Real-world implications of ARRIVE
Scheduled induction of labour for low risk nulliparous women at 39 weeks?
So what are the real-world implications of ARRIVE. The paper below is interesting: a retrospective comparison of US practice comparing pre-ARRIVE with post-ARRIVE. The practicalities of offering routine IOL and the controversial implications of doing so were unknown.
Summary of findings:
Pre-group: 1.9 million nulliaparous women birthing after 39/40
Post- group: 600k similar women
Post group were statistically more likely to be older, higher BMI, have infertility and less likely to be white – although the clinical significance of these differences were minimal.
After adjusting for differences, post-ARRIVE women were more likely to have IOL (36.1% vs 30.2%) and deliver before 40/40 (42.8% vs 39.9%). They were less likely to have a CS, although it wasn’t a clinically significant decrease: 27.3% vs 27.9%
Newborns in the post-ARRIVE group were more likely to need assisted ventilation at birth (3.5% vs. 2.8%; aOR = 1.28) and for longer than 6 hours (0.6% vs. 0.5%; aOR = 1.36). No differences in neonatal admission, seizures or surfactant use.
Beyond the RCT
These are all first-order questions: what happens to mothers and babies who undergo IOL or not. What I'm more interested in are the wider system effects of this policy. Thinking beyond the RCT is second-order thinking as Howard Marks calls it.
It might include questions like:
What are the expected or unexpected implications for the service I work in with higher rates of IOL? Are we staffed for this? What does it mean for our skill-mix at midwifery and registrar/PHO level?
What about the IOLs we want to book for IUGR/pre-eclampsia – are there implications for delaying other patients when we are busy with less urgent inductions? What is the perinatal risk to the IUGR baby or maternal risk for a woman with pre-eclampisa that waits 2 days longer than they should?
Are we offering genuine evidence-based, non-directive counselling for IOL per ARRIVE (and using real-world results like these)? Are we training our RMOs how to do this if they are seeing 36/40 women in busy clinics? What are the implications for natural childbirth and midwifery. Have we sought the consumer perspective? Choice is great, but ideally people would get an unbiased overview of all the options. We're all biased, so what counselling tools will help?
Is a 6% increase in IOL rate that results in 0.6% reduction in CS worth it? And the 28% higher rate of neonatal ventilation - is it real and what are the implications?
All interesting questions. Especially for exam candidates!
Cheers
Danny
