Dr. Rebecca Dekker:

Hi, everyone. On today’s podcast, we’re going to talk about the evidence on the ARRIVE trial, an elective induction at 39 weeks. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. 

Hi, everyone. Welcome to today’s episode of the Evidence Based Birth® Podcast. My name is Dr. Rebecca Decker, pronouns she/her, and I’ll be your co-host for today’s episode. Today, along with our co-host Morgan Richardson Cayama, we are going to be bringing you some brand new evidence-based information all about the ARRIVE trial and elective induction at 39 weeks. If you’re listening to this podcast, you will also be able to access all the information we’re talking about, including references, a full-length Signature Article, and a free two-page handout to help in your informed decision-making by visiting evidencebasedbirth.com/ARRIVE. 

Before we get started with the content for today’s episode, I have two brief announcements. First, I want to give you a head’s up that next week on the podcast will be a quiet week. So we will be taking a one week break. But, right before we come back on November 13th, there is going to be something big that we’re going to be announcing on social media on November 12th. And then on November 13th, we’re going to have a special surprise episode for you focused on the evidence on two topics we’ve never covered here before on the Evidence Based Birth® podcast. So you are definitely going to want to keep an eye out for the announcement on November 12th and the podcast episode drop on November 13th. If you don’t want to miss it, make sure you go to our homepage at EBBirth.com and join our free newsletter today. And now let’s turn towards today’s topic all about elected inductions.  

As a content note, today’s podcast will include discussion on statistics related to stillbirth, newborn death and serious maternal health complications. Also, I want to acknowledge that at the time of year we’re releasing this episode we’re in the midst of a national shortage of intravenous fluids here in the U.S. due to the impacts of Hurricane Helene on the main IV fluid production facility here in the U.S. So, we are currently seeing elective inductions across the United States being cancelled at this time. But, as the IV fluid shortage alleviates, it’s likely that the push for elective inductions will return and it’s also important to remember that from time to time there are shortages of Pitocin and other induction medications and supplies and that these shortages can lead to temporary rationing of medical supplies and rationing of labor induction.  

And now I’d like to introduce my co-host for today’s episode. Today we have with us Morgan, pronouns she/her, a doctoral candidate in public health and an Evidence Based Birth® research fellow. Morgan, we’re so happy to have you here. Do you mind just introducing yourself quickly for the audience?

Morgan Richardson Cayama:

Yeah, yeah. Thank you so much for having me again. My name is Morgan. I’m super excited to speak with you guys today about the ARRIVE trial and some of the other recent research that I’ve been finding on elective inductions at 39 weeks. And actually alongside my work here at Evidence Based Birth®, my dissertation research focuses on something called respectful maternity care or respectful perinatal care. And so it’s been really interesting for me to consider how the ARRIVE trial and induction relates to that topic, which we’ll actually be talking a little bit more about later.

Dr. Rebecca Dekker:

Yeah. And I’m excited. This whole podcast is an incredible wealth of information, but if you stick with us all the way to the end, we’re going to get into some really interesting info about respectful maternity care that Morgan pulled up for us. So Morgan joined our team in Evidence Based Birth® earlier in 2024, and she’s worked on a lot of projects. She’s helped update our pain management series, specifically the info about epidurals during labor and the effects of epidurals on the second stage of labor. So if you listen to our epidural podcast episodes this year, that work came from Morgan’s research. She also co-hosted our spring webinar earlier in 2024, all about the ARRIVE trial. And so since that time, she’s been working with me to develop a full-length Signature Article on the topic of elective induction at 39 weeks. Now we did have a podcast episode on this subject. It was episode 10, released back in February of 2018. This was not long after we were dealing with the publication of the ARRIVE trial. And at that time, I wanted to talk about the findings while it was still hot off the press. We also published a two-page handout at that time, which has been very popular. And we have since updated that handout. You can find it for free on our website at ebbirth.com/ARRIVE. But still, you know, five years or more later, we are getting so many questions about the ARRIVE trial. Questions from birth workers and families about elective induction at 39 weeks and this study, the ARRIVE trial, has been the subject of so much attention and controversy. And there have been several new studies that have come out after the ARRIVE trial was published in 2018. So Morgan and I felt like it was important to put together a new comprehensive Signature Article. And it covers a lot of information. So for today’s podcast episode summarizing what we’re publishing. We have decided to focus on the key parts of the Signature Article, including what an elective induction is. We’re going to review the ARRIVE trial and some of its criticisms. And we’re going to talk about the updated evidence on elective inductions at 39 weeks. We’re going to talk about the benefits and risks of this procedure, what the professional guidelines say. And we’ll wrap up this episode with our usual bottom line. Again, because there is so much information, we do plan to have some future episodes on breaking down common questions we’ve been getting about elective inductions. And we also have a special episode planned about ways to lower the risk of Cesarean for those who are interested in having a vaginal birth. So Morgan, can you start us off, take us to the beginning of the article and tell us what is an elective induction?

Morgan Richardson Cayama:

Yeah, sure. So an elective induction is where labor is induced without any sort of specific medical reason, or you might hear a medical indication. So it’s also sometimes referred to as a non-medically indicated induction. Elective inductions might happen for a variety of reasons. They might happen for social reasons, like a healthcare provider really wants to be able to attend a birth, and they might be going out of town planning a trip, so they want to make sure that the birth happens before they do that. Or even a non-medical reason, like maybe someone is just ready to be done with a very uncomfortable pregnancy, and they really want to have an elective induction. And so inductions are generally only considered to be elective when it is with a healthy birthing person who is pregnant with only one baby and who is less than 41 weeks pregnant. Otherwise, the induction might be considered medically indicated. And so if you kind of Google around or you search on the American College of Obstetrician and Gynecologist website or ACOG, you’ll find that elective inductions at 39 weeks are really only, again, recommended for healthy birthing people who are, again, giving birth for the first time and who are pregnant with a single healthy baby.

Dr. Rebecca Dekker:

And with that definition, it can be helpful to talk about some of the common ways that labor is induced. So we have natural methods. We have medical methods. So some of the natural methods that can be used to stimulate or try to get labor started include procedures like acupuncture or nipple stimulation or different herbal treatments. And we actually have a podcast series here at EBB and a YouTube series that we’ve done on this topic where you can learn about these different types of methods. And then we have medical methods of induction that are usually divided into two types, mechanical methods of induction and pharmacological or medication methods. So mechanical methods include the use of hands or medical devices. One of the most common is a membrane sweep. Now, a membrane sweep is not the most reliable way to get labor started, but it is an attempt to get things moving. Other mechanical methods include devices like cervical osmotic dilators, balloon catheters like the Foley bulb, and amniotomy or artificial rupture of membranes. And we’ve covered all of these on the podcast before at Evidence Based Birth. And then we have the medication or pharmacological methods. These include medicines like prostaglandin E1, which is often referred to as mesoprostol or by its brand name of Cytotec. And we have prostaglandin E2, which you might hear referred to by the brand names Cervidil or Previdil. And then we also have synthetic oxytocin, which you might hear referred to as Pitocin or Syntocinon. So when we talk about induction methods, they can be used alone or in combination with other methods and combining different methods does tend to be more effective. Some of the methods I was mentioning help more with cervical ripening where you’re helping the cervix prepare for labor. And then some of the methods are better at starting contractions or strengthening contractions. 

Now, the alternative to labor induction is something called expectant management. Expectant management is often described as a wait and watch approach. Where you’re waiting to see, you know, when will labor start on its own? We call that spontaneous labor when it starts on its own. With expectant management, if you’re choosing this wait and watch approach, an induction still might eventually happen if you decide later that you would like to be induced or if there ends up being a medically necessary reason to induce, like if there’s a health issue or if the pregnancy goes past 41 or 42 weeks. Now, going back to elective inductions that are not medically necessary, we’ve personally seen and heard from many people about how common elective inductions have become over the years. And rates of elective inductions vary across different parts of the world. Even within regions, they can vary from hospital to hospital. And even in the same hospital, rates of elective induction can vary among the different health care providers practicing there. And we don’t know for sure how many pregnancies are being electively induced. Because in birth certificates, for example, in the United States, inductions are not always reported or recorded accurately. So we can’t look at large data sets to see how many inductions are happening. 

But what we do know is that the overall induction rate, which is a combination of medically necessary plus elective inductions, is estimated to be about 30%. However, it’s not uncommon to hear from health care workers and birth workers that they’re seeing rates of induction that are much higher than 30%. We do know that elective induction rates have gone up since the ARRIVE trial was published in 2018. We’ll talk about this more in depth later, but there was an excellent study published by Nethery et al. In 2023. They used data from 13 hospitals in the Pacific Northwest in the United States. They found that before the ARRIVE trial, the overall induction rate was 35%, and afterwards, the overall induction rate increased to 43%. And looking at the rate of elective inductions, that increased from 4% before the ARRIVE trial to 11% afterwards. In writing this article, we also looked at the international or global literature on induction, and we found that rates have gone up in many countries, and they do tend to vary geographically. However, most places around the world, the rates of induction are going up because of increases in medically indicated inductions. However, what we also found was that these increases were driven by increases in medically indicated inductions, not elective inductions. Outside of the United States, many countries are not recommending elective inductions at 39 weeks. And this makes sense for them because their health issues and their health systems are quite different than the United States. And many of these countries don’t expect to see any benefit from elective induction. And so for financial and practical reasons, they are not recommending it. And so we should talk some more about the ARRIVE trial. Morgan, can you tell us a little bit about this particular study?

Morgan Richardson Cayama:

Yeah, absolutely. So first-ARRIVE, it’s an acronym, and it stands for A Randomized Trial of Induction Versus Expected Management. So researchers conducted this study because they wanted to compare elective induction in the 39th week of pregnancy to expected management or that wait and watch approach that you described earlier. And so the study was conducted between March 2014 and August 2017, and results were published in August of 2018 in the New England Journal of Medicine. And one of the big reasons that they did this study was because obstetricians in the U.S. were conflicted about whether elective inductions at 39 weeks increased that risk of Cesarean birth. And some older observational studies up until this point had found higher rates of Cesareans among those who were induced. But these studies were kind of flawed in that they didn’t always have true elective induction and expectant management groups to compare. And then later studies that ended up using some more modern research methods were actually beginning to find that maybe elective inductions has slightly lower rates of Cesareans compared to expectant management. And so the researchers in this study in the ARRIVE trial conducted this large randomized control trial, and they were hoping that that would answer the question about elective inductions and Cesarean rates. But actually their primary outcome or the thing that they were most importantly sort of looking at was whether elective inductions could lead to improved health for babies. And so again, that was their main focus. And then this look on the impact on Cesarean birth and Cesarean rates was kind of their secondary outcome that they were interested in.

