Outcome of induction and associated factors among induced laboring mother at Dessie Comprehensive specialized Hospital, Dessie, Ethiopia.

doi:10.21203/rs.3.rs-3945333/v1

Background

Induction of labor refers to iatrogenic stimulation of uterine contractions before the onset of spontaneous labor to accomplish vaginal delivery. It is a common obstetric procedure performed during pregnancy and is thought to be associated with greater maternal or fetal risk. Although the induction of labor is commonly practiced, its outcomes and associated factors are rarely assessed in our settings. Therefore, this study aimed to fill this gap by studying the outcomes of labor induction and associated factors among women who delivered at the Dessie Compressive Specialized Hospital.

Objective

The objective of this study was to assess the outcome induction of labor and associated factors among induced laboring mothers at the Dessie Compressive Specialized Hospital from March 1, 2023 to June 30, 2023.

Methods

An institution-based cross-sectional study was conducted on 308 study participants from March 1, 2023 to June 30, 2023. Data were collected through daily patient interviews and chart reviews of the individual mothers for additional information. Study participants were recruited using a consecutive sampling method. Data were entered using Epi-Data Version 4.6 and analyzed using SPSS Version 25. A bivariate logistic regression model was used to identify factors affecting the outcome of labor induction. Variables with P-values less than 0.25 in the bivariate analysis were entered into the multivariate analysis. Odds ratios (ORs) with 95% confidence intervals (CI) were used to assess association strength. Statistical significance was set at P < 0.05.

Results

The results of the study revealed that, out of 308 total cases of labor induction, 232(75.32%; 95% CI = 70–80) of them achieved successful labor induction. A favorable Bishop Score (AOR = 16.46, 95% CI = 7.685–35.283), multigravida (AOR = 5.17, 95% CI = 2.293–11.657), rural resident (AOR = 3.0393, 95% CI = 1.270–7.5730), and ripening by misoprostol (AOR = 5.203, 95% CI = 1.834–14.763) were significantly associated with successful labor induction.

Conclusion

The proportion of successful induction of labor was moderate in the study area. Favorable Bishop Score, Multigravida, ripening by misoprostol, and rural residency are the main determinants. It may be necessary to conduct case-control or cohort studies to further investigate factors that increase the likelihood of failed induction.

Labor induction

success of labor induction

Bishop Score

oxytocin

Induction of labor (IOL) refers to the iatrogenic stimulation of uterine contractions after 28 weeks of gestation and before the onset of spontaneous labor to accomplish vaginal delivery, It is a common procedure which is indicated when the benefit of expeditious delivery outweighs the risk of continuing the pregnancy to either mother or fetus. Induction of labor is certainly one of the most frequently performed obstetric procedures in the world, with recent data indicating an induction rate of up to 35.5% in Sri Lanka, 24.5% in the United States, and 6.8–33% in Europe. (1, 8) The study conducted in southwest Shewa showed that the prevalence of induction in Wolisso St. Catholic Hospital was 22.4%, and that in Northern Ethiopia at Woldia General Hospital was 24.4%. The success rates of induction in the studies conducted in Spain, Nigeria, and Mekelle, were 61.4%, 82.2%, and 76%, respectively. (4, 10, 21, 31)

The definition of successful and failed induction differs from study to study, in which the success of labor induction is defined as if a woman delivered vaginally either spontaneously or after induction. On the other hand, failed induction is defined as failure to achieve regular contractions and cervical change after at least 6–8 hours of the maintenance dose of oxytocin administration, with artificial rupture of membranes if feasible. (7) Because of the fear of risk of failed induction of labor, a variety of maternal and fetal factors have been detected before the starting of induction to predict labor induction success. These include maternal factors, such as parity, maternal age, Bishop Score, and its individual components, and fetal factors, such as presentation, birth weight, and gestational age. (34)

To overcome the morbidity and mortality of the mother and infant, induction of labor (IOL) is the most essential process to initiate labor by artificial means starting at 28 weeks of gestation. It is a modern obstetric practice that decreases the risk of maternal and neonatal morbidity and mortality by ending pregnancy in the presence of many obstetric and medical conditions. (10) No research has been conducted at the Dessie Comprehensive Specialized Hospital on the outcomes of induction and factors that determine the success of induction.

