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Obstet Gynecol. Author manuscript; available in PMC 2019 January 01.
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Published in final edited form as:

Obstet Gynecol. 2018 January ; 131(1): 12–22. doi:10.1097/AOG.0000000000002408.

Term Elective Induction of Labor and Pregnancy Outcomes

Among Obese Women and Their Offspring
Cassandra M. Gibbs Pickens, PhD, MPH1,2, Michael R. Kramer, PhD, MMSc, MS1, Penelope
P. Howards, PhD, MS1, Martina L. Badell, MD3, Aaron B. Caughey, MD, PhD4, and Carol J.
Hogue, PhD, MPH1
1Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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2Laney Graduate School, Emory University, Atlanta, GA

3Divisionof Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, School of
Medicine, Emory University, Atlanta, GA
4Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR

Abstract
Objective—To evaluate whether elective induction of labor between 39 through 41 weeks, as
compared to expectant management, is associated with reduced cesarean delivery and other
adverse outcomes among obese women and their offspring.

Methods—We conducted a retrospective cohort study using the 2007–2011 California Linked
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Patient Discharge Data–Birth Cohort File of 165,975 singleton, cephalic, non-anomalous

deliveries to obese women. For each gestational week (39–41), we used multivariable logistic
regression models, stratified by parity, to assess whether elective induction of labor or expectant
management was associated with lower odds of cesarean delivery and other adverse outcomes.

Results—At 39 and 40 weeks, cesarean delivery was less common in obese nulliparous women
who were electively induced versus those who were expectantly managed (at 39 weeks,
frequencies were 35.9% versus 41.0%, respectively [p<0.05]; adjusted odds ratio [OR] [95%
Confidence Interval (CI)]: 0.82 [0.77, 0.88]). Severe maternal morbidity was less frequent among
electively induced obese nulliparous patients (at 39 weeks, 5.6% versus 7.6% [p<0.05]; adjusted
OR: 0.75 [95% CI 0.65, 0.87]). Neonatal intensive care unit (NICU) admission was less common
among electively induced obese nulliparous women (at 39 weeks, 7.9% versus 10.1% [p<0.05];
adjusted OR: 0.79 [95% CI 0.70, 0.89]). Patterns were similar among obese parous women at 39
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weeks (crude frequencies and adjusted ORs [95% CIs] were as follows: for cesarean delivery,
7.0% versus 8.7% [p<0.05], and 0.79 [0.73, 0.86]; for severe maternal morbidity, 3.3% versus

Corresponding Author: Dr. Cassandra M. Gibbs Pickens, PhD, MPH, Department of Epidemiology, Rollins School of Public Health,
Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322. Phone: (404) 855-1166. Fax: (404) 727-8737.
[email protected].
Presented at the 29th Annual Meeting of the Society for Pediatric and Perinatal Epidemiologic Research, Miami, FL, June 20–21,
2016.
Financial Disclosure
The authors did not report any potential conflicts of interest.
Each author has indicated that he or she has met the journal’s requirements for authorship.
 Gibbs Pickens et al. Page 2

4.0% [p<0.05], and 0.83 [0.74, 0.94]; for NICU admission: 5.3% versus 7.4% [p<0.05], and 0.75
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[0.68, 0.82]). Similarly, elective induction at 40 weeks was associated with reduced odds of
cesarean delivery, maternal morbidity, and NICU admission among both obese nulliparous and
parous patients.

Conclusion—Elective labor induction after 39 weeks was associated with reduced maternal and
infant morbidity among obese women. Further prospective investigation is necessary.

INTRODUCTION
Maternal obesity (pre-pregnancy body mass index ≥30 kg/m2) increases the risks of adverse
obstetric, fetal, and infant outcomes (1–3). These risks persist even in the absence of other
chronic diseases (3). Despite the high U.S. prevalence of pre-pregnancy obesity (24.8%) (4)
and the myriad of complications associated with this condition, a uniform standard of care
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regarding delivery timing and method does not exist specifically for obese gravid patients.

Obese women and their infants are at elevated risk of preeclampsia, macrosomia, shoulder
dystocia, brachial plexus injury, meconium aspiration syndrome, and stillbirth (1,2,5,6), all
of which increase with advancing gestational age (7–10). It is plausible that these adverse
outcomes could be prevented through elective induction of labor and earlier delivery (11–
13). However, the potential negative side effects of elective labor induction and earlier
delivery must also be considered (14,15). The risks and benefits of elective labor induction,
as compared to expectant management, at different gestational ages have not been
thoroughly evaluated among obese gravid patients. Most previous research has focused on
the general population (12), although some recent analyses have evaluated obese women
specifically (7,16). Notably, although elective labor induction is not the only method to
effect earlier delivery, it may be associated with fewer complications and lower costs than
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elective cesarean delivery (12,17,18).

Our objective was to assess whether elective induction of labor at each gestational week
from 39—41 weeks, as compared to expectant management, was associated with reduced
cesarean delivery and other adverse outcomes among obese gravid patients without chronic
disease.

