Marjana Woloshyn, a 35-year-old
prosecution lawyer in Halifax, is in the 41st week of
her first pregnancy. Her obstetrician's told her that
if she doesn't go into labour by next Friday, he wants
to induce. Although Marjana's relieved to know that she'll
soon be able to tie her own shoes again, she's also a
little alarmed ? can't induction lead to complications?
According to a recent report released
by the Canadian Institute for Health Information (CIHI),
Marjana's not alone in her fears. Labour induction is
on the rise across Canada, although rates vary wildly
from province to province. In Newfoundland 13% of births
are induced, while in Marjana's home province of Nova
Scotia rates are double that.
Dr Michael Helewa, president-elect
of the Society of Obstetricians and Gynaecologists of
Canada (SOGC), points out that more medical intervention
in labour isn't necessarily a bad thing, given that
it coincides with a steady drop in perinatal mortality
rates. And while induction can lead to longer labour
and increased risk of cesarian deliveries, most of these
complications are a result of unfavorable condition
of the cervix at the time of induction or the effect
of the pre-existing problems in pregnancy that prompted
the induction in the first place.
A variety of factors have sparked
the induction trend, according to Dr Helewa. First,
he says, there's the matter of patient demographics.
Women are having their first babies later in life, obesity
is rife, and the increasing use of reproductive technologies
to get pregnant can lead to more complicated births.
Patients' expectations are also
changing. "They're expecting perfect babies, and relatively
painless labour," says Dr Helewa. These expectations
can put pressure on doctors to use whatever technologies
are available.
BEYOND
DEMOGRAPHY
But there are also reasons beyond demographics, Dr Helewa
points out. Residents may be fuelling the trend by imitation.
"When residents see that obstetricians induce at 41
weeks, they're going to perpetuate that scenario," he
says.
Not surprisingly in a country this
size, geography often comes into play. Many smaller
hospitals have closed their maternity units due to funding
cuts or a dearth of physicians willing to deliver babies,
so rural women must be transported to urban centres
to deliver. Once in the city, they can be induced so
as to avoid a long wait far from home. "They're what
we call a 'social induction' or a 'convenience induction,'"
says Dr Helewa.
Finally, there's the evidence.
An emerging body of research suggests that induction
can lead to better outcomes in a number of situations,
including two recent Canadian studies, both led by Dr
Mary Hannah of the University of Toronto Perinatal Clinical
Epidemiology Unit. The first, the Canadian Multi-centre
Post Term Pregnancy Trial, showed that in post-date
pregnancies (lasting more than 41 weeks), inductions
reduced rates of caesarean infection (results published
in June 11, 1992 issue of NEJM). A second trial
showed that induction of labour for women with rupture
of membranes at term reduces the risk of maternal infections
(in the April 18, 1996 issue of NEJM). The SOGC
also recommends induction for the 7% of women who suffer
from hypertensive diseases during pregnancy as well
as diabetics.
"The main contributing factor for
the recent rise in inductions of labour is the increase
in inductions for post-date pregnancies," says Dr Helewa.
"That's not based on the whim of physicians. It's based
on evidence that induction produces superior outcomes."
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