ABSTRACT

Purpose: To reduce elective inductions among nulliparous women in

a community hospital by adding
standardized education regarding
induction risks to prepared childbirth classes.
Study Design and Methods: Elective
induction rates were compared
between class attendees and
nonattendees before and after the
standardized content was added to
prepared childbirth classes. A survey of nulliparous womens decisions regarding elective induction
was conducted.
Results: Elective induction rates
of 3,337 nulliparous women were
evaluated over a 14-month period
(n = 1,694, 7 months before adding
content to classes; n = 1,643, 7
months after). Rates did not differ
between class attendees (35.2%,
n = 301) and nonattendees (37.2%,
n = 312, p = .37) before the content
was included. However, after standardized education was added, class
attendees were less likely to have
elective induction (27.9%, n = 239)
than nonattendees (37%, n = 292,
p < .00). Sixty-three percent of women who attended the classes and did
not have elective induction indicated
that the classes were influential in
their decision. Physicians offered the
option of elective induction to 69.5%
(n = 937) of survey participants. This
was a factor in womens decisions;
43.2% (n = 404) of those offered
the option had elective induction,
whereas 90.8% (n = 374) of those
not offered the option did not have
elective induction.
Clinical Implications: Education
regarding elective induction offered
during prepared childbirth classes
was associated with a decreased
rate among nulliparous women who
attended classes when compared
to those who did not attend. Patient
education may be beneficial in
reducing elective inductions.
Key words: Elective labor induction;
Nulliparous women; Patient education; Prepared childbirth classes
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nnecessary procedures such as elective labor induction have risen

sharply in the United States over the past two decades with associated
increases in cesarean births and late preterm births (Martin, Hamilton
et al., 2009; Martin, Kirmeyer, Osterman, & Shepherd, 2009). The
reported rate of labor induction in the United States has more than doubled since
1990 from 9.5% to 22.5% in 2006 (most recent year for which induction data
are available) (Martin, Hamilton et al.). During this same period, the cesarean
birth rate increased 33% from 23.5% to 31.1% (Kozak & Lawrence, 1999;
Martin, Hamilton et al.), and the percentage of late preterm vaginal births for
which labor was induced increased 130%, from 7.5% to 17.3% (Martin, Kirmeyer et al.).

July/August 2010

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It has been estimated that approximately 10% of elective births are performed before 39 completed weeks
of gestation (Clark et al., 2009), despite long-standing
recommendations against this practice from the American
Academy of Pediatrics (AAP) and the American College of
Obstetricians and Gynecologists (AAP & ACOG, 1983;
ACOG 1999). These babies are more likely to suffer
symptoms of iatrogenic prematurity requiring admission

2008; Vahratian et al.; Vrouenraets et al.). Cesarean birth

after labor is associated with increased maternal and neonatal morbidity and mortality, as well as an increase in inpatient length of stay and healthcare costs (Allen, OConnell,
& Baskett, 2006a, 2006b; Cheesman, Brady, Flood, & Li,
2009; Deneux-Tharaux, Carmona, Bouvier-Colle, & Breart,
2006; Getahun, Oyelese, Salihu, & Ananth, 2006; LydonRochelle, Holt, Easterling, & Martin, 2001).

