CLINICAL OBSTETRICS AND GYNECOLOGY

Volume 57, Number 2, 331342

r 2014, Lippincott Williams & Wilkins

Global Perspectives on
Elective Induction
of Labor
JOSHUA P. VOGEL, MBBS,*w
AHMET M. METIN GULMEZOGLU, MD, PhD,w
GEORGE J. HOFMEYR, MB BCh, MRCOG,z
and MARLEEN TEMMERMAN, MD, PhDw
*School of Population Health, Faculty of Medicine, Dentistry and
Health Sciences, University of Western Australia, Crawley, Western
Australia, Australia; w UNDP/UNFPA/UNICEF/WHO/World
Bank Special Programme of Research, Development and Research
Training in Human Reproduction (HRP), Department of
Reproductive Health and Research, World Health Organization,
Geneva, Switzerland; and z Effective Care Research Unit, University
of the Witwatersrand/Fort Hare, Eastern Cape Department of
Health, Eastern Cape, South Africa
Abstract: Elective labor induction is an increasingly
common practice not only in high-income countries,
but also in many low-income and middle-income
countries. Many questions remain unanswered on
the safety and cost-effectiveness of elective labor
induction, particularly in resource-constrained settings where there may be a high unmet need for
medically indicated inductions, as well as limited or
no access to appropriate medications and equipment for induction and monitoring, comprehensive
emergency obstetric care, safe and timely cesarean
section, and appropriate supervision from health

professionals. This article considers the global perspective on the epidemiology, practices, safety, and
costs associated with elective labor induction.
Key words: elective, labor, induction, global

Introduction
Since the discovery of the uterine effects of
oxytocin in 19061 and prostaglandin F2a
in 1964,2 pharmacological induction of
labor (either alone or in combination with
mechanical methods) has steadily become
more widespread. Labor induction is not
without risk to both mother and fetus and
should only be used in circumstances in
which the risks of waiting for the onset of
spontaneous labor are judged by clinicians to be greater than the risks association with shortening the duration of

Correspondence: Ahmet M. Gulmezoglu, MD, PhD,

UNDP/UNFPA/UNICEF/WHO/World Bank Special
Programme of Research, Development and Research
Training in Human Reproduction (HRP), Department
of Reproductive Health and Research, World Health
Organization, Geneva, Switzerland. E-mail: gulmezoglum
@who.int
The authors declare that they have nothing to disclose.
The views contained herein represent the views of the
named authors only.
CLINICAL OBSTETRICS AND GYNECOLOGY

VOLUME 57

NUMBER 2

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Vogel et al

pregnancy.3 By this standard, the use of

labor induction is appropriate for several
obstetric and medical indications, including pregnancies beyond 41 weeks gestation, premature rupture of membranes,
hypertensive disorders of pregnancy,
chorioamnionitis, intrauterine growth
restriction, fetal death, multiple pregnancy, maternal medical complications,
and isoimmunization.36 However, with
improvements in the safety and effectiveness of labor induction regimens, intrapartum care, fetal monitoring, and careful
patient selection, some have argued that
labor induction in the absence of a clear
medical indication can be used safely in
certain circumstances and subpopulations.7,8 Others argue the practice constitutes an unnecessary increase in the risk of
adverse maternal and perinatal outcomes
and women should be counseled against
the practice.9 The lack of a universally
accepted definition of what constitutes a
medical or an elective labor induction is a
further complication. We have adopted
the definition of elective induction as
those inductions occurring in the absence
of a clear maternal and/or fetal medical
indication and before 41 completed weeks
of gestation. Regardless of the uncertainty surrounding risks and benefits,
elective labor induction is becoming
an increasingly common practice worldwide.1013
WHY PERFORM AN ELECTIVE LABOR
INDUCTION?

The distinction between indicated and

nonindicated inductions is becoming increasingly blurred. Women may request
induction due to geographical remoteness
from hospital, fatigue, or discomfort associated with pregnancy or concerns that
awaiting a spontaneous or unexpectedly
rapid labor may complicate timely arrival
at hospital and receipt of interventions,
such as pain relief. Mothers may also be
concerned about maternal or perinatal
complications associated with continuing
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pregnancy. Labor induction guidelines

from the American College of Obstetricians (ACOG) and the UK National Institute of Clinical Excellence (NICE)
acknowledge some of these issues, such
as living a long distance from hospital,
psychosocial reasons, or exceptional family circumstances.14,15 Clinicians, midwives, and other health workers may
prefer to manage pregnancy-associated
discomfort or prevent possible complications proactively using elective labor induction. They may also be incentivized to
use elective labor induction for financial
reasons or scheduling preferences. Improved delivery scheduling could be
potentially advantageous to staff in overburdened labor wards, although evidence
is lacking.16 Others have argued that
widespread use of elective labor induction
is not consistent with patient safety.17
Although control over the time of delivery
may be desirable for both mothers and
caregivers, mothers must be fully informed on the risks, benefits, and
alternatives.
Although the majority of evidence on
the use of labor induction is from highincome countries, the majority of the
worlds nearly 135 million annual births
occur in low-income and middle-income
countries (LMICs). Seventy-five of these
countries account for 95% of all maternal, newborn, and child deaths and
stillbirths,18 and many (particularly in
sub-Saharan Africa) are experiencing
chronic shortages of health workers,19
considerable shortfalls in health expenditure,20 and a lack of essential, life-saving
interventions for mothers and newborns.18
Providing safe, effective, and timely care
during pregnancy, delivery, and the postpartum period to women in these settings
is challenging. Despite this, in some lowincome countries elective labor induction
is a common practice.11,12 The ethical
question of providing elective labor induction in settings with a significant unmet
need for medically indicated induction

Elective Induction of Labor

and other obstetric interventions remains.
This article takes the global perspective,
describing current practices, outcomes,
and issues related to the use of elective
induction of labor worldwide.