Identifying outcome and factors associated with the induction of labor will emphasize improvements in access to qualified care for laboring women that are necessary for a reduction in life-threatening maternal conditions. Furthermore, studies on labor induction outcomes related to events in the study area are crucial to further understand the associated issues and provide an evidence-based platform for appropriate interventions. Therefore, the current study aimed to determine the success of induction and the associated factors that affect the success of induction at the labor ward of the Dessie Comprehensive Specialized Hospital.

Study design, area, and period

This prospective hospital-based cross-sectional study was conducted at the Dessie Comprehensive Specialized Hospital in Dessie, Ethiopia. The data collection period was from March 1, 2023, to June 30, 2023. After 28 weeks of gestation, all pregnant mothers were admitted to the labor ward and induced during the study period. Pregnant women who underwent induction after GA for 28 weeks and provided written informed consent were included in this study. Women who underwent labor induction for fetal death or lethal congenital anomalies were excluded. additionally Pregnant women before GA of 28 weeks and those with communication difficulties were excluded.

Sample size and sampling procedure

The sample size was calculated using the single population proportion formula:

where: n = the required sample size, p = the proportion of successful induction, Z_α/2 = the critical value at 95% confidence level of certainty (1.96), and d = the margin of error between the sample and the population 5%.

The proportion of successful induction from the previous study was 76%. (31)

For the second objective, the sample size was calculated using Epi-info version 7.2.2.6.

Table 1

Sample size determination using Epi info v7.2.2.6 DCSH, Ethiopia, 2023(5, 34)
Factors for outcome of induction	% outcome in unexposed group	% outcome in exposed group	Sample size using 95%CI and power 80%	Sample size + 10% non- response rate
Gestational age (5)	47.6%	68.7%	188	206
Parity (34)	66.9%	82.5%	268	294
Bishop score (5%)	30%	66%	84	92

Therefore, the first objective should be taken as the final sample size for this study after adding a non-response rate of 308 because the sample size is obtained by taking the greatest value from the four alternatives. All women who induced labor during the study period were included until the desired sample size was achieved. Data were collected from the labor ward during labor and delivery.

Data collection procedure

Data were collected from the mothers using an interviewer-administered structured and pre-tested questionnaire, and other data that were not directly obtained from the respondents were collected from their documents. The questionnaire was developed by reviewing different literature, which has been conducted in Ethiopia so far, prepared in English, and translated into Amharic by language experts. It was then translated back into English to check for consistency. The principal investigator trained the data collectors on a pretested checklist. The principal investigator checked the completeness, accuracy, and consistency of the collected data. The success of labor induction was the dependent variable, and the independent variables were sociodemographic characteristics (age, residency, education level, BMI, religion, and ethnicity), obstetric and maternal factors (Bishop score, gravidity, parity, indication for induction, ANC follow-up, abortion history, stillbirth history), fetal and neonatal factors (estimated fetal weight, APGAR score), method of ripening (misoprostol, balloon catheter), and method of induction (high-dose oxytocin).

Data processing and analysis

Consecutive sampling technique data were collected and each questionnaire was checked for completeness before entering the software. The collected data were entered into the Epi Data version 3.1. and exported to SPSS version 24.0 for cleaning, coding, and any further statistical analysis. Descriptive statistical analysis was performed to compute the proportion and mean with standard deviations, and the results were presented using text, frequency tables, and graphs. Associations between dependent and independent variables were assessed using binary logistic regression analysis. Variables with a p-value less than 0.25 in the bivariate analysis, were entered into the multivariable analysis model. A multivariate logistic regression analysis model was built to assess the influence of possible potential confounding variables and strength of association. The degree of association between dependent and independent variables was assessed using adjusted odds ratio with a 95% confidence interval (CI) and factors with P-values < 0.05 were considered as statistically significant. Model adequacy was checked using the Hosmer-Lemeshow goodness-of-fit test.

All data and materials are available in the manuscript and supporting tools.

