Change In Perinatal Mortality Research Articles

Trend, and multivariate decomposition of perinatal mortality in Ethiopia using further analysis of EDHS 2005–2016

BackgroundPerinatal mortality is a global health problem, especially in Ethiopia, which has the highest perinatal mortality rate. Studies about perinatal mortality were conducted in Ethiopia, but which factors specifically contribute to the change in perinatal mortality across time is unknown.ObjectivesTo assess the trend and multivariate decomposition of perinatal mortality in Ethiopia using EDHS 2005–2016.MethodsA community-based, cross-sectional study design was used. EDHS 2005–2016 data was used, and weighting has been applied to adjust the difference in the probability of selection. Logit-based multivariate decomposition analysis was used using STATA version 14.1. The best model was selected using the lowest AIC value, and variables were selected with a p-value less than 0.05 at 95% CI.ResultThe trend of perinatal mortality in Ethiopia decreased from 37 per 1000 births in 2005 to 33 per 1000 births in 2016. About 83.3% of the decrease in perinatal mortality in the survey was attributed to the difference in the endowment (composition) of the women. Among the differences in the endowment, the difference in the composition of ANC visits, taking the TT vaccine, urban residence, occupation, secondary education, and birth attendant significantly decreased perinatal mortality in the last 10 years. Among the differences in coefficients, skilled birth attendants significantly decreased perinatal mortality.Conclusion and recommendationThe perinatal mortality rate in Ethiopia has declined over time. Variables like ANC visits, taking the TT vaccine, urban residence, occupation, secondary education, and skilled birth attendants reduce perinatal mortality. To reduce perinatal mortality more, scaling up maternal and newborn health services has a critical role.

Neonatal near-miss audits: a systematic review and a call to action

BackgroundNeonatal near-miss (NNM) can be considered as an end of a spectrum that includes stillbirths and neonatal deaths. Clinical audits of NNM might reduce perinatal adverse outcomes. The aim of this review is to evaluate the effectiveness of NNM audits for reducing perinatal mortality and morbidity and explore related contextual factors.MethodsPubMed, Embase, Scopus, CINAHL, LILACS and SciELO were searched in February/2023. Randomized and observational studies of NNM clinical audits were included without restrictions on setting, publication date or language. Primary outcomes: perinatal mortality, morbidity and NNM. Secondary outcomes: factors contributing to NNM and measures of quality of care. Study characteristics, methodological quality and outcome were extracted and assessed by two independent reviewers. Narrative synthesis was performed.ResultsOf 3081 titles and abstracts screened, 36 articles had full-text review. Two studies identified, rated, and classified contributing care factors and generated recommendations to improve the quality of care. No study reported the primary outcomes for the review (change in perinatal mortality, morbidity and NNM rates resulting from an audit process), thus precluding meta-analysis. Three studies were multidisciplinary NNM audits and were assessed for additional contextual factors.ConclusionThere was little data available to determine the effectiveness of clinical audits of NNM. While trials randomised at patient level to test our research question would be difficult or unethical for both NNM and perinatal death audits, other strategies such as large, well-designed before-and-after studies within services or comparisons between services could contribute evidence. This review supports a Call to Action for NNM audits. Adoption of formal audit methodology, standardised NNM definitions, evaluation of parent’s engagement and measurement of the effectiveness of quality improvement cycles for improving outcomes are needed.

Gestational age, morbidity and mortality among twin births in New South Wales, Australia 2003-2014: A cohort study.

Evidence suggests that the trend toward early planned births observed among singletons may be evident among twin pregnancies. To describe trends in gestational age at birth, pregnancy characteristics, neonatal morbidity and mortality among twin pregnancies. Population-based data linkage study of twin births of ≥30weeks of gestation without a major congenital anomaly born in 2003-2014 in New South Wales (NSW), Australia. Linked pregnancy and birth, hospital and mortality data were used. Generalised linear regression was used to assess linear trends. Risk difference (RD) and 95% confidence intervals were estimated. Among 28076 eligible twin births (14038 pregnancies), 49% of births occurred prior to 37weeks and 69% of births were planned (pre-labour caesarean or induction of labour). There were increases over time in the proportion of twin births at preterm gestations (30-34weeks (RD 2.1, 95% CI 0.1, 4.0), 35-36weeks (RD 7.5, 95% CI 5.4, 9.7)) and in the rates of planned births (pre-labour caesarean (RD 6.4, 95% CI 4.0, 8.8), induction (RD 4.6, 95% CI 2.6, 6.6)). There was no significant change in stillbirth or neonatal death rates, but there was an increase in neonatal morbidity over the study period. Concurrently, there were increases in the prevalence of gestational diabetes; and decreases in pregnancy hypertension, assisted reproductive technology use, small-for-gestational age and birthweight discordance. Gestational age at birth among twin births is decreasing and birth intervention is increasing. There are increasing rates of neonatal morbidity, but no overall change in perinatal mortality.

