Running head: AN INTEGRATIVE REVIEW 1

An Integrative Review

Jamie J. Borel

Bon Secours Memorial College of Nursing

Arlene Holowaychuk MSN, RN

Nursing Research – NUR 4122

April 18, 2018

Honor Code “I have neither given nor received aid, other than acknowledged, on this assignment

or test, nor have I seen anyone else do so.”

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The purpose of this integrative review is to determine if induction of labor is a greater risk factor

for cesarean section delivery among women of advanced maternal age (AMA) versus women of

normal maternal age. Women of AMA are more likely to have their labor induced to reduce the

risk of poor fetal outcomes; however, induction of labor is also thought to increase the risk for

cesarean section. With a push to decrease the number of cesarean sections performed, the link

between these variables must be studied. Databases such as EBSCOhost and PubMed were used

to locate research articles. While three articles supported the conclusion that AMA was a risk

factor for cesarean section following induction of labor, the other two articles found that there

was no increased risk for cesarean section among women of AMA. Limitations to the studies in

this review include the fact that most of the studies were retrospective, which can create gaps in

data and no way to control bias in the selection of data chosen. Another limitation to the

research reviewed is the inability to study all confounding factors which may increase a women’s

risk for cesarean section. The information concluded for these studies can be used in practice to

help inform women of AMA on the risks and benefits associated with induction of labor based

on their current health status. Recommendations for future research include more efficient ways

to induce labor in women of AMA to decrease the incidence of cesarean section.

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An Integrative Review

The purpose of this integrative review is to determine if induction of labor in mothers of

advanced maternal age (AMA) is a risk factor for cesarean section delivery outcomes. AMA is

defined as any women giving birth at the age of 35 or older. An increasing number of women

are giving birth later in life for several reasons including advancing careers and problems with

infertility. Whether the decision to have a baby later in life is made involuntarily or voluntary, it

should be noted that having children after 35 puts the mother and baby at increased risk for

adverse delivery outcomes. It is thought that women of AMA are more likely to delivery via

cesarean section. Cesarean sections increase the risk for intrapartum and postpartum

complications for the mother and newborn. For this reason, the goal is to reduce the number of

cesarean sections performed. Research suggests that AMA also puts the neonate at increased

risk for stillbirth. To decrease the risk of stillbirth, it has been found that induction of labor

decreases this risk when performed at term gestation (Dunn, Kumar, & Wong, 2017). Although

the risk of stillbirth is reduced, it is known that “induction increases the risk of medical

intervention, analgesia, episiotomy, vacuum extraction, and the possibility of cesarean section”

(Rijal, 2014). The purpose of this integrative review is to compile relevant literature to answer

the researcher’s PICO question, does induction of labor in women of advanced maternal age,

increase the risk of cesarean section versus women of normal maternal age?

Design and Research Methods

The research design is an integrative review. EBSCOhost and PubMed were the search

engines used to compile research articles for this review. Search words used to locate articles

related to the researcher’s topic included, ‘cesarean delivery’, ‘induction of labor’, ‘advanced

maternal age’, ‘risk factors’, ‘randomized trial’, and ‘delivery outcomes.’ Using these keywords,
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the search yielded 79 research articles which indicated that there was adequate research to further

explore this topic. In an effort to compile the most recent and reliable research on this topic, the

search was limited to peer-reviewed, full-text articles published in English between 2013 and

2018. The research articles chosen were also limited to quantitative and qualitative research

studies. All of the articles chosen were relevant to the researcher’s PICO question, “Does

induction of labor of women of advanced maternal age increase the risk for cesarean section,

compared to women of normal maternal age?” The following inclusion criteria were used to

select five quantitative articles used in this research: advanced maternal age, cesarean section

delivery outcomes, and induction of labor. Exclusion criteria included any meta-analysis,

systemic review, or articles that did not relate to the PICO question as previously defined.

Findings and Results

The results of these five research studies varied in their findings determining the link

between induction of labor among women of AMA and the delivery outcome of cesarean

section. Although all studies did indicate that induction of labor was an independent risk factor

for cesarean section, there was not consensus among whether AMA was a contributing factor,

(Dunn, Kumar, & Beckmann, 2017; Islam & Bakheit, 2014; Muto et al., 2017; Rijal, 2014;

Walker et al., 2016). A synopsis of the research reviewed can be found in the Appendix where

each article is summarized into separate tables. The researcher framed the review according to

the following categories: maternal complications and neonate outcomes.