Global Epidemiology of Labor

Induction
PREVALENCE OF LABOR INDUCTION

Labor induction is a common practice in

high-income countriesaccounting for
23.4% of deliveries in the United States
(2010),21 22.1% of deliveries in England
(2011 to 2012),22 and 25.4% of deliveries
in Australia (2010).23 The 2008 European
Perinatal Health Report (2004 data)
showed wide ranges in national induction
rates among European countries, ranging
from <9% (Baltic countries and the
Czech Republic) to over 30% in Malta
(37.9%) and Northern Ireland (30.7%).24
There is substantially less populationbased data on the use of labor induction
in low-income countries; however, among
facility deliveries in 22 LMICs in the
WHO Global Survey on Maternal and
Newborn Health the induction rate was
somewhat lower11.4% in 8 Latin
American countries,25 4.4% in 7 African
countries, and 12.1% in 9 Asian countries.11 Several low-income countries, notably Sri Lanka (35.5%) and Cuba
(20.1%), had induction rates comparable
with high-income countries, which may
be attributable to the facility-based sampling frame.
TRENDS IN THE USE OF LABOR
INDUCTION

Zhang et al10 analyzed US population

data and reported an increase in induction
from 9.5% in 1989 to 19.4% to 1998, with
substantial variations at the subnational
levelsome New York counties increased
from 6.5% to 53.2%. Rates increased
for both nulliparous and multiparous

333

mothers and all gestational ages. Studies

from other countries show similar
trendsa population-based study by
Mealing et al13 of 739,904 deliveries in
New South Wales, Australia between
1998 and 2007 showed inductions increasing from 25.3% to 29.1%an increasing
proportion were nulliparous.26 This trend
is not universal; however, a Dutch population analysis showed a stable induction
rate of approximately 15% between 1993
and 2002.27 Similarly, NHS maternity
statistics showed that induction rates in
England only increased to 22.1% in 2011
to 2012 from 20% in 2004 to 2005.22,28
Calculating the incidence of elective
labor induction from national birth statistics is generally not possible as indications are not routinely recorded and
health workers may be reluctant to document the absence of an indication. In 1
study, Stock et al29 reported that in Scotland from 1981 to 2007, elective labor
inductions peaked in 2001 (over 8% of
all singleton deliveries) and have since
reduced to approximately 6%. However,
there is general agreement that induction
rate increases are at least partly attributable to increased use of elective labor
induction.10,30 Other changes in clinical
practices have also been identified as potentially contributing to these trends, including increases in pregnancies in women
with medical conditions, more liberal use
of induction (both medically indicated
and elective labor induction), the desires
of clinicians, mothers, and families to plan
the time of delivery, better detection of atrisk pregnancies (necessitating induction), more widespread use of cervical
ripening agents, changes in attitude toward elective labor induction, and greater
availability of routine ultrasound in the
first and second trimesters.10,16,31 Sociodemographic characteristics have also
been implicated in increasing induction
use, such as variations in race, ethnicity,
earlier antenatal care, marital status, and
level of insurance.10,32 Location and
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Vogel et al

level of hospitals are also contributing

factors.30 A qualitative review by Moore
and Low33 identified a number of factors
contributing to the increasing use of elective labor induction at the patient (such as
preference, fear of outcomes, external
pressures), provider (such as convenience,
financial incentives, and patient demand),
and organizational (such as lack of enforcement, hospital culture, and staff
scheduling) levels.
The WHO Global Survey has yielded
important insights on the use of elective
labor induction in LMICs. Guerra et al12
reported that elective labor inductions
accounted for one sixth of all inductions in 8 Latin American countries, or
4.9% of all low-risk deliveries. Although
elective labor induction was generally uncommon (<1% of all deliveries) in
Africa and Asia, there were exceptions
Sri Lanka (27.8%), India (3.6%), and
Thailand (3.5%).11 Some literature reports the widespread community use of
oxytocin for unsupervised induction in
other countries in the region.34,35 These
authors also suggest that social disparities
are at play in elective labor induction use
in LMICs, reporting higher rates among
nulliparous women and women over 35,
and those with more education and >4
antenatal care visits.11,12