Association of Temporal Changes in Gestational Age With Perinatal Mortality in the United States, 2007-2015

Whether the changing gestational age distribution in the United States since 2005 has affected perinatal mortality remains unknown. To examine changes in gestational age distribution and gestational age-specific perinatal mortality. This retrospective cohort study examined trends in US perinatal mortality by linking live birth and infant death data among more than 35 million singleton births from January 1, 2007, through December 31, 2015. Year of birth and changes in gestational age distribution. Changes in the proportion of births at gestational ages 20 to 27, 28 to 31, 32 to 33, 34 to 36, 37 to 38, 39 to 40, 41, and 42 to 44 weeks; changes in perinatal mortality (stillbirth at ≥20 weeks, and neonatal deaths at <28 days) rates; and contribution of gestational age changes to perinatal mortality. Trends were estimated from log-linear regression models adjusted for confounders. Among the 34 236 577 singleton live births during the study period, the proportion of births at all gestational ages declined, except at 39 to 40 weeks, which increased (54.5% in 2007 to 60.2% in 2015). Overall perinatal mortality declined from 9.0 to 8.6 per 1000 births (P < .001). Stillbirths declined from 5.7 to 5.6 per 1000 births (P < .001), and neonatal mortality declined from 3.3 to 3.0 per 1000 births (P < .001). Although the proportion of births at gestational ages 34 to 36, 37 to 38, and 42 to 44 weeks declined, perinatal mortality rates at these gestational ages showed annual adjusted relative increases of 1.0% (95% CI, 0.6%-1.4%), 2.3% (95% CI, 1.9%-2.8%), and 4.2% (95% CI, 1.5%-7.0%), respectively. Neonatal mortality rates at gestational ages 34 to 36 and 37 to 38 weeks showed a relative adjusted annual increase of 0.9% (95% CI, 0.2%-1.6%) and 3.1% (95% CI, 2.1%-4.1%), respectively. Although the proportion of births at gestational age 39 to 40 weeks increased, perinatal mortality showed an annual relative adjusted decline of -1.3% (95% CI, -1.8% to -0.9%). The decline in neonatal mortality rate was largely attributable to changes in the gestational age distribution than to gestational age-specific mortality. Although the proportion of births at gestational age 39 to 40 weeks increased, perinatal mortality at this gestational age declined. This finding may be owing to pregnancies delivered at 39 to 40 weeks that previously would have been unnecessarily delivered earlier, leaving fetuses at higher risk for mortality at other gestational ages.

Using statistical process control methods to trace small changes in perinatal mortality after a training program in a low-resource setting.

To trace and document smaller changes in perinatal survival over time. Prospective observational study, with retrospective analysis. Labor ward and operating theater at Haydom Lutheran Hospital in rural north-central Tanzania. All women giving birth and birth attendants. Helping Babies Breathe (HBB) simulation training on newborn care and resuscitation and some other efforts to improve perinatal outcome. Perinatal survival, including fresh stillbirths and early (24-h) newborn survival. The variable life-adjusted plot and cumulative sum chart revealed a steady improvement in survival over time, after the baseline period. There were some variations throughout the study period, and some of these could be linked to different interventions and events. To our knowledge, this is the first time statistical process control methods have been used to document changes in perinatal mortality over time in a rural Sub-Saharan hospital, showing a steady increase in survival. These methods can be utilized to continuously monitor and describe changes in patient outcomes.