Maternal Complications

Three of the five articles reviewed conclude that there are additional maternal risk

factors, beyond AMA, that increase a women’s risk for cesarean section following induction of

labor (Islam & Bakheit, 2014; Muto et al., 2017; Rijal, 2014). The quantitative retrospective
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study by Islam & Bahkeit (2014) was a population-based study performed in Oman, to address

the increasing number of women waiting until later in life to have children and what impact that

is having on their pregnancy outcomes in a country where technology and medicine are not as

advanced as other countries. The aim of the study was to determine risk factors of AMA patients

for adverse obstetric outcomes during delivery, while controlling the effects of potentially

confounding factors. A stratified sample of 2,037 Omani women were chosen and placed into

two groups based on maternal age: ages 20 to 34 and ages 35 and older. Twenty-five teams were

assembled, including a female health educator, registered nurse (RN), lab tech, health inspector,

and field supervisor were sent into the community to visit each household. A household

questionnaire, reproductive health questionnaire, and a gynecological morbidity symptoms

questionnaire were administered, and the participants were instructed to follow-up at a healthcare

clinic for a full-exam. Data analysis was performed using SPSS software. Chi-square analysis

testing was performed to find associations between categorical variables and student’s t-test was

used for comparing means between the two groups. Bivariate analysis was used as a first step to

understanding outcome variables in relation to age; however, multivariate logistic regression

analysis was needed to identify which factors were independently associated with adverse

obstetric outcomes while controlling for potential confounding factors. Statistically significant

factors for adverse obstetric outcomes such as cesarean section was found to be AMA, in

addition to other maternal complications such as gestational diabetes, preeclampsia, gestational

hypertension, spontaneous abortion, and prolonged labor.

The quantitative retrospective cohort study by Muto et al., (2017) acknowledged that

AMA has been considered a significant risk factor for cesarean section delivery; however, these

studies didn’t discuss other antepartum and intrapartum factors that may play a role in increasing
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this risk. The aim of this study was to determine which risk factors were most highly associated

with AMA women delivery via cesarean section. A sample of 935 nulliparous women at full

term, at least 37 weeks’ gestation, were selected retrospectively from databases of Osaka

Women’s and Children Hospital in Japan. Data was collected from the participants medical

records from baseline characteristics throughout the postpartum period. Data analyzed included

maternal age, gestational week at delivery, assisted reproductive technology, maternal height and

maternal body mass index. Additional data collected included indications for emergency

cesarean section such as arrest of labor, non-reassuring fetal status, and maternal complications

including, preeclampsia, gestational hypertension and gestational diabetes mellitus. The data

was analyzed using JMP version 10 software. Statistical analysis was done through chi-square

tests, multivariate logistic regression analysis and decision-making tree analysis. It was found

that 21% of nulliparous women of AMA delivered via emergency cesarean section; however,

when induction of labor was performed that statistic jumped to 43%. When a woman of AMA

was induced with gestational hypertension, the chances of cesarean delivery was at 56.7% which

is a significant finding.

The prospective observational quantitative study performed by Rijal (2014) sought to

identify what the risk factors were for cesarean section following induction of labor, since it is

one of the most common procedures in obstetrics. A sample of 348 participants were chosen

from the database of the Obstetrics Unit of BP Koirala Institute of Health Sciences. Data was

collected during the pre-induction phase, one-hour post induction, and the fetal heart rate data

was collected every 30 minutes during the latent and active phases of labor. Data collected

included pre-induction Bishop’s score, the number of Misoprostol doses administered, oxytocin

augmentation, obesity, maternal age, parity, meconium presence in the amniotic fluid,
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hypertension, prolonged latent and/or active phase, and newborn birth weight. The data was

analyzed using SPSS software. Chi-square test and logistic regression analysis was used to

assess significant variables contributing to cesarean section. Significant findings suggested that

AMA is not an independent risk factor; however, Bishop’s scores less than five, multiple doses

of Misoprostol, prolonged latent and active labor, oxytocin augmentation, meconium presence in

the amniotic fluid and large birthweight were all risk factors for cesarean section following

induction of labor.