MATERIALS AND METHODS

In this retrospective cohort study, we used the 2007–2011 California Linked Patient
Discharge Data–Birth Cohort File (19). To create this dataset, the California Office for
Statewide Health Planning and Development linked vital records with maternal and infant
hospital discharge data for deliveries in California, plus out-of-state deliveries to California
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residents. Over 95% of deliveries were successfully linked (19). Women could potentially be
included more than once in our dataset, as deliveries occurring to the same woman in
different years were not linked. We used hospital discharge data from the delivery visit,
which included ICD-9-CM diagnostic and procedure codes. Medical diagnoses and
procedures (including induction of labor, most study outcomes, and pregnancy
characteristics) were coded as present if detected in either vital records or discharge data.
This approach improves the sensitivity of detecting pregnancy complications while

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negligibly impacting specificity (20–22). Infant birthweight was taken from vital records
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data only.

Obese women (pre-pregnancy body mass index ≥30 kg/m2) with singleton, ≥39-week
deliveries in cephalic presentation were included if they did not have preexisting medical
complications (including chronic hypertension, preexisting diabetes, gestational diabetes,
preexisting cardiac disease, preexisting renal disease, preexisting liver or biliary tract
disorder, placenta previa, vasa previa, or isoimmunization), a prior cesarean delivery, or an
infant with a major congenital anomaly that was likely to have affected clinical management
(many of these anomalies would have been diagnosed prenatally). Observations were
excluded due to missing data on study eligibility criteria, the exposure variable, or other
covariates (observations with missing data on outcome variables remained eligible for
inclusion in our study sample). Gestational age was defined by best obstetric estimate. Parity
was defined as the number of previous pregnancies reaching ≥20 weeks of gestation. Pre-
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pregnancy body mass index was derived using vital records data.

We evaluated pregnancy outcomes at each gestational week (39–41) by comparing exposed

women (those who underwent induction without medical indication in the given week) with
unexposed women (expectantly managed women who delivered at a later gestational week).
The expectant management group consisted of all women who delivered in later weeks,
regardless of delivery method or labor onset type. Medical indications for labor induction
(used to classify inductions as elective versus non-elective) were defined using recent Joint
Commission guidelines (Appendix 1, available onlineat http://links.lww.com/AOG/B41,
contains a list of conditions in this study) (7,23).

Our primary outcome was maternal mode of delivery (cesarean delivery, operative vaginal
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delivery [forceps or vacuum], and non-operative vaginal delivery). Secondary study

outcomes included severe maternal morbidity (a composite outcome of postpartum
hemorrhage, third- or fourth-degree perineal lacerations, unplanned surgical procedure,
uterine rupture, maternal intensive care unit admission, maternal sepsis, and endometritis),
infant mortality (death in first year of life), neonatal intensive care unit (NICU) admission
(NICU stay >24 hours [for infants who died ≤24 hours after birth, any NICU admission],
neonatal transfer, or infant hospital stay exceeding maternal postpartum stay (8)),
macrosomia (birthweight ≥4500 grams), clinical chorioamnionitis, meconium aspiration
syndrome, respiratory distress syndrome (RDS), shoulder dystocia, and brachial plexus
injury.

We used χ2 and Fisher’s Exact tests to evaluate whether the distributions of maternal
sociodemographic characteristics and pregnancy outcomes differed between electively
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induced and expectantly managed women. We modeled associations between elective labor
induction and pregnancy outcomes using logistic regression. In multivariable analyses, we
adjusted for maternal characteristics (age, race and ethnicity, education, obesity class,
payment source, first-trimester prenatal care initiation), birth year (before 2009 versus 2009
or later), and hospital type (community or teaching). These covariates were selected a priori
based on evidence of their associations with elective labor induction and the outcomes (7,8);
we did not adjust for potential intermediates of the associations between elective labor

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induction and pregnancy outcomes. With the exceptions of hospital type, payment source,
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and birth year, covariates were classified using vital records.

We calculated crude and adjusted odds ratios (ORs) comparing elective labor induction in
each individual week (39–41) to expectant management, stratifying by parity (nulliparous,
parous). Specifically, each model compared electively induced deliveries during the given
week to all deliveries in later weeks. In each model, spontaneous and medically indicated
deliveries that occurred during the index week were excluded. We assessed effect measure
modification by obesity class using χ2 tests of the interaction terms (p<0.20). In
supplemental analyses, we calculated adjusted ORs stratified by both obesity class (1 to 3)
and parity. In sensitivity analyses, we revised our list of indications for labor induction
(Appendix 1, available online at http://links.lww.com/AOG/B41). We added certain
intrapartum complications to the list of indications (coagulation deficiency hemorrhage,
amniotic infection, and fetal distress or fetal heart rate abnormalities with unspecified time
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of onset) and removed others (placental abruption and fetal-maternal hemorrhage). These
intrapartum complications could either be medical indications for labor induction or
consequences of labor induction, depending on their timing.

We used SAS Version 9.4 (Cary, NC) for data analysis. This study was approved by the
Emory University Institutional Review Board, the California Committee for the Protection
of Human Subjects, and the California Office for Statewide Health Planning and
Development. Informed consent was not necessary due to the de-identified nature of the
dataset.

