Researchers in Sri Lanka tested a program to improve how doctors decide when to induce labor (start labor artificially) and involve patients in decisions. Over four years, they trained healthcare workers, created new guidelines, and added safety checklists. The results showed big improvements: doctors now document why they’re inducing labor 90% of the time (up from 59%), and patients give informed consent 91% of the time (up from just 2%). While some outcomes improved, cesarean section rates increased, likely due to staff shortages and other hospital challenges. This study shows that better training and clear protocols can significantly improve patient care, even in hospitals with limited resources.
The Quick Take
- What they studied: Whether a quality improvement program could help hospitals make better decisions about inducing labor and involve patients more in their care
- Who participated: A large hospital in Sri Lanka that serves many patients. The study looked at labor induction cases over a four-year period (2019-2022), comparing practices before and after the improvement program
- Key finding: After implementing training, new protocols, and safety checklists, hospitals dramatically improved patient involvement in decisions (from 2% to 91%) and better documented reasons for inducing labor (from 59% to 90%). However, cesarean section rates increased from 22.3% to 35.4%, possibly due to hospital staffing and supply issues
- What it means for you: If you’re having labor induced, hospitals using these evidence-based practices are more likely to explain why it’s necessary and get your permission first. However, this study suggests that improving one part of care may have complex effects on other outcomes, so hospitals need to monitor all aspects of patient safety
The Research Details
This was a quality improvement study conducted at a hospital in Sri Lanka from 2019 to 2022. The researchers used a four-step approach: First, they reviewed past medical records to see how labor inductions were being done (baseline audit). Second, they worked with hospital staff to design better practices based on medical evidence. Third, they put these new practices into action through training, new written protocols, safety checklists, and patient information sheets. Fourth, they reviewed medical records again to see if things had improved (re-audit).
The improvement program focused on three main areas: training doctors and nurses on best practices, creating clear written guidelines for when and how to induce labor, and making sure patients understood their options and gave permission before procedures. They also introduced safety checklists to catch potential problems before they happened.
This type of study is valuable because it shows real-world improvements in actual hospitals, rather than testing something in a controlled laboratory setting. It reflects how changes actually work when implemented in busy healthcare settings.
Quality improvement studies are important because they test whether evidence-based practices actually work when hospitals try to use them in real life. Many hospitals, especially in low-resource countries, may not follow best practices due to lack of training, unclear guidelines, or limited resources. This study shows that even with limited resources, hospitals can make significant improvements by training staff, creating clear protocols, and involving patients in decisions. Understanding what works helps other hospitals make similar improvements.
Strengths of this study include: it was conducted over four years (long enough to see sustained changes), it compared practices before and after the intervention (showing cause and effect), and it measured multiple important outcomes (patient consent, documentation, and baby health). The study was published in a respected international medical journal. Limitations include: the study was conducted at only one hospital, so results may not apply everywhere; the sample size wasn’t specified in the abstract; and the researchers couldn’t control for all factors that might have changed during the study period (like staff changes or patient population differences)
What the Results Show
The quality improvement program led to dramatic improvements in how hospitals document and communicate about labor induction. Documentation of why labor was being induced improved from 59% to 90%—meaning doctors were much better at recording their medical reasons. Most importantly, informed consent (getting patient permission after explaining the procedure) jumped from just 2% to 91%, showing that patients were finally being included in decisions about their own care.
Pre-induction assessments (checking the mother’s health before starting labor) improved from 30.8% to 100%, meaning every patient was properly evaluated before the procedure. The use of Foley catheters (a specific safe method for inducing labor) increased from 39% to 68%, suggesting doctors were using more standardized, evidence-based methods.
Baby health outcomes also improved. Fewer babies needed admission to special care units, and the rate of babies dying during labor decreased. These improvements suggest that better-trained staff and clearer protocols led to safer outcomes for newborns.
However, the cesarean section rate (surgical delivery) increased from 22.3% to 35.4%. This is a concerning finding that the researchers note may be related to hospital staffing shortages, limited availability of labor-inducing medications, and an increase in mothers with obesity during the study period—not necessarily because the new protocols were causing unnecessary surgeries.