Kathleen Rice Simpson, PhD, RNC, FAAN,

Gloria Newman, MSN, RNC, and Octavio R. Chirino, MD, FACOG, FACS

Patient Education
to Reduce
Elective Inductions
to a special care nursery or neonatal intensive care unit
(Clark et al.). From 1992 to 2002, the mean gestational
age for singleton births in the United States decreased
from 40 weeks to 39 weeks, in part related to the rise in
medical procedures such as labor induction and cesarean births (Davidoff et al., 2006). Although precise data
are unknown due to inability to abstract indications for
induction from certificates of live births, approximately
one half to two thirds of labor inductions are performed
for nonmedical indications (Clark et al.; Moore & Rayburn, 2006). The incidence of elective and medically indicated induction varies widely by institution (community
or academic), area of the country (region, state, rural,
or urban setting), and individual care providers (Glantz,
2005). The overall rate of induction is rising faster than
the rate of pregnancy complications that would suggest a
need for a medically indicated induction (Caughey et al.,
2009; Martin, Hamilton et al., 2009).
There is evidence that elective labor induction significantly increases risk of cesarean birth for nulliparous women
(Clark et al., 2009; Luthy, Malmgren, & Zingheim, 2004;
Reisner, Wallin, Zingheim, & Luthy, 2009; Shin, Brubaker,
& Ackerson, 2004; Vahratian, Zhang, Troendle, Sciscione,
& Hoffman, 2005, Vrouenraets et al., 2005). Use of pharmacologic agents required for labor induction increases risk
of complications related to excessive uterine activity, fetal heart rate abnormalities, and cesarean birth for failure
to progress in labor and/or concern regarding fetal status
(Bakker, Kurver, Kuik, & Van Geijn, 2007; Oscarsson, AmerWahlin, Rydhstroem, & Kallen, 2006; Simpson & James,
July/August 2010

The primary purpose of this study was to test an educational intervention in the context of prepared childbirth
classes to decrease the rate of elective labor induction
among nulliparous women at our community hospital.
The project was initiated after numerous discussions at department meetings where physicians indicated they often
felt pressure from nulliparous women to induce their labor
electively. In 2004, the medical center instituted a policy
discouraging elective births before 39 completed weeks of
gestation with requirements that a form with the indication for labor induction, gestational age, and cervical status be faxed to the unit before an elective induction could
be scheduled. Mean gestational age for elective induction
was 39.6 weeks (SD = .8) in 2007 and 2008, so the issue
was not elective induction before 39 completed weeks, but
rather elective induction specifically for nulliparous women. Physicians were concerned about the increased risk of
cesarean birth for this patient population. Education about
risks of elective labor induction during childbirth classes
was identified as one possible way to minimize these types
of requests. We hypothesized that women who were provided thorough information on risks of elective induction
would be less likely to ask their physician for an induction
of labor. A secondary aim was to explore reasons why nulliparous women choose to have an elective labor induction.
Although risks of elective induction have been studied,
there are limited data as to whether patient education can
be helpful in discouraging elective induction, and little
is known about reasons nulliparas choose this method
of labor. No studies of U.S. womens decisions regarding
MCN

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189

Education about risks of elective labor

induction presented during childbirth classes
was identified as one possible way to minimize
requests from nulliparous women to have their
labor induced.

elective induction or educational interventions to assist women in the decision-making process were found
searching the electronic databases PubMed, CINAHL,
and the Cochrane Library from January 1988 to November 2009 using the terms elective labor induction,
womens/patients choices/decisions for labor/childbirth,
patient education and prepared childbirth classes.
Given that there are known associated clinical, operational, and economic implications of elective induction,
evaluation of efforts to discourage nulliparous women
from choosing this method of labor is warranted. The
childbearing woman is a key member of the perinatal
team; providing as much accurate information as possible to assist with her decision-making regarding elective induction is consistent with patient advocacy as supported by the Association of Womens Health, Obstetric
and Neonatal Nurses ([AWHONN], 2009) and ACOG
(2008, 2009), and is a component of patient education
standards from the Joint Commission (TJC, 2009).

Study Design and Methods

Institutional review board approval was obtained at St.
Johns Mercy Medical Center in St. Louis, MO, which is
a community teaching hospital with an average of over
8,000 births per year where private attending obstetricians are the primary care providers for 95% of childbearing women. Baseline data indicated that the elective
induction rate for nulliparous women at our hospital
was approximately 36%, with no difference between
those who attended prepared childbirth classes (35%)
and those who did not attend (37%; p = .37). Based on
data that approximately 50% of nulliparous women at
St. Johns Mercy attend prepared childbirth classes, we
developed a standardized 40-minute educational session
regarding risks and benefits of elective induction for
those who attend classes and then compared elective induction rates between class attendees who were exposed
to the education and nonattendees who did not receive
the education over a 7-month period. These rates were
also compared for class attendees and nonattendees using
the prior 7-month period as a baseline.
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A power analysis determined that a sample size of 300