RESULTS
Out of 2,622,927 California deliveries occurring between 2007–2011, we excluded
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2,456,952 ineligible births, mostly due to maternal pre-pregnancy BMI <30 kg/m2 (Figure
1). A total of 165,975 deliveries occurring at 39 weeks of gestation or later to obese women
remained eligible for analysis.

The frequencies of most maternal sociodemographic characteristics varied by exposure

status and gestational age (Table 1). Electively induced obese women were more likely than
expectantly managed obese women to be ≥25 years of age and to have initiated prenatal care
in the first trimester. In addition, obese women who were electively induced at 39 or 40
weeks were more likely than expectantly managed obese women to be parous and to deliver
in a community hospital.

The frequencies of adverse pregnancy outcomes also varied between electively induced and
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expectantly managed obese women (Table 2). Cesarean delivery was less common among
electively induced, versus expectantly managed, obese women at 39 weeks of gestation
(among nulliparous patients: 35.9% [95% Confidence Interval (CI) 34.1%, 37.8%] versus
41.0% [95% CI 40.4%, 41.6%], respectively); among parous patients: 7.0% [95% CI 6.4%,
7.6%] versus 8.7% [95% CI 8.4%, 9.0%], respectively; Table 2). Similarly, the frequency of
cesarean delivery was lower among electively induced obese women at 40 weeks of
gestation (e.g., among nulliparous women: 41.8% [95% CI 40.4%, 43.2%] versus 46.2%

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[95% CI 45.2%, 47.3%], respectively). In contrast, at 39 and 40 weeks, the risk of operative
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vaginal delivery was moderately increased among electively induced, as compared to

expectantly managed, obese women (e.g., among nulliparous women at 39 weeks, 8.9%
[95% CI 7.9%, 10.1%] versus 7.1% [95% CI 6.8%, 7.4%], respectively). Severe maternal
morbidity occurred less frequently among obese women who were electively induced,
versus expectantly managed, at 39 and 40 weeks of gestation (e.g., among nulliparous
women at 39 weeks: 5.6% [95% CI 4.9%, 6.3%] versus 7.6% [95% CI 7.3%, 7.8%],
respectively; among parous women at 39 weeks: 3.3% [95% CI 3.0%, 3.7%] versus 4.0%
[95% CI 3.9%, 4.2%]). Infant death was rare, and it occurred at a similar frequency among
electively induced and expectantly managed obese women at all gestational ages (e.g.,
among nulliparous women at 40 weeks, 0.1% [95% CI 0.0%, 0.2%] versus 0.1% [95% CI
0.1%, 0.2%]). NICU admission was less common among electively induced obese patients
in all gestational weeks (e.g., among nulliparous patients at 39 weeks, 7.9% [95% CI 7.1%,
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8.7%] versus 10.1% [95% CI 9.8%, 10.4%], respectively). The frequencies of several other
adverse perinatal outcomes were also lower among electively induced obese patients (Table
2). Cesarean delivery, severe maternal morbidity, NICU admission, chorioamnionitis, RDS,
and meconium aspiration syndrome increased between 2007 and 2011, while operative
vaginal delivery, macrosomia, shoulder dystocia, and infant death decreased.

There was no statistically significant effect measure modification by obesity class. Crude
ORs (Table 3) were similar in magnitude to adjusted ORs (Figure 2; Table 4). In adjusted
models, elective induction of labor between 39 and 40 weeks was associated with reduced
odds of cesarean delivery (among obese nulliparous women, adjusted OR at 39 weeks=0.82
[95% CI 0.77, 0.88], and adjusted OR at 40 weeks=0.85 [95% CI 0.80, 0.90]; among obese
parous women, adjusted OR at 39 weeks=0.79 [95% CI 0.73, 0.86], and adjusted OR at 40
weeks=0.81 [95% CI 0.74, 0.89]; Figure 2a). The odds of operative vaginal delivery were
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slightly elevated among electively induced obese nulliparous women at 39 weeks (adjusted
OR=1.16 [95% CI 1.03, 1.31]) and electively induced obese parous women at 40 weeks
(adjusted OR=1.25 [95% CI 1.10, 1.41]; Figure 2b). Elective labor induction between 39 and
40 weeks was associated with reduced odds of severe maternal morbidity, with adjusted ORs
(95% CIs) ranging from 0.75 (0.65, 0.87) to 0.84 (0.75, 0.94) among obese nulliparous
women and from 0.75 (0.66, 0.85) to 0.83 (0.74, 0.94) in obese parous women (Figure 2c).

Elective induction of labor was not associated with infant death in adjusted models;
however, models at 41 weeks did not converge (Figure 2d). Elective induction of labor at 39
and 40 weeks was associated with reduced odds of NICU admission (e.g., adjusted ORs
[95% CIs] at 39 weeks were 0.79 [0.70, 0.89] among obese nulliparous women and 0.75
[0.68, 0.82] among obese parous women; Figure 2e).The adjusted odds of other neonatal
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complications were generally lower in offspring of electively induced versus expectantly

managed obese women (Figures 2f through 2k), with some exceptions (e.g., there was no
association between elective labor induction and RDS).

