Among the many things that distinguish the newsletter form from traditional journalism is the opportunity to have ongoing conversations. This has happened a lot with COVID, where the evolving situation and new data mean that I frequently revisit the same questions. But it’s true more broadly, and there are often times when I want to do just a bit of follow-up on earlier topics.
Today is one of those posts.
Labor-induction decision tree
One of the most common things I get asked about, on Instagram and elsewhere, is labor induction. In particular, pregnant people wonder whether they should be induced at 39 weeks or if it makes sense to wait; are there risks to induction, or benefits? The question of whether to induce labor has always been present, but a large randomized trial published in 2018 — the ARRIVE trial — changed the calculus for many providers by suggesting that labor induction did not increase the risk of C-section.
I’ve written much more about that trial in this post, but my primary takeaway is that these results should be a part of the discussion though not dispositive. This is an area where shared decision-making is the key to reaching a choice that works for you. But shared decision-making can be hard without a good structure.
Which is why I was very happy to see and share an excellent decision tool, developed by Ann Peralta. Ann has worked in maternal and children’s health for the past 15 years and has a doctorate in public health (DrPH) from Boston University. In her words:
Each year, about 600,000 people in the U.S. have an induction of labor without a medical indication. The American College of Obstetricians and Gynecologists, the American College of Nurse-Midwives, and researchers on all sides of this issue all agree that shared decision-making should be used when counseling pregnant people on this topic. That means they think pregnant people should be informed of their options and the evidence and then they should ultimately decide how their labor starts. But right now, that’s not how many people experience it.
So for my DrPH dissertation project, I tried to make shared decision-making happen on this topic. I formed a core group of providers (an OB, a family medicine physician, and two midwives), and we created an initial prototype of a shared decision-making tool and process. We recruited a larger group of providers (OBs, midwives, and nurse practitioners) to test the tool and process in three languages because we wanted to solve for inequities in who gets to experience shared decision-making. Once the tool was in use, I interviewed a very diverse group of pregnant people who experienced it to get feedback on the tool and assess whether or not shared decision-making was happening. After we had some clear improvement themes from the interviews, we revised the tool and tested the next version.
We did this three times — until we were making very minor changes to it and were hearing consistently positive experiences using the tool. I also talked to providers during each testing cycle. Many of the pregnant people I interviewed described using the tool as “awesome” and “empowering,” and providers said it improved the quality of their care and reduced bias. Our study team is working to publish our process and results in a peer-reviewed journal, but in the meantime, I know a tool on this topic has been called for by many, so we wanted to share it: www.inductiondecisionaid.org