(n = 150 women per group) was necessary to achieve a
power of .80 at the .05 level of significance to detect a
difference of at least 10% in induction rates between class
attendees and nonattendees. As there were four types of
prepared childbirth classes in which the content was offered (traditional 6-week format, 6-week format for
women who preferred minimal intervention during labor,
4-week format, and 1-day format), a sample of approximately 1,300 patients was desired in order to have at least
150 patients in each subgroup of class attendees to be able
to further evaluate the rate of elective induction between
types of classes. The Statistical Program for Social Sciences
(SPSS 16.0 for Windows; SPSS, Chicago, IL) was used for
data analysis. Descriptive data, paired t-tests, and 2 analysis were used to evaluate data between the two groups.
Specific risks of elective induction presented during the
class included cesarean birth with longer postpartum
recovery, pain, and potential complications as well as other
associated risks such as longer labor, use of pharmacologic agents and their effects on the mother and fetus,
and neonatal morbidity. Benefits included advance planning and timing with personal schedules. Women were
encouraged to discuss the labor induction process with
their physician during their prenatal visits. As preparation for a discussion about elective induction if suggested
by their physician, they were given cards with talking
points listing potential questions they could ask including indication, what to expect during labor induction,
potential methods, as well as risks, benefits, and alternatives such as waiting for spontaneous labor (Table 1).
The content of the slide presentation and written materials was based on current evidence and recommendations
regarding appropriate candidates and timing for elective
induction as well as associated risks of the procedure
from ACOG (1999, 2001), AWHONN (2009; [Simpson]
2009), the National Institute of Child Health and Human
Development (Raju, Higgins, Stark, & Leveno, 2005),
and the March of Dimes (2008a, 2008b, 2008c, 2008d).
A literacy expert assisted with development of the presentation. All but 6 of the 37 slides in final presentation were
July/August 2010

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determined to be at or below the eighth-grade readability

level. A decision was made to include these six slides
based on the known level of education of the population
served (mean years of education = at least some college).
The classes were provided by 15 Lamaze certified
childbirth educators. A series of meetings were held with
the childbirth educators before incorporating the education into the classes to review the content and emphasize
importance of presenting the information in a standardized objective format. One of the investigators attended
selected class sessions over the course of the 7 months
to monitor consistency and objectivity in presentation of
the information.
Nulliparous women who gave birth in the 7-month period after the content was added to the classes were invited
to participate in a survey to explore the genesis of the decision to related to an elective induction of labor (Table 2
for selected items from the survey). Potential responses to
structured survey items were derived from common reasons nulliparous women at our hospital indicate that they
choose to have an elective induction as noted via review of
medical records (indication for induction per patient) and
discussions with clinicians. Content validity of the survey
was determined through a review and revision process by
obstetricians, childbirth educators, labor nurses, and patients. The survey was pilot tested during the first week,
and minor changes were made to several items based on
patient and research nurse feedback. The survey can be obtained via e-mail to the primary author.
Our data indicated that mean gestational age of women in the first prepared childbirth class was approximately 32 weeks; therefore, the second 7-month comparison
group and survey period began 9 weeks after the standardized labor induction education content was added to
prepared childbirth classes to ensure that all potential
survey participants were exposed to the intervention.
Inclusion criteria were nulliparity, singleton pregnancy, gestation 37 weeks, live birth, and English speaking. Eligible patients were identified from the daily log.
During the inpatient postpartum stay, eligible patients
were approached by a research nurse, provided information about the survey, and invited to participate. If they
agreed, the survey was provided, selected clinical data including indication for induction were collected from the
medical record, and the completed survey was obtained
during the inpatient stay. Indications for induction (elective vs. medically indicated) in the medical record were
coded based on those listed in the ACOG (1999) practice
bulletin Induction of Labor.
Baseline data on elective induction rates of those who
attended prepared childbirth classes and those who did
not attend were obtained from a review of the birth log,
prepared childbirth class rosters, and medical records of
all women meeting inclusion criteria in the 7 months immediately before the survey period, before the standardized educational content on elective induction was added
to the childbirth classes. From November 1, 2006 to
May 31, 2007 there were 5,309 births, 1,694 of which
met inclusion criteria. Women were invited to participate
July/August 2010

Table 1.