Dr. Rebecca Dekker:

Yeah. And so Morgan, before we dive deeper into how the study was carried out, I think it might be helpful to talk about the different perspectives or viewpoints on elective induction and kind of what was happening before the ARRIVE trial was published. So back in 2016, two years before the ARRIVE trial was published, ACOG, the American College of Obstetricians and Gynecologists, hosted a debate at their conference. The debate was called, Why Not Induce Everyone at 39 Weeks? And I actually attended this conference virtually and saw this debate live. The debaters were both obstetricians and they both took slightly different approaches to talking about the subject, but they ended up making the same argument that elective induction at 39 weeks was a good idea, primarily for the health of babies. And so this debate really only represented one side, that of people who believe that babies need to be rescued by making sure that they’re born as early as safely possible. And the side that was not represented in this debate was, you know, the people who believe in letting labor begin on its own unless there’s a medical reason to intervene. And so another way to describe these differences is the one approach is, you know, why not intervene versus why intervene? And this perspective reflects a larger divide between the midwifery model of care and the medical model. So in the midwifery model of care, it tends to focus more on trusting people’s bodies to give birth with minimal use of medical intervention. So you only use interventions if they’re necessary or wanted. The medical model tends to view birth as inherently risky and recommends broad, sweeping use of interventions for everyone to prevent rare but serious complications. And so it should be said, talking about the medical model versus the midwifery model, there were no midwives among the ARRIVE trial authors. And even when Morgan and I looked deeper into the supplemental appendix from the study that lists all of the various staff and personnel from across the United States, we could not find a single person on that list who appeared to have a background or training in midwifery. This lack of perspective for midwives is important because midwives in many places have been impacted by this study and by the ensuing recommendations on 39-week elective inductions. For example, if midwives share clients or work with obstetrician colleagues, they’re going to have to navigate differences of opinion and preferences for elective induction. And ACOG and then the American College of Nurse Midwives, or ACNM, have differing perspectives on elective inductions, which we’ll talk about later. But overall, you know, even though they said they were trying to see if elective induction was better, the belief that there were benefits to elective inductions was already pretty well established among OBs at the time the study was conducted. And so many of these researchers who came from the medical model may have had pre-existing biases about these benefits. Going back to that debate in 2016, they did a live poll where before the debate began, they found that 20% of OBs in the audience agreed with routine elective induction for everyone at 39 weeks. And that jumped to 70% of OBs at the conference believed that everyone should be electively induced at 39 weeks. So you can kind of see these, there’s this underlying movement happening while the study is going on. So then going back to the study, Morgan, can you tell us more about how it was conducted and then what did they end up finding?

Morgan Richardson Cayama:

So the ARRIVE trial was a pretty big randomized control trial, and it took place at 41 hospitals across the United States. And all of these hospitals were a part of something called the Maternal Fetal Medicine Units Network with the National Institute of Child Health and Development. And so that’s going to kind of come into play in a little bit when we talk about how these hospitals might be a little bit different than other types of hospitals and sort of real-world practice settings. But participants in the study had to be giving birth for the first time with a single head down baby and have no major medical conditions. So that’s kind of what we consider to be called low risk. They also had to be eligible for vaginal birth and medically eligible to wait until at least 40 weeks and five days before giving birth. The hospitals also needed to have reliable information on the gestational age or the length of each participant’s pregnancy. And overall, researchers across these 41 hospitals ended up finding about 22,500 people who were eligible to participate in their study. But actually only a little bit over a quarter, about 27%, agreed to participate. So they ended up with about 6,106 participants who again agreed to be in the study. 

The researchers then randomly assigned about half of those people, so around 3,000, to be induced selectively at 39 weeks, and then the other half to expectant management. And they did some comparisons across the groups and found that both ended up being pretty similar. And that’s really what you want. You want two groups that are similar other than the thing that’s happening to them. So other than the elective induction or expectant management. And both groups ended up being relatively young. The average age in the groups was 24. And they were both relatively diverse in terms of race and ethnicity. Births in both groups also predominantly ended up being attended by physicians, with only about 6% of births attended by midwives. And we’ll talk a little bit more about that later, too. So you can learn a lot more about these specific study protocols in our full-length Signature Article but in short, those in the elective induction group had their labors induced between 39 weeks 0 days and 39 weeks 4 days. So the researchers in the study recommended that after they’d completed cervical ripening, birthing people be given at least 12 hours in early labor with synthetic oxytocin before being diagnosed with a failed induction and recommending a Cesarean. Unless, of course, there was an otherwise immediate and medical need for one. 

And the people in the expected management group had weekly follow-up visits with their care providers to monitor their pregnancies, see if any issues arose. And so participants in that group ended up having a mix of spontaneous labors, labors induced for medical reasons, and electively induced labors after 40 weeks and five days. And the reason this group was a mix of labor types was because of a research principle that the researchers followed in this study called intent to treat. And that’s where you include everyone in their originally assigned group, regardless of what actually ended up happening or which path their medical care took. And we touched on this earlier, too, but the main thing that they were looking at in their study, again, was the impact of elective inductions at 39 weeks on health issues for babies. And they looked at something that we call a composite outcome. And that’s where you combine multiple outcomes into one larger one. So they looked at multiple serious complications and deaths for babies into this larger outcome. And so if any of these serious complications occurred, it was considered a poor outcome. And some examples of these included stillbirth or newborn death, intensive respiratory or breathing support, seizures, and low blood pressure that required intervention. And there’s a list of some other things, too, that, again, you can find in the Signature Article. 

And then that secondary outcome, again, that they were interested in was that impact on Cesarean rates. And so what they found was that electively inducing labor at 39 weeks had no impact on the primary outcome of death or serious complications for babies. However, they did look at some of those sort of individually, and they found that fewer newborns in the elective induction group needed respiratory or breathing support, although that was a pretty rare outcome overall. And newborns in the elective induction group also had shorter hospital stays. Only about 23% in the induction group had a stay of three or more days in the hospital compared to 27% in the expectant management group. But they did not find any differences in any of those other outcomes that they looked at. And again, overall for that larger composite. So looking at their secondary outcome or that impact of 39-week elective inductions on Cesarean rates, they did see a difference between their two groups. They found that the risk of having a Cesarean was 16% lower in the induction group. And although that does sound like a big difference at first, this represents something that we call a relative risk. And a relative risk is the risk of something happening to you in comparison to someone else. 

But if you look at something called an absolute risk between the two groups, you kind of get a bit different of a perspective. And it is important to consider both relative risk and absolute risk. And there’s some mathematical formulas you can do to kind of get between the two. But if you look at the absolute risk or that true risk of a Cesarean occurring in each group, that was 18.6% in the elective induction group and 22.2% in the expected management group. So that’s really only a 3.6% difference in that absolute or true risk of Cesarean between these two groups. So yeah, there was a difference between the two groups and elective inductions did have a slightly lower rate of Cesareans, but it might not be as big or drastic of a difference if you hear that 16% difference in risk that some healthcare providers might present as well. So again, taking both into consideration is important. And they also looked at some other differences in maternal health between the two groups as well. So they found that the people in the elective induction group spent more time in the hospital and labor. And this does make sense because inductions can take several days. They tend to be some long processes. 

But the expectant management group ended up spending more time in the hospital postpartum. And that also makes some sense. And it might be explained by that slightly higher rate of Cesareans that they did see in that group, which would, of course, require some more time spent in the hospital and postpartum in recovery. And then they also found that elective inductions at 39 weeks lowered the risk of developing pregnancy-related high blood pressure. And again, this is a finding that also makes some sense because the risk of high blood pressure does increase the longer pregnancy continues. So it would be reasonable to see a higher rate of that pregnancy-related high blood pressure in the expectant management group. And so Rebecca, you had mentioned earlier that the ARRIVE trial does have some limitations and it has been criticized a little bit. So can you tell us a little bit more about that?

Dr. Rebecca Dekker:

Yeah, so as I touched on earlier, the researchers in this study who are running the study, designing it, carrying it out, came from a medical model perspective. And so they were likely a little biased in hoping to find good outcomes with elective induction. So normally what you would do in a randomized trial like this to control for your bias and to try and remove bias is you would blind or hide what is happening to each patient so that you can’t influence the results. But with induction, it’s impossible to blind researchers and doctors and patients to who is in which group because everybody knows who’s being induced and who’s not being induced. It’s not something you can hide. So this makes it more likely that something called the Hawthorne effect can happen. This is a well-known effect in research and in everyday life that when people know they’re being observed, they may change their behaviors. This may particularly happen if they know they’re being watched and they know that outcomes are being recorded and that something important depends on those outcomes. So when you think about the secondary outcome of Cesareans, deciding to do a Cesarean is usually a subjective clinical decision that is highly impacted by physician practice patterns and attitudes. So if physicians were motivated to avoid Cesareans in the elective induction group because they wanted to see a lower Cesarean rate in that group. They could have acted consciously or subconsciously to try and prevent Cesareans in that group whenever possible. 

And so because of this, it’s possible that the Cesarean rates we saw in this study, the low 18%-ish rate of Cesarean in the elective induction group might not be replicated in real life situations if the doctors are not being closely observed and their outcomes being recorded. It’s also possible that the hospitals participating in this trial are not representative of other hospitals. So remember, Morgan, you said that the hospitals were part of a special network. They consist mainly of teaching and academic hospitals. They might be more likely to follow stricter protocols and evidence-based guidelines and induction that we know aren’t always followed in real life. And overall, the Cesarean rate that you were talking about is pretty low compared to most hospitals in the U.S. for first-time birthing people. And so there were other important limitations that have been written about. For example, the people who chose to participate in the study were willing to be randomly assigned elective inductions. They might have already had more positive attitudes towards induction. And so the findings of the study might not apply to someone who’s motivated to wait for spontaneous labor or who wants to avoid unnecessary medical interventions. So participants in the study also had different characteristics than the general population of pregnant people in the United States. 

For example, they tended to be younger and more racially and ethnically diverse in the study. And these differences are important because sometimes we see differences in the real world in rates of elective induction and Cesareans based on factors like age and race and ethnicity. And you also mentioned that the vast majority, 94%, were receiving care from a physician. Only 6% had midwifery care. Today, about 12% of births in the U.S. are attended by midwives. And midwifery-led care has been shown to lower the risk of Cesareans without needing to rely heavily on interventions like elective inductions. And then there were other important factors that we know can impact health outcomes and Cesarean rates that were not measured or reported in the study. For example, we have no idea how many participants in each group received labor support from a doula. We don’t know the different methods of pain management used by participants. And we don’t know which participants had continuous electronic fetal monitoring compared to intermittent auscultation and then other factors that could lower the Cesarean rate. Still, despite these limitations, the ARRIVE trial immediately got widespread media attention, and doctors very quickly began recommending 39-week elective inductions. And so as expected, induction rates immediately began to increase in the U.S., and so this essentially created two time periods we can look at, a pre-ARRIVE world in the United States and a post-ARRIVE world. And so Morgan, that was one of your big jobs this year, was to look at all of this research on the post-ARRIVE world in terms of Cesarean rates and other health outcomes. So what has been the real-life impact of this study?

Morgan Richardson Cayama:

Yeah, so that is a great question, and I have spent a lot of time looking into this research. And before we get into it, it is important to acknowledge some limitations. And so no research is perfect, and none of this research is perfect as well. And there are definitely challenges when it comes to comparing inductions and expectant management and studying this topic, again, because it is difficult to create those perfectly comparable and distinct groups. And although all of the more recent research on this topic is something that we call observational research, and it tends to be seen as a little bit less rigorous or strong compared to randomized control trials like the ARRIVE trial, both randomized control trials and observational studies have their pros and cons, again, especially when it comes to studying this topic. Some of these new studies compared outcomes between all births in a time period before the ARRIVE trial was published to all the births after, instead of being able to compare or comparing inductions or elective inductions to expectant management. And so the goal of some of these studies was to look at all of these births and see if they did end up seeing changes in things like Cesarean rates or health issues for babies since the study was published. And a good thing about these studies is that they can tell us a lot about the impact of the ARRIVE trial and sort of that unofficial policy of elective induction at 39 weeks. So for these researchers, they were saying, if we know that we’re seeing increases in inductions or we’re expecting to see increases. Let’s do the research and see then are we seeing things that we might expect like reducing Cesarean rates or reducing some of these health issues? 