Neonate Complications

Two of the articles chosen for review looked at the risk for cesarean section following

induction in mothers of AMA because with this age group, induction of labor at term (37 weeks

gestation) is indicated for lowering the risk of stillbirth of the neonate (Dunn, Kumar, &

Beckmann, 2017; Walker et al., 2016). The quantitative retrospective cohort study conducted by

Dunn, Kumar, & Beckmann (2017) sought to find out if AMA was a risk factor for emergency

cesarean section following induction of labor because many clinicians recommend induction of

labor for this population. The study sample included 7,459 records from the Mater Mother’s

Hospital’s obstetric database MatriX. Data was collected during the prenatal, intrapartum, and

postpartum phases of delivery. The researchers collected data regarding maternal age, body

mass index, parity, gestational age at time of induction, Bishop’s score, and induction of labor

indication and method. Other variables considered were mode of delivery, indication of cesarean

section, continuous electronic fetal monitoring, maternal complications, fetal complications,

birthweight, APGAR, and neonatal resuscitation. Data was analyzed using StataSE 13.0.

Outcomes were compared using the Parson’s x2 test and student’s T-test. Significant findings
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concluded that AMA was independently associated with a two-fold increase in likelihood of

emergency cesarean section following induction of labor.

The randomized-controlled trial study done by Walker et al., (2016) was a quantitative

study conducted across 38 National Health Service hospitals and one primary care trust

organization in the United Kingdom. This study was conducted because of increased stillbirth

rates among women of advanced maternal age. Induction of labor is indicated in many instances

to avoid this risk, so the aim of the study was to determine delivery outcomes for mothers of

AMA following induction of labor versus expectant management of delivery. A randomized

sample of 619 women, 35 years of age and older, were divided into two groups: 305 women

assigned to the induction of labor group and 314 were assigned to expectant management. Data

was collected immediately after discharge by the research midwife at each facility. The mother’s

expectations and experience were measured by a questionnaire using a 0-4 scale. Data collected

included method of delivery, indication for cesarean section, epidural use, gestational age at

delivery, maternal complications, live born infants, deaths, gender, birthweight, APGAR scores,

neonatal intensive care admission, newborn complications, and required interventions. All

analysis were performed using Stata software, version 13. Primary delivery outcomes were

measured using a generalized linear model and a multinomial logistic regression model to

calculate relative risks for mode of delivery. A generalized linear model was used to analyze

maternal and neonatal complications. Finally, a complete case analysis was used to analyze the

women’s experience and expectations of childbirth. It was determined that in women of AMA,

there was no significant increase in risk of cesarean section following induction of labor versus

expectant management of delivery.

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Discussions and Implications

Each of the five articles chosen for this integrative review address the effects of AMA

and delivery outcomes. Each of the articles reviewed take on a different aspect of the

connections between women of AMA, induction of labor, and cesarean section delivery. The

study by Dunn, Kumar, & Beckmann (2017) concluded that “advanced maternal age is

associated with an increased likelihood of cesarean section among women whose labors are

induced; however overall the majority of advanced maternal age women achieved a vaginal birth

following induction of labor”. The study conducted by Islam & Bakheit (2014) determined that

AMA is a risk factor for cesarean delivery and also a risk factor for other adverse obstetric

outcomes such as gestational diabetes mellitus, preeclampsia, gestational hypertension, and

prolonged labor. Because this study was done in a less developed country and was population-

based, rather than hospital-based, induction of labor was not evaluated; however, the correlation

between maternal age and cesarean section should still be considered. The study done by Muto et

al. (2017), concluded that induction of labor is a significant risk factor for emergency cesarean

section among women of AMA and the risk is even higher among those with gestational

hypertension. The prospective observational study conducted by Rijal (2104) found that in

isolation, AMA was not a risk factor for cesarean section following induction of labor. Finally,

the randomized-controlled trial performed by Walker et al., (2016) concluded that induction of

labor among women of AMA did not have an increased risk of cesarean section when compared

to women of AMA who underwent expectant management of delivery. Although this study did

not compare the results to women of normal maternal age, the findings are still relevant to the

discussion of AMA, induction of labor, and cesarean section outcomes.

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With the increasing number of women giving birth at AMA, and the increase in cesarean

sections being performed, these study findings can be used by healthcare providers to educate

women on the benefits and risks associated with induction of labor after the age of 35 (Dunn,

Kumar, & Beckmann, 2017; Islam & Bakheit, 2014). In addition to education, Muto et al.

(2017) suggests that clinicians use this information to initiate studies to find more efficient ways

to induce labor in women of AMA so that the cesarean section rates can be decreased.

