Induction at 39 weeks – does it really benefit women?

Induction at 39 weeks – does it really benefit women?

A presentation of the preliminary results of the ARRIVE study on Induction at 39 weeks was given at the Society for Maternal Fetal Medicine Annual Meeting. The internet was all abuzz about the results.  One group saying it indicates that if we want to reduce cesareans we should automatically be inducing at 39 weeks; and the other saying it is wholly inappropriate.

Dr. Rebecca Decker from Evidence based birth did a podcast on the subject, and did a great job at disseminating what we know so far.  This was my takeway from that podcast:

  1. Yes, this does seem to reduce cesareans by a very small amount – 3.5%
  2. But there were flaws in the study, including bias, and lack of true controls.
  3. This method does not work with the Midwifery Model of care.
  4. This method would only be for those who do not care if they have a medicalized/Interventional birth, or who truly medically need an induction.
  5. If you desire a natural birth there are much better ways to reduce your chances of a cesarean (see below).
  6. The NUMBER NEEDED TO TREAT (NNT) was 28.  That means you would have to induce 28 women to prevent 1 cesarean.
  7. Walking, Doulas, Waterbirth and Birth Centers all have an NNT# of 9. That means using these methods prevents 1 cesarean for every 9 women.  Not only statistically better, but all are much better, safer, and  less technical ways of preventing cesareans.
  8. Following ACOG’s new guidelines for Normal birth (reducing interventions, only inducing for medical reasons, allowing longer times in labor and pushing, intermittent auscultation, etc.) has been shown in two recent studies (Bell 2017, and Jabbernick 2017) to reduce the cesarean rate by anywhere from 25 – 50%.
  9. *2022 update: “Obstetricians are increasingly recommending routine labor induction at 39 weeks because a large obstetric trial found that 19% of low-risk first-time mothers allocated to induction at 39 weeks had cesareans compared with 22% allocated to planned expectant management. If those same women had planned community birth, 8 to 12 fewer women per 100 would have had cesareans, thereby sparing them, their babies, and the babies of future pregnancies the hazards of surgical delivery. ” (Henci Goer, https://childbirth-u.com/safe-at-home-or-birth-center/ )
  10. Bottom line: You do  not have to have an induction to reduce your cesarean rate. There are safer, cheaper, easier ways of doing that.

Update 2024:

Normally it takes anywhere from 13 to 20 years of a preponderance of research to change clinical practice, but since the Arrive trial came out officially in 2018 hospitals and Obstetricians have jumped on the band wagon, and adopted the practice whole heartedly. (Azria, et. al. )  This means it is now common practice to convince women to allow themselves to be induced for non-medical reasons. We wish they had waited because no fewer than 6 new studies have emerged that negate the conclusions of the Arrive trial.  But no one seems to be paying attention to them.

To quote Dr. Sara Wickham:    “Another study has shown that induction for non-medical reasons in healthy women increases the chance of caesarean section. By non-medical reasons, we mean where induction is offered because of a risk factor (such as age, BMI, or having reached a particular week of pregnancy) rather than because of an actual medical condition, such as pre-eclampsia. Analysis of data from all of the births that occurred in Victoria, Australia over an eight-year period showed that induction rates increased over that time. The researchers also discovered that induction in lower-risk women having their first baby was associated with a higher chance of having a caesarean. Induction didn’t make a significant difference to perinatal mortality, which was rare in both induced and non-induced women. This is one of many studies which have found that induction increases caesarean without leading to significant benefit in perinatal mortality. It should cause us to continue to question some clinicians’ quoting of studies such as the ARRIVE trial, which have been shown to be flawed, and not an accurate representation of what happens in the real world. Induction also has medium- and long-term consequences, which aren’t always considered in studies looking only at immediate outcomes. Induction is a significant decision and it is important to weigh up the pros and cons before you decide what’s right for you.”   (Dr. Sara Wickham)   https://www.sarawickham.com/research-updates/induction-increases-caesarean/

I also suggest reading researcher Henci Goer’s analysis of the studies before making a choice. https://hencigoer.com/routine-39-week-induction-busting-the-arrive-trial/?mc_cid=a1d920be7a&mc_eid=596f4ec5f1 

That said, in looking at the statistics for my Bradley students it becomes obvious that taking a Bradley class also reduces your chances of a cesarean by more than 50% (from the national average of 32.2% down to 15%. (Population 591, over a 29 year period).  The national average for Bradley students is even lower – 13%.

So, take a Bradley class, learn how to stay healthy and low risk, hire a doula, use a Midwife, and move during labor. Consider using a Birth Center and having a Water-birth if those options are available in your area.

Contact me for more information: Amy  V. Haas, BCCE ajvhaas@gmail.com

Original References:

https://clinicaltrials.gov/ct2/show/NCT01990612
https://www.sciencedaily.com/releases/2018/02/180201115718.htm

http://www.midwife.org/induced-labor-study-statement

http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/arrive-study-39-week-induction-reduces-frequency-cesarean-healthy-women

https://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-past-your-due-date/

https://www.facebook.com/EvidenceBasedBirth/ -Live analysis of the study

http://www.ajog.org/article/S0002-9378(17)32491-2/fulltext

https://childbirth-u.com/safe-at-home-or-birth-center/

Davey M-A and King J (2016). Caesarean section following induction of labour in uncomplicated first births- a population-based cross-sectional analysis of 42,950 births. BMC Pregnancy and Childbirth 2016:16:92

Kjerulff K, Attanasio LB, Edmonds JK et al (2017). Labor induction and cesarean delivery: A prospective cohort study of first births in Pennsylvania, USA. Birth: Issues in Perinatal Care. DOI:10.1111/birt.12286

References: newer studies 2020 + since the publication of the Arrive Trial:

  • Khalaf SY, Heazell AEP, Kublickas M et al (2024). Risk of stillbirth after a previous caesarean delivery: A Swedish nationwide cohort study. BJOG. 2024; 00: 1–8. https://doi.org/10.1111/1471-0528.17760
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  • Butler SE, Wallace EM, Bisits A et al (2024). Induction of labor and cesarean birth in lower-risk nulliparous women at term: A retrospective cohort study. Birth. 2024; 00: 1-9. doi:10.1111/birt.12806
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  • Hu Y, Homer CSE, Ellwood D et al (2024). Likelihood of primary cesarean section following induction of labor in singleton cephalic pregnancies at term, compared with expectant management: An Australian population-based, historical cohort study. Acta Obstet Gynecol Scand. 2024; 00: 1-9. doi:10.1111/aogs.14785

Amy V. Haas 2024