After stratifying by obesity class, precision decreased, and some findings were no longer
statistically significant (Appendices 2–4, available online at http://links.lww.com/AOG/
B41). In addition, various models for rare outcomes did not converge. Most stratified
associations were in the same direction as in the main analyses. Point estimates were fairly

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similar by obesity class, and 95% CIs overlapped by obesity category for nearly all
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outcomes. Two new associations emerged in stratified analyses: elective induction at 40

weeks was associated with reduced odds of RDS among class 2 obese nulliparous women,
while elective induction at 41 weeks was associated with increased odds of severe maternal
morbidity among class 2 obese parous women (Appendix 3, available online at http://
links.lww.com/AOG/B41). After altering our assumptions about the timing of intrapartum
complications, associations between elective labor induction and cesarean appeared stronger
(Appendix 5, available online at http://links.lww.com/AOG/B41). Most other maternal and
infant outcomes were relatively unaffected.

DISCUSSION
In this study, elective induction of labor at 39 and 40 weeks of gestation was associated with
reduced odds of cesarean delivery, severe maternal morbidity, and neonatal morbidity, with
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no change in the odds of infant mortality. Elective induction at 41 weeks was also associated
with reduced odds of some neonatal complications. With the exception of operative vaginal
delivery at 39 weeks (nulliparous women) and 40 weeks (parous women), elective induction
was not associated with increased pregnancy complications. There were no significant
differences by obesity class.

This is an extension of the analysis conducted by Lee et al., who examined obese women in
the 2007 California Linked dataset (7). Similarly to our analysis, Lee et al. found that
elective labor induction from 39–41 weeks was associated with reduced odds of cesarean
delivery, macrosomia, and chorioamnionitis among obese women (7). With five years’ data
(2007–2011), we were able to newly document several significant associations between
elective labor induction between 39 and 41 weeks of gestation and reduced odds of other
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major complications (e.g., NICU admission, meconium aspiration syndrome, and others).

Similarly to our study, Schuster et al. reported that a clinical protocol to induce obese
women by their estimated due date reduced the rate of cesarean delivery, as compared to
rates of cesarean delivery before the protocol was initiated (24). Unlike our study, Schuster
et al.’s clinical protocol was associated with a slight increase in NICU admission, although
these findings were not specific to obese women (24). This clinical protocol was tested in a
single healthcare system, and analysis was limited to proxy indicators of neonatal morbidity
(e.g., NICU admission) (24). In a hospital-based retrospective cohort study, Wolfe et al.
found that elective labor induction at 39 or 40 weeks, as compared to expectant management
≥39 weeks, was associated with increased risk of cesarean delivery and NICU admission
among obese nulliparous patients with an unfavorable cervix (16). Although Wolfe et al.
accessed medical records, they did not include parous women, adjust for covariates, or
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stratify analyses by gestational week at induction (16). Our method may more closely
represent “real-time” obstetric-decision making.

Our study has many strengths. We included a large sample of over 165,000 deliveries. This
allowed us to examine rare outcomes, such as brachial plexus injury. Our analysis also
produced more precise estimates than prior investigations. We used expectant management
as the comparison group (rather than spontaneous labor), which is a valid clinical alternative

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to labor induction (12). Another strength is our comparison of elective labor induction to
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expectant management for each week between 39–41 weeks. In contrast to earlier studies,
we assessed elective labor induction at 41 weeks of gestation and stratified by obesity class.
Our dataset is diverse and population-based with high rates of record linkage (19). Finally,
we tested the robustness of our assumptions in sensitivity analyses. Limitations in this study
included inability to evaluate stillbirth, as all stillbirths were excluded due to preexisting
maternal conditions or missing data on study eligibility criteria. As stillbirth at subsequent
gestational ages is prevented with induction at an earlier gestational age, this may have
impacted our perinatal mortality estimates. Due to low numbers of events, we could not
evaluate neonatal mortality separately from total infant mortality. Our analyses for cesarean
delivery could be biased down and away from the null, as the risk of cesarean increases with
gestational age (25). There may be residual confounding in our study, as our dataset did not
contain information on maternal discomfort, provider preferences, or cervical status (15,26).
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Women with a favorable cervix or those who are healthy may be more likely to be electively
induced and less likely to deliver via cesarean section (8,26). This could bias our results in
favor of elective induction. Our results may only be generalizable to obese Californian
women without preexisting disease who delivered between 2007 and 2011. Due to changing
outcome frequencies over time, the patterns and associations in our study (years 2007–2011)
may not represent those in 2012 or later. Finally, although medical complications may be
underreported in administrative data, linked datasets are accurate for many complications
and procedures (20–22).

Additional research using larger sample sizes of morbidly obese women may help determine
whether a uniform policy on term elective induction is appropriate for all obese women. In
addition, future studies should consider utilizing a randomized, controlled trial design to
reduce unobserved confounding. Future analyses of stillbirth and neonatal mortality are also
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essential. In conclusion, elective labor induction between 39 0/7 and 40 6/7 weeks of
gestation may be associated with reduced maternal and neonatal morbidity among obese
women and their offspring.

Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
Supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National
Institutes of Health (Grant 5T32HD052460-10, Emory University), Maternal and Child Health Bureau, Health
Resources and Services Administration (Grant T03MC07651, Emory University), and Emory University Laney
Graduate School. The funders had no role in study design; in data collection, analysis, or interpretation; in the
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writing of the manuscript; or in the decision to submit the article for publication.

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Figure 1.
The top of this flow chart shows the number of women excluded from our sample due to
study ineligibility (eg, BMI less than 30, pre-existing maternal conditions, multiple
gestations) or missing data. Numbers of excluded observations do not overlap. The bottom
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of this flowchart represents the number of obese women analyzed at each gestational week
(39 weeks through 41 weeks), stratified by parity. Some of these numbers overlap, because
obese women who were expectantly managed at one gestational week could be electively
induced at a later week. In each comparison (eg, elective induction at 39 weeks of gestation
compared with expectant management), spontaneous and medically indicated deliveries that
occurred during the index week were excluded. As a consequence, week-specific counts
may not sum to the total number of observations.*Pre-existing medical conditions include

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chronic hypertension, pre-existing or gestational diabetes, pre-existing cardiac disease, pre-

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existing renal disease, pre-existing liver or biliary tract disorder, vasa or placental previa, or
isoimmunization.
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 Gibbs Pickens et al. Page 12
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Figure 2.
Adjusted odds ratios for elective labor induction, as compared to expectant management,
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and pregnancy outcomes among obese women. A–K display adjusted odds ratios, stratified
by parity, for elective induction of labor (compared with expectant management) and
pregnancy outcomes among obese women and their offspring. Models were adjusted for
maternal age, education, and race and ethnicity; first-trimester prenatal care initiation;
payment source for delivery; birth year; obesity class; and delivery at a teaching hospital.
Cesarean delivery (A), operative vaginal delivery* (B), severe maternal morbidity† (C),
infant death‡ (D), neonatal intensive care unit (NICU) admission§ (E), macrosomia (≥4,500

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 Gibbs Pickens et al. Page 14

g) (F), chorioamnionitis (G), meconium aspiration syndrome (H), respiratory distress

syndrome (I), shoulder dystocia (J), and brachial plexus injury‖ (K). *Mode of delivery was
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a three category outcome modeled using multinomial logistic regression. †Includes

postpartum hemorrhage, third-or-fourth degree perineal lacerations, unplanned surgical
procedure, uterine rupture, maternal intensive care unit admission, sepsis, and endometritis.
‡Models for infant death did not converge at 41 weeks of gestation. §Number of observations

with missing values on NICU admission, by parity (nulliparous; parous): 39 weeks of

gestation (21; 5), 40 weeks of gestation (1; 30), 41 weeks of gestation (12; 5). ‖Models for
brachial plexus injury did not converge among nulliparous patients at 41 weeks of gestation.
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Table 1

ies of Maternal Characteristics among Electively Induced and Expectantly Managed Obese Women

39 weeks 40 weeks 41 weeks

l characteristic Elective Induction (n=13,568) Expectant Management (n=95,094) Elective Induction (n=17,809) Expectant Management (n=25,279) Elective Induction (n=9,909) Expectant Management (n=1,928)
Gibbs Pickens et al.

us (%) 29.1* 42.8 39.6* 49.3 50.1 50.2

lass

35.0 kg/m2) 63.9 64.0 63.7* 62.2 61.6 61.1

40.0 kg/m2) 23.7 24.0 24.1 24.7 25.2 24.2

g/m2) (%) 12.4 12.0 12.2 13.1 13.3 14.7

l age, years

31.9* 36.5 36.1* 37.6 37.0* 40.4

) 54.9 52.2 52.1 51.3 52.3 49.7

13.3 11.4 11.8 11.1 10.8 9.9

ethnicity
(all races) (%) 58.8* 61.8 61.8* 56.8 55.4 54.6

anic Black (%) 5.3 6.8 6.0 7.4 7.4 8.3

anic White (%) 29.4 25.0 26.2 29.3 31.3 30.4

n-Hispanic (%) 6.5 6.4 6.0 6.5 5.9 6.7

ester prenatal care initiation

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84.0* 79.3 80.7* 75.9 77.5* 68.0

elivery
008 (%) 38.3* 39.9 40.7 40.5 39.6* 45.3

at teaching hospital

4.4* 9.9 6.0* 11.7 10.4 11.2

re percentages (%) within exposure categories. No observations in our analytic sample were missing data on the exposure or covariates.

sed on χ2 test examining whether covariate frequencies varied by exposure category.

