title: Using inter-institutional practice variation to understand the risks and benefits of routine labour induction at 41(+0) weeks.
abstract: OBJECTIVE
  To evaluate the risks and benefits of routine labour induction at 41(+0) weeks' gestation for mother and newborn.
  
  
  METHODS
  Population-based retrospective cohort study of inter-institutional variation in labour induction practices for women at or beyond 41(+0) weeks' gestation.
  
  
  METHODS
  Women in British Columbia, Canada, who remained pregnant ≥41(+0) weeks and delivered at one of the province's 42 hospitals with >50 annual deliveries, 2008-2012 (n = 14,627).
  
  
  METHODS
  The proportion of women remaining pregnant a week or more past the expected delivery date who were induced at 41(+0) or 41(+1) weeks' gestation for an indication of 'post-dates' was calculated for each institution. We used instrumental variable analysis (using the institutional rate of labour induction at 41(+0) weeks as the instrument) to estimate the effect of labour induction on maternal and neonatal health outcomes.
  
  
  METHODS
  Caesarean delivery, instrumental delivery, post-partum haemorrhage, 3rd or 4th degree lacerations, macrosomia, neonatal intensive care unit admission, and 5-minute Apgar score <7.
  
  
  RESULTS
  Institutional rates of labour induction at 41(+0) weeks ranged from 14.3 to 46%. Institutions with higher (≥30%) and average (20-29.9%) induction rates did not have significantly different rates of caesarean delivery, instrumental delivery, or other maternal or neonatal outcomes than institutions with lower induction rates (<20%). Instrumental variable analyses also demonstrated no significantly increased (or decreased) risk of caesarean delivery (0.69 excess cases per 100 pregnancies [95% CI -10.1, 11.5]), instrumental delivery (8.9 per 100 [95% CI -2.3, 20.2]), or other maternal or neonatal outcomes in women who were induced (versus not induced).
  
  
  CONCLUSIONS
  Within the current range of clinical practice, there was no evidence that differential use of routine induction at 41(+0) weeks affected maternal or neonatal health outcomes.
authors.affiliation: Perinatal Services British Columbia, Provincial Health Services Authority, Vancouver, British Columbia, Canada.|Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: J A
authors.initials: JA
authors.lastname: Hutcheon
authors.affiliation: Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.
authors.forename: S
authors.initials: S
authors.lastname: Harper
authors.affiliation: Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.|Department of Economics, McGill University, Montreal, Quebec, Canada.
authors.forename: E C
authors.initials: EC
authors.lastname: Strumpf
authors.affiliation: Perinatal Services British Columbia, Provincial Health Services Authority, Vancouver, British Columbia, Canada.
authors.forename: L
authors.initials: L
authors.lastname: Lee
authors.affiliation: Perinatal Services British Columbia, Provincial Health Services Authority, Vancouver, British Columbia, Canada.|Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: G
authors.initials: G
authors.lastname: Marquette
mesh_terms: D001955:British Columbia / Q000453:epidemiology; D003299:Cooperative Behavior; D036861:Delivery, Obstetric / Q000009:adverse effects / Q000706:statistics & numerical data; D005260:Female; D005865:Gestational Age; D006801:Humans; D007325:Institutional Practice / Q000706:statistics & numerical data; D007751:Labor, Induced / Q000009:adverse effects* / Q000706:statistics & numerical data; D011247:Pregnancy; D011256:Pregnancy Outcome; D011273:Pregnancy, Prolonged / Q000453:epidemiology; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors
keywords: Caesarean delivery; instrumental variable; labour induction; post-dates; prolonged pregnancy