Effect of tobacco control policies on perinatal and child health: a systematic review and meta-analysis

SummaryBackgroundTobacco smoking and smoke exposure during pregnancy and childhood cause considerable childhood morbidity and mortality. We did a systematic review and meta-analysis to investigate whether implementation of WHO's recommended tobacco control policies (MPOWER) was of benefit to perinatal and child health.MethodsWe searched 19 electronic databases, hand-searched references and citations, and consulted experts to identify studies assessing the association between implementation of MPOWER policies and child health. We did not apply any language restrictions, and searched the full time period available for each database, up to June 22, 2017. Our primary outcomes of interest were perinatal mortality, preterm birth, hospital attendance for asthma exacerbations, and hospital attendance for respiratory tract infections. Where possible and appropriate, we combined data from different studies in random-effects meta-analyses. This study is registered with PROSPERO, number CRD42015023448.FindingsWe identified 41 eligible studies (24 from North America, 16 from Europe, and one from China) that assessed combinations of the following MPOWER policies: smoke-free legislation (n=35), tobacco taxation (n=11), and smoking cessation services (n=3). Risk of bias was low in 23 studies, moderate in 16, and high in two. Implementation of smoke-free legislation was associated with reductions in rates of preterm birth (–3·77% [95% CI −6·37 to −1·16]; ten studies, 27 530 183 individuals), rates of hospital attendance for asthma exacerbations (–9·83% [–16·62 to −3·04]; five studies, 684 826 events), and rates of hospital attendance for all respiratory tract infections (–3·45% [–4·64 to −2·25]; two studies, 1 681 020 events) and for lower respiratory tract infections (–18·48% [–32·79 to −4·17]; three studies, 887 414 events). Associations appeared to be stronger when comprehensive smoke-free laws were implemented than when partial smoke-free laws were implemented. Among two studies assessing the association between smoke-free legislation and perinatal mortality, one showed significant reductions in stillbirth and neonatal mortality but did not report the overall effect on perinatal mortality, while the other showed no change in perinatal mortality. Meta-analysis of studies on other MPOWER policies was not possible; all four studies on increasing tobacco taxation and one of two on offering disadvantaged pregnant women help to quit smoking that reported on our primary outcomes had positive findings. Assessment of publication bias was only possible for studies assessing the association between smoke-free legislation and preterm birth, showing some degree of bias.InterpretationSmoke-free legislation is associated with substantial benefits to child health. The majority of studies on other MPOWER policies also indicated a positive effect. These findings provide strong support for implementation of such policies comprehensively across the world.FundingChief Scientist Office Scotland, Farr Institute, Netherlands Lung Foundation, Erasmus MC.

Intervention Improved Health Workers’ Neonatal Resuscitation Skills and Knowledge, but Not Neonatal Mortality

Health care workers who participated in a mobile phone-based safe delivery intervention had greater skills and knowledge regarding neonatal resuscitation than control workers, according to a cluster-randomized clinical trial conducted at 70 health care facilities in rural Ethiopia. (1) Neonatal resuscitation skills scores six months and 12 months after implementation of the safe delivery app intervention were higher among intervention health care workers than among controls (mean differences, 6.0 and 8.8 points, respectively); neonatal resuscitation knowledge was higher among intervention health care workers than among controls at six months postimplementation (mean difference, 1.7 points), but not at 12 months. The intervention was not associated with a significant change in perinatal mortality of infants delivered at study health care facilities. The safe delivery app was designed to provide health care workers in low-income countries with the knowledge and skills to manage obstetric and neonatal emergencies; the app consisted of videos on topics such as neonatal resuscitation, as well as a catalog of essential obstetric drugs and equipment. To examine whether use of the app was associated with changes in perinatal mortality rates and in health care workers' knowledge and skill levels, researchers conducted a cluster-randomized clinical trial of health care facilities in five rural districts of Ethiopia's Oromiya region. Of the 131 facilities that were screened, 70 met the study's eligibility criteria (i.e., having a midwife or health extension worker on staff and having been the site of deliveries in the previous year) and were included in the study sample. Half of eligible facilities were randomly selected to the intervention group and were supplied with smartphones loaded with the safe delivery app; health care workers at intervention facilities received a one-day training session on how to use the phones and app. The other half of facilities were selected to the control group, and did not receive phones or additional training; the researchers ensured that both intervention and control facilities had an adequate package of drugs and equipment. Between September 2013 and February 2015, data were collected on women delivering at study facilities and on their birth outcomes; women were contacted in person or by phone seven days after delivery to follow up about perinatal mortality. In addition, facility health care workers' knowledge and skills regarding neonatal resuscitation were assessed by questionnaire and structured assessment tools (e.g., simulated scenarios using mannequins) before implementation of the intervention and at six and 12 months afterward. Descriptive and logistic regression analyses were used to compare perinatal mortality rates at intervention and control facilities, and to compare health care workers' neonatal resuscitation knowledge and skills index scores over time. The analysis sample included 1,474 women in the intervention group and 1,665 in the control group. Most women in each group (>85%) reported being younger than 29, having a primary or lower education and being a housewife; more than one-third of women in each group were pregnant for the first time. …