And so that was the goal of a lot of these studies. Some of the other considerations about this research is that they, like the ARRIVE trial, were mostly limited to only low-risk birthing people who, again, were giving birth for the first time. This research is pretty U.S.-centric, and most of these studies were done in the U.S. So we ended up finding, I think it’s a total of eight separate studies, and you can definitely read a lot more about those in our full-length article. I’m just going to kind of go through and highlight a few here. So one of the studies that we included was done using hospital data that was collected at 13 different hospitals in the U.S., Pacific Northwest. And this study was done by Netherhead et al., and it was published in 2023, so a pretty recently published study. And in that study, they did a time series analysis, and that’s a validated way to look at changes over time and trends and changes in outcomes. And so they were looking at births in a time period before and after the ARRIVE trial. And they were looking for changes in rates of elective induction, unplanned Cesareans, pregnancy-related high blood pressure, and again, serious health issues for babies, including NICU admission. 

They ended up comparing about 15,000 births from the year and a half before the ARRIVE trial was published to around 13,000 in that year and a half after. What they found was increases in inductions and elective inductions across those 13 hospitals. But they did not see any difference before or after the ARRIVE trial in unplanned Cesarean births, pregnancy-related high blood pressure, or NICU admissions. So some of those things that the ARRIVE trial found, they did not see in their 13 hospitals. There was another study that was published in 2023 by Wood et al. And in this study, the researchers used U.S. birth certificate data. So they had this big pool of birth certificates from across the U.S. and they looked at changes specifically in Cesarean rates before and after the arrived trial. And their study ended up including over 2.8 million births in that pre-ARRIVE period and 970,000 in their post-ARRIVE period. And they did find a decrease in Cesarean rates. And they were able to do some analyses and they determined that that decrease was lower than what would have been expected based on trends at the time before the ARRIVE trial was published. Can they definitively say it was because of the ARRIVE trial? Not necessarily, but those did decrease more than would have been expected. However, that change was pretty small. So it decreased from 25.1% in that pre-ARRIVE period to 24.7% in the post-ARRIVE period. 

We also included a study that looked at the impact of a pretty open and liberal policy of elective inductions at 39 weeks. And this was in one hospital in California. And this study was done by Jelks et al. And was also, again, published in 2023. And that hospital decided to explicitly permit 39-week elective inductions in their policy. And they pretty much left it up to the professional judgment of each of their health care providers to determine which of their patients would be good candidates for induction or elective induction. The researchers then compared the changes one year before and one year after that policy was implemented and their impact on induction rates and elective induction rates, Cesarean births, and health issues again for birthing people and babies. Something interesting and unique to this study was that they actually did look at changes, not only in those who were giving birth for the first time or who were low risk, but they also wanted to see if there were any changes or any impact on those who had given birth before or who were in different high risk groups. And I’m not going to go into all of the findings because they do actually kind of split it up by these different groups. And it’s really interesting to see. But essentially, they found that inductions increased across the board for everyone. So everyone was getting more inductions after this policy and elective inductions at 39 weeks increased specifically for those in those low risk groups. And so, for example, among low risk birthing people giving birth for the first time, the rate of elective induction at 39 weeks increased from 6% to 28%. So that’s a pretty big jump. However, rates of Cesarean births did not change overall or for any specific subgroups. So again, seeing increases in rates of inductions, but not necessarily changes in Cesarean rates.

And so looking at all of these findings across these and the other five studies that we included in the Signature Article, what did we find? And I’ll try and summarize it here. So that main outcome that was focused on by the ARRIVE trial, again, was that impact on health issues for babies. And what we found was that the evidence was mixed. Only one study found a reduced risk of death or severe health issues for babies. And they were comparing an elective induction group with expectant management. So they did find a reduced risk. Another study found no immediate changes in things like NICU admission or serious health issues for babies. But they did see a slight concerning increase in these health issues over time after the ARRIVE trial. And again, that was all births in that study. And then another study found higher rates of shoulder dystocia in their 39-week elective induction group compared to their expectant management group. But they found no difference for any other health issues. So again, that impact on babies is kind of mixed. While the ARRIVE trial did find that elective inductions reduced Cesarean rates, we also found mixed results on this newer research about this. So as you can see from a few of the studies that I just summarized, some found no differences. And three studies that used data from hospitals found no decreases in their Cesarean rates after the ARRIVE trial. 

But three very large studies that used data from U.S. birth certificates actually found some slight decreases in Cesarean rates. And we do go into some more detail in our Signature Article about some of the limitations with birth certificate data. But that is something to note that those studies did find slight decreases in Cesarean rates. The ARRIVE trial also found that elective inductions lowered that risk of pregnancy-related high blood pressure. And two out of the three studies that we found that measured this did find lower rates of pregnancy-related high blood pressure among those who were induced either electively or medically. But another study found no difference. And so I would say, kind of putting this all together, that although we are absolutely seeing increases in rates of inductions and elective inductions at 39 weeks, The overall benefit is still uncertain. And again, electively inducing at 39 weeks does appear to be preventative for developing pregnancy-related high blood pressure. It’s questionable about how much it lowers the risk of serious health issues in babies or lowers that risk of Cesarean birth. And so, Rebecca, based on all of this research, I know that was a lot, and the ARRIVE trial findings, do you think it’s reasonable to conclude or reasonable for someone to suggest that everyone should be induced at 39 weeks?

Dr. Rebecca Dekker:

My short answer is no. The results from the ARRIVE trial and the recent post-ARRIVE research do not suggest that, quote unquote, everyone should be induced electively. I think that it was really interesting hearing you go over the findings of the post-ARRIVE research, because what I felt like I was seeing after the ARRIVE trial came out is that this was like the promised land. We’re going to have lower Cesarean rates as a result of electively inducing everyone. And the research is not showing that. It either has no impact on Cesarean rates or maybe a very slight decrease, but it’s not some kind of cure-all for the high Cesarean rates in our country. And doesn’t seem to have resulted in the benefits they were expecting for babies. And what we still hear providers saying, this is better for your baby, even though the ARRIVE trial did not really show that, and neither did, we don’t have confirmatory research about that in the post-ARRIVE period. So elective inductions might not lower the risk of Cesarean for everyone, and some people might prefer to wait for labor to start on its own, especially if you prefer to avoid medical interventions. If you want to avoid the methods that I described earlier that are commonly used to mechanically or use medications to ripen the cervix or to start contractions. There are other medical interventions that are kind of typically packaged together with an induction, including frequent cervical exams, intravenous fluids, continuous fetal monitoring, and other things that can restrict your freedom of movement and your freedom of eating. 

A lot of hospitals have policies that forbid eating during an induction. And then these research results might not be applicable to you if you have midwifery care. You know, as we mentioned, very few participants in the ARRIVE trial had a midwife, and having a midwife leading your care has been shown to lower the risk of Cesarean without needing elective inductions across the board. Also, these research results might not be applicable to you if your care provider has a very high Cesarean rate with their inductions. So, it is possible. I think one of the cool things about the ARRIVE trial is that it showed that it is possible to keep your Cesarean rate below 20% with an elective induction. If the providers are motivated to follow best practices and to avoid unnecessary failed inductions. But not everyone follows these best practices. And so it’s important if you’re considering an elective induction that you know what your provider’s Cesarean rate is, and you know what their Cesarean rate is with elective inductions. And then as you’ve mentioned many times, almost all this research is on people who are low risk, giving birth for the first time, having an accurately estimated due dates. So if you don’t fall into that category, this research might not apply to your situation. And if you have a high risk medical condition, you might end up needing a medically indicated induction. So for example, if you have high blood pressure, gestational diabetes that needs medication, or if your water is breaking at term before the start of labor, those might be reasons to consider having a medically indicated induction. And all of this elective conversation doesn’t really apply to you. 

Now, there are some pros and cons, advantages and disadvantages to elective induction at 39 weeks that people might want to be consider if this is something that’s being offered to them or they’re considering having an elective induction. Some of the advantages include avoiding the complications associated with having a longer pregnancy, such as the increasing possibility of developing high blood pressure. An advantage is ending an uncomfortable or painful pregnancy. There may be benefits to scheduling an induction to accommodate having your preferred care provider at the birth, or if you need a specific family member present. It could potentially slightly lower the risk of Cesarean if you’re giving birth for the first time and your care provider is following best practices on induction. And it’s possible that this could prevent rare cases of infant death or stillbirth. Though the research is mixed on this, the ARRIVE trial was probably too small to study this, and the absolute risk of stillbirth is very low until about 41 weeks of pregnancy. 

On the other hand, there are disadvantages or risks associated with elective induction. It’s possible the induction might not work, and it might lead to what could have been a preventable. You are probably going to spend more time in labor with an elective induction than a spontaneous labor. You may experience a highly medicalized birth and a bundle of interventions that I mentioned earlier, such as intravenous fluids, restriction of movement, and it also might limit your access to some birth options you’re interested in, like getting into a tub, having a home birth, or spending your early labor contractions in your own home environment. That might all go away if you elect an elective induction. And then medically induced contractions could increase pain and the likelihood of needing an epidural, though we need more research on that. And there is some research that suggests that induction and the use of multiple interventions bundled together during labor and birth can lower the likelihood that you will be able to achieve your breastfeeding or chestfeeding goals. So when we’re making decisions about things like elective inductions at 39 weeks, it’s helpful to consider the full range of options available, including the risks, benefits, effectiveness, and cost, and to know that there might be other options that are more affordable and less invasive than doing an elective induction that could lower the true risk of Cesarean by a lot more than 3.6%. So you can read the full article and look for a table that describes all of those full range of options. And we’re going to do another episode on that in a few months. So stay tuned for that. So Morgan, one of the last things I want to talk about is like your interest in research on respectful maternity care. Can you tell us more about what respectful care is and how it’s related to the ARRIVE trial?

Morgan Richardson Cayama:

Yeah, so respectful maternity care is an approach to care that’s really rooted in human rights. And that includes the right to make decisions about one’s own body, the right to inform choice, and that right to consent about what happens to someone’s body during their pregnancy, birth, and postpartum period. And it is an approach to care that’s recommended by the World Health Organization and some other international organizations. And it is gaining some momentum here in the U.S. as well. There’s a lot more research coming out on this topic we’re seeing here in the U.S. and with respectful care, we’re not just concerned about achieving specific health outcomes like lowering Cesarean rates or having a healthy baby. But we also want to make sure it’s also important that the birthing person’s experience during labor and birth is positive and safe, that they feel respected, that they felt dignified during their birth. And so some key aspects of respectful care include care that maintains someone’s dignity, respects their privacy and confidentiality. Enables informed choice and continuous support during labor and birth, and is free from harm and mistreatment. And so kind of the opposite side of this, violations of respectful care are often referred to as mistreatment and obstetric violence. Obstetric racism is another term that you’ll hear with this too. 

