Elective labor induction vs expectant management of pregnant women at term and children's educational outcomes at 8 years of age

Abstract

Objective To estimate the effect of elective induction of labor at 39 weeks' gestation on children's educational outcomes as measured using the Australian National Assessment Program—Literacy and Numeracy (NAPLAN) tests in school year 3 (∼8 years of age), compared with expectant management. Methods We merged perinatal data on all infants born in South Australia from 1999 to 2008 with children's school assessment data from NAPLAN. The study population included all singleton infants born without a malformation at 39–42 weeks in vertex presentation. Children who had undertaken the NAPLAN test in school year 3 were included. We excluded births to women who had a contraindication to vaginal delivery and those with a condition possibly justifying elective delivery before 39 weeks. The outcome of interest was children's educational outcome as measured using NAPLAN, which includes five learning domains (reading, writing, spelling, grammar and numeracy). Each domain was categorized according to performance at or below vs above the national minimum standard (NMS). Average treatment effects (ATEs) of elective induction of labor at 39 weeks compared with expectant management on the proportion of children performing at/below the NMS for each domain were estimated using the augmented inverse‐propensity‐weighted estimator, accounting for potential confounders. Results Of 53 843 children born at 39–42 weeks in vertex presentation from 1999 to 2008 and who were expected to participate in the year‐3 NAPLAN from 2008 to 2015, a total of 31 120 had at least one year‐3 NAPLAN domain. Of these, 1353 children were delivered after elective induction of labor at 39 weeks while 29 767 children were born following expectant management. The ATEs (mean differences) of elective induction of labor at 39 weeks compared with expectant management on the proportion of children scoring at/below the NMS on each domain were 0.01 (95% CI, –0.02 to 0.03) for reading, 0.02 (95% CI, 0.00–0.04) for writing, 0.01 (95% CI, –0.01 to 0.04) for spelling, 0.02 (95% CI, –0.01 to 0.04) for grammar and 0.03 (95% CI, 0.00–0.05) for numeracy. Conclusion Elective induction of labor at 39 weeks did not affect children's standardized literacy and numeracy testing outcomes at 8 years of age when compared with expectant management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology

Developmental Outcomes for Children After Elective Birth at 39 Weeks’ Gestation

“…A large retrospective cohort study from Scotland demonstrated a step-wise decrease in the probability of special education needs with advancing gestation, a trend that extended into postterm gestations. 5 Recent cohort studies have concluded that those born electively at 39 or 40 weeks' gestation had similar year 3 school performance outcomes compared with those born following expectant management (from Australia, where 1353 were induced at 39 weeks' gestation 6 ; and Rhode Island, where 455 were induced at 39 or 40 weeks' gestation 7 ). To our knowledge, no large cohort studies have examined the impact of inducing birth at 39 weeks' gestation on global childhood developmental outcomes beyond educational performance, such as social competency, emotional maturity, and communication skills.…”

New Markers for Placental Dysfunction at Term – Potential for More

“…The results of a large randomized controlled trial concerning the clinical benefit of induction of labor at term (ARRIVE study: A Randomized Trial of Induction Versus Expectant Management) indicate that in primipara without relevant risk factors an elective induction of labor from 39 + 0 weeks of gestation (WG) may lower the caesarean section rate without negatively influencing the perinatal outcome [16]. Furthermore, a recent study of a large number of cases (n = 53 843) was able to demonstrate that the elective induction of labor from 39 + 0 WG did not seem to have an influence on the childʼs school performance at an age of 8 years [17]. Recently, an increased rate of IUFD could be observed when exceeding the delivery date and prolongating beyond 41 + 0 WG (SWEPIS study: SWEdish Post-term Induction Study), although methodological limitationsparticularly those concerning the heterogeneity of the study populationneed to be considered [18].…”

“…The currently available results concerning fetomaternal Doppler ultrasound in the low-risk population (AGA fetuses) and its association with an APO, in particular in late-term cases, raise the question of whether abnormal Doppler indices can or even should be cause for clinical consequences (even in the case of physiological amniotic fluid volume and CTG). Taking into account the current data around the added value of induction of labor in the low-risk population at term or late term 16 , 17 , 18 , anomalies in the established fetomaternal Doppler indices should give rise to the consideration of whether the recommended offer of induction of labor at 41 + 0 20 in the S3 guideline should be a recommendation instead of an offer. At the very least, the authors believe that – if the fetomaternal Doppler ultrasound is properly used as part of the fetal monitoring in the low-risk population – an appropriate patient education and a participative form of decision-making should be employed when deciding on the timing of induction of labor during the late-term period.…”

“…Die Ergebnisse einer großen randomisiert-kontrollierten Studie zur Frage des klinischen Nutzen einer Geburtseinleitung am Entbindungstermin (ARRIVE-Studie: A Randomized Trial of Induction Versus Expectant Management) deuten darauf hin, dass bei Erstgebärenden ohne bedeutsame Risikofaktoren durch die elektive Geburtseinleitung ab 39 + 0 SSW die Sectiorate gesenkt werden kann ohne Negativbeeinflussung des perinatalen Outcomes 16 . Hinzu kommt, dass die elektive Geburtseinleitung ab 39 + 0 keinen Einfluss auf die Schulleistung im Alter von 8 Lebensjahren zu haben scheint, wie eine aktuelle Studie mit großer Fallzahl (n = 53 843) belegen konnte 17 . In der Phase der Terminüberschreitung konnte kürzlich eine erhöhte IUFT-Rate bei Prolongation über 41 + 0 SSW hinaus beobachtet werden (SWEPIS-Studie: SWEdish Post-term Induction Study), wenngleich methodische Schwächen – insbesondere, was die Heterogenität des Studienkollektivs betrifft – berücksichtigt werden müssen 18 .…”

“…Vor dem Hintergrund aktueller Daten zum Mehrwert der Geburtseinleitung im Low-Risk-Kollektiv in Terminnähe bzw. in der Terminüberschreitung 16 , 17 , 18 ist bei Auffälligkeit von etablierten fetomaternalen Doppler-Indices zu überdenken, inwieweit es sich bei dem in der S3-Leitlinie empfohlenen Angebot der Geburtseinleitung in 41 + 0 20 nicht um ein Angebot, sondern um eine Empfehlung handeln sollte. Zumindest verlangt es nach Einschätzung der Autoren – sofern die fetomaternale Doppler-Sonografie regelhaft angewandt wird in der fetalen Überwachung im Low-Risk-Kollektiv – eine adäquate Aufklärung der Patientin und partizipative Entscheidungsfindung, wenn es um die Frage des Zeitpunkts der Geburtseinleitung in der Terminüberschreitung geht.…”