Talking Points for Women to Discuss

With Their Caregiver if Labor
Induction Is Suggested
What is the reason you are suggesting induction
and is it a serious problem?
How does an induction occur? Can you tell me about
the process?
What are the risks or side effects associated with
this method of induction?
What is the next step if the induction doesnt work?
What are the alternatives to induction including
waiting? Would I be at risk or would my baby be at
risk if we wait?

Table 2.

Selected Patient Survey Items

Selected Patient Survey Items
All Women
During your pregnancy did your physician offer you the
option of having your labor induced? Y/N
If yes, when during your pregnancy did your physician
offer you this option?

Early in my pregnancy
During the middle of my pregnancy
A few weeks before my due date
Right around my due date
After my due date had passed

Women Who Did Not Have Induction

If your labor was not induced, was this your decision or
your physicians decision?
My decision (I did not ask my physician to induce
my labor)
My decision (My physician suggested labor
induction, but I did not want my labor induced)
My physicians decision (I asked my physician for a
labor induction, but he or she said no)
If you attended prepared childbirth classes, did the information you received in the classes in any way influence
your decision to not have your labor induced? Y/N
Women Who Had Labor Induction
What was the main reason that your labor was induced?
If your labor was induced, was this primarily your decision or your physicians decision?
My decision (I asked my physician to induce my
labor and he or she agreed)
My physicians decision (My physician suggested
labor induction or said that I needed to be induced
and I agreed)
MCN

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191

Table 3.

Elective Induction Rates Based on Class

Attendance: Comparison of Rates Before
and After Adding Elective Induction Content
to Classes

