Background
There are marked disparities between black and nonblack women in the United States
in birth outcomes. Yet, there are little data on methods to reduce these disparities.
Although the cause of racial disparities in health is multifactorial, implicit bias
is thought to play a contributing role. To target differential management, studies
in nonobstetrical populations have demonstrated disparity reduction through care standardization.
With wide variation by site and provider, labor management practices are the ideal
target for standardization.
Objective
In this study, we aimed to evaluate the effect of a standardized induction of labor
protocol on racial disparities in cesarean delivery rate and maternal and neonatal
morbidity.
Study Design
We performed a prospective cohort study of women undergoing an induction from 2013
to 2015. Full-term (≥37 weeks’ gestation) women carrying a singleton pregnancy with
intact membranes and an unfavorable cervix (dilation ≤2 cm, Bishop score of ≤6) were
included. We compared the cesarean delivery rate and maternal and neonatal morbidity
between 2 groups stratified by race (black vs nonblack) as follows: (1) women induced
in a randomized trial (n=491) that utilized an induction protocol with standardized
recommendations for interventions such as oxytocin and amniotomy at particular time
points and (2) women in an observational arm (n=364) enrolled at the same time whose
induction and labor management occurred at provider discretion. Regression modeling
was used to test an interaction between the induction protocol and race.
Results
A significant reduction in cesarean delivery rate in black women managed with the
induction protocol was noted when compared with those in the observational group (25.7%
vs 34.2%; P=.02), whereas there was no difference in cesarean delivery rate in nonblack women
(34.6% vs 29.9%; P=.41). The induction protocol reduced the racial disparity in cesarean delivery rate
(interaction term, P=.04), even when controlling for parity, body mass index, indication for labor induction,
and Bishop score at induction start. In addition, a significant reduction in neonatal
morbidity was found in black women managed with the induction protocol (2.9% vs 8.9%;
P=.001), with no difference in nonblack women (3.6% vs 5.5%; P=.55). The induction protocol did not significantly affect maternal morbidity for
either race.
Conclusion
A standardized induction protocol is associated with reduced cesarean delivery rate
and neonatal morbidity in black women undergoing induction. Further studies should
determine whether implementation of induction protocols in diverse settings could
reduce national racial disparities in obstetrical outcomes.
Key words
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Article info
Publication history
Accepted:
May 21,
2020
Received in revised form:
May 20,
2020
Received:
November 14,
2019
Footnotes
This study was funded in part by a career development award in Women’s Reproductive Health Research (K12-HD001265-15) and a T32 training grant in reproductive epidemiology (T32-HD007440).
The authors report no conflict of interest.
Cite this article as: Hamm RF, Srinivas SK, Levine LD, et al. A standardized labor induction protocol: impact on racial disparities in obstetrical outcomes. Am J Obstet Gynecol MFM 2020;2:100148.
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