PATTERNS AND OUTCOMES OF INDUCTION

OF LABOUR IN AFRICA AND ASIA: A

SECONDARY ANALYSIS OF THE WHO

GLOBAL SURVEY ON MATERNAL AND

NEONATAL HEALTHHTTP://WWW.PLOSONE.ORG/ARTICLE/INFO%3ADOI%2F10.1371%2FJOURNAL.PONE.0065612

By Shreena and Tasneem

WHAT IS LABOUR INDUCTION?

Induction of labour artificially

Carried out when baby is overdue or when there is a risk to

the mother’s or baby’s health

Induction can be caused by inserting a tablet or gel into the

vagina

Sometimes, hormone drips can be used to speed up

induction

Labour inductions were investigated in Asia and Africa by

WHO.

The paper uses the WHO Global Survey Data Set to

investigate the reasons for inductions and the medical

effects.

This is because labour inductions should only be performed

when the benefits outweigh the risks and in places where

caesarean sections can be performed.

METHOD

The WHO Global Survey on Maternal and Perinatal Health

was a multi- country, cross-sectional survey

Stratified multistage sampling used to obtain global sample

of countries and health institutions

Twenty-four countries participated:

Capital city + two provinces selected at random

Seven institutions randomly selected

Those institutions with 1,000+ births annually and ability to

perform caesarean sections

WHOGS contains data on 290,000+ deliveries in 373

institutions across Africa, Latin America and Asia

Analysis on seven African countries, including Kenya,

Nigeria and Uganda, and eight Asian countries including

China, India, Japan and Sri Lanka

Maternal outcomes of interest included:

Caesarean following failure of induction

Maternal death

Blood transfusion

Perinatal outcomes of interest included:

Apgar score <7at 5 minutes

Low birthweight

Early neonatal (child) death

Data from two regions analysed and reported

Mothers stratified into three groups: spontaneous labour,

induction with medical indication (defined using WHOGS

guidelines) and elective induction

Maternal, neonatal and facility characteristics compared

across three groups using percentages and chi square

tests of significance

Patterns, indications and success of induction reported as

percentages at regional and country level

Maternal models adjusted for: maternal age, marital

status, years of maternal education, number of antenatal

care visits, previous caesarean sections, medical

conditions and other factors

RESULTS•It was more frequent to have

women with medical conditions

or/and ten or more years of

educations and/or more

antenatal care visits

undergoing medical induction

as opposed to spontaneous

labour.

•Inductions were more

frequent in urban areas and

tertiary facilities.

RESULTS-RATES OF INDUCTIONS

The rates of inductions varied between regions and countries.

In Africa, the average rate of induction was 4.4% whereas in Asia the average rate was significantly higher at 12.1%.

The country with the highest rate of induction in Africa was Algeria with 6.8% and the lowest was 1.4% in Niger.

In Asia the country with the highest rate was 35.5% in Sri Lanka and the lowest was in Cambodia in 2.5%. The highest MEDC in Asia, Japan, had a rate of 19%.

Induction without medical indication was less than 2% in all the countries except from in Sri-Lanka (27.8%) , Japan (8.5%), India (3.6%) and Thailand (3.5%).

In Africa the most common indication for the induction of labour was prelabour rupture of membrane (27.9%) whereas in Asia the highest induction rates were as a result of elective inductions (47.2%)

METHODS OF INDUCTIONS

A very common method of Labour Induction was using oxytocin.

Oxytocin used alone accounted for 45.9% of induced labours inn Africa. Oxytocin used with non-drug methods accounted for 20.2%. The figures for Asia were 31.5% and 28.2% respectively.

Use of misoprostol or other prostaglandin was 15%.

Success of inductions was 84.4% in Africa and 81.6% in Asia.

Oxytocin alone was the most successful method in Africa.

Oxytocin or prostaglandin used in conjunction with non-drug methods was the most successful method in Asia.

Countries with significantly low induction rates were Uganda, Nepal, China, the Philippines, Thailand and Vietnam.

SUCCESS OF INDUCTIONS

Induction with medical indication:

was linked to increasing the odds of an Apgar score of lower than 7 at 5 mins, a lower birthweight, stillbirth and ICU admissions in both Africa and Asia.

In Africa the odds of perineal laceration increased.

In Asia the odds of not able to breastfeed within 24 hours of birth were increased.

The odds of needing a caesarean section and having to stay at hospital for longer than 7 days decreased.

In Asia the odds of hysterectomy decreased slightly

Induction without medical indication:

Induction without medical indication was linked to an increase in NICU admission in Africa and ICU admission in Asia- puts strain on resources.

There was a decrease in adjusted odds of low birth weight in Asia.

DISCUSSION

In general HICs have a higher rate of elective induction.

Some inductions were taking place before 39 weeks but this

led to less favourable outcomes.

Sometimes inductions were carried out on people who had

previously had caesarean sections (2.2% in Africa and 1.6%

in Asia). This is not recommended and therefore may have

led to poorer outcomes of inductions.

Although prostaglandins increase the chances of having

vaginal birth within 24 hours, oxytocin was still the most

common method in 10/16 countries.

DISCUSSION CONT.

In several countries in resource constrained settings, the high presence of doctors often led to more risks as they were carrying out upscale inductions excessively.

The data was not representative of the whole of Asia and Africa as only a few sites were chosen and only sites which had the capacity to perform caesareans were investigated.

Future investigations should include factors which explain why patients choose elective inductions.

Cost effectiveness and induction practices in smaller facilities should be investigated.

Recent article from the BBC states that there could be a link between induced labour and autism: http://www.bbc.co.uk/news/health-23666840

CONCLUSION

Inductions more common in Asia than Africa.

Inductions more common in HICs.

However Sri-Lanka and India are exceptions- managing to

scale up inductions in resource constrained settings.

Widespread oxytocin use.

One third of elective inductions occurred before 39 weeks.