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A Preventive Approach to Obstetric Care in a Rural Hospital: Association Between Higher Rates of Preventive Labor Induction and Lower Rates of Cesarean Delivery

¹ Department of Family Medicine and Community Health, University of Pennsylvania Health System, Philadelphia, Pa
² Private Practice, Putnam, Conn
³ Department of Obstetrics and Gynecology, Washington University, St Louis, Mo

CORRESPONDING AUTHOR: James M. Nicholson, MD, Department of Family Medicine and Community Health, Hospital of the University of Pennsylvania, 3400 Spruce St, 2 Gates, Philadelphia, PA 19104, james.nicholsonMD{at}uphs.upenn.edu

PURPOSE Annual cesarean delivery rates in North America are increasing. Despite the morbidity associated with cesarean delivery, a safe preventive strategy to reduce the use of this procedure has not been forthcoming. During the 1990s, clinicians in a rural hospital developed a method of care involving prostaglandin-assisted preventive labor induction. An inverse relationship was noted between yearly hospital rates of labor induction and cesarean delivery. The purpose of our study was to compare cesarean delivery rates between practitioners who often used preventive induction and practitioners who did not, while controlling for patient mix and differences in practice style.

METHODS Between 1993 and 1997, different hospital practitioners used risk-guided prostaglandin-assisted preventive labor induction with differing intensity. We used a retrospective cohort design, based on the practitioner providing prenatal care, to compare birth outcomes in women exposed to this alternative method of care with those in women not exposed. Multiple logistic regression analysis controlled for patient characteristics and clustering by practitioner.

RESULTS The exposed group (n = 794), as compared with the nonexposed group (n = 1,075), had a higher labor induction rate (31.4% vs 20.4%, P<.001), a greater use of prostaglandin E₂ (23.3% vs 15.7%, P <.001), and a lower cesarean delivery rate (5.3% vs 11.8%, P <.001). Adjustment for cluster effects, patient characteristics, and the use of epidural analgesia did not eliminate the significant association between exposure to this preventive method of care and a lower cesarean delivery rate. Rates of other adverse birth outcomes were either unchanged or reduced in the exposed group.

CONCLUSIONS A preventive approach to reducing cesarean deliveries may be possible. This study found that practitioners who often used risk-guided, prostaglandin-assisted labor induction had a lower cesarean delivery rate without increases in rates of other adverse birth outcomes. Randomized controlled trials of this method of care are warranted.

Key Words: Cesarean delivery • preventive care • labor induction • prostaglandin E₂ • birth outcomes • maternity care • practice-based research

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