Ethical considerations

Ethical clearance was obtained from the Wollo University Health and Medical Sciences College’s Ethical Review Committee. A permission letter was submitted to the concerned body of the DCSH, and all study participants were informed about the purpose of the study, as well as their right to refuse and withdraw from the study. Written informed consent was obtained from all participants prior to the interview. Respondents were also informed that their information obtained from them was treated with complete confidentiality and did not cause any harm to them.

A total of 308 mothers participated in the study: 227 (73.7%) delivered vaginally with no instrumental delivery, 15 (4.9%) were assisted by instrumental delivery, and 76 (24.7%) by Cesarean section. Induction was successful in 232 mothers (75.32%; 95% CI = 70–80).

Socio-demographic characteristics of respondents

The mean age of the participants was 27.3 (± 5) years, ranging from 19–40 years. The study also revealed that about 72 (23.4%) and 17 (5.5%) of the mothers have BMI with a range of 25–29.9 and > 30 kg/m², respectively. Of the mothers, 299 (97.1%) were married, and 115 (62.7%) were from urban areas. Sixty-six (22.4%) respondents were able to read and write, and 271 (88%) were housewives.

Table 2

Socio-demographic characteristics of the mothers who have undergone induction of labor in Dessie Comprehensive Specialized Hospital, Amhara region, in Ethiopia, 2023.[7]
Variables	Category	Frequency	Percentage (%)
Age of mothers	≤ 19	12	3.9
	20–34	267	86.7
	≥ 35	29	9.4
BMI	< 25	219	71.1
	25–29.9	72	23.4
	≥ 30	17	5.5
Educational status	Cannot read and write	53	17.2
	Can read and write	69	22.4
	Primary school	103	33.4
	High school	39	12.7
	Collage and above	44	14.3
Resident	Urban	115	37.3
Resident	Rural	193	62.7
Marital status	Married	299	97.1
	Single	4	1.3
	Widowed	5	1.6
Occupation	Farmer	5	1.6
	House wife	271	88
	Merchant	12	3.9
	Government employee	20	6.5
Ethnicity	Amhara	282	91
	Oromo	18	5.8
	Tigre	8	2.5

Obstetric and maternal characteristics

One hundred and sixty-seven (54.2%) subjects were multigravida. Three of the 263 (85.7%) participants had no history of abortion. Approximately 251 (81.5%) of the study participants had at least one ANC follow-up for their current pregnancy. One hundred and sixty (51.9%) of the mothers had a gestational age of 37–41 weeks and 21 (6.8%) had unknown LNMP. Regarding the indication for induction, nearly half (44.5%) of the mothers were indicated for PIH, and only eight (2.9%) had chorioamnionitis. Before induction, 97 (31.5%) women had a Bishop score of < 6, and the most commonly used ripening agent was a balloon catheter (81.8%).

Table 3

Obstetrics and maternal characteristics of women who had undergone induction of labor in Dessie compressive specialized hospital, Ethiopia, 2023GC.
Variables	Category	Frequency	Percentage (%)
Gravidity	Multigravida	167	54.2
Gravidity	Primigravida	141	45.8
Abortion history	Yes	45	14.6
Abortion history	No	263	85.4
ANC follow-up for the current pregnancy (at least one)	Yes	251	81.5
ANC follow-up for the current pregnancy (at least one)	No	57	18.5
If yes where was the follow-up	Health Centre	142	46.1
	Hospital	87	28.8
	Private clinic	19	6.2
	Health post	3	1
Still birth history	Yes	21	6.8
Still birth history	No	287	93.2
GA of current pregnancy	< 37 weeks	56	18.2
	37–42 weeks	160	51.9
	≥ 42 weeks	71	23.1
	Unknown LNMP	21	6.8
Indication of induction	Post-term pregnancy	75	24.4
	PROM	33	10.7
	PIH	137	44.5
	Chorioamnionitis	8	2.6
	Oligohydramnios	46	14.9
	APH	9	2.9
Bishop score	≥ 6	211	68.5
Bishop score	≤5	97	31.5
Any ripening agent	Yes	300	97.4
Any ripening agent	No	8	2.6
If yes ripening agent	Misoprostol	48	15.8
If yes ripening agent	Balloon catheter	252	81.8
Mode of delivery	Vaginal delivery	220	71.4
	C/S	76	24.7
	Instrumental	12	3.9