(27.9%; n = 239) than women who did not

attend classes (37%; n = 292, p < .00). Sixtythree percent (n = 289) of women who atComparison of Rates Before and After Adding Elective
tended classes, participated in the survey,
Induction Content to Classes
and did not have elective induction indicatElective Induction Rates
ed that the classes in some way influenced
their decision not to have their labor electively
Second 7-month
First 7-month
induced. Labor inductions decreased 20.7%
period (n = 1,643)
period (n = 1,694)
Sig
from 35.2% to 27.9% (p = .01) among class
patients meeting
patients meeting
attendees comparing the 7 months before
inclusion criteria
inclusion criteria
adding the standardized content and the 7
Attended
months after. The decrease in the rate of elec35.2 (301)
27.9 (239)
p = .01*
class
tive induction among class attendees resulted
in an overall 10.7% decrease in elective
Did not attend
inductions of nulliparous women meeting
37.2 (312)
37.0 (292)
p = .93*
class
inclusion criteria from 36.2% to 32.3%
(p = .05) comparing the two 7-month periods.
Sig.
p = .376*
p < .00*
Although a majority of survey parOverall rate
36.2 (613)
32.3 (531)
p = .05*
ticipants noted that the class content was
helpful in their decision-making process
Data are presented as % (n).
regarding elective induction, a significant
2
*Pearson analysis
factor was whether the physician offered
the option (p < .00). Physicians offered
in the survey from June 1, 2007 to January 31, 2008
the option of elective induction to 69.5% (n = 937) of
during which there were 5,274 births, 1,643 of which
survey participants; 33% (n = 311) ranging from early
met inclusion criteria. Eighty-two percent (n = 1,349) of
in the pregnancy to several weeks before the estimated
eligible women completed the survey. Various reasons
date of delivery (EDD). Forty-seven percent (n = 436)
patients offered for not participating were postoperative
were offered the option around the EDD and 20% (n
pain, fatigue, breastfeeding difficulties, multiple visitors,
= 190) were offered the option after their EDD. There
and time constraints.
was no difference in physicians offering the option for
elective induction between class attendees (70.4%; n =
Results
522) and nonattendees (68.2%; n = 415, p = .38) who
During the first and second 7-month periods, 51% (n =
completed the survey; however, class attendees who were
856) and 52% (n = 854), respectively, of women who met
offered the option chose elective induction less (37.7%; n
inclusion criteria attended hospital-sponsored prepared
= 195) than non attendees who were offered the option
childbirth classes. Fifty-five percent (n = 741) of women
(50%; n = 209, p < .00). Forty-three percent (n = 404)
who participated in the survey attended classes. Survey
of all women offered the option had elective induction,
participants who attended classes were significantly older
whereas 90.8% (n = 374) of all women who were not of(M = 27.2 years) than those who did not attend (M =
fered the option did not have elective induction (p < .00).
24.8 years; p < .00) and had significantly more years of
Ninety-one percent (n = 275) of women who comeducation (attended class = 89% some college; did not
pleted the survey and did not have an elective induction
attend class = 40% some college; p < .00). Sixty-seven perindicated that it was their decision (did not ask physicent and 25% of class attendees completed college and
cian; did not want an induction), whereas 9% (n =
had a graduate or professional degree, respectively, com27) indicated it was their physicians decision (asked,
pared to 25% and 11% for the same education levels in
but physician said no). Seventy-five percent (n = 320)
the group that did not attend classes (p < .00).
of women who completed the survey and had an elecElective induction rates based on class attendance for
tive induction indicated that the physician suggested the
the first 7 months before the content was added to the
option compared to 25% (n = 104) who indicated that
prepared childbirth classes and the next 7 months after
they asked the physician to perform an elective inducare presented in Table 3. In the 7 months before adding
tion. These data are consistent with the various reasons
the content to the classes, there was no significant differwomen noted why they chose elective induction. Seventyence in the elective induction rates of women who attwo percent (n = 317) indicated that chose to be induced
tended prepared childbirth classes (35.2%; n = 301) and
after their physician suggested elective induction due to a
those that did not attend (37.2%; n = 312, p = .37).
large baby or being due now or overdue, whereas 20%
However, after the content was added, elective induction
of women (n = 88) chose elective induction for personal
rates differed significantly based on class attendance.
reasons such as wanting relief from pregnancy discomWomen who attended prepared childbirth classes that
forts, specific timing of birth, or to have their own physiincluded the standardized content related to elective
cian deliver their baby rather than another physician in
induction were less likely to have an elective induction
the group practice (Table 4).
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Table 4.

Reasons Women Chose Elective Induction

Reasons Women Chose Elective Induction

Clinical Implications

n (%)