Additional recommendations for future research are more studies aimed at directly comparing

delivery outcomes following induction of labor in women of AMA versus women of normal

maternal age.

Limitations

Limitations to this integrated review include the limited number of articles reviewed.

Only five articles were chosen, and they were limited to the last five years of research so the

review was not exhaustive. The researcher also has limited research experience as a full-time

student in an undergraduate program. This lack of clinical experience leads to a limited

understanding of the research topic being reviewed. General limitations to the research include

retrospective data collection being incomplete with variations in practice. Another limitation is

that all confounding factors for increasing risk of caesarean section were not accounted for, so

bias could have been introduced based on the majority of the studies implementing convenience

samples versus randomization.

Conclusion

The findings of this integrative review indicate that while there is a link between

induction of labor and cesarean section, there is no consensus indicating that AMA following

induction of labor is an independent risk factor for cesarean section. It was found that women of
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AMA are more likely to have maternal complications that may increase the likelihood of a

cesarean section, versus mothers of normal maternal age. Although all of the articles reviewed

take on different aspects of the PICO question, because of the limitations and the lack of

consensus among the research reviewed, there is not sufficient evidence to fully evaluate the

PICO question as it is written.

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References

Dunn, L., Kumar, S., & Beckmann, M. (2017). Maternal age is a risk factor for cesarean section

following induction of labour. Australian and New Zealand Journal of Obstetrics and

Gynaecology, 57, 426-431. doi:10.1111/ajo.12611

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Critical

appraisal of the evidence: Part I. American Journal of Nursing, 110(7), 47-52.

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Critical

appraisal of the evidence: Part II. American Journal of Nursing, 110(9), 41-48.

Islam, M. M., & Bakheit, C. S. (2014). Advanced maternal age and risks for adverse pregnancy

outcomes: A population-based study in Oman. Health Care for Women International,

36(10), 1081-1103. doi:10.1080/07399332.2014.990560

Muto, H., Ishii, K., Nakano, T., Hayashi, S., Okamoto, Y., & Mitsuda, N. (2017). Rate of

intrapartum cesarean section and related factors in older nulliparous women at term.

Journal of Obstetrics and Gynaecology Research, 44(2), 217-222. doi:10.1111/jog.13522

Rijal, P. (2014). Identification of risk factors for cesarean delivery following induction of labour.

Journal of Nepal Health Research Council, 12(27), 2nd ser., 73-77. Retrieved February

21, 2018.

Ryan, F., Coughlan, M., & Cronin, P. (2007). Step-by-step guide to critiquing research. Part 2:

qualitative research. British Journal of Nursing, 16(12), 738-744.

doi:10.12968/bjon.2007.16.12.23726

Walker, K. F., Bugg, G. J., Macpherson, M., McCormick, C., Grace, N., Wildsmith, C.,

…Thornton, J.G. (2016). Randomized trial of labor induction in women 35 years of age
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or older. The New England Journal of Medicine, 374(9), 813-822.

doi:10.1056/NEJMoal509117
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Appendix

First Author Dunn (2017) – Mater Research Institute, University of

(Year)/Qualifications Queensland, Brisbane, Queensland, Australia
Background/Problem Greater than 20% of mothers giving birth are greater than
Statement 35. Induction is the AMA recommendation, once at term
gestation due to the high risk of stillborn birth. Problem –
Does the practice of induction of labor, put these mothers at
a higher risk for eCS?
Conceptual/theoretical  The concept behind the study was to determine the
Framework relationship between induction of labor and birth outcomes
for AMA women.
 Theoretical framework was not discussed.
Design/  Quantitative – Retrospective Cohort Study
Method/Philosophical  A retrospective look at women with live-born, singleton,
Underpinnings cephalic, non-anomalous pregnancies; whose labor was
induced between 37&42 weeks was included.
Sample/  7,459 woman sample / Setting: Mater Mother’s Hospital’s
Setting/Ethical obstetric database MatriX.
Considerations  The research study was deemed low and negligible risk by
the Mater Health Services Human Research Ethics
Committee.
Major Variables  Maternal characteristics: Age, BMI, Ethnicity, interpreter
Studied (and their requirement, relationship status, smoker, ETOH, parity,
definition), if gestational age at time of IOL, modified Bishop’s score,
appropriate IOL indication & method, and artificial reproduction
technique