Inducing Labor Safely

There has long been controversy surrounding the safety of elective labor induction and 3 main methodological
obstacles have hampered clarity. First,
many studies have used women in spontaneous labor as the control group; however, the more appropriate control group
are those women managed expectantly,
as these are the management choices
available to the clinician at a given point
in time. Expectantly managed women
carry the inherent risk of developing
further complications as the pregnancy
continuesthey may go into spontaneous
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labor, develop complications (such as

oligohydramnios, postterm pregnancy, or
fetal death in utero), or require intervention
(such as a medical induction or cesarean).7
The risks of elective labor induction therefore need to be weighed against the risks of
continuing the pregnancy. The remaining 2
analytical challenges relate to stratification
by parity (nulliparous and multiparous)
and cervical status at time of admission.31
Differences in baseline risk for cesarean
section after induction vary depending on
parity and cervical favorability (Bishop
score); the likelihood of a failed induction
is higher in women with an unfavorable
cervix.31,36,37
Considering these issues, it is unsurprising that there are conflicting conclusions in the literature regarding the risk of
adverse maternal and perinatal outcomes,
particularly the risk of cesarean section.
Any increase in the risk of cesarean carries
morbidity and mortality risks, increased
inpatient length of stay and health care
costs, and increased risk of future cesarean deliveries.9,38,39 A systematic review
by Caughey et al7 captured both the evidence and controversy surrounding cesarean section risk after elective labor
induction. The authors found 11 randomized controlled trials (RCTs) and 25
observational studies (cohort and casecontrol studies) of elective labor induction before 42 weeks gestationmost
were small (<400 women) and there was
considerable heterogeneity across studies.
Of the RCTs, 9 compared electively induced women with expectantly managed
women. Expectant management was associated with increased odds ratios (OR)
of cesarean delivery (OR, 1.22; 95% CI,
1.07-1.39; P<0.01). Inclusion of the 2
trials that compared elective labor induction with spontaneous labor did not alter
the results significantly (OR, 1.21; 95%
CI, 1.03-1.44; P<0.02). In contrast, 24 of
the 25 observational studies compared
elective labor induction to spontaneous
labor. Among these, the risk of cesarean

Elective Induction of Labor

delivery among women after spontaneous
labor was lower than that of women who
had elective labor induction (OR, 0.65;
95% CI, 0.52-0.81; P<0.01). There was
insufficient evidence to conclude whether
the risk of cesarean delivery was different
between nulliparous and multiparous
women. The review also found moderate
quality evidence that the incidence of
meconium-stained amniotic fluid was increased with expectant management (OR,
2.04; 95% CI, 1.34-3.09; P<0.01), but the
study results were heterogenous (I2 = 83).
There was insufficient evidence to establish any increase in the risk of other
maternal and perinatal outcomes. It is of
concern that elective labor induction is so
widespread with such uncertainty surrounding the effect on mothers and infants. In addition, extrapolating evidence
from studies that were conducted in higher resource tertiary centers or academic
settings (with high levels of supervision,
diagnostic capacity, and access to comprehensive emergency obstetric care) to
low-resource settings is riskythis may
be the case for secondary or remote hospitals. In many LMICs, any increase in
the risk of cesarean section carries significant resource and safety implications.
Given the lack of RCTs from LMICs, it
is not yet possible to determine if elective
labor induction is as safe and effective in
low-resource settings as existing evidence
may suggest.

Performing Elective Induction

of Labor
Simpson and Atterbury9 drew attention
to the fact that labor induction (with or
without medical indication) is not an
isolated intervention, requiring a range
of human resources, services, monitoring,
and interventions. Many hospitals face
significant hurdles in the availability of
safe and effective medications, trained
staff and fetal monitoring, clinical

335

practice guidelines, epidural analgesia/

anesthesia, safe cesarean section, and
other life-saving interventions,9 all of
which should be available if elective labor
induction is to be conducted safely.
METHODS OF INDUCTION

There is some variation in induction

guidelines from major international and
national bodies (such as ACOG, NICE,
and WHO).3,14,15 This can be at least
partly attributed to the different settings
they apply tofor example, misoprostol
is not licensed for use in labor induction in
the UK, and WHO guidelines are aimed
at an international audience. All groups
agree that membrane sweeping is an effective method to reduce the need for
formal labor induction, whereas amniotomy alone is not recommended. Whereas
ACOG and WHO recommend the routine use of balloon catheters, NICE states
that although mechanical methods (balloon catheters and laminaria tents) may
reduce the incidence of uterine hyperstimulation, they do not improve the rate of
vaginal birth within 24 hours, nor reduce
the cesarean section rate and increase the
risk of neonatal infection.
Recommendations regarding pharmacological induction also differ. WHO recommends the use of low-dose vaginal
misoprostol (25 mg, 6 hourly), oral misoprostol (25 mg, 2 hourly), and low doses
of vaginal prostaglandinsif prostaglandins are not available, intravenous
oxytocin alone can be used. ACOG
recommends the use of both misoprostol
(synthetic PGE1 analog) and dinoprostone (PGE2) for cervical ripening and
induction, and states that vaginal or intracervical administration of PGE2 is appropriate. They also support the use of
low-dose or high-dose oxytocin regimens
for induction. Conversely, NICE states
that vaginal PGE2 is preferred and
recommends specifically against other
modes of administration (including intracervical). The NICE guidelines also cite
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Vogel et al