And so when I was kind of researching this topic and looking into the ARRIVE trial, I found that the ways that respectful care and mistreatment really relate to this really have to do with the way that induction is communicated with birthing people and whether someone has truly informed choice and uncoerced consent. These are really important principles for respectful care. At Evidence Based Birth®, we’ve heard from birth workers about the ways and we researched like the ARRIVE trial and other research has been used to pressure and coerce people into interventions like 39-week elective inductions. And care providers might also tend to present biased or misleading information. You know, they might talk about that benefit for babies that we haven’t really seen. They might accuse somebody of not caring about their baby’s health if they don’t agree to have an induction. Or they might even attempt to perform an induction method like a membrane sweep without somebody’s knowledge and explicit consent. So again, this is a very invasive procedure. And not telling someone that they’re doing this. And so all of this is considered mistreatment and obstetric violence. 

And again, just to reiterate, truly informed consent requires that healthcare providers provide full and accurate information to patients about the benefits of any procedure, their risks, and their alternatives, and accept and respect the patient’s choice on whether to accept or decline anything that’s recommended, including an elective induction. And something else to keep in mind is that inductions can really impact the way that care is delivered and someone’s perception of their birth experience. So that includes how satisfied someone was with their birth and whether they even consider their birth to be traumatic. There is some research that has shown that birthing people who experience lots of interventions during their birth have more symptoms of trauma. And inductions specifically have been associated with less satisfaction in birth compared to spontaneous birth. And that all might be especially true for someone who does really want to be able to move and exercise their right to be able to move during their labor and birth or eat and drink. And even though these are rights that are owed to everyone, someone going through an induction might find themselves up against hospital policy or having to, you know, advocate harder for those rights. And I also just want to reiterate that it is always the right of the birthing person to decide whether an elective induction at 39 weeks or any induction is right for them. That is a choice that you should be able to make for yourselves in following this sort of respectful care practice. In light of everything that we’ve talked about, about what the ARRIVE trial was and what they found and what other research has shown and the ways that that research might impact care, you know, positively, negatively. What do the professional guidelines say, Rebecca, about elective inductions at 39 weeks?

Dr. Rebecca Dekker:

Okay, so just quickly, we looked at guidelines published by several different professional organizations. You can access our summaries of those recommendations in the Signature Article. But something we found that was a common theme was that the importance of the birthing person’s preference for whether or not they have an induction, which goes back to what you were talking about, Morgan, with respectful maternity care. But there were also some interesting differences in their recommendations. So ACOG states it’s reasonable to offer a 39-week elective induction to a low-risk first-time birthing person. But they also note that care providers should consider staffing and facility resources to support inductions because they require longer labors and that they need to have protocols in place to prevent failed inductions whenever possible. In contrast, the American College of Nurse Midwives generally discourages the use of elective inductions. They recommend that care providers practice shared decision-making and talk about induction risks, benefits, and alternatives, as well as the potential impact of an induction on the labor and birth experience. I found it interesting that in the United Kingdom, the National Institute for Health and Care Excellence recommends that low-risk birthing people be given every opportunity to go into spontaneous labor, and they really don’t encourage elective inductions before 41 weeks. 

However, they say that care providers can offer membrane sweeps at prenatal visits after 39 weeks. They recommend that patients be told that an induction will impact their birth options and birth experience and that care providers must respect any decision to delay, decline, or stop an induction. In Canada, the Society of Obstetricians and Gynecologists also does not recommend routine elective inductions at 39 weeks, although they do note that these elective inductions can be offered to people who are advanced maternal age, which they define as 40 years or older. So after all this information, what’s the bottom line? So we know now that elective inductions at 39 weeks have become much more common in the United States, and that the ARRIVE trial is a big reason for this increase. The ARRIVE trial was meant to look and see if 39-week elective induction lowered the risk of death or severe health issues in babies. And they did not find this to be the case. They were also interested in the impact on Cesarean rates, and they found that there was a slight decrease in Cesarean rates with elective induction at 39 weeks, as well as a decrease in pregnancy-related high blood pressure. But this study had important limitations. The care providers and hospitals in the study might not represent the average care provider or hospital. Very few people in the trial were cared for by midwives. And participation in the study was pretty low. 

This might be a sign that some people don’t really want to be told what to do. They’d rather have a choice. And researchers running the study possibly had preexisting biases about the benefits of elective induction, and they were eager to prove that it could lower the Cesarean rate. Since the ARRIVE trial came out, studies have been published showing mixed results on the impact of elective inductions at 39 weeks in the real world. There is no strong evidence that elective inductions significantly lower Cesarean rates or improve newborn health. However, there is more consistent evidence that it might lower the risk of developing pregnancy-related high blood pressure. So that might be something important to consider if you’re at risk for that. There are benefits and risks and pros and cons to elective induction at 39 weeks. We’ve talked about those at length, but some people just prefer to end an uncomfortable pregnancy. Maybe they need to schedule their labor and they might want to avoid some complications that might happen with a longer pregnancy. But some of the risks include that the induction might not work and it either has to be stopped or end in a Cesarean. It may be longer than a spontaneous labor and there may be challenges with the bundle of interventions you need to go along with elective induction, including more monitoring and limited movement, hospital restrictions, potentially more painful contractions, and the need for pain medication. Elective inductions are not some kind of cure for lowering the risk of Cesarean. 

Most of this research was done with a very specific group of birthing people who were giving birth for the first time and who were low risk. And the decreases they saw in ARRIVE trial, as we’ve mentioned, were small in terms of the Cesarean rate being lowered. So we really encourage people to have conversations with their care providers about the benefits and risks of elective induction. Remember that you have the right to unbiased and evidence-based information, and you have the right to choose an elective induction or decline one if that is what you prefer. So I just want to let you know that we have many resources at Evidence Based Birth® where you can go to learn more. If you want to dive down more rabbit holes or you just want to arm yourself with information, we have an article about inducing for due dates. We have a podcast about Pitocin for inducing labor. We have a Pocket Guide to labor induction so that if you are needing or choosing an induction, you have all the tools you need to make it a better experience. And we have a full Signature Article on the ARRIVE trial at ebbirth.com/ARRIVE, along with an updated two-page handout all about this topic. So thank you, Morgan, for joining us this week.

Morgan Richardson Cayama:

Yeah, thank you so much. It was my pleasure.

Dr. Rebecca Dekker:

It was great having you. This is a big splash for your first episode, and we’re really thrilled you helped put this article together. For those of you who are listening, just a heads up that we will be taking next week off as a quiet week. We will be back on November 13 and 20 with two really important episodes all about the evidence. So I know a lot of you are going to really enjoy those episodes. So keep an eye out for all the new research coming out at Evidence Based Birth® next month. Thanks again, and we’ll see you soon. Bye! 

Today’s podcast was brought to you by the Signature Articles at Evidence Based Birth®. Did you know that we have more than 20 peer-reviewed articles summarizing the evidence on childbirth topics available for free at evidencebasedbirth.com? It takes six to nine months on average for our research team to write an article from start to finish. And we then make those articles freely available to the public on our blog. Check out our topics ranging from advanced maternal age to circumcision, due dates, big babies, pitocin, vitamin K, and more. Our mission is to get research evidence on childbirth into the hands of families and communities around the world. Just go to evidencebasedbirth.com, click on blog. And click on the filter to look at just the EBB Signature Articles.

Rebecca Dekker – 00:00:00:

Hi, everyone. On today’s podcast, we’re going to answer your questions all about the evidence on the ARRIVE trial and elective induction at 39 weeks. Welcome to the Evidence Based Birth® podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, and welcome to the Evidence Based Birth® podcast. Before we get started, I wanna let you know that we do have some big plans coming up for 2025. So if you’re not already receiving our free email newsletter, make sure you go to our homepage at evidencebasedbirth.com so you can get a notification when we announce our plans for 2025 and how you can benefit. So a few weeks ago in Evidence Based Birth® Podcast episode 334, we shared the evidence on the ARRIVE trial and elective induction at 39 weeks. You can find that episode and a full-length signature article on that subject by simply navigating to ebbirth.com/ARRIVE. You can also get a free two-page handout there on the ARRIVE trial. So if you haven’t listened to episode 334 yet, I strongly recommend you do so before listening to today’s episode. But as a quick refresher, the ARRIVE trial was a large, randomized control trial published in 2018. Comparing elective induction at 39 weeks of pregnancy with expectant management or waiting for labor to start on its own or inducing labor later if there was a medical reason or if the patient elected to induce labor. So they compared health outcomes from those two options and they did not find any difference between groups with regard to their primary research outcome of serious injury or death for babies. However, they did see a slight decrease in the rate of cesarean with elective induction. As a result, obstetricians in the US and some in other places around the world started recommending elective induction to all of their clients. And we’ve seen the induction rate go up quite a bit in the United States as a result. The post-ARRIVE research or research that came out after the ARRIVE trial is implemented is not showing clear benefits to 39-week elective induction with the exception of it possibly lowering rates of pregnancy-induced high blood pressure. Again, we cover all of this in detail in episode 334 of the Evidence Based Birth® podcast, which you can find on any podcasting platform or on YouTube. So today I’m gonna share with you a Q&A that Morgan Richardson Cayama and I hosted at a live webinar in the spring of 2024. This was a popular training session that was watched live by thousands of people from all around the world. And our PRO Members at EBB have had continuous access to that replay, plus a certificate for contact hours they can download since that time. But the replay has not been available to the public until now. As a content note, today’s podcast episode does include a discussion on the statistics of serious illness and death related to pregnancy and childbirth. And now I’d like to invite you to join me in listening to this Q&A all about the ARRIVE trial and elective inductions at 39 weeks. So welcome everyone. My name is Rebecca Decker. I’m the host of the Evidence-Based Birth® podcast and researcher here at EBB. Morgan, do you want to introduce yourself as well?

Morgan Richardson Cayama – 00:03:38:

Sure. Yeah. Hi everyone, my name is Morgan Richardson Cayama. I am a PhD candidate studying public health at the University of South Florida, College of Public Health. And I am the new EBB Research Fellow. So I will be the Research Fellow for this year. And happy to be here.

Rebecca Dekker – 00:03:52:

Many of you have already watched some of the videos with both myself and Morgan. So I have to give Morgan a lot of credit for helping put that presentation together for you. Morgan has been hard at work researching the answers to your questions. So Morgan, do you want to take the first question? Okay, let’s talk about the elephant in the room. The elephant in the womb, the elephant in the room. How often are we seeing pressure from obstetricians to induce?

Morgan Richardson Cayama – 00:04:21:

That’s a great question. So I haven’t actually found much recent research on this topic, but there is some research from around the time that the ARRIVE trial was published and actually some earlier studies. And anecdotally, of course, we hear that tons of birthing people and birth workers are having this sort of push on them. But there was a study that explored this topic, maternity care experiences, and it was done in 2014. So it’s a little bit older now. And it was with around 2000 women and birthing people in Canada. And so around 16% of them in the study reported feeling pressured from a healthcare provider to have an induction. So this was obviously a pre-ARRIVE and we can imagine that it’s probably gone up since then. And among those who ended up having an induction over half, like around 54% said that they felt pressured into it. So that’s telling.

Rebecca Dekker – 00:05:08:

So that’s British Columbia in Canada.

