Did I really just read that?

My last post was about a study showing that labor induction at 41 weeks leads to fewer cesarean deliveries than expectant managment of labor. After I posted, a friend forwarded me a link to the full text of that study (thank you Ellie!!), which you can find here http://www.annals.org/content/151/4/252.full Her first comment was, "I think if you look at the induction studies, you'll find it is not really relevant to how induction is really used in the United States." I was intrigued...

So I started reading, and while the authors do conclude that "elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid" the VERY NEXT SENTENCE says "There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided." Hmmmm... What in the world does that mean? Is this review actually providing good information to use in making decisions about induction vs expectant management, or not?

The majority of the studies in the review are rated "fair" or "poor" in quality, and the authors admit that "few (of the studies) had calculated sample sizes to determine whether the study had adequate power to address the primary study question." The largest study relevant to the primary study question was excluded from results because it was published in French and non-English-language studies were automatically excluded. Many of the studies reviewed were not from the US-- and "When we stratified the analysis by country we found that the odds of cesarean delivery were higher in women who were expectantly managed than in those with elective induction of labor in studies conducted outside the United States but were not statistically different in studies conducted in the United States."

Suddenly I was realizing that this US review, that I had seen discussed on various US websites, wasn't really saying what the summaries I'd read said it should say. Induction in the US is not like induction in other countries- just like "normal" birth in the US is not like normal birth in other countries. I was starting to feel vindicated once again in feeling that my induction had led to my c-section, and then I came across this line:

"insufficient information exists with which to draw any conclusions about the effect of elective induction specifically in nulliparous women."

Even in the studies from other countries, they are unable to say that induction is a better option than expectant management for a first-time mom, and these studies don't even begin to hold the level of detail necessary to determine the effect of induction on a first-time mom with no dilation, no effacement, a baby not engaged in her pelvis. I'll never know if I could have delivered vaginally if I'd continued to wait for labor with my first baby, but this particular study no longer makes me question my deeply held belief that spontaneous labor gives a woman the best chance possible of delivering outside the operating room.