safety concerns regarding a lack of evidence on possible long-term effects on

babies exposed to misoprostolthey
therefore recommend its use only for induction after intrauterine fetal death, in
the context of a clinical trial. NICE does
not recommend the use of intravenous
oxytocin alone.
Few large studies of trends in induction
report the indication and/or the method
used; however, the available evidence suggests that globally many inductions are
not in line with best practice. Although
prostaglandin use is increasing, oxytocin
is still the preferred method. In a retrospective cohort of over 1.2 million deliveries in Scotland, Stock et al29 showed a
proportional increase in the use of prostaglandins in elective labor induction;
however, oxytocin and artificial rupture
of membranes was still in use in approximately 15% of inductions. Mealing and
colleagues showed that for inductions in
women in New South Wales, Australia,
between 1998 and 2007, oxytocin alone
was the most commonly used agent and
was actually increasing in use over time
(47.2% to 50.9%, P<0.001), whereas the
proportion induced with prostaglandin
alone decreased from 33.5% to 23.8%
(P<0.001).
Evidence on the methods of induction
from LMICs confirms that prostaglandins and particularly misoprostol are not
in widespread use. Oxytocin alone was the
single most frequently used induction
method (65.9%) in elective labor inductions in 8 Latin American countries,
whereas misoprostol alone was used in
only 8.9%.12 Oxytocin alone or oxytocin
in combination with mechanical methods
was the most common in all inductions in
Africa (45.9% and 20.2%) and Asia
(31.5% and 28.2%). Misoprostol or other
prostaglandins were used in approximately 15% of inductions in both
regions.11
Although misoprostol has been shown
to be a highly effective induction agent at
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very low doses, its use is associated with

some risks, and these may be amplified in
low-resource settings with limited clinical
surveillance. Misoprostol has been associated with increased risks of meconium
staining of the amniotic fluid40 and thus of
neonatal meconium aspiration syndrome.
Although the mechanism of this is unclear, in vitro rat tissue studies have
shown that misoprostol, unlike oxytocin,
stimulates both bowel and uterine smooth
muscle, and it has been postulated that
misoprostol may cross the placenta to
directly stimulate fetal bowel.41 Misoprostol is also associated with an
increased risk of uterine hyperstimulation40 and thus fetal distress.
In low-resource settings the risk of
uterine rupture is more common than in
high-resource settings and although
randomized trials have not been large
enough to show an association, the possibility exists that in these settings, induction, using misoprostol may be associated
with increased risks of uterine rupture. In
the most recent South African confidential report on maternal deaths (2008 to
2010),42,43 of 688 deaths due to obstetric
hemorrhage, 47 were due to ruptured
uterus with previous cesarean section
and 61 were due to ruptured uterus without a previous cesarean section. This was
thought to be an underestimate, as ruptured uterus may have been responsible
for a proportion of unexplained maternal
deaths also. The association between uterine rupture and labor induction with
misoprostol was highlighted in the report.
SELF-ADMINISTERED LABOR
INDUCTION

There is evidence to show that the

self-administration of medications (using
either traditional remedies or known
oxytocic drugs) is a common practice.
In Southern Africa, it is common for women in late labor to take herbal remedies
such as Isihlambezo to promote labor.44
Isihlambezo preparations contained plant

Elective Induction of Labor

ergot alkaloids with uterotonic properties,45 and an association between Isihlambezo use and meconium staining of the
amniotic fluid has been reported.46 Because
the use of herbal medication is unregulated,
unstandardized, and usually unreported,
the possibility of harm to mother or fetus
from excessive dosage is a real one.
In the Eastern Cape in South Africa, an
increasing trend of misoprostol self-administration to induce labor before term
has been observed, usually by women who
do not wish to be pregnant and may be
unaware of the advanced gestation of the
pregnancy. In a series of 18 cases of selfadministered labor induction at the East
London Hospital Complex between July
and December 2011, the gestational age of
the babies ranged from 24 to 39 weeks, 8
being above 28 weeks (S. Mandonondo,
unpublished data, data was collected in
2011). In this series, there was 1 uterine
rupture, high rates of neonatal intensive
care admission, and only 1 baby survived.
These findings suggest that in certain settings, self-administered labor induction is
an important contributor to preterm
birth, perinatal mortality, and utilization
of neonatal services.
GLOBAL AVAILABILITY OF
MEDICATIONS FOR INDUCTION

Prostaglandin preparations other than

misoprostol are more expensive47 and
dinoprostone is generally unaffordable
in low-income settings. In such circumstances, methods for induction with an
unfavorable cervix are limited to low-cost
options, such as extra-amniotic placement of a Foley catheter bulb, or misoprostol.3 Misoprostol is on the WHO
Essential Medicines List for induction of
labor, as well as for management of incomplete abortion and miscarriage, and
prevention of postpartum hemorrhage
where oxytocin is not available or cannot
be safely used.48 The low cost, heat stability, and ease of administration and storage of misoprostol are advantageous,