Morgan Richardson Cayama – 00:05:10:

Yeah. Okay. And then we have the most recent Listening to Mothers study in California that was done with around 2,500 birthing people. And again, that was in 2016. So still pre-ARRIVE, but in that sample, about 40% of participants said that their healthcare provider tried to induce their labor and around 37% of those said that they didn’t really have a medical reason for it. And there was actually more pressure for those who had planned a vaginal birth. They said they felt more pressure by their providers to have an induction. And again, more people who felt pressured went on to have an induction compared to those who weren’t pressured. So about 30% of those who were pressured had induction compared to only like 7% who weren’t pressured chose to have an induction. And then there was like a smaller qualitative study that was done in Australia. I think we saw some people in Australia in the chat. And so they did interviews with some birthing people there and they kind of wanted to hear about their shared decision-making experiences related to their induction. And so some of the common themes that came out of this study were participants feeling like they were told they needed an induction rather than being given the choice, not feeling like they were given enough information about the induction or induction processes, and really not given enough information about the pros and cons of if they didn’t choose to have an induction. And they also found that satisfaction with their induction experience was really related to their general openness towards having an induction in general. So if they felt like they were already kind of more open to it, that they sort of trusted their provider, that they kind of deferred to their provider to make that decision, then they were more satisfied with that experience versus people who felt like they wanted more of a choice and they wanted sort of more of that shared decision-making role, were less satisfied with their induction. And yeah, so that’s about all the research we’ve seen so far on pressure. But again, anecdotally, we’re hearing a lot from people that this is happening.

Rebecca Dekker – 00:06:56:

Yeah. And you mentioned in your part of video three, that coercing someone into an induction is considered mistreatment in maternity care by researchers. So hopefully as mistreatment becomes a bigger research topic and there’s more funding around that, we’ll see more data on pressure and coercion. So do you want to ask me the question that’s right underneath it? Because it’s related.

Morgan Richardson Cayama – 00:07:20:

Sure. So how can a birthing person manage pressure from an obstetrician to get an induction at 39 weeks?

Rebecca Dekker – 00:07:26:

Yeah, I think one of the things that came up in the PRO member training when we did a private showing for them, we had a discussion about how, you know, sometimes you hear you should be induced at 39 weeks. And they’ll give a medical reason or they’ll say because of the ARRIVE trial, but sometimes they just say because. And then the patient assumes that there’s a medical reason. So it’s almost like. You think because the doctor’s recommending it that it’s medically necessary. Because why would they recommend something that’s not necessary? And so that’s one thing is to find out what’s the actual reason they’re recommending an induction. And I think I’m actually gonna have, I’m using my induction pocket guide because it has a page on this about how to manage pressure. So the most important thing to know is that you have options. So if you’re told you need to have an induction or that an induction is recommended, most people just assume they have to do as they’re told, but you have the right to ask questions. You have the right to have those questions answered with accurate information. You have the right to say yes. You have the right to say no without being pressured. And if you say yes to an induction, you have the right to help decide which methods will be used. So I think for me, that’s always been an important teaching point is to just explain that you do have options. You don’t have to just do whatever you’re told. And I have questions that I would ask. I would say, you know, what’s the medical reason for this induction? What do the professional guidelines say about inducing for this specific reason? If they say it’s because of the ARRIVE trial, I would say, well, what do your professional guidelines state about induction, elective induction at 39 weeks? And hint, hint, it does not say you should always be induced. And then if you’re really thinking about considering an induction, how ripe is my cervix? What is my Bishop score? What are your preferred methods for cervical ripening? What options do I have to prepare for this induction? And then you can even go further back. Many of you birth workers may know this. There are certain providers that always recommend an induction. So that would be very useful info to know earlier in pregnancy. So I like to help parents ask questions earlier in pregnancy, such as what is the induction rate in your practice out of the last 10 births that you did? How many were induced labors? And also what is your cesarean rate with inductions out of the last? 10 inductions that you did, how many of them ended in cesareans? So you can ask those questions early to find out what their practice patterns are. And I think. A lot of parents are just kind of blindsided by this in the third trimester, and they did not realize that this was a thing. So the more we can do to educate people that there are certain practices out there that are pressuring people into inductions and that they know that this discussion is coming, then they can prepare for it with the evidence. But know that you have options. And also, I think induction at 39 weeks for elective reasons, it can also be considered evidence-based because the evidence does not show it’s dangerous. You know, if it’s something you want, it’s a good option, but it should not be across the board everybody has to have this. So that’s how I would answer that. True absolute risk reduction with cesareans from the ARRIVE trial. So some people get confused between relative risk and absolute risk. Relative risk is the risk of something happening to you in comparison to something else. So the absolute risk is the absolute chance, the actual chance something might happen to you. So the absolute risk in the ARRIVE trial, induction dropped the cesarean rate from 22% to 19%. So it was a 3% total reduction. But the relative risk, sometimes doctors will say the risk of cesarean was 16% lower. If you do the math, a decrease from a 22 to a 19 out of 100 is like a 16% chance, relative chance, but it’s a complicated math equation to get to that number. And it doesn’t really make sense in people’s minds. So really it’s better to give the actual numbers, which is a drop from 22% to 19%. But again, we covered in the videos that that is not necessarily going to happen in every hospital that implements the ARRIVE study. So I’ll go ahead and see. You should be induced at 39 weeks. So because of the research showing better outcomes for babies, 71% said yes, that’s pretty high. Morgan.

Morgan Richardson Cayama – 00:12:07:

Yes.

Rebecca Dekker – 00:12:09:

I’m looking for geographic trends. So I know we covered that a little bit in the video. I think that’s number nine on our question list.

Morgan Richardson Cayama – 00:12:17:

Yes, it is. So 39-week elective inductions are what we’re seeing more common in the US, compared to many other countries. And we did talk a little bit about that in the videos because other countries haven’t really kind of hopped on the bandwagon of sort of routinely recommending 39-week elective inductions. And usually they prefer to wait, like sort of recommend waiting until 41 or 42 weeks. And then inductions at that point are often done because the pregnancy is reached like post-term or there are other health issues like, you know, gestational diabetes or high blood pressure during pregnancy. And elective induction rates themselves can vary pretty significantly from state to state in the US, and I’m sure it’s probably similar in other countries, depending on the area you’re in and the hospital you’re in. But data are really difficult to find. And actually, I did try to find research on this, but inductions tend not to be reported accurately on birth certificates. Which is like one of the biggest sources of this information, because they’re just not captured. They’re not really reporting for sure if it’s an induction. That’s like one of the outcomes that isn’t reported very accurately. We’ve heard of rates like as low as 10%, but as high as like 40, 50% plus. So yeah, this is just kind of a question for chat too. It’s like, you know, what trends, and you kind of talked about this before, but what trends, you know, are you seeing in your area and, you know. If you had to guess. And again, that’s also going to vary provider to provider. Like Dr. Dekker said, that’s a conversation to have with your provider as well. It just, there’s a lot of variables and a lot of things that impact that.

Rebecca Dekker – 00:13:41:

Yeah. Do you want to go to question number two then, since that’s kind of related to what we’re talking about and some people are asking about that in the chat too.

Morgan Richardson Cayama – 00:13:49:

Yeah, sure. So just a trigger warning for this question, we are going to be talking about some statistics on, you know, infant death and mortality. And so a stillbirth is the death of a baby after 20 weeks of pregnancy, just to kind of throw out some definitions and they can be defined as early. So that’s like, between 20 and 27 weeks late, which would be 28 to 36 weeks or term more than 37 weeks. And the rate of stillbirths in the US actually went down a lot in the 1990s and early 2000s. Then went up a little bit again in the 2010s. But since then, it’s been about the same. And it was like around 5.8 infant deaths per 1,000 births in 2020. That’s how we measure it is like per 1,000 births. But I mean, the rate hasn’t changed much in the years before or after the ARRIVE trial. And I also looked at some of the more recent data for perinatal and early newborn deaths. And there also hasn’t been much of a change. So perinatal deaths are the death of a fetus after 28 weeks or an infant death younger than seven days. And so the rate in 2020 was about 5.6 deaths per 1,000 live births. And in 2021 was 5.5 deaths. So not much of a change. Early newborn deaths include, again, the death of an infant within the first seven days. And those decreased by about like 4% between 2020 and 2021. But overall, like a lot of the stuff that you’ll say is just says it’s like been pretty much the same for the last like decade or so. We haven’t seen much movement either way. Um, pre or post ARRIVE trial, so.

Rebecca Dekker – 00:15:17:

And 4% is the relative risk. So the absolute risk reduction is smaller.

Morgan Richardson Cayama – 00:15:22:

Yes, correct.

Rebecca Dekker – 00:15:23:

You had written 2.86 per 1,000 births versus 2.75 per 1,000 births. So roughly.

Morgan Richardson Cayama – 00:15:31:

Yes.

Rebecca Dekker – 00:15:32:

Roughly the same.

Morgan Richardson Cayama – 00:15:33:

Correct. Yeah.

Rebecca Dekker – 00:15:36:

And the ARRIVE trial, as we talked about in the videos, did not find difference in the primary outcome. For a couple of reasons, one, because stillbirth is pretty rare. You would need, they had about 6,000 participants, but you would need way more than that to see any kind of a difference. Theoretically though, it could prevent a stillbirth in a rare scenario. So you would need a huge research study to actually have those numbers play out. I think we talked about stillbirth prevention on the EBB podcast episode, it was about count the kicks, 243, the importance of kick counts for preventing stillbirth. And there’s a lot of resources in that article about evidence-based ways to lower the chances of stillbirth. Induction is not the only way. Other questions? You want to pick one out to ask me?

Morgan Richardson Cayama – 00:16:32:

Sure. So this is one kind of interesting. What if a midwife or obstetrician refuses a 39 week elective induction, if you’re a birthing person who wants it, but then, um, They don’t want to provide it.

Rebecca Dekker – 00:16:43:

Okay. So. I hear this happening occasionally. In fact, I have a good friend who’s a provider who does not do induction, elective inductions for, because that person provides continuity of care. So in a lot of practices, they rotate call, meaning they’re kind of on a shift, an assigned shift to attend births, and that happen in that 24 hours. And this particular provider that I’m thinking of provides continuity of care, which means she attends your birth no matter what. So she is not going to pass you off to somebody else. And as you all know from the videos, one of the problems with inductions is that they can be very long and tedious. And so it’s one thing if you’re working shifts, but it’s another, if you are the provider for that patient and you have promised them, you will be there at that birth and you’re giving birth in a place where it’s, maybe they don’t trust you in the hands of another provider while you’re gone. So that provider in particular says, I don’t do elective inductions. They’re too hard on me. I’m a mom with small kids. I can’t be at the hospital for that long. So she only does medically indicated inductions. So I would say if that’s something you’re interested in is to find out earlier in pregnancy and some people, want an elective induction for social reasons, emotional reasons, other reasons. So just knowing in advance what your provider does or does not do can be helpful. It can also be helpful if you’re planning a home birth or a freestanding birth center birth to talk with your midwife about. Ways they like to encourage labor to get started if you’re wanting to go into labor sooner rather than later. And there can be reasons for that as well, right? In some states, midwives cannot legally attend home births after a certain gestational period. So there might be some real incentives to get labor started. So that’s my, and if anybody has any thoughts in the, in the chat, you’re welcome to share. Yeah. Rotating call. Somebody says we’ve rotating call. We don’t do elective inductions. Um, you, you show people what the induction involves, the balloon and what has to be done to dilate or ripen your cervix. It can. Yeah. With informed consent, people might still choose not to do it. And another thing that we didn’t really talk about, we’re not going to cover, is the whole area of research on outpatient inductions. In some countries, that’s becoming the standard where you do a large part of the induction outpatient, which I think is really interesting. There’s actually Cochrane reviews on that. You can just do a PubMed search for outpatient labor induction and find a whole bunch of research. I’m not going to go in that tonight, though. That’s a whole different rabbit hole. Okay. So let’s talk about. Preeclampsia. So we’re not going to go into depth about high blood pressure and preeclampsia, but one of the things that struck me about the ARRIVE trial was they had such a high rate of preeclampsia and hypertension. So what was the deal with that?