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Table 2

bution of Pregnancy Outcomes among Electively Induced and Expectantly Managed Obese Women and their Offspring

arous women (n=65,333)

39 weeks 40 weeks 41 weeks

me Elective Induction (n=3,942) Expectant Management (n=40,667) Elective Induction (n=7,061) Expectant Management (n=12,453) Elective Induction (n=4,961) Expectant Management (n=967)
Gibbs Pickens et al.

ean delivery, n 1,416 (35.9)* 16,673 (41.0) 2,948 (41.8)* 5,757 (46.2) 2,258 (45.5) 478 (49.4)

tive vaginal 352 (8.9)* 2,890 (7.1) 554 (7.8)* 848 (6.8) 366 (7.4) 59 (6.1)
ry (total), n (%)

um, n (%) 327 (8.3) 2,657 (6.5) 525 (7.4) 774 (6.2) 327 (6.6) 55 (5.7)
eps, n (%) 18 (0.5) 183 (0.5) 22 (0.3) 59 (0.5) 31 (0.6) 4 (0.4)
ecified or both 7 (0.2) 50 (0.1) 7 (0.1) 15 (0.1) 8 (0.2) 0 (0.0)

aneous vaginal 2,174 (55.2)* 21,104 (51.9)* 3,559 (50.4)* 5,848 (47.0) 2,337 (47.1) 430 (44.5)
, n (%)

e maternal 221 (5.6)* 3,071 (7.6) 483 (6.8)* 1,053 (8.5) 408 (8.2) 87 (9.0)
dity, n (%)†

death, n (%)‡ 1 (0.0) 48 (0.1) 6 (0.1) 15 (0.1) 5 (0.1) 0 (0.0)

admission, n (%) 311 (7.9)* 4,104 (10.1) 612 (8.7)* 1,291 (10.4) 449 (9.1)* 137 (14.2)

somia, n (≥4500 27 (0.7)* 977 (2.4) 144 (2.0)* 430 (3.5) 182 (3.7)* 53 (5.5)
)

oamnionitis, n (%) 151 (3.8)* 2,818 (6.9) 354 (5.0)* 1,037 (8.3) 392 (7.9) 91 (9.4)

nium aspiration 20 (0.5)* 398 (1.0) 27 (0.4)* 161 (1.3) 45 (0.9)* 19 (2.0)
ome, n (%)‡

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ratory distress 74 (1.9) 888 (2.2) 134 (1.9)* 296 (2.4) 101 (2.0) 26 (2.7)
ome, n (%)

der dystocia, n 62 (1.6) 577 (1.4) 115 (1.6) 175 (1.4) 90 (1.8) 10 (1.0)

ial plexus injury, 3 (0.1) 77 (0.2) 15 (0.2) 28 (0.2) 12 (0.2) 2 (0.2)

‡

s women (n=100,642)

39 weeks 40 weeks 41 weeks

me Elective Induction (n=9,626) Expectant Management (n=54,427) Elective Induction (n=10,748) Expectant Management (n=12,826) Elective Induction (n=4,948) Expectant Management (n=961)
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ean delivery, n 673 (7.0)* 4,722 (8.7) 892 (8.3)* 1,289 (10.0) 473 (9.6) 111 (11.6)

tive vaginal 426 (4.4)* 2,152 (4.0) 532 (4.9)* 486 (3.8) 199 (4.0) 34 (3.5)
ry (total), n (%)

um, n (%) 399 (4.2) 2,040 (3.8) 504 (4.7) 464 (3.6) 187 (3.8) 33 (3.4)
eps, n (%) 23 (0.2) 80 (0.2) 19 (0.2) 18 (0.1) 11 (0.2) 1 (0.1)
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ecified or both 4 (0.0) 32 (0.1) 9 (0.1) 4 (0.0) 1 (0.0) 0 (0.0)

aneous vaginal 8,527 (88.6)* 47,553 (87.4) 9,324 (86.8)* 11,051 (86.2) 4,276 (86.4) 816 (84.9)
, n (%)

e maternal 319 (3.3)* 2,200 (4.0) 396 (3.7)* 623 (4.9) 261 (5.3) 50 (5.2)
dity, n (%)†

death, n (%)‡ 5 (0.1) 59 (0.1) 15 (0.1) 16 (0.1) 5 (0.1) 2 (0.2)

admission, n (%) 514 (5.3)* 4,039 (7.4) 656 (6.1)* 1,023 (8.0) 325 (6.6) 79 (8.2)

somia (≥4500 g), 169 (1.8)* 1,804 (3.3) 299 (2.8)* 638 (5.0) 259 (5.2)* 67 (7.0)

oamnionitis, n (%) 62 (0.6)* 583 (1.1) 89 (0.8)* 191 (1.5) 78 (1.6) 10 (1.0)

nium aspiration 15 (0.2)* 221 (0.4) 26 (0.2)* 74 (0.6) 20 (0.4)* 11 (1.1)

ome, n (%)‡

ratory distress 109 (1.1) 622 (1.1) 118 (1.1) 174 (1.4) 55 (1.1) 14 (1.5)
ome, n (%)

der dystocia, n 201 (2.1)* 1,553 (2.9) 296 (2.8)* 465 (3.6) 186 (3.8) 41 (4.3)

ial plexus injury, 20 (0.2) 120 (0.2) 16 (0.2)* 41 (0.3) 12 (0.2)* 7 (0.7)
‡

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ata are frequencies (n) and percentages (%) within exposure categories.

