5 Ways to Prevent the Need for Induction of Labor – A Response to the ARRIVE Study

— by Faith Groesbeck, BA, CCCE, CD (BAI)

This month, the results of the ARRIVE study, or A Randomized Trial of Induction Versus Expectant Management, were presented at the Society for Maternal-Fetal Medicines annual meeting, called the Pregnancy Meeting™. This study is explained in more depth on the Evidence Based Birth® website, in the article on due dates.

The research showed that in over 6,000 women, inducing labor at 39 weeks without any other medical indication, reduced the overall risk of cesarean, developing pregnancy complications and harm to the baby. While advocates warn that this may mean that we face a future in which all pregnancies will be forced to end before reaching their due date, I’m a little more optimistic. In my experience, I’ve found it more likely that the pregnant person will choose an induction once this becomes an option for them rather than their healthcare provider imposing it on them. Provider practices vary greatly across the country, so I’m not sure this is the case everywhere, but to date, no professional organizations have said that this should become the standard of care (SMFM).

This research brings attention to two sides of the coin when it comes to the induction debate between those who advocate for physiologic birth versus those who seek better outcomes through technology. On the one hand, birth is a normal process, best left unhindered when possible. On the other, the longer a person remains pregnant, the more likely they are to develop pregnancy complications and the more time the fetus has to grow inside the uterus. I’m not saying our bodies are not marvelous and capable of birthing babies much larger than average, which is around seven and a half pounds.  I’m sitting somewhere in the middle of do nothing and intervening thinking, is there a way to prevent the need for induction and still have good outcomes?

While I realize the tremendous pressure parents are under to do everything “right,” I’ve also spoken to a lot of women who have said that if they had known that there was any chance that they could have possibly prevented the need for an induction or a cesarean, they would have gladly made changes in their lifestyle to at least reduce the risk.

So, here are some tips that may help to reduce the need for induction. I’m not saying that if everyone follows these ideas that they are guaranteed the outcome they desire or that women who do not do these things are at fault if intervention is necessary. I am saying that we may have some control over outcomes if it is our desire and within our means to explore these options. As always, please consult with your healthcare provider before making dietary or fitness changes during pregnancy.

  1. Hire a doula. Having a doula present at your birth increases the likelihood of having a spontaneous vaginal delivery (Hodnet). A spontaneous vaginal delivery is when the pregnant person goes into labor on their own, without the use of drugs and that the baby is born without the use of forceps, vacuum extraction or cesarean.
  2. Eat Dates. Several studies have shown that eating dates at the end of pregnancy, can reduce the need for an induction (Al-Kuran; Jadidi and Kordi). The general recommendation is to eat 6 dates per day, starting at 36 weeks.
  3. Practice Yoga. While yoga has many health benefits throughout a person’s life, a study done in Iran found specifically that doing one hour of yoga, six times per week, starting at 26 weeks, reduced the need for induction and resulted in fewer cesarean births (Jahdi).
  4. Quit Smoking. Smoking is a risk factor for having a smaller than expected fetus or having the amniotic sack, or bag of waters, break before their due date. Both may, under certain circumstances, be indications for induction of labor.
  5. Eat a Low GI Diet. While early induction for those who develop diabetes in pregnancy is not evidence based, gestational diabetes does increase the risk of developing other complications which may then make induction the safest choice. Eating a low glycemic diet during pregnancy decreases the risk of developing gestational diabetes and thus the risk of developing further complications (Brand-Miller).

As a doula, I’m here to support families, often with otherwise healthy pregnancies, who face decisions around inductions. I’m also glad that through childbirth education, families can adopt healthy lifestyle practices that may be able to prevent the need for an induction in the first place.

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Al-Kuran, O., Al-Mehaisen, L., Bawadi, H., Beitawi, S., & Amarin, Z. (2011). The effect of late pregnancy consumption of date fruit on labour and delivery. Journal of obstetrics and gynaecology31(1), 29-31.

Brand-Miller, J., Marsh, K., & Moses, R. (2013). The Low GI Eating Plan for an Optimal Pregnancy: The Authoritative Science-Based Nutrition Guide for Mother and Baby. Workman Publishing.

Hodnett, E. D., Gates, S., Hofmeyr, G. J., Sakala, C., & Weston, J. (2012). Continuous support for women during childbirth. Cochrane Database Syst Rev10.

Jadidi, M. Y., Sang, S. J. B., & Lari, H. (2016). The effect of date fruit consumption on spontaneous labor. Journal of Research on Religion & Health1(3).

Jahdi, F., Sheikhan, F., Haghani, H., Sharifi, B., Ghaseminejad, A., Khodarahmian, M., & Rouhana, N. (2017). Yoga during pregnancy: The effects on labor pain and delivery outcomes (A randomized controlled trial). Complementary therapies in clinical practice27, 1-4.