Morgan Richardson Cayama – 00:19:56:

Yeah, that is a great question. And like you said, kind of has come up with people who have reviewed the study, um, commenting on that. And so, uh, just to remind folks around 9% of the people who were induced at 39 weeks in the ARRIVE trial had a hypertensive disorder of pregnancy. So like gestational hypertension or preeclampsia, um, and that was compared to around 14% in the expectant management group. And so people noted that this was high because the sample was supposed to be kind of like low risk pregnant people. And, um, those rates are actually like higher, especially at that time than what you would see sort of in the general population. And we really don’t know why that might be because we don’t really have enough information from the study and on the participants. So like in one critique, I saw that the author said it would have been helpful to know how the people who chose to participate in the study, like at the study sites at the 41 hospitals who participated compared to like the people who chose not to participate. Like, was there something kind of different about the people that chose to participate in the study versus those that didn’t? And of course you can’t really collect data from people who choose not to participate in the study. But just to kind of compare like how their health outcomes were different. And they also said it would have been interesting to know whether some of the ARRIVE Trial outcomes like cesarean birth were different, like higher or lower among the birthing people in the study who didn’t develop hypertension. So kind of, they call that like sort of a stratified analysis too. And we haven’t really seen that. And I also do want to note though, that since the ARRIVE Trial was conducted back in 2018 rates of just as gestational hypertension have like continued to go up in the US, so in 2019, 13% of pregnant people delivering in hospitals, were diagnosed with a hypertensive disorder of pregnancy. And that was compared to like 11% in 2017. And we don’t really know why for certain, like no one can definitively say why this is, but some researchers speculate it’s because we’re also seeing increases in some of the things that, you know, increase the risk for gestational hypertension, like more birthing people giving birth at older ages who might have higher BMIs and more who are diabetic giving birth as well.

Rebecca Dekker – 00:21:51:

Interesting. We have had a request. From team EBB to cover preeclampsia. So we do have a training on high blood pressure and evidence-based care in pregnancy. And that is in the PRO membership, but we’re thinking about doing a, we’ve had a request. So if you want to put your name in the hat for like, say yes, please, not for you to teach it, but that you want us to do it. Tell us, as you can see our team, EBB, Jen, Chanté, they say the people want it. So. Okay. One more question for you, Morgan. How long was the average or median induction length in the trial? Because I mentioned inductions can take two to three days. So what was the average?

Morgan Richardson Cayama – 00:22:33:

Yes, that’s also a great question. So the median length of stay during labor or of the labor on the labor delivery unit for those who were induced was about 20 hours. And I think they give that range of like 13 to 28 hours. And that’s compared to the median length of stay in the expectant management group. That was 14 hours. So 14 hours versus 20 hours were like the median sort of range. And in that range in the expectant management group was nine to 20 hours. So, yeah, about 20 hours.

Rebecca Dekker – 00:23:00:

That range seems low to me, like because I’ve known so many people have gone to 48 or even 72 hours with an induction. And people were saying, oh, induction outpatient sounds dangerous. But most of the time, induction outpatient is the cervical ripening part, which can take a really long time if it’s your first baby. Do you have a question picked out you want to ask me?

Morgan Richardson Cayama – 00:23:22:

I don’t know. Should we tackle kind of the ones around sort of due dates and like how long a pregnancy is and sort of that impact?

Rebecca Dekker – 00:23:30:

Yeah. Let me do that briefly. Cause we do have a whole signature article on that. So a lot of people are like, well, you’re inducing at 39 weeks. Is that even accurate? You know, is there a due date for your baby? And so at EBB, we have a signature article. I’ll have our team drop the link. We actually have two, one is ebbirth.com/duedates. And that describes the whole concept of a due date and how accurate it is or inaccurate and the best way to date pregnancies, which is actually an early pregnancy ultrasound, along with your LMP or last menstrual period. And it seems that the typical pregnancy that’s not induced is about 40 weeks and five days if it’s your first pregnancy and 40 weeks and three days if it’s a subsequent pregnancy. So as you can see with the ARRIVE trial, affects a lot of people because about half of people don’t even go into labor until 40 weeks and five days with their first pregnancy. So you’re going to, I think the rate of spontaneous labor by 39 weeks, if you haven’t had a preterm birth, it’s like 10%. So we’re talking about… a huge, like most people who are pregnant will be, if, if their provider is recommending an induction will be recommended either an elective or a medically indicated induction. So we have two peer reviewed articles on one for due dates and one for inducing for your due date. And the inducing for due dates article is really important because it goes over all of the risks of stillbirth, all of the risk factors for stillbirth, and induction benefits versus risks at different points in pregnancy. So tonight we’re specifically focusing on the 39-week induction, but that article goes into more depth about 40, 41-week, and 42-week inductions. Hopefully that is helpful. What’s next? So could you talk about the standardization of induction methods used in the ARRIVE trial? Like what were the methods that they used? They managed to achieve a 19% cesarean rate with inductions of first-time moms. So what did they do?

Morgan Richardson Cayama – 00:25:46:

Yeah, so I was able to find this information. I pulled it directly from kind of one of the supplementary materials that the authors published with the study. So just kind of like reading what they did. And it was in their study protocol. And so this is what they kind of recommended that providers participating in the study do. So for those with a favorable cervix, so like a soft cervix, it’s like ready for labor and there’s like Bishop scores and stuff like that. But for those with a favorable cervix, they were given oxytocin. For those with an unfavorable cervix who had a Bishop score of less than five, they had to first undergo cervical ripening along with or followed by oxytocin. And so the method of cervical ripening was left up to the individual healthcare provider. They didn’t really stipulate or recommend one method over the other. They did expect that the baby’s heart rate would be monitored throughout induction or labor, either continuous or intermittent fetal monitoring. So that’s where they either listen to the heart, like there’s a heart monitor kind of strapped on the birthing person all the time, or it’s like checked periodically. And patients were also expected to stay in the hospital from the time the induction or ripening began until birth. So like none of that sort of outpatient situation. And then per the ARRIVE trial protocol, it was suggested to healthcare providers that birthing people be allowed at least 12 hours in sort of the latent phase of labor after any cervical ripening or rupture of membranes or oxytocin was used before they would be diagnosed with a failed induction and a cesarean would be ordered. And so we do think that a lot of providers sort of adhered to those sort of recommendations and guidelines, again, because they were able to get an unusually low cesarean rate for first-time birthing people compared to what we sort of see in other hospitals around the US.

Rebecca Dekker – 00:27:29:

Yeah. With the Post-ARRIVE Studies, I think it’s interesting somebody was pointing out, like, why aren’t we just recommending birth centers and home births if you’re trying to decrease the cesarean rate? And I think that it’s important to point out that they wanted to show that 39-week induction was effective because they were already using it, which is not the best way to design or carry out a study because it can introduce bias, such as we talk about in the videos, the Hawthorne effect, where they knew they were being watched. They wanted to find a specific result so they could have worked extra hard to try and keep the cesarean rate lower in the one group. They were not blinded, so they knew which patients were in which arm of the study. So I think you have to remember, this is coming from the medical model of care, not the midwifery model of care. And in fact, there were very few midwives participating in this study. So almost everybody had obstetrician-led care. And in the Post-ARRIVE Studies, they haven’t even looked at the effects of doulas or midwives in terms of like, you know. Because exactly, this is when the ARRIVE trial came out, people were freaking out. I remember in 2018, it was right before it came out, everybody was like, oh no, what are they going to find? They’re going to show it’s, you know, they’re going to use this to tell everybody they need to be induced. And I went, and so I went and looked at the study and I published a blog article before the results were even out, just explaining how they did the study so that people would understand it. And I said from the very beginning, like you don’t have to induce to lower your chances of cesarean. There’s so many options. This is just like one option and it only lowers your risk a little bit. It’s way more effective to just have a doula present at every birth. If they really wanted to lower the cesarean rate and were serious about it, and they bill a lot for these inductions. So you can’t say that the doula is too expensive. Speaking of cost, Morgan, can you talk briefly about that?

Morgan Richardson Cayama – 00:29:36:

Yes, I can, because that is another sort of hot topic in question, because again, that was one of the motivations is that induction could be more cost-effective. And the research is kind of mixed on this. And it really comes down to and is sort of dependent upon the cesarean rates that we actually end up seeing in people who are induced. So as long as the cesarean rates end up being lower in the induced sort of folks who are induced versus those whose pregnancies or births are expectantly managed, then it can be more cost-effective. But if you kind of look down how sort of costs break down through like labor and delivery and postpartum. Labor and delivery costs do appear to be higher for people with elective inductions because they often do spend much more time in labor and they often need more interventions. But their postpartum costs might be lower, again, really dependent upon that cesarean situation. So if they’re less likely to have a cesarean and less likely to be in the hospital for as long as postpartum, then those costs will be lowered. But there were a few specific studies I can just kind of talk about briefly. So in one of them, researchers used like a cohort of around 1.6 million births, sort of a theoretical cohort, and they pulled like outcomes based on actual data and statistics from the CDC. And they were able to sort of predict the likelihood of all the different outcomes that the ARRIVE trial looked at. And they found that induction did have higher costs, but it increased something that we call quality-adjusted life years, which is kind of a measure of how well different kinds of medical treatments like improve and lengthen patients’ lives. And so based on that, they said it could be considered cost-effective, but it was only cost-effective about 65% of the time. And that cost effectiveness was really dependent upon the cost of the induction. And again, that cesarean birth rate. So they found that if this was back in 2019, when the study was published, and they found that if the cost of elective inductions were to increase by $180, it would no longer be cost-effective. And I’m not sure where they like pulled their prices because I know prices are kind of proprietary and hospitals don’t openly share a lot of that data. But they said if they went up by $180, they wouldn’t really be cost-effective anymore. They also wouldn’t be cost-effective if the cesarean rate among those who were induced was 22%, which was the rate that we saw, in the expectant management group in the ARRIVE trial. So if that cesarean rate again went up and like sort of met the 22% of the expectant management group, no longer cost-effective.

Rebecca Dekker – 00:31:52:

This is where I think the problem is because you can’t generalize these results from the ARRIVE trial to every hospital because there are plenty of hospitals that with an induction, you could easily have a 40% cesarean rate if the providers are not using correct evidence-based methods of preventing failed inductions. So when you said cost-effective, that was for just the healthcare system in general, correct?

Morgan Richardson Cayama – 00:32:16:

Yes. Yeah, correct. Yeah. And there was another study that used, it was actually five hospitals in Utah that participated in the ARRIVE trial, and they looked at their actual cost data, and they had it for around, I think, 1,200 people. 600 issue were induced and 600 issue had expected management. And that included the total cost of maternal and newborn care from the time the patients like were randomized into the study through eight weeks postpartum. And they found that maternal outpatient costs were lower among those who were induced, but their inpatient, again, those delivery and care costs that happened during sort of the labor and birth were higher. And they also kind of did some analyses looking at, you know, maternal age and pregnancy BMI and the need for cervical ripening. And they weren’t really different. So, the total cost wasn’t different between the two. So, it doesn’t appear to really reduce costs and can, again, increase costs in some ways.