Trends in birth asphyxia, obstetric interventions and perinatal mortality among term singletons: a nationwide cohort study

Objective: The objective of the present study is to investigate trends in birth asphyxia and perinatal mortality in the Netherlands over the last decade.Methods: A nationwide cohort study among women with a term singleton pregnancy. We assessed trends in birth asphyxia in relation to obstetric interventions for fetal distress. Birth asphyxia was defined as a 5-minute Apgar score < 7 (any asphyxia) or 5-minute Apgar score < 4 (severe asphyxia). Perinatal mortality was defined as mortality during delivery or within 7 days after birth. Multivariable analyses were used to adjust for confounding factors.Results: The prevalence of birth asphyxia was 0.85% and severe asphyxia 0.16%. Between 1999 and 2010 birth asphyxia decreased significantly with approximately 6% (p = 0.03) and severe asphyxia with 11% (p = 0.03). There was no significant change in perinatal mortality rate (0.98 per 1000 live births). Simultaneously the referral rate from primary to secondary care during labor increased from 20% to 24% (p < 0.0001) and the intervention rate for fetal distress from 5.9% to 7.7% (p < 0.0001).Conclusion: In the Netherlands, the risk of birth asphyxia among term singletons has slightly decreased over the last decade; without a significant change in perinatal mortality.

A matched pair cluster randomized implementation trail to measure the effectiveness of an intervention package aiming to decrease perinatal mortality and increase institution-based obstetric care among indigenous women in Guatemala: study protocol

BackgroundMaternal and perinatal mortality continue to be a high priority problem on the health agendas of less developed countries. Despite the progress made in the last decade to quantify the magnitude of maternal mortality, few interventions have been implemented with the intent to measure impact directly on maternal or perinatal deaths. The success of interventions implemented in less developed countries to reduce mortality has been questioned, in terms of the tendency to maintain a clinical perspective with a focus on purely medical care separate from community-based approaches that take cultural and social aspects of maternal and perinatal deaths into account. Our innovative approach utilizes both the clinical and community perspectives; moreover, our study will report the weight that each of these components may have had on reducing perinatal mortality and increasing institution-based deliveries.Methods/DesignA matched pair cluster-randomized trial will be conducted in clinics in four rural indigenous districts with the highest maternal mortality ratios in Guatemala. The individual clinic will serve as the unit of randomization, with 15 matched pairs of control and intervention clinics composing the final sample. Three interventions will be implemented in indigenous, rural and poor populations: a simulation training program for emergency obstetric and perinatal care, increased participation of the professional midwife in strengthening the link between traditional birth attendants (TBA) and the formal health care system, and a social marketing campaign to promote institution-based deliveries. No external intervention is planned for control clinics, although enhanced monitoring, surveillance and data collection will occur throughout the study in all clinics throughout the four districts. All obstetric events occurring in any of the participating health facilities and districts during the 18 months implementation period will be included in the analysis, controlling for the cluster design. Our main outcome measures will be the change in perinatal mortality and in the proportion of institution-based deliveries.DiscussionA unique feature of this protocol is that we are not proposing an individual intervention, but rather a package of interventions, which is designed to address the complexities and realities of maternal and perinatal mortality in developing countries. To date, many other countries, has focused its efforts to decrease maternal mortality indirectly by improving infrastructure and data collection systems rather than on implementing specific interventions to directly improve outcomes.Trial registrationClinicalTrial.gov,http://NCT01653626.

