Risk factors for labour induction and augmentation: a multicentre prospective cohort study in India

OBJECTIVETo investigate clinical and non-clinical factors influencing labour induction and augmentation in pregnant women in India. DESIGNProspective cohort study of 9305 pregnant women. SETTING13 tertiary and community hospitals in six states across India. PARTICIPANTSWomen [≥]18 years of age and planning a vaginal birth in the study hospital were recruited in the third trimester of pregnancy ([≥]28 weeks of gestation) and followed-up during labour and up to 48 hours of childbirth. MAIN OUTCOME MEASURESOutcomes were induction and augmentation of labour as per childbirth records. Maternal and fetal clinical conditions in current pregnancy were abstracted from medical records at recruitment and after childbirth, and classified based on guidelines to generate induction- related clinical indication groups: (i) [≥]2 indications, (ii) one indication, (iii) no indication and (iv) contraindication. Non-clinical factors included self-reported maternal socio-demographic and lifestyle factors, and maternal medical and obstetric histories from medical records at recruitment. Multivariable logistic regression analyses were performed to identify independent associations of induction and augmentation of labour with the clinical and non- clinical factors. RESULTSAmong 9305 women, over two-fifth experienced labour induction (n=3936, 42.3%) and about a quarter had labour augmentation (n=2537, 27.3%). The majority who received labour induction/augmentation had at least one or more clinical indications, but around 34% did not have an indication. Compared with women with [≥]2 indications, those with one (adjusted odds ratio 0.50, 95% confidence intervals 0.42 to 0.58) or no (0.24, 0.20 to 0.28) indication or with contraindications (0.12, 0.07 to 0.20) were less likely to be induced, adjusting for non-clinical characteristics. These associations were similar for augmentation of labour (0.71, 0.61 to 0.84, for one indication; 0.47, 0.39 to 0.55 for no indication; 0.17, 0.09 to 0.34 for contraindications). Several maternal demographic, healthcare utilization and socio-economic factors were independently associated with labour induction and augmentation. CONCLUSIONSDecisions about induction and augmentation of labour in our study population in India were largely guided by clinical recommendations but in nearly a third, there was no clinical indication based on guidelines. Further research is required to understand the complex influence of clinical need and socio-demographic factors on labour induction/augmentation in the context of risk and safety. What is already known on this topicO_LISeveral established international and national guidelines recommend specific clinical indications and/or contraindications for induction of labour. C_LIO_LIPregnant women are also given the option to decide on labour induction and/or augmentation after providing relevant information C_LI What this study addsO_LICompared to women with at least two clinical indications as per guidelines, those with one or no indication or with contraindications were less likely to be induced or augmented, independent of other non-clinical maternal characteristics. C_LIO_LIIn a third of the participants, there was no clinical indication for induction/augmentation of labour based on guidelines. C_LIO_LISeveral non-clinical factors including maternal demographic, healthcare utilization and socio-economic factors influenced the decision for labour induction and augmentation, which in turn could be due to womens choice or clinicians unconscious bias and warrants further research. C_LI