Rebecca Dekker – 00:33:10:

It does. I don’t know if any of you have seen this in the chat here, but one thing I have seen is that some hospitals are so full with people getting 39 week inductions that it can delay medically necessary inductions. Or PRO Members were telling me that sometimes parents are really confused because their doctors are saying, hey, it’s really important that you have this induction to lower the risk of stillbirth at 39 weeks. And then 39 weeks and every day their induction is pushed back for like a week because the hospital is so full of inductions that they can’t get in. And then the parents are like, why can’t I have my induction? You said that I needed this for my baby and it’s really confusing. So I don’t know if anybody is seeing that play out in their hospital. Okay. People in the chat are saying yes. Our L&D floor is bursting at the seams with inductions. Patients upset for being delayed. Yeah. Labor intensive care, high use of resources. And there was a shortage of oxytocin in the United States last year. And it was interesting to see like whether or not the inductions would be kind of pushed back. And again, you have this whole field telling patients, you must have this because it’s what’s safest. And then we can’t provide it to you. Sorry, you know, but it’s not necessary. So you’re okay. It’s just very confusing. I wonder if we have time for a couple more questions. Is there one in particular you think we should? Oh, can you do Morgan, the breastfeeding and epidurals? Because a lot of people are mentioning that, you know, they’re curious, are these inductions affecting breastfeeding rates or epidural rates, things like that?

Morgan Richardson Cayama – 00:34:54:

Yeah, we had, we had a few questions of people asking about different sort of postpartum outcomes and different things with that. So we do typically see more epidurals among birthing people who are induced. And some studies have also shown that they opt for an epidural earlier in labor compared to those who aren’t induced. And speculation on why that might be is because of the higher pain that is often attributed to medically induced contractions with like synthetic oxytocin. And the ARRIVE trial did look at some of these like other sort of maternal health factors like perineal tears, infection of the placenta, amniotic fluid, postpartum hemorrhage was another question that people had a lot. Did that increase? They didn’t find any differences between the two groups and sort of any of those like birthing people sort of focused outcomes. There were a few other studies that were done. One study that looked at, which we actually featured in the videos, looked at births pre and post-ARRIVE, and they found that birthing people in the post-ARRIVE were more likely to need a blood transfusion and to be admitted to the maternal ICU. But blood transfusions were already on the rise prior to the publication of the ARRIVE trial. And that study didn’t really differentiate between births that were induced and not. They just kind of looked at pre and post-ARRIVE. But regarding breastfeeding, there is some research that suggests that inductions reduce the likelihood that a birthing person will breast or chest feed or do so for the recommended length of time, which is about six months exclusively is what’s recommended. So there was a pretty big study that was done in Australia that had about 600,000 people. And they found that synthetic oxytocin use, like it’s often used in inductions, was associated with an increased odds in the use of formula in the hospital and decreased odds of exclusive breastfeeding at three and six months postpartum. And they also found that like the more interventions someone experienced during their labor and birth. Then those sort of outcomes were even worse, like they were even less likely to initiate breastfeeding in the hospital or less likely to be exclusively breastfeeding at three and six months out. And then there’s kind of a question that was related to this, Dr. Dekker. I don’t know if they want to like touch on it now, but about sort of maternal satisfaction and people’s birthing experiences as something being looked at. So I don’t know if you want to, um.

Rebecca Dekker – 00:36:54:

Yeah. Go ahead, yeah.

Morgan Richardson Cayama – 00:36:55:

Oh, yeah. So that isn’t something. And that also came up during the PRO membership webinar too, is birthing people’s like satisfaction hasn’t really been measured that I’ve seen in the research. And that also, you know, something to consider is, you know, people’s experiences of autonomy and respect during their birth hasn’t come up or like ties to postpartum mental health. And we can kind of see how those things might be impacted if people are reporting pressure to be induced. The ARRIVE trial didn’t measure maternal satisfaction, but I do want to mention that they measured pain levels and people’s experiences of control, like their perception of their control during their birth using something called the labor agentry scale. So I didn’t want to like not say that. Because, if people were to read it, you would see that come up.

Rebecca Dekker – 00:37:37:

But that’s not the best way to measure. It doesn’t measure satisfaction in that tool.

Morgan Richardson Cayama – 00:37:42:

Exactly.

Rebecca Dekker – 00:37:42:

It’s not that great at measuring control, feelings of control.

Morgan Richardson Cayama – 00:37:45:

Exactly. And the scores, the median scores, like were barely different between the two groups. And they think that even the difference that they saw could have just been because the study was so large. It had like enough people to kind of detect what we call a statistically significant difference. So, no, we haven’t really seen much done on birthing people’s actual satisfaction with their birth and their experience of their birth based on elective inductions.

Rebecca Dekker – 00:38:10:

Yeah, that’s really helpful. I’m going to briefly just let everybody know that we do have EBB articles and podcasts on big babies. That’s in the signature article directory. So if you have a question about preventing shoulder dystocia, that would be answered in that article. People are asking about advanced maternal age, and we have an article about induction for being 35 and older. And people are asking about postpartum hemorrhage. We have an article on that as well. It’s called, it’s like the Evidence-Based Birth® article on Pitocin in the third stage, but it focuses on everything related to bleeding postpartum. So that is also in that directory.

Morgan Richardson Cayama – 00:38:54:

Yeah. So someone commented that they’re seeing most of their IVF and advanced maternal age clients being offered or pressured on induction. And that’s something that we’ve heard a lot as well. So I looked into the IVF stuff a little bit earlier and the recommendation to be induced at 39 weeks for IVF probably comes from the increased risks associated with IVF for some complications and issues like placental abruption and cesarean delivery and stillbirth. But those risks, I do want to say again, that absolute risk is pretty small for some of those outcomes. And they’re typically higher when someone is pregnant with multiple babies, which can happen with IVF versus one baby. And because of those risks, that’s why you’ll see some providers recommending an induction. And we do see high rates of induction in studies comparing people who have IVF to those with spontaneous or non-IVF pregnancies. But as of 2022, The Society for Maternal-Fetal Medicine, SMFM, you’ll see it, states that it isn’t currently known whether elective delivery at 39 weeks reduces the risk of maternal death and health issues in babies IVF pregnancies, compared to expected management. So they can’t say definitively that induction should be done for people with IVF. They recommend instead shared decision-making between birthing people and their doctors when considering elective induction at 39 weeks as an option. So again, leaving that decision between the birthing person and their doctor.

Rebecca Dekker – 00:40:11:

That’s new because, yeah, thank you for sharing that, Morgan, because in the AMA article, we didn’t, last time we looked that up, we didn’t have that statement. There actually really wasn’t any guidance at all from the professional organizations. That’s interesting that they say it’s not known if it’s helpful. And so they just recommend having a shared decision-making conversation. Right. That’s coming from the Society for Maternal-Fetal Medicine in the United States, those are the high-risk obstetricians.

Morgan Richardson Cayama – 00:40:40:

And so for advanced maternal age, there’s some research that compares that too. And IVF is also kind of associated with like advanced maternal age to people that are advanced maternal age is like older than 35. More of them tend to be like IVF pregnancies as well. And like it’s kind of like a weak recommendation that induction at 39 weeks for birthing people who are at least 35 years of age. But also taking into consideration like fetal and maternal monitoring and the patient preference. So again, that sort of shared decision making piece is important there. And again, no, nothing that’s saying definitively, like this must be a thing that people do, but should be something considered to reduce risks of potential health issues.

Rebecca Dekker – 00:41:24:

All right. I think my last question is just, and we can crowdsource this a little bit if you want. There’s so many doulas in the room. So what are some strategies that doulas can use to help their clients if their clients are just continuously experiencing this talk about the 39-week induction with their provider? So. Sasha says prepare them ahead of time that they will face this. Molly says, ask the, what would it look like question? So like, what would an induction look like for you versus what would spontaneous labor? Ask why? Refer them to EBB. Sing the boundary song. Oh, we need someone to sing that for us. I don’t know if I knew that. Using the BRAIN or BRAND acronyms, which most birth workers are familiar with. Ask why this is relevant for me as an individual and my baby. What is the diagnosis for it? Bring it up during your prenatal appointments as a doula, because it’s one of the biggest things that happens to your clients. Ask your provider in advance, at what point do you recommend an induction and why? Asking what are my risk factors, not just for generalizing me as part of a large group. Teach them they have rights to their body and their autonomy. Take a doula with you to your late-term appointments. That’s great. I was just at a Kansas City, birth worker conference, and there were several maternal fetal medicine and obstetrician doctors in the room. And one of them said, I love it when doulas come with their clients to their prenatal visit, because then I can meet them and we can build a rapport. So that was really cool. 

So that concludes the replay from our live Q&A all about the evidence on the ARRIVE trial. Thank you so much for listening, and I’d love to know what did you think? What did you learn? Were your questions answered? Please let us know. You can message us at Instagram @ebbirth, or you can leave a review of the Evidence Based Birth® podcast on your favorite podcast platform. 

I have good news for you. If you enjoyed today’s episode, we will be adding one more podcast to our mini-series on the ARRIVE trial. That will come out in mid-January 2025 when we will talk about evidence-based ways to lower the risk of cesarean that do not involve having an elective medical induction. So that will come out in Evidence Based Birth® podcast episode 343. If you’re listening to this episode and you’re already an Evidence Based Birth® PRO Member, I wanted to let you know that you can get a contact hour for this Q&A inside your Evidence Based Birth® Academy monthly training replay page, and you can also access inside your PRO Member library, a full-length printer friendly PDF of all the evidence on the ARRIVE trial, if you’re not an EBB PRO Member but you’re interested in getting involved, keep your eyes peeled because we will be hosting a special end-of-the-year sale on our PRO membership the last days of December. Thanks everyone for joining us, and I’ll see you next week. Bye! 

Today’s podcast was brought to you by the signature articles at Evidence Based Birth®. Did you know that we have more than 20 peer-reviewed articles summarizing the evidence on childbirth topics available for free at evidencebasedbirth.com? It takes six to nine months on average for our research team to write an article from start to finish. And we then make those articles freely available to the public on our blog. Check out our topics ranging from advanced maternal age to circumcision, due dates, big babies, Pitocin, vitamin K, and more. Our mission is to get research evidence on childbirth into the hands of families and communities around the world. Just go to evidencebasedbirth.com, click on blog. And click on the filter to look at just the EBB signature articles.

The lead researcher on the ARRIVE Trial also conducted a meta-analysis on induction of labor at 39 weeks, looking at prior studies on this topic (Grobman & Caughey 2019). It’s difficult to tell if this analysis was completed before or after the ARRIVE trial data had been analyzed, but the ARRIVE trial was not used in this paper. Instead, the researchers only included studies with observational data, such as data collected via hospital records. The patients in these studies were not assigned randomly to receive different types of interventions or treatments. Researchers simply “observed” what happened.

For this meta-analysis, the researchers were interested in looking at differences in Cesarean births and other health outcomes among birthing people and babies between people who were induced at 39 weeks and those who had expectant management. Their meta-analysis included 6 studies with 66,109 birthing people who were inducted at 39 weeks and 584,390 who had expectant management. They found that those in the 39- week induction group had fewer Cesarean births (26% compared to 29% in the expectant management group). In contrast to the ARRIVE trial, the Cesarean rates in this meta-analysis are more comparable to the real world.