Beyond the main findings, the study showed that implementing safety checklists and patient information sheets helped standardize care across the hospital. The training program appeared to have lasting effects, with improvements sustained over the four-year period. The study also demonstrated that even in a low-resource setting, hospitals can achieve high compliance with evidence-based practices when they provide proper training and clear guidelines. The improvement in neonatal (newborn) outcomes suggests that better documentation and assessment practices may have prevented complications before they became serious.
This study aligns with previous research showing that quality improvement programs can enhance patient safety and outcomes in hospitals. Earlier studies have shown that training healthcare workers and implementing protocols improve care quality. However, this study is valuable because it demonstrates these improvements in a low-resource setting, where many hospitals struggle with limited budgets and staffing. The finding about increased cesarean sections is more complex and suggests that improving one aspect of care requires careful monitoring of other outcomes—a lesson that previous research has also highlighted.
The study was conducted at only one hospital in Sri Lanka, so the results may not apply to all hospitals or all countries. The researchers didn’t specify exactly how many labor inductions were reviewed, making it harder to understand the study’s size. The increase in cesarean sections is concerning, but the study couldn’t definitively prove why this happened—it could be due to the factors mentioned (staffing, medications, patient obesity) or other unmeasured factors. The study also couldn’t control for all changes that happened during the four-year period. Finally, we don’t know if these improvements would last beyond 2022 or if they would work as well in other hospitals with different resources or patient populations.
The Bottom Line
High confidence: Hospitals should implement training programs for staff on evidence-based labor induction practices and create clear written protocols. High confidence: Hospitals should obtain informed consent from patients and involve them in decision-making about labor induction. Moderate confidence: Hospitals should use standardized safety checklists and pre-induction assessments. Moderate confidence: Hospitals should monitor all outcomes (including cesarean section rates) when implementing quality improvement programs, not just the targeted improvements, to ensure they’re not inadvertently causing other problems.
This research matters for: pregnant people considering labor induction, who should expect better communication and involvement in decisions; hospital administrators and healthcare workers in low-resource settings, who can learn practical ways to improve care; and policymakers, who can see that quality improvement is possible even with limited resources. This research is less directly relevant to people in high-resource countries with already-strong protocols, though the lessons about monitoring multiple outcomes apply everywhere.
Improvements in documentation and patient consent happened relatively quickly after training and protocol implementation (within the first year). However, the full benefits of better care (improved baby outcomes) may take longer to become apparent. The study tracked changes over four years, suggesting that sustained improvement requires ongoing monitoring and reinforcement of new practices.
Want to Apply This Research?
- If you’re planning a labor induction, track whether your healthcare provider: (1) explains the medical reason for induction, (2) discusses alternatives with you, (3) answers your questions, and (4) obtains your written consent before starting the procedure. Rate your experience on a scale of 1-5 for each element
- Before a scheduled labor induction, use the app to prepare questions to ask your doctor, such as: ‘Why do I need to be induced?’ ‘What are the risks and benefits?’ ‘Are there alternatives?’ ‘What happens if I don’t want to be induced?’ Document your doctor’s answers in the app to help you make an informed decision
- After your labor induction, use the app to record: (1) whether you felt involved in decision-making, (2) how well the hospital staff explained procedures, (3) your satisfaction with communication, and (4) your baby’s health outcomes. Over time, this helps you and your healthcare team identify patterns and areas for improvement in your care
This study describes improvements in labor induction practices at one hospital in Sri Lanka and should not be interpreted as medical advice. The decision to induce labor is complex and should be made between you and your healthcare provider based on your individual medical situation. While this research shows that better communication and documentation improve care, the increase in cesarean section rates noted in the study suggests that quality improvement requires careful monitoring of all outcomes. If you’re considering labor induction, discuss the risks, benefits, and alternatives with your doctor. This information is for educational purposes and does not replace professional medical advice.