ANC, antenatal care; C/S, Cesarean section; PROM, prelabor rupture of membrane

PIH, pregnancy induced hypertension; APH, antepartum hemorrhage

Neonatal and fetal factors

In regard to fetal outcome, more than half of the neonatal birth weights (186; 60.4%) ranged from 2.5–3.9 kg, 89 (28.9%) were between 1.5–2.4 kg and 25 (8.1%) ≤1.5 kg, while five (1.6%) were stillbirth and 30 (9.7%) had a low Apgar score.

Table 4

Fetal and neonatal characteristics of women who underwent induction of labor at DCSH, Ethiopia, 2023GC
Variables	Category	Frequency	Percentage (%)
New-born status at birth	Alive	303	98.4
New-born status at birth	Stillbirth	5	1.6
5th minute APGAR score	< 7	30	9.7
	≥ 7	273	88.6
	No	251	81.5
Neonatal weight	≤1,500	25	8.1
	1,500–2,499	89	28.9
	2,500–3,999	186	60.4
	≥ 4,000	8	2.6

Factors associated with induction of labor

In the bivariate logistic regression analysis, the Bishop score, residency, gravidity, history of abortion, history of ANC follow-up, gestational age at induction, cervical ripening, and method of ripening were eligible for multivariate analysis with a P-value < 0.25. However, in the multivariate analysis, only Bishop score, residency, gravidity, and ripening method remained statistically significant.

The odds of successful labor induction among mothers who had a favorable Bishop score were 16.46 times more likely to have successful labor induction as compared to mothers who had unfavorable Bishop scores (AOR = 16.46, 95% CI = 7.685–35.283). Multigravida mothers who were multigravida were 5.2 times more likely to undergo successful induction than primigravida mothers (AOR = 5.17, 95% CI = 2.293–11.657).

Mothers who lived in rural areas were 3.09 times more likely to have successful labor induction than mothers who had urban residency (AOR = 3.0393, 95% CI = 1.270–7.5730). Mothers who were ripened with misoprostol were almost 5.2 times more likely to undergo successful induction than those who were ripened with a Foley catheter (AOR = 5.203, 95% CI = 1.834–14.763).

Table 5

Factors associated with outcome of induction of labor among women who underwent induction of labor in Dessie Comprehensive Specialized Hospital, Ethiopia, 2023 GC
Variable	Category	Outcome of Induction		COR (95% CI)	AOR (95% CI)
Variable	Category	Successful	Unsuccessful	COR (95% CI)	AOR (95% CI)
Bishop	≥ 6 (favorable)	194 (91.9%)	17 (8.1%)	17.718 (9.325–33.665)	16.466 (7.685–35.28) *
Bishop	≤ 5 (unfavorable)	38 (39.1%)	59 (60.8%)	1**
Gravidity	Multigravida	143 (85.6%)	24 (14.4%)	3.481 (2.006–6.042)	5.170 (2.293–11.657) *
Gravidity	Primigravida	89 (63.1%)	52 (36.9%)	1**
Resident	Rural	93 (80.9%)	22 (19.1%)	1.642 (0.937–2.878)	3.093 (1.270–7.530) *
Resident	Urban	139 (72%)	54 (28%)	1**
Abortion history	Yes	27(60%)	18 (40%)	1**
Abortion history	No	205 (77.9%)	58 (22.1%)	0.24 (0.219–0.824)	0.343 (0.137–0.858)
GA	< 37 weeks	34 (60.7%)	22 (39.3%)	12.941 (1.619–103.456)	3.640 (0.371–35.721)
	37–42 weeks	121 (75.6%)	39 (24.4%)	10.456 (0.838–49.602)	1.551 (0.721–13.271)
	≥ 42 weeks	57 (80.3%)	14 (19.7%)	4.912 (0.607–39.784)	1.677 (0.180–15.582)
	Unknown LNMP	20 (95.2%)	1 (4.8%)	1**
ANC follow-up for the current pregnancy (at least once)	Yes	184 (73.3%)	67 (26.7%)	0.515(0.240, 1.106)	0.791(0.294, 2.129)
ANC follow-up for the current pregnancy (at least once)	No	48 (84.2%)	9 (15.8%)	1**
Any Cervical Ripening done	Yes	230 (76.7%)	70 (23.3%)	9.857 (1.946–49.934)	1.699 (0.209–13.810)
Any Cervical Ripening done	No	2 (25%)	6 (75%)	1**
Ripening Agent	Misoprostol	39 (81.3%)	9 (18.7%)	2.244 (1.091–4.616)	5.203 (1.834–14.763) *
Ripening Agent	Balloon Catheter	191 (75.8%)	61 (24.2%)	1**