Standardized information based on curMy physician said my baby was getting too big
219 (49.5)
rent evidence and recommendations from
professional organizations regarding risks
My physician said I was due now or overdue
98 (22.2)
and benefits of elective induction presentI wanted relief from pregnancy discomforts
51 (11.7)
ed during prepared childbirth classes was
beneficial in discouraging some women
Im not sure why my labor was induced
30 (6.8)
from choosing this option for labor in this
study and may be applicable to other setI wanted to have my physician deliver my baby
20 (4.5)
tings where prepared childbirth classes are
I wanted to time the birth for personal reasons
17 (3.8)
offered (Table 5). Patient education before
clinical procedures is important to promote
Did not answer
7 (1.6)
informed consent (TJC, 2009). Before induction, ACOG (2009) and AWHONN
442 (100)
(Simpson, 2009) recommend counseling
women regarding indications, pharmacoclass attendance; rather class attendance was per patient
logic agents and methods, and possible need for repeat
choice. Among patients who participated in the survey,
induction or cesarean birth. Nulliparous women with an
class attendees were slightly older and had a higher level
unfavorable cervix should be counseled about a twofold
of education than those who did not attend. However,
increased risk of cesarean birth (ACOG). Women who
although the elective induction rate was essentially the
participated in the recent Listening to Mothers Survey
same between class attendees and nonattendees before
II (Declercq, Sakala, Corry, & Applebaum, 2006) overthe study intervention, a significant difference in elective
whelmingly expressed a desire for information regarding
induction rates was noted between these two groups after
potential risks of elective induction; nearly all first time
the standardized educational content on elective inducmothers surveyed wanted to know every complication
tion was added to the classes.
(74.7%) or most complications (24%) of labor inducThe potential of patient education to reduce elective intion. Standardized evidence-based information provided
duction rates has not been well studied. Despite availabilin prepared childbirth classes can meet these desires and
ity of prepared childbirth classes in many settings, the high
serve as a foundation for the discussion between the
percentage of women who receive prenatal care (Martin,
physician/nurse midwife and the patient regarding elecHamilton et al., 2009) with the opportunity for educative induction recommended by ACOG and AWHONN
tion, and patient information materials from the March of
(Simpson). Nurses working in the prenatal clinic or office
Dimes (2008a, 2008b, 2008c, 2008d), ACOG (2001), and
setting can reinforce this information and follow up with
Lamaze International (2007) delineating the risks of elecpatients who have additional questions.
tive induction, until now none of these mediums have been
Although education provided in prepared childbirth
tested for efficacy in discouraging women from choosing
classes can be helpful for women in making the choice of
to have an elective induction. Much more data are needed
whether or not to have their labor electively induced, the
on effective patient education methods, settings, and maphysician is a powerful influence. Contrary to the initial
terials to help women make informed decisions. Further
perceptions of our physicians that most elective inductions
there are limited data based on direct feedback from womare performed based on requests from patients, physicians
en who undergo labor induction that can assist clinicians
offered the option to nearly 70% of women who particiin offering effective guidance in patients decision-making
pated in the survey. It is possible that patients perceive the
regarding method of labor. Future research involving
offer of the option for elective induction as a recommendiscussions with women as they are making the decision
dation that they actually have the procedure, particularly
about whether or not to have an elective induction may
if they are told they are due now, overdue, or their baby
be useful in gaining more insight on this topic. Based on
is getting too big. When the option for elective induction
results of this study, pregnant women who are provided
was offered by their physician, women were significantly
standardized evidence-based education regarding specific
more likely to choose elective induction than when the
risks and benefits of elective induction in the context of
option was not offered. Offering the option in the absence
prepared childbirth classes may be less likely to choose
of patient request, especially before cervical readiness has
this method of labor and thereby decrease their exposure
been achieved, may lead to unnecessary elective inductions
to the potential associated risks of this elective procedure.
with the associated increased risk of cesarean birth and
Patient education may be an effective tool in decreasing
increased healthcare costs (Allen et al., 2006b; Clark et al.,
elective inductions among nulliparous women.
2009; Reisner et al., 2009). With the ongoing decline in
the vaginal birth after cesarean birth rate (Martin, HamKathleen Rice Simpson is a Perinatal Clinical Nurse Speilton et al., 2009; Menacker, 2005), subsequent births are
cialist, Gloria Newman is Manager, Womens and Chilmost likely to be via cesarean as well.
drens Education, and Octavio R. Chirino is Chairman,
There are several limitations to this study. Patients
Department of Obstetrics and Gynecology, St. Johns
were not randomly selected for prepared childbirth
July/August 2010

MCN

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193

Clinical Implications
Standardized evidence-based information regarding risks of elective labor induction provided in
prepared childbirth classes may be helpful in discouraging nulliparous women from choosing to
have an elective induction.
Physicians offering the option of elective labor induction to nulliparous women in the absence of patient requests may be associated with an increased
likelihood of women having an elective induction.
Hearing from their physicians that they are due
now or overdue or that their baby is getting too big
may be associated with womens choices to have
an elective induction.
Patient education may be one method to decrease
the rate of elective induction for nulliparous women.

Mercy Medical Center, St. Louis, MO. Dr. Simpson can

be reached via e-mail at KRSimpson@prodigy.net.
The authors have disclosed that there are no financial
relationships related to this article.
Funding provided by Lamaze International and the
Department of Obstetrics and Gynecology at St. Johns
Mercy Medical Center in St. Louis, MO.
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