Sir,
We read with great interest the paper by Burger et al. 1 on whether elective induction of labor (IOL) may influence offspring school performance at 12 years of age after uncomplicated pregnancies. 1 We acknowledge the importance of the question raised. The authors conclude that with a fetus at risk approach, IOL is associated with significantly lower offspring school performance at age 12 and lower secondary school level compared with non‐intervention from 37 to 41 weeks and suggest that this information be conveyed to pregnant women prior to IOL.
The authors do acknowledge that residual confounding may exist. However, we believe that the authors underestimate the potential role of confounding by the indication of IOL. Even though women with medical indications for IOL (non‐singleton, hypertension, diabetes, fetal growth restriction, and malformations) were excluded from the study, the decision to induce labor at term might include several unknown factors that cannot easily be adjusted for. In clinical practice many or even most cases follow strict indications for IOL that are not confined to the indications excluded. Therefore, the extent to which IOL as exposure can be considered a proxy for the indication for IOL should be considered. We believe that the risk of confounding by indication is likely to be present yet in the study and may affect the presented estimates.
The absolute differences in mean school performance by gestational week are subtle (i.e., a mean score of 535 vs. 536.2 at 37 weeks, 536 vs. 536.6 at 42 weeks with standard deviations around 9.7). Bias introduced by confounding by indication might distort the association on school performance in either direction. So, do the findings of this study entitle a change in the counseling and decision‐making around IOL?
Randomized trials including long‐term follow up on selected outcomes are warranted. We urge conclusions based on observational studies to reflect the limitations of the design, and we think the question on whether IOL may affect school performance remains uncertain from the presented data.
CONFLICT OF INTEREST STATEMENT
JF is an Associate Editor of AOGS.
REFERENCE
- 1. Burger RJ, Mol BW, Ganzevoort W, et al. Offspring school performance at age 12 after induction of labor vs non‐intervention at term: a linked cohort study. Acta Obstet Gynecol Scand. 2023;102:486‐495. [DOI] [PMC free article] [PubMed] [Google Scholar]