Higher Costs With Inducing Labor at 39 Weeks? It’s Complicated

LAS VEGAS — Induction of labor at 39 weeks in low-risk nulliparous women was not linked to a universal increase in the utilization of healthcare resources, a researcher said here.

In a planned secondary analysis of a previous randomized trial, resource utilization varied greatly in the induction of labor group compared to expectant management in the antepartum, delivery admission, and post-discharge periods, reported William A. Grobman, MD, on behalf of the Eunice Kennedy Shriver National Institute for Child Health and Human Development Maternal-Fetal Medicine Units Network in Bethesda, Maryland.

Last year at the annual meeting of the Society for Maternal-Fetal Medicine, Grobman’s group presented the results of the ARRIVE trial, which found that women randomized to induction of labor had fewer cesarean deliveries, fewer hypertensive disorders of pregnancy, and their infants were linked with fewer respiratory complications. The results were later published in the New England Journal of Medicine.

But in a presentation at this year’s SMFM meeting, Grobman said that there have been concerns regarding resource implications for elective induction, including longer length of stay, more frequent use of oxytocin and epidural analgesia, and higher total costs.

He added that prior research found longer postpartum hospital stays with elective labor induction, at an estimated 15% to 30% higher cost.

“But this data was derived from observational studies where elective induction was compared to spontaneous labor, which as we know from studies of clinical outcomes is an inappropriate comparison with misleading results. The correct comparison is expectant management,” Grobman said at the presentation.

This planned secondary analysis of the ARRIVE trial examined data collected about resource utilization from time of randomization through 8 weeks post-discharge in these women. Time periods were categorized into antepartum, delivery admission, and post-discharge through 8 weeks postpartum.

Researchers analyzed data from about 3,000 women each in the induction of labor and expectant management groups from the ARRIVE trial. Baseline characteristics were similar, with women a mean age of about 25, about 45% were white, with a BMI of around 32.

Overall, a smaller portion of the induction of labor group had ambulatory and/or inpatient visits compared to expectant management:

• Office visit, routine prenatal care (32.4% vs 68.4%, respectively)
• Office visit, unanticipated (0.5% vs 2.6%)
• Urgent care/triage visit (16.2% vs 44.3%)
• Hospital admission (0.8% vs 2.2%, P<0.001 for all)

Women in the induction of labor group were associated with fewer tests, such as non-stress tests and sonograms, as well as complete blood count, and metabolic panel and preeclampsia panels. In addition, the induction of labor group was associated with fewer analgesics, IV hydration, and antibiotics.

Delivery admission was a different story, with the induction of labor group unsurprisingly linked with a significantly longer median labor and delivery duration versus expectant management (20 hours vs 14 hours, respectively, P<0.001). A significantly higher portion received cervical ripening agents and oxytocin infusion, Grobman said.

However, women in the induction of labor group were linked to significantly lower antibiotic infusion than the expectant management group and babies in the induction of labor group were linked to lower use of CPAP/high-flow oxygen. Both maternal and neonatal length of stay post-delivery were also significantly lower in the induction of labor group.

Post-discharge, babies in the induction of labor group were significantly more likely to have an unanticipated office visit, but Grobman noted they were no more likely to be taken to urgent care. There was also no difference in frequency of unanticipated postpartum visits or admissions, he said.

Grobman concluded that there were significant differences in resource utilization between the two groups, but it was dependent on when the care was received, and that the advantages of elective induction shown in the ARRIVE trial are “not gained at the expense of uniformly greater health care resource use.”

“I’m glad to see that the business side has not been lost in the medicine side of all this,” an audience member commented at the presentation.

Grobman responded that while he thought it was important to understand how the effect of the medical decisions on healthcare resources, “I think we need to be laser focused on health outcomes,” he said.