Note ** reference, * significantly associated.

COR, crude odd ratio; GA, gestational age; AOR, adjusted odd ratio.

This study found that the success rate of labor induction in the Dessie Comprehensive Specialized Hospital was 75.32% (95% CI = 70–80). A total of 227 (73.7%) patients were delivered vaginally with no assistance from the instrument, 15 (4.9%) were assisted by instrumental delivery, and 76 (24.7%) were assisted by Cesarean section. Variables that increased the likelihood of successful labor induction were Favorable Bishop Score, gravidity, cervical ripening by misoprostol, and rural residents.

The magnitude of success after induction in this study was in line with studies conducted at public hospitals in Mekelle Town (76%) (31) and Nepal (76.5%) (12), in which the three most common indications for induction were the same as those in this study: PIH, post-term pregnancy, and PROM. In addition, a study at the Catholic Maternity Hospital (CMH) in Ogoja, Cross River State, Nigeria (75.9%) (38), is in line with this study, which could be because it was conducted in a poor health resource setting like that of Ethiopia. However, this finding is higher than those reported by Lemlem Karl Hospital, Miachew Town (54.5%), Wolisso St. Luke, Catholic Hospital (57.89%), and Wolayita Sodo (59.7%) (20, 5, 36). This variation might be due to an increase in the follow-up of induction and care due to the increasing number of healthcare professionals such as gynecologists/obstetricians, midwives, and residents, as the study hospital is comprehensive, but the mentioned are general hospitals.

The success of induction was lower than that in the study conducted in Jos University Teaching Hospital, Jos, Nigeria (82.2%) (27), possibly due to induction by membrane rupture performed at the same time as induction commenced with oxytocin IV infusion, which increases the success of induction. It also had a lower proportion of successful induction than the study conducted in Aga Khan Hospital, Karimabad, Pakistan (81.9%) (21), because in that study, after 10–12 hours of Foley’s catheter insertion, Prostaglandin E2 (PGE2) 3 mg was inserted vaginally, and the dose was repeated after 6 hours, leading to the increased success of induction.

Those mothers who reside in rural areas chance of success of labor induction is more likely by 3.8 times (AOR = 3.09, 95% CI = 1.270–7.5730) as compared to mothers from urban residence. This study was supported by a study conducted at Dilchora Referral Hospital (9). A possible reason for this is that the living standard of urban residents is better or more luxurious than that of rural residents because the weight of urban residents is higher than that of rural residents, which leads to higher BMI measurement, and respondents who had higher BMI were more likely to have a failed induction.

A favorable Bishop score was associated with success of induction by 16.46 times (AOR = 16.46, 95% CI = 7.685–35.283) more successful induction than an unfavorable Bishop score. This study was supported by a study conducted at Aga Khan University Hospital, Karachi, Pakistan, and Jimma University Specialized Hospital (31, 34). If the cervix does not ripen, the effacement and dilation of the cervix are not changed by oxytocin, which is applied at the fundus of the uterus but not on the cervix, and the failure of induction increases without ripening of the cervix.

