Induction and augmentation of labor in India: A systematic review

A recent publication regarding intrapartum care in low- and middle-income countries (LMICs) found that India has the one of the highest proportions of women receiving pharmacological augmentation of labor (51%-78%). National guidelines on the use of uterotonics during labor are available in India, requiring appropriate indication and monitoring for optimal maternal and fetal outcomes.

The aim of this research was to quantify induction and augmentation of labor in India and describe the characteristics of these practices and related outcomes for women and newborns.

The following electronic databases of published studies and gray literature were searched: PubMed, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Global Health, African Journals Online, Global Health Library, Global Index Medicus, ProQuest Dissertations & Theses, Cochrane Central Register of Controlled Trials, EMCare, Google Scholar, JSTOR, and Snowglobe (snowball search). We also consulted gray literature in Clinicaltrials.gov, WHO Trials, Cochrane Trials, OpenGrey, and the International Clinical Trials Registry Platform. All searches were completed on October 6, 2022. Search terms relevant to the research aims were applied, with initial searches for research conducted in any LMIC.

The review included primary research articles in English on induction and augmentation of labor in any setting in India, between January 1, 2011 and October 6, 2022. Two reviewers worked independently screening titles and abstracts for relevance to the research aims using Covidence® software. Non-concordant selection was resolved by a third team member. The full texts of included references were then retrieved for review and data extraction. Studies with low quality of evidence were excluded.

The data extraction grid was piloted on five full-text reports. One reviewer manually extracted data from each full text. Three categories of variables were included in that grid: study characteristics, exposure variables, and outcome variables. The quality of the evidence was assessed by one reviewer using the National Institute for Health and Care Excellence preferred tools for the corresponding study design. To synthesize and present results, we used percentages for prevalence studies, survey studies, and for descriptive sections of comparative studies. For comparative studies, associations between variables were presented using odds ratios, risk ratios, and risk differences with their 95% confidence interval (CIs) and P-values (where the latter was the only measure used to assess difference). For each quantitative outcome of the review, we compiled and interpreted results extracted from individual studies. Qualitative findings were grouped by domains of interest (settings, category of providers, induction and augmentation procedures). Meta-analysis was not possible due to the marked heterogeneity between studies.

This review included 59 studies and provided evidence of moderate quality that high proportions of laboring women receive induction and augmentation of labor for facility-based childbirth across Indian geographies. Included studies reported that from 2.6% to 84.3% of laboring women received induction of labor; and from 9.6% to 86.9% received augmentation of labor. The review indicated that induction and augmentation are used in home-based childbirths as well, although these account for less than 10% of deliveries in India. The review identified several practices related to induction and augmentation of labor that are non-compliant with WHO guidelines, driven by synergistic promoting factors pertaining to both health systems and communities. Studies documented relatively high rates of complications, and reported descriptions suggest that these were related to type and regimens of induction and augmentation drugs, settings, and qualifications of providers. However, statistical associations between induction and augmentation and complications were not assessed. Included studies also revealed varied and inappropriate oxytocin storage conditions across settings. Finally, this review indicated that women were generally satisfied with the care provided to them during induction and augmentation of labor.

This review documented high use of pharmaceuticals for the induction and augmentation of labor, including practices that are not compliant with global and Indian recommendations for safety and quality. The review also identified both provider- and community-side drivers of these practices. These findings suggest multiple interventions that can be taken at the policy, facility, and community levels to monitor and improve induction and augmentation practices at health facilities in India. This review was funded by USAID and its protocol was registered in PROSPERO (2022 CRD42022298949).