Measurement  Proportional data of maternal, intrapartum, and neonatal

Tool/Data Collection outcomes was compared using Parson’s x2 test and
Method continuous data using Student’s t-test.
Data Analysis  Multivariate logistic regression analysis was undertaken to
determine if AMA was an independent predictor of CS
following IOL. Statistical significance of variables was
considered at a 0.05 level.
Findings/Discussion  AMA was independently associated with a two-fold
increase in likelihood of CS following induction of labor.
Appraisal/Worth to  With the recommendation by clinicians of IOL at term for
practice AMA women, this data can be used for counseling women
on the potential for CS following IOL.
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First Author Islam (2013) – Department of Mathematics and Statistics,

(Year)/Qualifications Sultan Qaboos University, Sultanate of Oman
Background/Problem  In Oman, increasing number of women are waiting until
Statement AMA to start families. Problem – studies are contradictory
in determining whether AMA increased the risk of adverse
pregnancy outcomes.
Conceptual/theoretical  The concept is to investigate the influence of AMA on
Framework adverse obstetric outcomes during delivery, by controlling
the effects of potential confounding factors.
 Theoretical framework was not discussed.
Design/  Population-based retrospective study – quantitative
Method/Philosophical  Not much research is done in countries that aren’t as
Underpinnings advanced technologically
Sample/  2,037 Omani women chosen with a stratified sample /
Setting/Ethical Setting – Survey conducted by the Ministry of Health of
Considerations Oman in collaboration with the UN organizations such as
UNFPA, UNICEF, WHO, and the UN Statistics Division.
All participants gave informed consent to participate in the
survey.
Major Variables  Two groups: Maternal Age 20-34 and 35+
Studied (and their  Outcome variables: self-reported pregnancy
definition), if complications and adverse pregnancy outcomes, delivery
appropriate complications, CS, Spontaneous abortion, stillbirth, LBW,
and preterm birth. Explanatory variables: Maternal age
and potential confounding factors
Measurement  Data obtained using the 2000 Oman National Health
Tool/Data Collection Survey determined eligible participants. 25 teams visited
Method each household and administered a household,
reproductive health, and gynecological morbidity
symptoms questionnaire. Participants then visited a
health clinic for a full exam.
Data Analysis  Chi-square test to find associations between categorical
variables, student’s t-test for comparing means between
the two groups, bivariate analysis and multivariate logistic
regression analysis.
Findings/Discussion  The study found that AMA patients are at higher risk for
cesarean section, along with GDM, preeclampsia,
gestational HTN, spontaneous abortion, and prolonged
labor, as opposed to their normal maternal age
counterparts.
Appraisal/Worth to Offers a cross-cultural understanding of delivery outcomes
practice and risk factors for AMA mothers in newly developed
countries which can be utilized to guide health care
practice.
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First Author Muto (2017) – Department of Obstetrics, Osaka Women’s

(Year)/Qualifications and Children’s Hospital, Izumi, Japan
Background/Problem Several studies have suggested that advanced maternal
Statement age is a significant risk factor for cesarean section.
Problem – these studies do not discuss intrapartum
management or other antepartum risk factors
Conceptual/theoretical  The concept behind this study was to determine which
Framework risk factors were the most highly associated with AMA
mothers delivering via cesarean section.
 Theoretical framework was not discussed.
Design/  Quantitative – Retrospective Cohort Study
Method/Philosophical  A retrospective look at delivery outcomes of nulliparous
Underpinnings women 35+ years of age and assesses the risk factors
which lead this age group to cesarean section most often
Sample/  935 nulliparous women at full term (>37 weeks gestation)
Setting/Ethical / Setting: Osaka Women’s and Children’s Hospital.
Considerations  Ethics approval granted by the Institute’s Review Board

Major Variables  Maternal Characteristics – Maternal Age (35-59 & 40+),

Studied (and their Gestational weeks at delivery, Assisted reproductive
definition) technology, Maternal height and BMI

Measurement  Cases were analyzed to determine Maternal

Tool/Data Collection characteristics among the subjects, and to determine
Method what indications led the patients to delivery via eCS. The
data was analyzed to determine which risk factors were
most highly correlated with eCS among the two different
age groups of AMA patient’s.

Data Analysis  For statistical analysis a Chi-square test, multivariate

logistic regression analysis and decision-making tree
analysis were used.