337

particularly for LMICs.49 However, a

minority of countries have misoprostol
registered for obstetric indications and it
is often only available through off-label
use.50 Although global obstetric misoprostol use is growing, the majority of
the worlds misoprostol is sold for nonobstetric indications in high-income
countries.51 Improving the availability of
misoprostol in countries with limited or
no access to it (and a concomitant overreliance on less effective induction methods) has the potential to improve
maternal and perinatal outcomes for all
inductions. Although oxytocin has greater global availability, considerable concern has been raised by the findings of
Stanton et al,52 who reported that the
median percentage of active ingredient
in oxytocin ampoules purchased in Ghana was only 64%. Another specific limitation of misoprostol is that in many
countries it is not marketed for labor
induction and the only preparation available is a 200 mcg tablet. Randomized
trials have shown the maximum initial
safe dose of misoprostol to be 25 mcg,
vaginally or orally.40,53 Although it is
possible to administer a small dose orally
by making a solution of the tablet in
water,54 the South African confidential
report on maternal deaths cited cases in
which larger doses of misoprostol were
used.
GESTATIONAL AGE ESTIMATION

The accuracy of gestational age estimates

can affect decisions regarding timing and
mode of delivery. In early pregnancy,
gestational age estimation is more accurate with ultrasound than with other
methods (such as last menstrual period)55
and can lead to better prevention of postdates pregnancies through induction.
However, access to early pregnancy ultrasound and antenatal care is often poor in
many LMICsthe coverage of Z4 antenatal visits in developing regions is 55%.56
As last menstrual period and clinical
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Vogel et al

examination can underestimate gestational age,55 there is a risk that elective labor
inductions based on these will be unintentionally earlier than 39 weeks, leading to
an avoidable burden of perinatal morbidity and mortality.57
HUMAN RESOURCES

Trained health workers are needed to

safely induce and monitor labor progress.
The chronic shortage of trained health
workers is impacting obstetric care in
many LMICsthe skilled birth attendance rate is only 65% in developing regions.56 In 2000, the United States had a
nursing and midwifery density 94 per
10,000 population. By comparison, in
2003 Nigeria had 17 nurses and midwives
per 10,000 people and in 2004 India had
13 per 10,000 people.58 The 2006 World
Health Report on global health personnel
estimated that 57 countries had critical
health workforce shortages, equating to a
global deficit of 2.4 million doctors,
nurses, and midwives.19 Overburdened
labor wards may find nurses, midwives,
and doctors caring for a significantly
higher number of women simultaneously
than in other centers. It is difficult
to perceive how many hospitals are able
to provide adequate monitoring of inductions in the face of such challenges.
CLINICAL RESOURCES AND COSTS

Although hospitals may have access to

induction agents, induction should only
be conducted where there is access to safe
cesarean section.3 In several observational studies, elective labor induction has
been associated with increased risks of
instrumental delivery,59,60 postpartum
uterotonic use,12 maternal and neonatal
intensive care admission,11,12,29,30,61 postpartum hysterectomy,12 epidural anesthesia/analgesia use,12,61 shoulder dystocia,60
lower Apgar scores,62 phototherapy,61 and
delayed breastfeeding.12 Given this, it
seems prudent to ensure the availability
of staff skilled and equipped for
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instrumental delivery, therapies for prevention and management of postpartum hemorrhage, newborn resuscitation, maternal
and neonatal intensive care services, anesthesia services, and postpartum interventions when elective labor induction takes
place. Although some authors have commented on the possible advantages of
scheduled deliveries for nursing schedules,16 prolonged hospital stays (including
predelivery) and/or avoidable ICU admissions associated with elective labor induction may outweigh such advantages. This
is also true in terms of expenditure
providing elective labor induction and
managing associated complications (particularly the increased demand for epidural
anesthesia/analgesia) may render elective
labor induction costly for health systems.16

COST-EFFECTIVENESS OF ELECTIVE
LABOR INDUCTION

Using the United States National Birth

Cohort dataset, Kaimal et al8 estimated
the cost-effectiveness of elective induction
of labor at 41 weeks versus expectant
management with monitoring until 42
weeks. They concluded that, compared
with expectant management, elective labor induction in a theoretical cohort of
200,000 women was more expensive.
However, it was deemed cost-effective,
as 204 perinatal demises were averted
and a cost of $10,945 per quality-adjusted
life year gained (cost-effectiveness thresholds in the United States are generally
$50,000 to $100,000). An earlier costeffectiveness analysis of elective labor
induction at term (vs. expectant management until 42 wk gestation) in a hypothetical cohort of 100,000 women by
Kaufman et al36 reported 133 fetal deaths
averted, however, at higher costs (nearly
$100 million) and >12,000 excess cesarean sections. Cost-effectiveness calculations will vary depending on national
levels of health expenditure.

