FOR IMMEDIATE RELEASE: Thursday, August 9, 2018
CONTACT: MAURA CHRISTOPHER, 240-485-1822
The American College of Nurse-Midwives Affirms Its Support of
Normal Physiologic Birth, Shared Decision Making, and Individual Autonomy
Silver Spring, MD --
The American College of Nurse-Midwives (ACNM) affirms its support for the
promotion of normal healthy physiologic birth and a women's right to
self-determination as we acknowledge the publication of the ARRIVE trial
results in "Labor Induction
verses Expectant Management in Low-Risk Nulliparous Women" in the New England Journal of Medicine on
August 8, 2018. The ARRIVE trial was a
randomized controlled clinical study that compared elective induction of labor
at 39 weeks to expectant management of labor with women who were nulliparous
and met study criteria to be identified as low risk. The primary outcome
assessed by the trial was a composite measure of perinatal mortality and severe
perinatal morbidity. This outcome was not statistically significant between the
groups. A secondary outcome, however, was focused on the role of elective
induction of labor and risk for primary cesarean birth. The results of the
trial suggest that elective induction of labor in women with low-risk
pregnancies at 39 weeks may reduce the need for cesarean delivery compared to
waiting for spontaneous labor to occur. The difference in the reduction of cesarean birth was 18.6% in the induced
group versus 22.2% in the expectant labor management group (P=<0.001).
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 asked. "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 continuous
labor support, 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."
ACNM has a number of resources available for health care providers and
consumers at www.BirthTOOLS.org that support
changing the culture of maternity care and optimizing health outcomes for
families. ACNM has noted there are a number of
potentially negative implications when we disrupt the normal physiological
processes of labor and birth. Research related to the longer-term
effects of induction of labor is emerging, but is still insufficient to
determine its full impact.
ACNM continues to stand by its
current recommendations and encourages its members and other providers to refer
to its formal position statements for guidance, including the Consensus Statement on Supporting
Healthy and Normal Physiologic Childbirth, Shared
Decision Making in Midwifery Care, and Appropriate
Use of Technology In Childbirth. We plan to review our current statement on Induction
of Labor to include the ARRIVE trial results and assess the need for more specific
practice recommendations very soon.
Susan Stone, DNSc, CNM, FACNM, FAAN,
President, American College of Nurse-Midwives
Bohren MA, Hofmeyr GJ, Sakala
C, Fukuzawa RK, Cuthbert A. Continuous support for women during
childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.:
CD003766. DOI: 10.1002/14651858.CD003766.pub6.
About ACNM
With nearly 7000 members, ACNM is the professional association that
represents certified nurse-midwives (CNMs) and certified midwives (CMs) in the
United States. ACNM promotes excellence in midwifery education, clinical
practice, and research. With roots dating to 1929, our members are primary care
providers for women throughout the lifespan, with a special emphasis on
pregnancy, childbirth, and gynecologic and reproductive health. ACNM provides
research, administers and promotes continuing education programs, establishes
clinical practice standards, and creates liaisons with state and federal
agencies and members of Congress to increase the visibility and recognition of
midwifery care.