Findings/Discussion  The factors related to eCS were determined to be AMA

>40, BMI >/= to 25kg/m2, hypertensive disorder during
pregnancy, Large-for-date (LFD) fetus, and induction of
labor; with induction of labor being the primary factor.

Appraisal/Worth to  Patients of AMA are at higher risk of c-section. Induction

practice of labor is a significant factor in this outcome so more
effective ways of inducing labor should be considered.
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First Author Rijal (2014) – Department of Obstetrics and Gynecology,

(Year)/Qualifications BP Koirala Institute of Health Sciences, Dharan, Nepal
Background/Problem  Induction of labor is an extremely common procedure in
Statement obstetrics
 Problem Statement: Various studies have found that
induction both increases and decreases the risk of
cesarean section
Conceptual/theoretical  Concept of research was to determine which risk factors
Framework of induction were most likely to lead to cesarean section
 Theoretical framework was not discussed

Design/  Quantitative - Prospective observational study

Method/Philosophical  Specific methodology was not discussed
Underpinnings
Sample/  Sample: 348 participants / Setting: Obstetric unit of BP
Setting/Ethical Koirala Institute of Health Sciences
Considerations  Consent was obtained for recruitment and the institutes
review board granted ethical clearance to the researcher
for the study

Major Variables  Pre-induction Bishop’s Score, number of Misoprostol

Studied (and their doses, obesity, maternal age, parity, meconium in the
definition), if amniotic fluid, hypertension, prolonged latent phase of
appropriate delivery, prolonged active phase, birth weight, and
oxytocin augmentation

Measurement  Specific data collection methods were not discussed;

Tool/Data Collection however, participants were monitored one hour after
Method induction with tocography, and the fetal heartrate was
monitored every 30 minutes during latent and active
labor.

Data Analysis  Logistic regression analysis and chi-square were used to

assess significant variables along
Findings/Discussion  Significant risk factors for cesarean following induction
were Bishop’s score </= 5, 3+ doses of misoprostol,
prolonged latent and active phases of labor, oxytocin
augmentation, meconium in the amniotic fluid, and
increased birthweight.

Appraisal/Worth to  Knowledge of what risk factors are more closely related to

practice cesarean delivery after induction, can help providers
determine who is a better candidate for induction.
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First Author Walker (2016) – M.R.C.O.G Division of Child Health,

(Year)/Qualifications Obstetrics and Gynecology, School of Clinical Sciences
Background/Problem Antepartum stillbirth rates are higher among AMA mothers
Statement so labor induction is indicated for these women in many
situations. Problem – Induction of Labor in AMA mothers
may increase the risk for cesarean section.
Conceptual/theoretical  The concept of the trial was to determine delivery
Framework outcomes for mothers of AMA when labor was induced vs
when expectorant management was provided.
 Theoretical framework was not discussed
Design/  Quantitative – randomized controlled trial
Method/Philosophical  Dividing women of AMA into two groups (women to
Underpinnings undergo induction of labor at 39wks of gestation and
women assigned to expectorant management) and
determining of induction of labor was more likely to lead
to cesarean section.
Sample/  619 primigravid women, 35 years of age and older.
Setting/Ethical Setting – 38 National Health Services Hospitals and 1
Considerations Primary Care Trust organization in the United Kingdom
 Trial approved by the East Midlands-Derby NHS research
ethics committee. All participants provided written
informed consent
Major Variables  305 assigned to the induction group / 314 assigned to
Studied (and their expectant management
definition), if  Maternal Outcome Variables – Method of delivery,
appropriate Indication for C-Section, Epidural use, Gestational age at
onset of labor, Complications
Measurement  Data about delivery outcomes, maternal and neonatal
Tool/Data Collection outcomes were collected immediately after the mother’s
Method hospital discharge by the research midwife at each
center. Mothers expectations/experience was measured
by Questionnaires (0-4 scale.
Data Analysis  Generalized linear model with binomial family and log link
was used to calculate relative risk, Multinomial logistic-
regression model to calculate relative risks, generalized
linear model, t-test, and Mann-Whitney U test was used to
calculate P values.
Findings/Discussion  In women of AMA, with induction of labor at 39wks
gestation, as compared with expectant management,
there was no significant effect on the rate of cesarean
sections
Appraisal/Worth to  Results will help counsel AMA patients on minimal
practice adverse effect of labor induction on cesarean section,
when considering the benefit of IOL on minimizing
stillbirth outcome.
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