Induced Labor Associated With Poor School Performance

Anke Brodmerkel

March 09, 2023

On average, children born following induced labor perform worse at school at age 12 years than their peers who were born after spontaneous onset of labor. This is the outcome of a report by Anita Ravelli, PhD, and her team of Dutch researchers in the Department of Obstetrics and Gynecology of the Amsterdam University Medical Center (UMC), published in Acta Obstetricia et Gynecologica Scandinavica.

For the retrospective cohort study, the team analyzed data from almost 230,000 patients. According to these data, the likelihood of children reaching higher secondary school level is around 10% lower after elective induction of labor.

Labor Induction Frequent

These days in Germany, more than 20% of all births are induced. Sometimes this decision is made because of medical reasons, such as the woman's having gestational diabetes, the presence of gestational toxicity, or the occurrence of a premature rupture of membranes. However, contractions are most often artificially triggered because the expected delivery date has passed.

Guidelines from the German Society of Gynecology and Obstetrics recommend inducing labor if there is a medical indication and if more than 10 days have passed since the expected delivery date. After 14 days, induction is strongly advised. This recommendation is based on studies that indicate that the child is at increased risk of disease and death once the expected delivery date is far exceeded.

Causal Relationship Unproven

It is still unclear whether and to what extent inducing labor affects a child's neurologic development. Since the frequency of induced labor has increased greatly worldwide, Ravelli and her colleagues investigated this matter.

The study may have limited validity, however. "The outcome of the study only determines an association between spontaneous labor in mature children vs induced labor, and a school performance test at 12 years of age," said Maria Delius, MD, MPH, head of the Perinatal Center at the Clinic and Polyclinic for Obstetrics and Gynecology of the Ludwig Maximilian University of Munich, Germany. "The study is unable to prove any causality, even if it sounds that way in the abstract."

This publication may in no way instigate a change in current practices, Delius emphasized. "There is a lot of potential for the wrong conclusions to be drawn from this study, and as a result — if it is presented and perceived in a subjective manner in public — to also cause harm to mothers and children," she warned. The study also must not be associated with the drug misoprostol, since the various mechanical and medicinal methods of induction were not the topic of the Dutch investigation.

Gestational-Week Differences

The primary author of the study, Renee J. Burger, MD, PhD, of Ravelli's UMC team, and her colleagues assessed the school performance of 226,684 children at age 12 years who were born in the 37th to 42nd week of gestation (WOG) between 2003 and 2008 in the Netherlands following an uncomplicated single pregnancy. They compared school performance, divided for each of the six WOG analyzed, between children whose birth was mechanically or medicinally induced and those who were born without intervention.

According to the report by the researchers, induced labor at every WOG up to the 41st week was associated with lower school performance in the children, compared with a spontaneous birth. In addition, fewer children whose birth was induced reached a higher secondary level of education. After 38 WOG, the figure stood at 48%, compared with 54% of children who were born without intervention. For 12-year-olds not born until the 42nd WOG, there were no significant differences between the two groups investigated.

Prospective Studies Pending

Burger and Ravelli emphasized that the results do not indicate that every child born after an induced labor will perform worse at school. This is a statistical correlation that cannot be transferred to a case-by-case basis. In addition, it is unlikely that all disruptive factors could be taken into consideration during the analyses. Nonetheless, the researchers conclude that the long-term effects of inducing labor should be considered during consultation and decision-making in the future.

In general, it is important that future randomized, controlled studies incorporate long-term measurements in their results and conclusions so that complete data on the present topic can be gathered. "Although the effect on the individual child is likely subtle, the impact on society due to the large number of early-term labor inductions should not be underestimated," the authors wrote.

Unexamined Disruptive Factors

Sven Kehl, MD, PhD, senior physician of the Department of Obstetrics and Gynecology and coordinator of the University Perinatal Center of Franconia at the University Hospital of Erlangen, Germany, is of a similar opinion. "Inducing labor causes birth to occur sooner and therefore for the pregnancy to finish prematurely," said Kehl. Such premature births, not the mechanical or medicinal procedures for inducing labor, could affect the child's cerebral development. "The results of this study suggest that inducing labor in uncomplicated pregnancies, in which there are no relevant medical indications, should be avoided," said Kehl. In these cases, the mother should wait for a natural birth.

Some of the study's strengths include the large quantity of data, the large number of participants, and the various disruptive factors taken into consideration, such as the mother's level of education, according to Kehl. "But it is not a study from which causality can be derived," he said.

Not all the potential disruptive factors could be found in the available data. For example, information regarding familial status, the father's level of education, the parents' smoking status, or the mother's body mass index was missing. Also, only a small number of the possible indications for inducing labor was disclosed.

No Elective Inductions

The study is unlikely to have a major effect on practice in German maternity clinics, since the routine induction of labor from the 39th WOG has always been regarded critically in German-speaking countries, said Kehl. It is still true that if there are any risks, a risk-benefit analysis must be performed, and the risks to the mother or child must be evaluated when considering labor induction.

"If there are no medical reasons for inducing labor, the women must also be informed about the possible long-term consequences and not just about the short-term risks," said Kehl.

His colleague in Berlin, Michael Abou-Dakn, MD, chief physician of gynecology and obstetrics at the St Joseph's Hospital in Berlin-Tempelhof, was more categorical. "It is right to criticize the fact that over 20% of births in Germany are induced," he said. He is rather dubious, however, about the effects on school performance found in the study following induced labor. Still, the investigation is a reminder that inducing labor could involve side effects. "There should therefore be no elective inductions, or any without a clear indication," said Abou-Dakn.

This article was translated from the Medscape German Edition.


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