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. 2020 Jul 15;2020(7):CD004945. doi: 10.1002/14651858.CD004945.pub5

Summary of findings 2. Labour induction versus expectant management (maternal outcomes).

Induction of labour for improving birth outcomes for women at or beyond term
Population: pregnant women at or beyond 37 weeks gestation
Setting: Austria, Canada, China, Finland, France, India, Malaysia, Netherlands, Norway, Spain, Sweden, Russia, Thailand, Tunisia, Turkey, UK, and USA
Intervention: labour induction
Comparison: expectant management
Outcomes Anticipated absolute effects* (95% CI) Relative effect
(95% CI) № of participants
(studies) Quality of the evidence
(GRADE) Comments
Risk with expectant management Risk with labour induction
Caesarean section Study population RR 0.90
(0.85 to 0.95) 21,030
(31 RCTs) ⊕⊕⊕⊝
MODERATE1  
186 per 1000 167 per 1000
(158 to 177)
Operative vaginal birth (forceps or ventouse) Study population RR 1.03
(0.96 to 1.10) 18,584
(22 RCTs) ⊕⊕⊕⊝
MODERATE1  
136 per 1000 140 per 1000
(131 to 150)
Perineal trauma (severe perineal tear) Study population RR 1.04
(0.85 to 1.26) 11,589
(5 RCTs) ⊕⊕⊝⊝
LOW1,2  
31 per 1000 33 per 1000
(26 to 39)
Postpartum haemorrhage Study population RR 1.02
(0.91 to 1.15) 12,609
(9 RCTs) ⊕⊕⊕⊝
MODERATE3 variously defined
79 per 1000 81 per 1000
(73 to 91)
Breastfeeding at discharge Study population RR 1.00
(0.96 to 1.04)
7487
(2 RCTs)
⊕⊕⊕⊝
MODERATE4  
505 per 1000 505 per 1000
(485 to 525)
Postnatal depression Study population (0 RCTs) No RCTs reported data for this outcome.
see comment see comment
Length of maternal hospital stay (days) Average MD 0.19 days shorter for women who were induced
(0.56 days shorter to 0.18 days longer) 4120
(7 RCTs) ⊕⊝⊝⊝
VERY LOW5
 
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; MD: mean difference; RCT: randomised controlled trial; RR: risk ratio
GRADE Working Group grades of evidenceHigh quality: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

1Downgraded 1 level for serious concerns regarding unclear allocation concealment methods for many of the 31 trials included for this outcome.
2Downgraded 1 level for serious concerns regarding imprecision with wde confidence intervals crossing the line of no effect, signalling some uncertainty about direction of effect.

3Downgraded 1 level for serious concerns regarding indirectness with postpartum haemorrhage defined in different ways for several of the trials.

4Downgraded 1 level for indirectness with one of the two studies reporting breastfeeding 4‐8 weeks after discharge (not at discharge).

5Downgraded 1 level for serious concerns regarding selection bias, with 4 of 5 trials having with unclear allocation concealment; and downgraded 2 levels for very serious concerns regarding inconsistency, with very high statistical heterogeneity (I² = 94%).