Reduced perinatal mortality following enhanced training of birth attendants in the Democratic Republic of Congo: a time-dependent effect

BackgroundIn many developing countries, the majority of births are attended by traditional birth attendants, who lack formal training in neonatal resuscitation and other essential care required by the newly born infant. In these countries, the major causes of neonatal mortality are birth asphyxia, infection, and low-birth-weight/prematurity. Death from these causes is potentially modifiable using low-cost interventions, including neonatal resuscitation training. The purpose of this study was to evaluate the effect on perinatal mortality of training birth attendants in a rural area of the Democratic Republic of Congo (DRC) using two established programs.MethodsThis study, a secondary analysis of DRC-specific data collected during a multi-country study, was conducted in two phases. The effect of training using the WHO Essential Newborn Care (ENC) program was evaluated using an active baseline design, followed by a cluster randomized trial of training using an adaptation of a neonatal resuscitation program (NRP). The perinatal mortality rates before ENC, after ENC training, and after randomization to additional NRP training or continued care were compared. In addition, the influence of time following resuscitation training was investigated by examining change in perinatal mortality during sequential three-month increments following ENC training.ResultsMore than two-thirds of deliveries were attended by traditional birth attendants and occurred in homes; these proportions decreased after ENC training. There was no apparent decline in perinatal mortality when the outcome of all deliveries prior to ENC training was compared to those after ENC but before NRP training. However, there was a gradual but significant decline in perinatal mortality during the year following ENC training (RR 0.73; 95% CI: 0.56-0.96), which was independently associated with time following training. The decline was attributable to a decline in early neonatal mortality. NRP training had no demonstrable effect on early neonatal mortality.ConclusionTraining DRC birth attendants using the ENC program reduces perinatal mortality. However, a period of utilization and re-enforcement of training may be necessary before a decline in mortality occurs. ENC training has the potential to be a low cost, high impact intervention in developing countries.Trial registrationThis trial has been registered at http://www.clinicaltrials.gov (identifier NCT00136708).

Type 1 Diabetes and Pregnancy

To examine changes in perinatal mortality and birth weight of babies born to mothers with pregestational type 1 diabetes over 40 years in a single teaching hospital clinic. This was a retrospective survey of cases from the combined diabetes and obstetrics antenatal clinic at the Royal Infirmary of Edinburgh and Simpson Memorial Maternity Pavilion, Edinburgh, Scotland. Birth weight, standardized birth weight, and perinatal mortality were obtained from 643 singleton babies born after 28 weeks of gestation to mothers with pregestational type 1 diabetes between 1960 and 1999. There was a dramatic improvement in perinatal mortality rate, falling from 225 (per 1,000 total births after 28 weeks of gestation) in the 1960s to 102 in the 1970s, 21 in the 1980s, and 10 in the 1990s (P < .001 for effect of birth year). In contrast, standardized birth weight (adjusted for sex, gestational age, and parity), which was significantly higher than the background population (+1.41 standard deviations above the population norm, P < .001) showed no significant change over time. Changes in diabetic management and obstetric practice over the 40 years of our survey have resulted in enormous improvements in the outlook for offspring of mothers with diabetes. Somewhat surprisingly this has not been associated with a reduction in overgrowth of the fetus. II-2.

Causes and Consequences of Recent Increases in Preterm Birth Among Twins

In Brief OBJECTIVE To examine the causes and consequences of the recent increase in preterm birth among twins. METHODS We studied all twin births among residents of the province of Nova Scotia, Canada, between 1988 and 1997. Rates of preterm birth, preterm labor induction, preterm cesarean, small-for-gestational age (SGA), respiratory distress syndrome (RDS), stillbirth, perinatal mortality, and infant mortality were compared between past and more recent years. Changes in perinatal mortality were examined using logistic regression to adjust for the effects of other determinants. RESULTS The study included 2516 twin births (73 stillbirths and 2443 live births). The rate of preterm birth increased from 42.3% in 1988–1992 to 48.2% of twin live births in 1993–1997 (14% increase, P = .04). Twin live births born after preterm labor induction increased from 3.5% in 1988–1989 to 8.6% in 1996–1997 (P for trend = .007). Of live births between 34 and 36 weeks' gestation, the proportion born SGA decreased from 17.5% in 1988–1992 to 9.2% in 1993–1997 (P = .005). Over the same period, rates of prophylactic maternal steroid therapy increased substantially and rates of RDS declined. Perinatal mortality rates among pregnancies reaching 34 weeks decreased from 12.9 per 1000 total births in 1988–1992 to 4.2 per 1000 total births in 1993–1997 (P = .05). CONCLUSION Increases in preterm labor induction appear to be responsible for the recent increase in preterm birth among twins. These changes have been accompanied by decreases in perinatal morbidity and mortality among twin pregnancies that reach 34 weeks' gestation. Increased preterm labor inductions in twin pregnancies appear to be responsible for recent increases in the number of preterm twin births, and for declines in perinatal morbidity and mortality.