. Unless otherwise noted, p-values come from a 1 df χ2 test of whether outcome frequencies varied by exposure category. P-values for cesarean delivery, operative vaginal delivery, and spontaneous
births (i.e., non-operative vaginal delivery) come from a 2 df χ2 test examining whether mode of delivery varies by exposure category. Although forceps delivery and vacuum extraction were
ed in all analyses, the breakdown of forceps delivery versus vacuum extraction is shown here.

529 women, 56.8% had postpartum hemorrhage, 31.9% had a third-or-fourth degree perineal laceration, and 11.3% experienced multiple or rare complications.

exact test examining whether outcome frequencies varied by exposure category.

stay >24 hours (or, for infants who died <24 hours after birth, any NICU admission), neonatal transfer, or infant hospital stay longer than maternal postpartum hospital stay. Number of observations
ssing values on NICU admission, by parity (nulliparous, parous): 39 weeks (21; 5), 40 weeks (1; 30), 41 weeks (12; 5). When considering all deliveries together (i.e., all types of labor onset and
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delivery), the frequency of NICU admission was lower among deliveries at 39–40 weeks versus deliveries at ≥41 weeks (e.g., among obese nulliparous women, 9.7% versus 10.4%, p<0.05; among obese
parous women: 7% versus 8%, p<0.05).
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Table 3

Crude Odds Ratios for Elective Induction of Labor Compared With Expectant Management and Pregnancy
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Outcomes Among Obese Women

Nulliparous women (n=65,333)

Outcome Elective Induction, 39 weeks Elective Induction, 40 weeks Elective Induction, 41 weeks
(n=3,942) vs. Expectant (n=7,061) vs. Expectant (n=4,961) vs. Expectant
Management (n=40,667) Management (n=12,453) Management (n=967)
Cesarean delivery 0.82 (0.77—0.88) 0.84 (0.79—0.89) 0.87 (0.75—1.00)

Operative vaginal delivery 1.18 (1.05—1.33) 1.07 (0.96—1.20) 1.14 (0.85—1.53)

Severe maternal morbidity* 0.73 (0.63—0.84) 0.80 (0.71—0.89) 0.91 (0.71—1.16)

Infant death 0.21 (0.03—1.56) 0.71 (0.27—1.82) Did not converge

NICU admission† 0.76 (0.68—0.86) 0.82 (0.74—0.91) 0.60 (0.49—0.74)

Macrosomia (≥4500 g) 0.28 (0.19—0.41) 0.58 (0.48—0.70) 0.66 (0.48—0.90)

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Chorioamnionitis 0.54 (0.45—0.63) 0.58 (0.51—0.66) 0.83 (0.65—1.05)

Meconium aspiration syndrome 0.52 (0.33—0.81) 0.29 (0.19—0.44) 0.46 (0.27—0.78)

Respiratory distress syndrome 0.86 (0.67—1.09) 0.79 (0.65—0.98) 0.75 (0.49—1.16)

Shoulder dystocia 1.11 (0.85—1.45) 1.16 (0.92—1.47) 1.77 (0.92—3.41)

Brachial plexus injury 0.40 (0.13—1.27) 0.94 (0.50—1.77) 1.17 (0.26—5.24)

Parous women (n=100,642)

Outcome Elective Induction, 39 weeks Elective Induction, 40 weeks Elective Induction, 41 weeks
(n=9,626) vs. Expectant (n=10,748) vs. Expectant (n=4,948) vs. Expectant
Management (n=54,427) Management (n=12,826) Management (n=961)
Cesarean delivery 0.79 (0.73—0.86) 0.82 (0.75—0.90) 0.81 (0.65—1.01)

Operative vaginal delivery 1.10 (0.99—1.23) 1.30 (1.14—1.47) 1.12 (0.77—1.62)

Severe maternal morbidity* 0.81 (0.72—0.92) 0.75 (0.66—0.85) 1.01 (0.74—1.38)

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Infant death 0.48 (0.19—1.19) 1.12 (0.55—2.26) 0.49 (0.09—2.50)

NICU admission† 0.70 (0.64—0.77) 0.75 (0.68—0.83) 0.78 (0.61—1.01)

Macrosomia (≥4500 g) 0.52 (0.44—0.61) 0.55 (0.48—0.63) 0.74 (0.56—0.97)

Chorioamnionitis 0.60 (0.46—0.78) 0.55 (0.43—0.71) 1.52 (0.79—2.95)

Meconium aspiration syndrome 0.38 (0.23—0.65) 0.42 (0.27—0.65) 0.35 (0.17—0.73)

Respiratory distress syndrome 0.99 (0.81—1.22) 0.81 (0.64—1.02) 0.76 (0.42—1.37)

Shoulder dystocia 0.73 (0.63—0.84) 0.75 (0.65—0.87) 0.88 (0.62—1.24)

Brachial plexus injury 0.94 (0.59—1.51) 0.46 (0.26—0.83) 0.33 (0.13—0.84)

Table data are crude odds ratios (95% confidence intervals). Mode of delivery was modeled using multinomial logistic regression. Other outcomes
were modeled using logistic regression.
*
Composite outcome including postpartum hemorrhage, third-or-fourth degree perineal laceration, unplanned surgical procedure, uterine rupture,
maternal intensive care unit admission, maternal sepsis, and endometritis.
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†
NICU stay >24 hours (or, for infants who died <24 hours after birth, any NICU admission) documented in vital records, neonatal transfer
documented in vital records, or infant hospital stay longer than maternal postpartum hospital stay (documented in hospital discharge data). Number
of observations with missing values on NICU admission, by parity (nulliparous, parous): 39 weeks (21; 5), 40 weeks (1; 30), 41 weeks (12; 5).

