Labor induction protocol fails to reduce disparities in c-section rates

Labor induction protocol fails to reduce disparities in c-section rates | Image Credit: © JenkoAtaman - © JenkoAtaman - stock.adobe.com.

A standardized protocol for labor induction across racial and ethnic groups is not linked to reduced racial disparities in cesarean section or maternal morbidity, according to a recent study published in Pregnancy.

Significant racial disparities have been observed in obstetric outcomes, included a 10% increase in cesarean delivery risk among Black women vs White women. Data has indicated improved care delivery from interventions designed to reduce these disparities but has not evaluated the impact on morbidity.

“Labor induction is associated with a cesarean delivery rate of around 25% nationally, thereby accounting for approximately 250,000 yearly US cesareans, making induction a critical target for interventions attempting to reduce cesarean rates,” wrote investigators

Assessing labor induction as a target for intervention

The retrospective study assessed the efficacy of a standardized labor induction protocol for reducing racial disparities in obstetrics. Characteristics of the protocol included frequent cervical examinations, amniotomy for cervical exam of 4 cm or greater, and interventions in patients with labor dystocia.

Pregnant patients receiving labor induction at term, with a singleton gestation and intact membranes, and seeking cervical ripening from their clinician were included in the analysis. Those with prior cesarean delivery were excluded.

Race and ethnicity data was collected from electronic health records alongside additional demographics, labor course, and delivery data. Cesarean delivery for any indication was reported as the primary outcome.

Time to delivery, clinical chorioamnionitis, postpartum hemorrhage, composite maternal morbidity, compositive neonatal morbidity, and neonatal intensive care unit (NICU) admission over 48 hours were reported as secondary outcomes.

Differences among racial groups

There were 8386 patients included in the final analysis, 60% of whom identified as People of Color (BIPOC) in the pre-implementation period vs 58.6% in the post-implementation period. Of these, 76.3% were Black, 11.7% Asian, 7.5% Hispanic White, and 4.4% other racial groups.

Differences in body mass index, insurance status, delivery site, maternal age, parity, gestational age, hypertension, and indication for induction were reported in BIPOC patients vs White patients. Diabetes also differed between these populations in the pre-implementation period, but not the post-implementation period.

The risk of cesarean delivery was higher among BIPOC patients vs White patients in both the pre-implementation and post-implementation periods, with adjusted risk ratios (aRRs) of 1.36 and 1.55, respectively. Chorioamnionitis and postpartum hemorrhage risks were also increased among BIPOC patients in both periods.

BIPOC patients also reported a higher risk of composite maternal morbidity in both periods, with an aRR of 1.33 in the pre-implementation period and 1.46 in the post-implementation period.

Additional risks and lack of protocol impact

A shorter time to delivery was also reported in this population, but this outcome was not significant in adjusted analyses. There were also no differences in neonatal morbidity or NICU admission based on race in either period.

No significant differences in cesarean delivery or other maternal outcomes were linked to the standardized protocol. This highlighted a lack of efficacy from the protocol toward reducing racial and ethnic disparities.

Investigators also assessed the impact of the 8 protocol components individually. Most components did not influence the established associations, but the one about leaving a cervical ripening balloon in place for 12 hours after use, followed by initiating or continuing oxytocin, had a greater fidelity for BIPOC patients vs White patients in the post-implementation period.

“Despite implementation of a standardized induction protocol across racial groups, this intervention did not mitigate observed racial disparities in cesarean delivery or maternal morbidity rates,” wrote investigators.

References

1. Hamm RF, Mumford SL, Forkpa M, et al. The impact of implementing a standardized protocol for labor induction on obstetric disparities: Secondary analysis of a type I hybrid effectiveness-implementation trial. Pregnancy. 2025. doi:10.1002/pmf2.70077
2. Yee LM, Costantine MM, Rice MM, et al. Racial and ethnic differences in utilization of labor management strategies intended to reduce cesarean delivery rates. Obstet Gynecol. 2017;130(6):1285-1294. doi:10.1097/AOG.0000000000002343