Intervention isn’t better for newborns

U. ROCHESTER (US) — In low-risk pregnant women, high induction and first-cesarean delivery rates do not lead to improved outcomes for newborns, bringing into question the skyrocketing number of them performed in the United States.

“Like virtually all medical therapies and procedures, these interventions entail some risk for the mother, and there is no evidence in this study that they benefit the baby,” says Christopher Glantz, professor of maternal fetal medicine at the University of Rochester.

“In my mind, if you are getting the same outcome with high and low rates of intervention, I say ‘Do no harm’ and go with fewer interventions.”

The study is reported in the Journal of Maternal-Fetal and Neonatal Medicine.

“More is better seems to be the epitome of U.S. healthcare today, with doctors and patients often choosing to do more rather than less, even when there is no evidence to support it,” Glantz says. “But, as our study suggests, more may not always be better.”

The optimal rate of any medical intervention is difficult to define, and larger studies are needed to better understand the relationship between intervention and outcome, Glantz says, but in the meantime, it’s hard to justify high rates of interventions—especially elective—in low-risk pregnant women without any known benefits to newborns, given that these interventions pose maternal risks.

Glantz focused on pregnant women delivering in level I hospitals—those lacking a Neonatal Intensive Care Unit or NICU—because they care primarily for low-risk women who don’t have major complications, including diabetes, high blood pressure, or other severe disease. The majority of women in the U.S. deliver at a level I hospitals.

To determine the health of newborns delivered at these hospitals, Glantz looked at three outcomes: transfer of the newborn to a hospital with a NICU (signifying the presence of complications that required a higher level of care); immediate ventilation or breathing assistance; and a low 5-minute Apgar score.

The relationship between rates of induction and cesarean delivery and rates of the three neonatal outcomes show intervention rates had no consistent effect on newborns.

Even after a second round of analysis that accounted for differences among pregnant women that could potentially impact the results, the finding was the same, hospitals with high intervention rates had newborn outcomes indistinguishable from hospitals with low rates.

“If higher intervention rates were preventing negative outcomes that otherwise would have occurred, and lower intervention rates led to negative outcomes that potentially could have been avoided, the data would have revealed these relationships, but there were no such trends,” Glantz says.

The study included a group of approximately 28,800 women who labored (some naturally and some induced), followed by re-analysis of 29,700 women who had no history of previous cesarean section (some of whom ultimately delivered vaginally and others by cesarean section).

Many women in the first group were also analyzed in the second group. Women who had had a previous cesarean delivery were excluded from the second analysis, because more than 90 percent of women with previous cesareans deliver by repeat cesarean, and these are not necessarily being done to benefit the newborns.

Glantz recognizes that some labor inductions and cesarean sections, when done for specific, established medical reasons, are necessary and lead to improved outcomes. But some interventions are elective or marginally indicated, driven by social reasons such as convenience and patient requests to deliver with their own physician.

Labor induction is not always successful and is associated with an increased likelihood of cesarean delivery. Cesarean delivery, while common, is a major surgery and like all surgeries increases the risk of infection, bleeding, the need for additional surgeries, and results in longer recovery times.

The study was funded in part by the New York State Department of Health.

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