Use of Induction of Labour and Emergency Cesarean Section and Perinatal Outcomes in English Maternity Services: A National Hospital-Level Study

Care provided by maternity services requires a fine balance between support for the physiological process of birth and clinical intervention when needed. Yet, clinical guidelines for maternity care vary widely within and between countries. For singleton babies born at term in 149 hospitals of the National Health Service (NHS) in the United Kingdom alone, the rate of induction of labor varied from 16% to 44%, and the overall rate of cesarean delivery (CD) varied from 17% to 35% between April 2016 and March 2017. This suggests a lack of consensus around the indications for interventions, such as induction of labor and emergency CD. The debate often focuses on either the safety of childbirth or the women's experience to deliver good maternity care. The aim of this study was to examine the association between the rates of induction of labor and emergency CD with the risks of stillbirth, neonatal intensive care unit (NICU) admission, and need for mechanical ventilation in neonates born at term. This was a national study using data collected from electronic maternity records between 2015 and 2017. Included were singleton pregnancies delivered in NHS hospitals providing maternity care. The primary outcomes were stillbirth, NICU admission, and mechanical ventilation. The entire cohort included 1,131,719 term, singleton births in 131 hospitals. The risks of stillbirth, NICU admission, and need for mechanical ventilation in the baby were 0.15%, 5.4%, and 0.54%, respectively. Between hospitals, the rate of induction of labor ranged from 17.5% to 40.7% (interquartile range, 24.6%-32.1%), and the rate of emergency CD ranged from 5.6% to 17.1% (interquartile range, 9.4%-11.8%). In hospitals with higher induction rates, the risk of adverse perinatal outcomes was lower, but the association was statistically significant only between the rate of induction and rates of stillbirth (P = 0.002) and mechanical ventilation (P = 0.001). For each 5%-point increase in the rate of induction at a hospital, there was a 9% decrease in the risk of stillbirth (odds ratio [OR], 0.91; 95% confidence interval [CI], 3%-15%) and a 14% decrease in the risk of mechanical ventilation (OR, 0.86; 95% CI, 6%-21%). There was no association between the rate of emergency CD and the primary outcomes (all P > 0.05). In the United Kingdom, the rates of induction of labor and emergency CD varied considerably between hospitals. Those hospitals with higher rates of induction had lower risks of adverse perinatal outcomes, but not for emergency CD.