ACNM Responds to Release of ARRIVE Trial Study Results: Acknowledges Quality of Study but Raises Concerns about Potential for Misapplying Results
FOR IMMEDIATE RELEASE: Thursday, August 9, 2018
The American College of Nurse-Midwives Affirms Its Support of Normal Physiologic Birth, Shared Decision Making, and Individual Autonomy
We acknowledge the quality of the study design and the comprehensive areas of assessment that were included in the ARRIVE trial. We note that of the 22,533 women eligible to participate in this study, only 27% (6,106) actually agreed to participate. This demonstrates that the process of an elective induction of labor is not something women may choose or desire.
ACNM President Dr. Susan Stone, DNSc, CNM, FACNM, FAAN raises concern about the costs to our society of adopting the use of elective inductions of labor given hospital stays, staffing resources and capacity of our maternity care system. Information about these costs is not yet available, but is forthcoming. “Could those costs be put to a better use adopting a more non-interventive, low cost strategy for reducing cesarean sections?” she noted. “There are many other evidence-based approaches to reducing primary cesarean birth that can also be adopted, such as continuity of care during labor.” For example, a recent Cochrane Database Systematic Review reported that if 14 women have , one cesarean birth can be prevented (Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert, 2017). The ARRIVE trial reported that 28 women will have to undergo an elective induction to prevent a single cesarean birth.
The selection criteria used for the women who participated in the trial are not generalizable beyond this particular group. Thus, the results should not be applied outside of the criteria used in the trial including women who are healthy, low risk, and experiencing their first birth.
We are concerned that these study results have a high potential to be applied in ways that are not consistent with the parameters of the ARRIVE trial, which can result in unintended consequences. While we strongly support measures to reduce the incidence of primary cesarean births for women in this country, we note that the cesarean section rates cited in the ARRIVE trial are below the national average goal of 23.9% for primary cesareans nationally. This may be attributed to the approach to care during labor used during this trial, which included adoption of the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) recommendations for extended time when an induction of labor is performed. Without this protocol, the results may have been different, and this will need to be emphasized in any recommendations for induction of labor aligned with these study results.
The American College of Nurse-Midwives strongly endorses the need for shared decision-making and equitable access to evidence-based information to use in discussions between childbearing families and their health care providers “We urge health care providers to be responsible, accurate, and cautious in their messaging to childbearing families about the use of elective induction of labor as an intervention to reduce the risk of cesarean delivery,” Dr. Stone said. “There are a number of implications for childbearing women. We will closely monitor the additional outcomes of this study to more fully consider the impact of elective induction compared to spontaneous labor and expectant management on other health outcomes for mothers and infants.”