A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes

Published on Aug 1, 2020
· DOI :10.1016/J.AJOGMF.2020.100148
Rebecca F. Hamm5
Estimated H-index: 5
(UPenn: University of Pennsylvania),
Sindhu K. Srinivas4
Estimated H-index: 4
(UPenn: University of Pennsylvania),
Lisa D. Levine15
Estimated H-index: 15
(UPenn: University of Pennsylvania)
Abstract: Background There are significant disparities between Black and non-Black women in the United States in birth outcomes. Yet, there are little data on methods to reduce these disparities. While the cause of racial disparities in health is multifactorial, implicit bias is thought to play a contributing role. To target differential management, studies in non-obstetric populations have demonstrated disparity reduction through care standardization. With wide variation by site and provider, labor management practices are the ideal target for standardization. Objective We aimed to evaluate the impact of a standardized induction of labor protocol on racial disparities in cesarean delivery rate and maternal/neonatal morbidity. Study Design We performed a prospective cohort study of women undergoing an induction from 2013-2015. Full-term (≥37 weeks) women carrying a singleton pregnancy with intact membranes and an unfavorable cervix (dilation ≤2cm, Bishop score ≤6) were included. We compared the cesarean delivery rate and maternal/neonatal morbidity between two groups stratified by race (Black vs. non-Black): 1) women induced in a randomized trial (n=491) that utilized an induction protocol with standardized recommendations for interventions such as oxytocin and amniotomy at particular time points and 2) women in an observational arm (n=364) enrolled at the same time whose induction and labor management occurred at provider discretion. Regression modeling was used to test an interaction between the induction protocol and race. Results A significant reduction in cesarean delivery rate for Black women managed with the induction protocol was noted when compared to those in the observational group (25.7% vs. 34.2%, p=0.02), while there was no difference in cesarean delivery rate for non-Black women (34.6% vs. 29.9%, p=0.41). The induction protocol reduced the racial disparity in cesarean delivery rate (interaction term p=0.04), even when controlling for parity, BMI, indication for labor induction, and Bishop score at induction start. Additionally, a significant reduction in neonatal morbidity was seen for Black women managed with the induction protocol (2.9% vs. 8.9%, p=0.001), with no difference for non-Black women (3.6% vs. 5.5%, p=0.55). The induction protocol did not significantly impact maternal morbidity for either race. Conclusion A standardized induction protocol is associated with reduced cesarean delivery rate and neonatal morbidity for Black women undergoing induction. Further studies should determine if implementation of induction protocols in diverse settings could reduce national racial disparities in obstetric outcomes.
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