Elective Induction of Labor

EQUITABLE ACCESS TO INDUCTION

Elective labor induction offers several

advantages to women and providers.
Many women prefer to know the date of
delivery, that it will occur during the daytime, and that it will be attended by health
professionals. For mothers in geographically remote areas, awaiting the spontaneous onset of labor and potentially
delivering outside of a hospital may seem
an unnecessary risk, although alternative
approaches such as maternity waiting
homes may mitigate this risk. However,
although women have a right to request
elective labor induction, it also carries
implications for other women whose
needs may be more medically urgent.
Fawole et al63 reported that the unmet
need for medically indicated induction
was 66.0% to 80.2% in African countries.
Essential, life-saving care in resource-constrained settings must be provided in an
equitable manner based on urgency and
medical need. It is difficult to see how a
reduction in the availability of beds (in
labor wards and intensive care), medications, interventions, and health workers
for elective labor inductions is appropriate in settings where resources are
extremely limited and preventable maternal and perinatal mortality is high.
MATERNAL PERSPECTIVES

Induction of labor has been associated

with reduced positive experiences of childbirth,64 which may be related to poor
understanding of the procedure beforehand. Informed consent should always be
obtained before elective labor induction
and should include clear communication
of the risks, benefits, methods used, and
alternatives. A survey of 270 mothers in
Finland undergoing elective induction of
labor demonstrated that although mothers experiences with elective labor induction were largely positive (80% reported
they would accept this for subsequent
pregnancies), one third felt they needed
more information on indications and

339

methods of induction.65 A similar survey

from Scotland showed that 34.7% of
induced women reported not being satisfied with the information they received
before the procedure.66 A survey of 305
women in Nigeria by Enabor et al67 reported that 71% of women had heard
about cervical ripening and induction of
labor; however, only 29.6% of women
had high knowledge of the practice.
Including information about induction
in antenatal education has been shown
to be of benefit. Incorporating standardized education on elective labor induction
into antenatal classes for 3337 nulliparous
women in the United States was associated with a reduction in elective labor
induction rates; 63% of women who decided against elective labor induction
cited this education as influencing their
decision.17

Future Work
A considerable research agenda remains
surrounding the use of elective labor inductions globally. Beyond establishing
the true prevalence, trends, and determinants of elective induction of labor at the
national and subnational level, further
trials are required to establish the effect
on other maternal and perinatal health
outcomes (beyond the risk of cesarean
section), across a range of settings (including rural facilities and LMICs). In addition, work remains to ensure women
are being induced as safely as possible
using appropriate methods in both
high-resource and low-resource settings.
From a health systems perspective, the
cost-effectiveness of elective labor induction in the context of unmet need for
medically indicated induction needs to
be addressed.

Conclusions
Elective induction of labor may be appealing to women, families, and health
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Vogel et al

providers. However, despite the growing

use of elective labor inductions globally,
critical questions remain on safety, risks,
benefits, and cost-effectiveness. A cautious approach to the use of elective labor
induction seems most prudent and it
should be performed only in the context
of informed consent, access to comprehensive emergency obstetric care services, and appropriate monitoring and
supervision.

References
1. Dale H. On some physiological actions of ergot.
J Physiol. 1906;34:163206.
2. Karim SM, Trussell RR, Patel RC, et al. Response of pregnant human uterus to prostaglandin-F2-alpha-induction of labour. BMJ. 1968;4:
621623.
3. World Health Organization. WHO Recommendations for Induction of Labour. Geneva, Switzerland: World Health Organization.
4. Gulmezoglu A, Crowther C, Middleton P. Induction of labour for improving birth outcomes for
women at or beyond term. Cochrane Database
Syst Rev. 2012;6:CD004945.
5. Mozurkewich E, Chilimigras J. Indications for
induction of labour: a best-evidence review. Br J
Obstet Gynaecol. 2009;116:626636.
6. Sanchez-Ramos L. Induction of labor. Obstet
Gynecol Clin N Am. 2005;32:181200.
7. Caughey AB, Sundaram V, Kaimal AJ, et al.
Systematic review: elective induction of labor
versus expectant management of pregnancy. Ann
Intern Med. 2009;151:252263.
8. Kaimal AJ, Little SE, Odibo AO, et al. Costeffectiveness of elective induction of labor at 41
weeks in nulliparous women. Am J Obstet Gynecol. 2011;204:00.
9. Simpson KR, Atterbury J. Trends and issues in
labor induction in the United States: implications
for clinical practice. J Obstet Gynecol Neonatal
Nurs. 2003;32:767779.
10. Zhang J, Yancey MK, Henderson CE. US
national trends in labor induction, 1989-1998.
J Reprod Med. 2002;47:120124.
11. Vogel J, Souza JP, Gulmezoglu AM. Patterns and
outcomes of induction of labour in Africa and
Asia: a secondary analysis of the WHO Global
Survey on Maternal and Neonatal Health. PLoS
One. 2013;8:e65612.
12. Guerra G, Cecatti J, Souza J. Elective induction
versus spontaneous labour in Latin America. Bull
World Health Organ. 2011;89:657665.

