The total number of deliveries for all countries reported during the survey was 83,437. There were 81,941 singleton births, 1,437 twin deliveries, 38 triplets and one set of quadruplets and quintuplets each; number of neonates was not documented for 19 births. Congenital malformations were reported in 1,570 newborns. Total live births were 80,297 while fresh stillbirths and macerated stillbirths were 1,855 and 1,199 respectively; 950 early neonatal deaths occurred prior to mother’s discharge from the hospital. Almost 70% of the reported fetal deaths occurred beyond 34 weeks. The mode of onset of labor and the rates of induction of labor by country are shown in Table . Rates of induction of labor were variable from country to country, ranging between 1.4% in Niger to 6.8% in Algeria. Overall rate of induction for the African region was 4.4%. Most inductions were performed between 37 and 41 weeks of gestation (Figure ). However, in Angola, there was an even distribution of induction of labor between 34 – 36 weeks (44.8%) and 37 – 41 weeks (44.0%). Although there were 3,700 positive responses to induction of labor, however, an indication for induction of labor was reported for 4,736 women. Indication for induction of labor according to gestational age is shown in Table . Pre-labor rupture of membranes was the commonest indication for induction of labor. Term pre-labor rupture of membranes (i.e. gestational age
34 weeks) accounted for 95% of these cases. Using the pre-specified criteria for selected complications of pregnancy to identify women who had an indication for induction of labor, 2,776 women had induction of labor while 7,996 women with indications for induction of labor did not receive the intervention. The frequency of stillbirths and sperinatal deaths in the two groups is shown in Table . There was an apparent reduction of stillbirths and perinatal deaths among women who had induction of labor compared with women who did not. This difference was most obvious among women with selected medical complications of pregnancy where doubling of the risk for both stillbirths and perinatal deaths was noted among women who did not have induction of labor.
Percentage distribution of gestational age at induction of labor by country.
Indications for induction of labor by gestational age (weeks)
frequency of stillbirths and perinatal deaths in induced and not induced groups
Thus, perinatal mortality rate among women in the Induced group was 31.7 per 1,000 deliveries while perinatal mortality rate among the Not Induced group was 87.7 per 1,000 deliveries. These differences were statistically significant [OR – 0.34 95% CI (0.27 – 0.43)], implying that induction of labor results in about 66% reduction of perinatal deaths.
For the selected complications of pregnancy we determined the proportion of women who could not benefit from induction of labor (i.e. the unmet need for induction of labor) and its effect on the newborn (Table ). For all the complications shown in Table , the vast majority of women had a huge unmet need for induction of labor. Apparently for most of these conditions, induction of labor was associated with significant reduction in perinatal deaths e.g. induction for pre-eclampsia, severe anemia and other medical conditions were associated with 78%, 87%, 83% reduction in perinatal deaths respectively. Induction of labor for post-term pregnancy, diabetes and IUGR had no significant impact on perinatal deaths. Unmet need for induction of labor at the country level and perinatal death is shown in Table . Angola, where the induction rates between 34 and 36 weeks surpasses the induction rates at term, had the lowest unmet need for induction of labor (66%); unmet need in most countries was above 70%. Thus, unmet need for induction of labor was relatively high in all countries. However, the intervention was significantly associated with reduction of perinatal deaths in all countries ranging between 53 and 67%.
Unmet need for induction of labor and perinatal deaths
Unmet need for induction of labor and perinatal deaths at country level
We assessed the effects of induction of labor on some other maternal and newborn outcomes (Table ). The intervention also had significant impacts on some other newborn outcomes. Women who had induction of labor had 71% reduction of risk of having fresh or macerated stillbirths. However, the newborn was 25% more likely to be admitted into the intensive care unit following induction of labor.
Other maternal and newborn outcomes
For the mother, induction of labor was not significantly associated with increased risk of emergency caesarean section, hysterectomy or maternal death (Table ).
The woman’s age, parity, duration of schooling and antenatal care were associated with induction of labor (Table ). Maternal age
20 years, < 4 antenatal visits and low level of education were associated with reduced rates of induction of labor while urban location, care at a tertiary health facility or teaching facility were associated with higher rates of induction of labor (Table ).
Maternal characteristics and induction of labor
Health facility characteristics and induction of labor
In order to determine which characteristics in either the mother or the health facility predicted the likelihood of having induction of labor, variables with significant impact on maternal and newborn outcomes were entered into a multivariate logistic regression model. All maternal and health facility characteristics that were significantly associated with induction of labor were shown to independently predict the likelihood of the mother having induction of labor (Table ). When these characteristics were further subjected to stepwise regression, the relative importance of these characteristics in predicting induction of labor was in the following order: location of the woman was the strongest predictor followed by duration of schooling, level of the health facility, whether the facility was teaching or non-teaching and antenatal care. Payment for delivery, higher cost of caesarean section and caesarean section being of economic benefit to attending staff were weaker predictors of a woman having induction of labor.
Independent predictors of induction of labor
Thus, compared with urban dwellers, women in peri-urban or rural locations were significantly less likely to receive induction of labor; compared with women in tertiary health facilities, women in secondary health facilities were significantly more likely to receive induction of labor while those in primary health facilities were significantly less likely to receive it; women in non-teaching facilities were significantly less likely to have induction of labor and when women received no antenatal care or made less than 4 antenatal visits, they were significantly less likely to have induction of labor compared with women who had 4 or more visits.