related to who provides the care suggests that these miss-ing data would not affect the direction of the findings,but this remains an uncertain conclusion.

The importance of this article leads one to wish formore information. For example, the article does not iden-tify cause of death for the 345 fetuses and babies whodied by day seven. A comparison of the causes of deathcould provide additional topics for study. The maternalage category of < 25 years of age does not reveal the in-cidence of adolescent pregnancies in this study. Readerswill also find themselves asking for a copy of the Obstet-ric Indication List that identifies when referral to an ob-stetrician is expected.

The publication of this article provides an opportunityto revisit the status of home birth in the United States. Itis clear that the ACOG position works in opposition tothose who might strive to establish a safety net compara-ble to the Netherlands for women who want—or in thecase of a disaster, are forced—to give birth outside ofthe hospital. On the other hand, this research providesmidwives who attend births at home the opportunity toincorporate new evidence into their practice that mightlead to greater acceptance by their medical colleagues.There is little doubt that community-wide acceptance ofand support for home birth cannot be expected until pro-fessionals can speak in unison about the risk factors thatpreclude a home birth. Unfortunately, the rapid increasein the number of primary cesarean deliveries and the lackof opportunity to have a vaginal birth after cesarean inthe United States has made reaching these agreementsmore difficult. Some women now see birth outside thehospital as their only option if they wish to avoid therisks of multiple cesarean deliveries. It remains to beseen if the future of home birth in the United States restsin the hands of those who have staked out opposing po-sitions or if new data will tip the discussion toward theprovision of maternity care that is more inclusive thanwhat currently exists.

LABOR INDUCTION: DO GUIDELINES DECREASE ADVERSEOUTCOMES?

Fisch JM, English D, Pedaline S, Brooks K, Simhan HN. Labor in-duction process improvement: A patient quality-of-care initiative.Obstet Gynecol 2009;113:797–803.

Reviewed by: Tekoa L. King, CNM, MPH.

The rate of labor induction in the United States has in-creased dramatically in the last 15 years, from 9.5% in1990 to 22.3% in 2006.1 As the number of inductions hasincreased, adverse outcomes associated with inductionshave also increased. Elective induction of labor before 39weeks of gestation increases the risk of neonatal morbid-ities, including respiratory distress, temperature instability,

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hypoglycemia, hyperbilirubinemia, difficulty feeding, andhospital readmission.2 Retrospective studies of the out-comes of women who undergo elective induction of laborhave confirmed these findings.3 Since 1999, the AmericanCollege of Obstetricians and Gynecologists has recom-mended that elective induction not be performed before39 completed gestational weeks.4 Unfortunately, profes-sional association guidelines have not stemmed the induc-tion epidemic.

Magee Hospital in Pittsburgh, PA developed guidelinesin 2004 stating that elective induction should not be per-formed unless the woman was $ 39 weeks of gestationwith accurate dating and had a Bishop score of $ 8 for pri-miparas and $ 6 for multiparas. The incidence of electiveinductions continued to be high despite these guidelines.In 2006, the staff at Magee Hospital initiated a quality im-provement project and a tougher induction scheduling pro-cess that was designed to strictly enforce the guidelinesand decrease the incidence of elective induction. Morethan 9300 women give birth at Magee Hospital every year.

Fisch et al conducted a retrospective cross-sectionalcomparison of the induction rates before and after theinitiation of the quality improvement project and induc-tion scheduling process. Outcomes of interest includedelective and total induction rates, gestational age atinduction, and birth outcomes. The authors comparedall scheduled inductions during 3 time periods: a 3-month period in 2004 (n = 533), the same 3-month pe-riod in 2005 (n = 454), and a 13-month period in 2006to 2007 (n = 1806) that followed the adaptation of thepolicies.

The maternal and obstetric characteristics of the womendid not differ in any of the three time periods. The electiveinduction rate (elective inductions/total deliveries) was9.1%, 9.3%, and 6.4% (P < .001) in the three time periods,respectively. The rate of elective inductions before 39weeks of gestation (< 39-week elective inductions/totalelective inductions) decreased from 11.8% to 10.0% to4.3% (P < .001) in the three time periods, respectively.The total induction rate (total inductions/total deliveries)decreased from 24.9% in 2004 to 16.6% in 2006 to 2007.The cesarean birth rate among nulliparas who had electiveinductions fell from 24.5% to 15.2% to 13.8% in the threetime periods, respectively.

The enforcement of strict guidelines was effective inlowering the total and elective induction rates in this insti-tution and the rate of cesarean births among nulliparouswomen who were induced. There are at least two ‘‘take-home’’ messages of import from this study. First, qualityimprovement projects that have buy-in from all involvedcan be successful. Secondly, the study findings with regardto cesarean birth rates following induction reinforce thevalue of requiring that a cervix be favorable before electiveinduction. As we enter a new era characterized by enthu-siasm for health care reform in a climate of economic hard-ship, models of care that improve health outcomes and

Volume 54, No. 4, July/August 2009

decrease costs are of significant interest to everyone con-cerned: childbearing women, health care providers,payers, and policy makers.

REFERENCES

1. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F,Kirmeyer S, et al. Births: Final data for 2006. Natl Vital Stat Rep2009;57:1–201.

Journal of Midwifery & Women’s Health � www.jmwh.org

2. Engle WA, Kominiarek MA. Late preterm infants, early terminfants, and timing of elective deliveries. Clin Perinatol 2008;35:325–41.

3. Clark SL, Miller DD, Belfort MA, Dildy GA, Frye DK,Meyers JA. Neonatal and maternal outcomes associated with elec-tive term delivery. Am J Obstet Gynecol 2009;200:156.e1–4.

4. American College of Obstetrician and Gynecologists. Induc-tion of labor. ACOG Practice Bulletin 10. Washington, DC: Amer-ican College of Obstetricians and Gynecologists, 1999.

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