www.clinicalobgyn.com

13. Mealing NM, Roberts CL, Ford JB, et al. Trends

in induction of labour, 1998-2007: a populationbased study. Aust N Z J Obstet Gynaecol. 2009;49:
599605.
14. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 107: Induction of labor. Obstet Gynecol. 2009;114:386397.
15. National Institute for Clinical Excellence. Induction of Labour. London: National Institute of
Clinical Excellence; 2008.
16. Rayburn W. Rising rates of labor induction:
present concerns and future strategies. Obstet
Gynecol. 2002;100:164167.
17. Simpson KR, Newman G, Chirino OR. Patient
education to reduce elective labor inductions.
MCN Am J Matern Child Nurs. 2010;35:188194.
18. Requejo J, Bryce J, Victora C. Countdown to 2015:
Building a Future for Women and Children. Washington, DC: World Health Organization and
UNICEF; 2012. Available at: http://www.countdown2015mnch.org/documents/2012Report/2012Complete.pdf.
19. World Health Organization (WHO). The World
Health Report: Working Together for Health.
Geneva, Switzerland: WHO; 2006.
20. Countdown to 2015 Coordinating Committee.
Countdown to 2015 Decade Report (2000-2010).
Geneva, Switzerland: World Health Organization; 2010. Available at: http://www.who.int/
pmnch/topics/child/2010countdown_decadereport/
en/index.html.
21. Martin JA, Hamilton BE, Ventura SJ, et al.
National Vital Statistics Reports. Report No. 1.
Hyattsville, Maryland, United States of America:
National Vital Statistics System; 2012.
22. The Health and Social Care Information Centre.
NHS Maternity Statistics 2011-2012 Summary
Report. Geneva, Switzerland: National Health
Service; 2012. Available at: http://www.hscic.gov.
uk/hes.
23. Australian Institute of Health and WelfareLi Z,
Zeki R, Hilder L, et al. Australias Mothers and
Babies 2010. Canberra, ACT, Australia: Australian
Institute of Health and Welfare; 2012. Available at:
http://www.aihw.gov.au/publication-detail/?id =
60129542376.
24. EURO-PERISTAT Project. European Perinatal
Health Report. Paris, France: EURO-PERISTAT; 2008. Available at: http://www.euro
peristat.com.
25. Guerra G, Cecatti J, Souza J. Factors and outcomes associated with the induction of labour in
Latin America. Br J Obstet Gynaecol. 2009;116:
17621772.
26. Patterson JA, Roberts CL, Ford JB, et al. Trends
and outcomes of induction of labour among
nullipara at term. Aust N Z J Obstet Gynaecol.
2011;51:510517.

Elective Induction of Labor

27. Kwee A, Elferink-Stinkens PM, Reuwer PJHM,
et al. Trends in obstetric interventions in the
Dutch obstetrical care system in the period
1993-2002. Eur J Obstet Gynecol Reprod Biol.
2007;132:7075.
28. The Information Centre, Community Health Statistics. NHS Maternity Statistics, England: 2004-05.
London, United Kingdom: The Information
Centre, Community Health Statistics; 2006. Available at: https://catalogue.ic.nhs.uk/publications/
hospital/maternity/nhs-mater-eng-2004-2005/nhsmater-eng-2004-2005-rep.pdf.
29. Stock S, Ferguson E, Duffy A, et al. Outcomes of
elective induction of labour compared with expectant management: population based study.
BMJ. 2012;344:e2838.
30. Yeast J, Jones A. Induction of labor and the
relationship to cesarean delivery: a review of
7001 consecutive inductions. Am J Obstet Gynecol. 1999;180 (pt 1):628633.
31. Grobman WA. Elective induction: when? ever?
Clin Obstet Gynecol. 2007;50:537546.
32. Coonrod DV, Bay RC, Kishi GY. The epidemiology of labor induction: Arizona, 1997. Am J
Obstet Gynecol. 182:13551362.
33. Moore J, Low LK. Factors that influence the
practice of elective induction of labor: what does
the evidence tell us? J Perinat Neonatal Nurs.
2012;26:242250.
34. Moran AC, Wahed T, Afsana K. Oxytocin to
augment labour during home births: an exploratory study in the urban slums of Dhaka, Bangladesh. BJOG. 2010;117:16081615.
35. Jeffery P, Das A, Dasgupta J, et al. Unmonitored
intrapartum oxytocin use in home deliveries: evidence from Uttar Pradesh, India. Reprod Health
Matters. 2007;15:172178.
36. Kaufman KE, Bailit JL, Grobman W. Elective
induction: an analysis of economic and health consequences. Am J Obstet Gynecol. 2002;187:858863.
37. Jackson M, Regan C. Elective induction of labor.
Clin Obstet Gynecol. 1997;40:496509.
38. Smith GCS, Pell JP, Dobbie R. Caesarean section
and risk of unexplained stillbirth in subsequent
pregnancy. Lancet. 2003;362:66.
39. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat
cesarean deliveries. Obstet Gynecol. 2006;107:
12261232.
40. Hofmeyr GJ, Gulmezoglu AM, Pileggi C. Vaginal
misoprostol for cervical ripening and induction of
labour. Cochrane Database Syst Rev. 2010;10:
CD000941.
41. Matonhodze BB, Katsoulis LC, Hofmeyr GJ.
Labor induction and meconium: in vitro effects
of oxytocin, dinoprostone and misoprostol on rat
ileum relative to myometrium. J Perinat Med.
2002;30:405410.