Kordi, M., Aghaei Meybodi, F., Tara, F., Nemati, M., & Taghi Shakeri, M. (2014). The effect of late pregnancy consumption of date fruit on cervical ripening in nulliparous women. Journal of Midwifery and Reproductive Health2(3), 150-156.

Society for Maternal-Fetal Medicine. (2018, February 1). Induced labor after 39 weeks in healthy women may reduce the need for cesarean birth: More information is needed before changes to clinical practice are made. ScienceDaily. Retrieved February 16, 2018 from www.sciencedaily.com/releases/2018/02/180201115718.htm

Top 5 Predictions for Childbirth in 2016

These are my predictions for childbirth in 2016.  What do you think? Please include your thoughts and your own predictions in the comments!

5.)           WHO changes their position on episiotomies

“Perhaps it is time to move beyond the question ‘What are the appropriate indications for episiotomy?’ to the more fundamental question ‘Is there an appropriate indication for episiotomy?’

— From D. Lyon, Global Library of Women’s Medicine

In 1996, the World Health Organization published “Care in Normal Birth: A Practical Guide,” recommending an episiotomy rate of 10%.  Since that time, episiotomy rates in most countries have declined.  The practice of selective episiotomies has continued despite the fact that there has never been a randomized controlled trial showing that they have any benefit whatsoever.

This has become a point of contention between some birthing women and their providers.  In fact, in 2015, an obstetrician in the United States surrendered his license after being caught on video performing a forced episiotomy on a patient.

In 2014, a study was undertaken in Brazil called, Comparison of Never Performing an Episiotomy to Performing it in a Selective Manner, or EPISIO.  Although the study is complete, the results are not yet published.  The researchers collected data on newborn, as well as maternal outcomes.  If this research shows that, even in cases of macrosomia and fetal distress, episiotomy holds no benefit, the World Health Organization may take a stand that even 10% is too high, with global implications.

4.)           ARRIVE study results increase elective inductions

In June of 2015, the Over the Moon Doula Group in Grand Rapids, Michigan, hosted Rebecca Dekker of Evidence Based Birth as a part of their Seminar Series.  The topic was due dates.

Dekker’s lecture introduced me to the A Randomized Trial of Induction Versus Expectant Management (ARRIVE) study, in which women would be randomly assigned to either induction at 39 weeks or expectant management.  Although some of the sites are still recruiting subjects, the data should be in by the summer of 2016 and results may become public by the year’s end.

Other than furthering the schism between the medical and natural childbirth camps, news that elective induction at 39 weeks prevents adverse outcomes could place a strain on hospitals.  As Dekker pointed out, if hospital maternity wards are full with women being induced, will there be enough room left for women who arrive already in labor?

3.)           US cesarean rates continue to decline

The cesarean rate for birth in the United States hit an all-time high in 2009, but has declined for most racial and ethnic groups since. This has not been an accident, but due to a concerted effort by consumers, researchers, hospitals and providers.

For example in 2014, the American Congress of Obstetricians and Gynecologists (ACOG) changed the definition of active labor from 4 to 6 cm, cause more women who present in early, or latent labor, to be sent home.

The coming year may also see changes in hospital policies on Vaginal Birth After Cesarean (VBAC), which holds the potential to further decrease the cesarean rate.  Many women choose to have their VBAC at home, not because that is their first choice, but because no other options are available. A study published in the Dec. 2015 issue of Birth showed that, although Home Births After Cesarean (HBAC) have high success rates, when a uterine rupture does occur, perinatal death is more likely.  As local work on perinatal regionalization, a system of designating where infants are born or are transferred based on the amount of care that they need at birth, continues, more community hospitals may reverse their VBAC bans.  This will make VBACs more accessible and safer for women who prefer a hospital birth closer to home.

2.)           Out-of-hospital birth rates continue to rise

While out-of-hospital births represent a small percentage of all birth in the United States, they have been on the rise since 2004. When it comes to home births in one West Michigan county, Kent, home births have increased 116% in the last 8 years!

According to the American Association of Birth Centers, the number of freestanding birth centers in the United States also continues to rise, from 170 in 2004 to 248 in 2013. There are currently two freestanding birth centers in West Michigan, Cedar Tree Birthing Suite in Grand Rapids and Midwifery Matters in Greenville.  As more birth centers continue to open, the number of women choosing this option will also grow.

1.)           More states will pass laws providing insurance reimbursement for doulas

All the research points to the potential healthcare savings if doulas become more widely available, due to the lower rates of cesareans, pitocin induction, medical pain relief and more.  At the present, only two states, Minnesota and Oregon, require Medicaid to cover the cost of a birth doula.

All that could change now if three national organizations, Choices in Childbirth, the National Partnership for Women and Families and Childbirth Connection, have anything to do with it!  Key Recommendation in an executive summary released in early 2016, include having congress mandate Medicaid coverage for doulas and state legislatures mandating private insurance coverage for doulas.  If policy makers take their advice, 2016 may turn out to be “The Year of the Doula”!