Causes and consequences of recent increases in preterm birth among twins

Objective: To examine the causes and consequences of the recent increase in preterm birth among twins. Methods: We studied all twin births among residents of the province of Nova Scotia, Canada, between 1988 and 1997. Rates of preterm birth, preterm labor induction, preterm cesarean, small-for-gestational age (SGA), respiratory distress syndrome (RDS), stillbirth, perinatal mortality, and infant mortality were compared between past and more recent years. Changes in perinatal mortality were examined using logistic regression to adjust for the effects of other determinants. Results: The study included 2516 twin births (73 stillbirths and 2443 live births). The rate of preterm birth increased from 42.3% in 1988–1992 to 48.2% of twin live births in 1993–1997 (14% increase, P = .04). Twin live births born after preterm labor induction increased from 3.5% in 1988–1989 to 8.6% in 1996–1997 ( P for trend = .007). Of live births between 34 and 36 weeks’ gestation, the proportion born SGA decreased from 17.5% in 1988–1992 to 9.2% in 1993–1997 ( P = .005). Over the same period, rates of prophylactic maternal steroid therapy increased substantially and rates of RDS declined. Perinatal mortality rates among pregnancies reaching 34 weeks decreased from 12.9 per 1000 total births in 1988–1992 to 4.2 per 1000 total births in 1993–1997 ( P = .05). Conclusion: Increases in preterm labor induction appear to be responsible for the recent increase in preterm birth among twins. These changes have been accompanied by decreases in perinatal morbidity and mortality among twin pregnancies that reach 34 weeks’ gestation.

Perinatal mortality trends among South Australian aboriginal births 1981-92.

To assess changes in perinatal mortality and risk factors for births to Aboriginal mothers in South Australia in 1981-92. All 4013 singleton Aboriginal births in the South Australian perinatal data collection were included. Trends in proportions with specific maternal and infant characteristics, and perinatal mortality by year of birth, were investigated by logistic regression analysis. Changes found included an increase in the proportion of mothers aged 35 years and over, preterm births and births of very low birthweight (< 1500 g), but a decrease in the proportions of births to women under 20 years of age, and of births with a birth defect. There was no statistically significant change in the crude perinatal mortality rate nor in the risk of perinatal death after adjusting for risk factors. The perinatal mortality rate among Aboriginal births, which is three times higher than the rate for all South Australian births, is not declining, in contrast to the State rate overall. This highlights the need for a concerted approach to Aboriginal perinatal health.

Increase in cerebral palsy in normal birthweight babies.

A register has been compiled of the 421 children with congenital cerebral palsy born between 1960 and 1975 from a defined geographical area of North East England (population 770 000). There was a fall in the rate of cerebral palsy among very low birthweight babies between 1964 and 1975 and also in the small group with dyskinetic cerebral palsy. The rate rose, however, among babies weighing more than 2.5 kg at birth in the second half of the study, in parallel with changes in perinatal mortality. The net effect is that the overall congenital cerebral palsy rate (mean 1.64 per 1000 livebirths) showed a gradual rise between 1968 and 1975. This conclusion is reinforced by evidence of a rise in incidence among the subgroup of patients with severe cerebral palsy (as defined by an interval measurement of handicap) during the same period.

Obstetric practice and outcome of pregnancy in Cardiff residents 1965-73.

Trends in management and outcome of pregnancy in Cardiff residents from 1965 to 1973 were reviewed. The mean age and parity of parturients fell. Hospital delivery became almost universal, monitoring the fetus during pregnancy was introduced, and induction and acceleration of labour became commonplace. These developments were not associated with any striking change in either the total perinatal death rate or the timing or cause of perinatal death. Possibly a real change in perinatal mortality between 1965 and 1973 was masked by random fluctuation of small numbers, or possibly factors peculiar to the Cardiff population prevented a decrease in perinatal mortality that would otherwise have resulted from improved medical care. Only by large-scale randomised trials can the true value of induction and other medical developments be assessed.