silver said, but the difference was not quite wide enough to be considered statistically significant.
The study did find statistically significant differences when measuring the rate of women who developed a high blood pressure condition called preeclampsia in connection with their delivery, as well as in subjects' babies who were born with respiratory distress. In each case, there were lower rates of the complication among women who had been induced at 39 weeks.
Still, "even though outcomes were better or borderline better for the baby (for those who were induced), it doesn't mean that your baby's going to be sick if you choose (differently)," Silver cautioned.
"The absolute risk is low. So if it's really important for a mom to not be induced, and try to be natural and holistic, that's an acceptable option, and most outcomes are still good," he said.
All of the study's findings "held true regardless of the woman's age, ethnicity" and body mass index, according Kiefer.
Increase in inductions?
In Utah, women who have already given birth previously are frequently induced, according to Silver.
"We have a lot of patients (in Utah) who have several kids, so over time we've learned that the outcomes with an elective induction (for mothers with multiple children) are really good, and so that's why it's become generally accepted," he said.
In other places in the country, the practice hasn't caught on as much, Silver added. So in Utah, the type of results as shown in his study may eventually lead to "about five to 10 percent of our patients" choosing to be induced "above and beyond what we are already doing," he said, but elsewhere the new information "may have more of an influence on labor and delivery."
From her perspective as a doctor and a mother, Page says, the value in the study "is that it gives the patient another option in terms of being able to make decisions for herself and her baby."
"Having that shared decision-making model, and giving them the information they need to approach that, that's kind of the big thing."
The funding for the study was provided by the National Institutes of Health, Silver said.