341

42. National Committee for Confidential Enquiry

into Maternal Deaths. The Fifth Report on Confidential Enquiries into Maternal Deaths in South
Africa. Pretoria: Health Department of South
Africa; 2012. Available at: http://www.health.
gov.za/docs/reports/2012/Report_on_Confidential_
Enquiries_into_Maternal_Deaths_in_South_
Africa.pdf.
43. Pattinson RC. Reducing maternal deaths. SAJOG. 2012;18:3236. Available at: http://www.
sajog.org.za/index.php/SAJOG/article/view/530/
282.
44. Veale DJ, Furman KI, Oliver DW. South African
traditional herbal medicines used during pregnancy and childbirth. J Ethnopharmacol. 1992;36:
185191.
45. Veale DJ, Oliver DW, Havlik I. The effects of
herbal oxytocics on the isolated stripped
myometrium model. Life Sci. 2000;67:13811388.
46. Mitri F, Hofmeyr GJ, van Gelderen CJ. Meconium during labourself-medication and other
associations. S Afr Med J. 1987;71:431433.
47. Ramsey PS, Harris DY, Ogburn PL, et al. Comparative efficacy and cost of the prostaglandin
analogs dinoprostone and misoprostol as labor
preinduction agents. Am J Obstet Gynecol.
2003;188:66.
48. World Health Organization. WHO Model Lists
for Essential Medicines. Geneva, Switzerland:
World Health Organization; 2011. Available at:
http://whqlibdoc.who.int/hq/2011/a95053_eng.pdf.
49. Blanchard K, Clark S, Winikoff B, et al. Misoprostol for womens health: a review. Obstet Gynecol.
2002;99:316332. Available at: http://eutils.ncbi.
nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom = pub
med&id = 11814515&retmode = ref&cmd = prlinks.
50. Weeks AD, Fiala C, Safar P. Misoprostol and the
debate over off-label drug use. BJOG. 2005;112:
269272.
51. Fernandez M, Coeytaux F, Ponce de Leon RG,
et al. Assessing the global availability of misoprostol. Int J Gynecol Obstet. 2009;105:180186.
52. Stanton CC, Koski AA, Cofie PP, et al. Uterotonic drug quality: an assessment of the potency of
injectable uterotonic drugs purchased by simulated clients in three districts in Ghana. BMJ
Open. 2011;2:pii: e000431.
53. Alfirevic Z, Weeks A. Oral misoprostol for induction of labour. Cochrane Database Syst Rev.
2006;2:CD001338.
54. Hofmeyr GJ, Alfirevic Z, Matonhodze B, et al.
Titrated oral misoprostol solution for induction
of labour: a multi-centre, randomised trial.
BJOG. 2001;108:952959.
55. Hoffman CSC, Messer LCL, Mendola PP, et al.
Comparison of gestational age at birth based on last
menstrual period and ultrasound during the first trimester. Paediatr Perinat Epidemiol. 2008;22:587596.

www.clinicalobgyn.com

342

Vogel et al

56. United Nations. The Millennium Development Goals

Report 2012. New York, USA: United Nations;
2012. Available at: http://www.un.org/millennium
goals/pdf/MDG%20Report%202012.pdf.
57. Clark SL, Miller DD, Belfort MA, et al. Neonatal
and maternal outcomes associated with elective
term delivery. Obstet Anesth Dig. 2009;29:195196.
58. World Health Organization. editor. WHO Statistical Information System. Available at: http://
apps.who.int/whosis/data/. Accessed March 14,
2014.
59. Cammu H, Martens G, Ruyssinck G, et al. Outcome after elective labor induction in nulliparous
women: a matched cohort study. Am J Obstet
Gynecol. 2002;186:240244.
60. Dublin S, Lydon-Rochelle M, Kaplan RC, et al.
Maternal and neonatal outcomes after induction
of labor without an identified indication. Am J
Obstet Gynecol. 2000;183:99.
61. Boulvain M, Marcoux S, Bureau M, et al. Risks of
induction of labour in uncomplicated term pregnancies. Paediatr Perinat Epidemiol. 2001;15:131138.
62. Baud D, Rouiller S, Hohlfeld P, et al. Adverse
obstetrical and neonatal outcomes in elective

www.clinicalobgyn.com

63.

64.
65.

66.

67.

and medically indicated inductions of labor

at term. J Matern Fetal Neonatal Med. 2013;26:
15951601.
Fawole B, Nafiou I, Machoki M, et al. Unmet
need for induction of labor in Africa: secondary
analysis from the 2004-2005 WHO Global Maternal and Perinatal Health Survey (a cross-sectional survey). BMC Public Health. 2012;12:
722722.
Bramadat IJ. Induction of labor: an integrated
review. Health Care Women Int. 1994;15:135148.
Nuutila M, Halmesmaki E, Hiilesmaa V, et al.
Womens anticipations of and experiences with
induction of labor. Acta Obstet Gynecol Scand.
1999;78:704709.
Shetty A, Burt R, Rice P, et al. Womens perceptions, expectations and satisfaction with induced
laboura questionnaire-based study. Eur J Obstet Gynecol Reprod Biol. 2005;123:66.
Enabor OO, Olayemi OO, Bello FA, et al. Cervical ripening and induction of labour-awareness,
knowledge and perception of antenatal attendees
in Ibadan, Nigeria. J Obstet Gynaecol. 2012;32:
652656.