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Table 4

Adjusted Odds Ratios for Elective Induction of Labor Compared With Expectant Management and Pregnancy
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Outcomes Among Obese Women

Nulliparous women (n=65,333)

Outcome Elective Induction, 39 weeks Elective Induction, 40 weeks Elective Induction, 41 weeks
(n=3,942) vs. Expectant (n=7,061) vs. Expectant (n=4,961) vs. Expectant
Management (n=40,667) Management (n=12,453) Management (n=967)
Cesarean delivery 0.82 (0.77—0.88) 0.85 (0.80—0.90) 0.87 (0.75—1.00)

Operative vaginal delivery 1.16 (1.03—1.31) 1.07 (0.95—1.20) 1.14 (0.85—1.53)

Severe maternal morbidity* 0.75 (0.65—0.87) 0.84 (0.75—0.94) 0.89 (0.69—1.13)

Infant death 0.23 (0.03—1.68) 0.75 (0.29—1.95) Did not converge

NICU admission† 0.79 (0.70—0.89) 0.84 (0.76—0.94) 0.60 (0.49—0.74)

Macrosomia (≥4500 g) 0.28 (0.19—0.41) 0.60 (0.50—0.73) 0.63 (0.46—0.86)

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Chorioamnionitis 0.56 (0.47—0.66) 0.61 (0.54—0.69) 0.77 (0.61—0.98)

Meconium aspiration syndrome 0.55 (0.35—0.87) 0.31 (0.20—0.46) 0.49 (0.28—0.84)

Respiratory distress syndrome 0.89 (0.70—1.13) 0.82 (0.67—1.01) 0.79 (0.51—1.23)

Shoulder dystocia 1.14 (0.87—1.48) 1.22 (0.96—1.56) 1.75 (0.91—3.40)

Brachial plexus injury 0.41 (0.13—1.29) 0.90 (0.48—1.70) Did not converge

Parous women (n=100,642)

Outcome Elective Induction, 39 weeks Elective Induction, 40 weeks Elective Induction, 41 weeks
(n=9,626) vs. Expectant (n=10,748) vs. Expectant (n=4,948) vs. Expectant
Management (n=54,427) Management (n=12,826) Management (n=961)
Cesarean delivery 0.79 (0.73—0.86) 0.81 (0.74—0.89) 0.81 (0.64—1.01)

Operative vaginal delivery 1.07 (0.97—1.20) 1.25 (1.10—1.41) 1.13 (0.77—1.64)

Severe maternal morbidity* 0.83 (0.74—0.94) 0.75 (0.66—0.85) 0.95 (0.69—1.30)

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Infant death 0.45 (0.18—1.13) 1.10 (0.54—2.23) Did not converge

NICU admission† 0.75 (0.68—0.82) 0.77 (0.70—0.86) 0.79 (0.61—1.03)

Macrosomia (≥4500 g) 0.50 (0.43—0.59) 0.55 (0.48—0.63) 0.74 (0.56—0.99)

Chorioamnionitis 0.60 (0.46—0.79) 0.57 (0.44—0.73) 1.35 (0.69—2.64)

Meconium aspiration syndrome 0.41 (0.24—0.69) 0.45 (0.28—0.70) 0.41 (0.19—0.87)

Respiratory distress syndrome 1.03 (0.84—1.26) 0.81 (0.64—1.03) 0.84 (0.46—1.54)

Shoulder dystocia 0.72 (0.62—0.83) 0.77 (0.66—0.89) 0.87 (0.62—1.24)

Brachial plexus injury 0.96 (0.59—1.54) 0.47 (0.26—0.83) 0.34 (0.13—0.89)

Table data are adjusted odds ratios (95% confidence intervals). These data are also presented graphically in Figure 2. Mode of delivery was
modeled using multivariable, multinomial logistic regression. Other outcomes were modeled using multivariable logistic regression. Models were
adjusted for maternal age, maternal education, maternal race and ethnicity, initiation of prenatal care in the first trimester, principal source of
payment for delivery, birth year, obesity class, and delivery at a teaching hospital.
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*
Composite outcome including postpartum hemorrhage, third-or-fourth degree perineal laceration, unplanned surgical procedure, uterine rupture,
maternal intensive care unit admission, maternal sepsis, and endometritis.
†
NICU stay >24 hours (or, for infants who died <24 hours after birth, any NICU admission) documented in vital records, neonatal transfer
documented in vital records, or infant hospital stay longer than maternal postpartum hospital stay (documented in hospital discharge data). Number
of observations with missing value on NICU admission, by parity (nulliparous, parous): 39 weeks (21; 5), 40 weeks (1; 30), 41 weeks (12; 5).

Obstet Gynecol. Author manuscript; available in PMC 2019 January 01.