Mothers who were multigravida had the chance of 5.2 times more likely to succeed in labor induction than primigravida, with AOR = 5.17 (95% CI = 2.293–11.657). This study was in line with a study conducted at Mekelle Town Public Health Institutions and Aga Khan University Hospital, Karachi, Pakistan, and Kenyatta National Hospital in Kenya (31, 27, 28). This might be attributed to an increase in the parity of the mother, and the likelihood of failed induction of labor decreases, as uterine muscles can be easily stimulated and contracted in multipara women, and labor will be prolonged in primipara women because the cervix is not tested for labor.

In this study, for mothers who were ripened by misoprostol, the chance of successful labor induction was 5 times more likely (AOR = 5.203, 95% CI = 1.834–14.763) as compared to those ripened by balloon catheter, which is also in line with the study done at King Saudi University on factors associated with success of labor induction and Jimma University Specialized Hospital (22, 34). It has been postulated that misoprostol increases contraction strength by increasing the expression of oxytocin receptors in the myometrium.

The strengths of this study include the prospective main data collection in a single interaction for each patient and a lower dropout rate. Additionally, the relatively long period of data collection could aid in capturing variation over time and improving the representativeness of the sample. Another strength was the sample size for each variable. This study also has limitations. As a cross-sectional study, it could not explain the cause-and-effect relationship. Furthermore, being a single-hospital-based study, the current study could have suffered from a selection bias.

The proportion of successful induction was moderate in the study area. The most common indications for labor induction were pregnancy-induced hypertension, post-term pregnancy, and premature membrane rupture. Variables that increased the likelihood of successful labor induction were Favorable Bishop score, gravidity, cervical ripening by misoprostol, and rural residents. However, because cross-sectional studies do not establish causality, it may be necessary to conduct case-control or cohort studies to further investigate the factors that increase the likelihood of failed induction. This thesis concludes that favorable cervical bishop and misoprostol usage for cervical ripening increases the success of induction, but it does not study which component of the cervical bishop, dose, and route of administration of misoprostol are associated with the success of induction. The authors recommend further studies to answer this question, using this thesis as a baseline.

ANC, antenatal care; AOR, adjusted odd ratio; BMI, body mass index; C/S, cesarean section; CPD, cephalopelvic disproportion; LBW, low birth weight; PROM, premature rupture of membrane; PIH, pregnancy induced hypertension; PPH, postpartum hemorrhage; WHO, World Health Organization; NRFHP, none reassuring fetal heart rate pattern; GA, gestational age; APH, antepartum hemorrhage; DCSH, Dessie comprehensive specialized hospital; LNMP, last normal menstrual period.

A. Ethical approval

Ethical clearance was obtained from the Wollo University Health and Medical Sciences College’s Ethical Review Committee. A permission letter was submitted to the concerned body of the DCSH, and all study participants were informed about the purpose of the study, as well as their right to refuse and withdraw from the study. Written informed consent was obtained from all participants prior to the interview. Respondents were also informed that their information obtained from them was treated with complete confidentiality and did not cause any harm to them.

B. Consent for Publication

Written informed consent was obtained from all participants that thier information will be used as primary data for publication.

C. Availability of data and materials

All data and materials are available in the manuscript and supporting tools

D. Competing interest

There is no competing interest mentioned.

E. Funding

There was no fund used for the research.

G. Authors contributions

Dr Abel shifefaw..Proposal writing ,data collection and analysis and thesis writing.

Dr Abdi dingeta...data collection and analysis

Dr Akebom kidanemariam...data collection and analysis

H. Acknowledgment

We would like to thank the ethical review board of Wollo University for ethical clearance and the hospital administration for permission to conduct the study. We would also like to thank all participants for their valuable contributions.

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No competing interests reported.

Outcome of induction and associated factors among induced laboring mother at Dessie Comprehensive specialized Hospital, Dessie, Ethiopia.

Status:

Version 1

Abstract

Background

Objective

Methods

Results

Conclusion

Figures

Introduction

Methods

Study design, area, and period

Sample size and sampling procedure

Data collection procedure

Data processing and analysis

Ethical considerations

Results

Socio-demographic characteristics of respondents

Obstetric and maternal characteristics

Neonatal and fetal factors

Factors associated with induction of labor

Discussion

Conclusions and recommendations

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1