In this analysis they also found lower risks of respiratory issues in newborns (0.7% in the induction group vs. 1.5% in the expectant management group), NICU admission (3.5% in the induction group vs. 5.5% in the expectant management group), and newborn death (0.04% in the induction groups vs. 0.2% in the expectant management group). However, the absolute risk of many of these outcomes was very small, meaning that these outcomes are rare overall.

Care	Routine Use	Cost	Effectiveness	Notes
Receive care from a provider with a low Cesarean rate	· In the U.S., most providers do not publicly report their individual Cesarean rates. · A study in the U.S. found that most people choose a maternity care provider based on who accepts their health insurance (86%), who is a good match for what they want/value (69%), and who attends births at their birth setting of choice (68%) (Declercq et al. 2014). · In an Australian study, participants ranked their top information needs when making decisions about their maternity care options. Their top three priorities were cost, choice of mode of birth (vaginal or Cesarean), and choice of care provider (Stevens et al. 2016).	· The ability to choose a care provider with a low Cesarean rate is dependent upon the health care system in which you are giving birth, whether you have private or public insurance coverage, the availability (or shortage) of providers, and their location.	· A study of the association between care provider attitudes towards birth and Cesarean rates found that those with more positive attitudes towards Cesareans (i.e. preferred Cesareans over vaginal births) had higher Cesarean rates. For every 1-point increase in their attitude, their Cesarean rate for low-risk first-time birthing people increased (White VanGompel et al. 2018).	· Cesarean rates vary widely by provider. · Financial incentives for providers have been found to increase the likelihood of Cesarean birth (Little et al. 2016; Foo et al. 2017).
Receive midwifery-led care	· Only 12% of all births in the U.S. were attended by a midwife in 2021 (Government Accountability Office 2023). · Maternity care is commonly provided by midwives in other countries. For example, 32% of births in England between 2021-2022 were attended by midwives (NHS, 2022). Midwives were the primary caregivers in 57% of births in the Netherlands in 2019 (UNFPA 2021). · Some countries (e.g., England, Netherlands, New Zealand, France, Italy) have midwifery units (MUs) that are locations where midwives have primarily responsibility for maternity care (Rayment et al., 2020).	· The ability to choose a midwife is dependent upon the health care system in which you are giving birth, if you have private or public insurance coverage, the availability (or shortage) of providers, and their location.	· A 2024 Cochrane review found that midwifery care likely reduces Cesareans (from 16% down to 15%) (Sandall et al. 2024). However, there were limitations with some of the studies included in this review. For example, some of the people in the comparison groups in these studies (the “physician” groups) also received care from midwives, which may have diminished the impact that could be observed in the midwifery care group. · A study conducted in the U.S. found a 30% decrease in the relative risk of Cesarean among first-time birthing people whose hospital care was provided by a midwife compared to an obstetrician (Souter et al. 2019). · Hospitals with a higher percentage of midwife-attended births have been found to have lower Cesarean rates. One US study found a Cesarean rate of 15% for hospitals that had more than 40% of their births attended by midwives (Attanasio and Kozhimannil 2018).	· The midwifery model of care is focused on patient autonomy, minimal use of interventions, and facilitating normal vaginal birth whenever safely possible. · For more information on midwives, check out EBB’s Podcast Episode #175 “Evidence on Midwives.”
Give birth in a setting with a low Cesarean rate	· A survey of birthing people in California found that only about a third (32%) looked for information on hospital Cesarean rates when choosing their hospital (Sakala et al. 2018). · Another survey found that many (77%) think the hospital they chose to give birth in will not impact their risk of Cesarean, and only 25% said the Cesarean rate of their hospital mattered to them (Gourevtich et al. 2017). · Rates of births in non-hospitals settings (where Cesarean rates are substantially lower) are rising but are still low overall. In 2019, only about 1% of U.S. births were planned home births and 0.6% were at birth centers (MacDorman et al. 2022). · Births outside of the hospital are more common in other countries. In England and Wales, 2.4% of births in 2020 were homebirths (ONS 2021). In Canada, 2.4% of births in 2021 were non-hospital births (Statistics Canada 2022).	· The ability to choose a hospital, birth center, or home birth is dependent upon health care system in which you are giving birth, if you have private or public insurance coverage, the availability of these options, and their location. · Hospitals that have lower Cesarean rates (<15%) exist, but are uncommon in the U.S., South and Central America, and other parts of the world.	· A study in the U.S. found that birthing people whose care was provided by midwives and who planned a home or birth center birth had a Cesarean birth rate of 11.4% (Nethery et al. 2021). · Studies have found Cesarean rates ranging from 6-12% in planned freestanding birth center births (NAS 2020). · Studies have found Cesarean rates of around 5% for planned home births (NAS 2020). · In contrast, low-risk Cesarean rates in hospitals across the US range from 9% to 19% (Ouyang et al. 2022).	· People giving birth in hospitals that make higher profits per Cesarean procedure have higher odds of their patients having a Cesarean birth (Sakai-Bizmark et al. 2021). · You can find additional information on U.S. hospital rates of Cesareans and other interventions at Leapfrog Group (www.leapfrogroup.org).
Avoid routine, non-medically indicated ultrasounds near the end of pregnancy	· ACOG recommends at least one standard ultrasound during pregnancy, between 18-22 weeks (ACOG 2024). · Elective ultrasounds (without a clear medical indication) near the end of pregnancy may increase the risk of induction and/or planned Cesareans if the care provider suspects a possible “big baby.”	· Cost savings from avoiding a routine third trimester ultrasound in the US may range from $200-$300, depending on location and insurance coverage. ·	· Only one in ten babies are born large, but a study published in the US found that two in three families were told their babies were “too big.” One in three families said their care provider discussed planning a Cesarean because of their suspected big baby (Declercq et al. 2013). Suspected big babies were the fifth most common reason for a Cesarean (Declercq et al. 2013). · Ultrasound estimates of babies’ birth weights are not always accurate, and care providers who suspect big babies are more likely to recommend Cesareans (Blackwell et al. 2009; Dude et al. 2019).	· Ultrasounds are only right at predicting a baby’s size about half of the time. · Ultrasound weight results near the end of pregnancy can fall anywhere from 15% above or below the baby’s actual weight. · For more information on big babies, check out EBB’s Signature Article, Evidence On: Induction or Cesarean for a Big Baby.
Receive doula support	· A survey in the US found that 6% of birthing people used a doula during childbirth (Declercq et al. 2013). · A survey of birthing people in California found that 9% use a doula and rates were higher among Black women (15%) and Latina women (10%) (Sakala et al. 2018).	· The cost of doula can vary based on a variety of factors (e.g., location; services provided; any specialized skills, training, or certifications the doula holds). · In some U.S. states, there is Medicaid coverage for doula support. · Some programs offer grant-funded doula services for free (grant-funded or volunteer doulas), or on a sliding scale for those unable to pay full price. · Researchers have looked at cost savings associated with doula support and its prevention of Cesareans and other health issues (e.g., preterm births) in the US. These costs savings range from $800 to over $1300 (Greiner et al. 2019; Kozhimannil et al. 2016).	· A Cochrane review found that continuous support in labor from a doula led to a 39% relative risk decrease in the risk of Cesarean (Bohren et al. 2017). · The Number Needed to Treat (NNT) is the number of patients who need to be treated to prevent one bad outcome. In this case, it’s the number of birthing people receiving doula support needed to prevent one Cesarean. · 1 Cesarean could be prevented for every 9 people receiving doula support. However, when looking only at those who were induced, 1 Cesarean could be avoided for every 2 people receiving doula These NNTs were calculated from a 2008 study assessing the impact of doula support on Cesarean birth in the U.S. (McGrath and Kennell 2008).	· A 2019 Cochrane Review found that there are barriers to doula care globally, including: 1) the perception that labor support and emotional support are lower priorities than physical health and medical care; 2) not all birth settings welcome labor companions; and 3) health care staff are not prepared to work together with doulas or value what they bring to the team. · For more information on doulas, check out EBB’s Signature Article Evidence on: Doulas.
Plan a waterbirth	· A study using hospital data from over 46,000 births in England found that 14% were waterbirths (Aughey et al. 2021). · A study from New Zealand looking at over 19,000 births found that 8% of people used a birth pool or bath during labor and birth (Maude & Kim 2020). · A study from the U.S. looking at birth centers between 2012-2017 found that 38% of their births were waterbirths (Snapp et al. 2020). · Researchers note that waterbirths aren’t always recorded or reported by the care provider, and so they may be underestimated in studies.	· If waterbirth is an option in your chosen birth setting, the cost will depend on whether you have public or private insurance and whether the setting charges any additional fees for waterbirths. For example, some may charge for a tub rental. It’s best to contact the birth setting directly to learn more about their options and costs. · Some birthing people may choose to purchase their own birthing tub, and prices range anywhere from $200 to over $1,000.	· Research on whether waterbirths can lower the risk of Cesarean are mixed. · In a study from Iran, birthing people who labored and birthed in water had a lower rate of Cesarean birth compared to those who gave birth on land (5% versus 16%) (Ghasemi et al. 2013). · In contrast, a systematic review and meta-analysis found no difference in rates of Cesarean between laboring or giving birth in water compared to no water immersion or land birth (Burns et al. 2022).	· Waterbirths are not available in many hospitals. It’s important to research nearby birth settings to find out whether this is an option for you. · Some birth settings support water immersion only during the pushing phase. Others allow babies to be born in the water. · For more information on waterbirths, check out EBB’s Signature Article, Evidence on: Waterbirth.
For a healthy person in spontaneous labor, wait to go to the hospital until you are in active labor or require medical interventions or pain relief.	· In one U.S. study, 65% of birthing people were admitted to the hospital after their contractions had become regular and were less than 5 minutes apart (Kjerulff et al. 2023). · A study in Italy found that about half (52%) of birthing people were admitted to the hospital in active labor (Rota et al. 2018).	· There is no monetary cost to waiting until active labor to go to the hospital.	· Studies have consistently found that birthing people admitted to the hospital in early labor are more likely to have a Cesarean. · A U.S. study found a lower rate of Cesareans for those admitted in active labor compared to pre-labor (7% versus 16%) (Neal et al. 2014). · Another study from the U.S. found that birthing people who were admitted to the hospital later with cervical dilation of 4.5-5.5 cm had a lower risk of Cesarean compared to those admitted early with a dilation of 0.5-1.5 cm (4% versus 18%) (Mikolajczyk et al. 2016). · A study from the U.S. found that birthing people who were admitted to the hospital after their contractions had become regular and were less than 5 minutes apart had about half the odds having a Cesarean birth compared to those admitted earlier (15.7% vs. 24.0%) (Kjerulff et al. 2023).	· Some people use the “4-1-1” rule to decide when to go to their birth setting – when you’ve been having contractions that are 4 minutes apart, that are about 1 minute long, and that have been happening for at least 1 hour. This is not a strict rule, but a general guideline (and may not work for everyone). · Other benefits of staying at home longer during the first stage of labor include the freedom to move around, be in a comfortable/familiar environment, and to eat or drink as you please. · However, some people may choose or need to arrive at the hospital earlier. For example, those who have challenges with transportation or those who desire pain relief earlier in their labor.
Movement during labor	· In a study of birthing people in the US, 43% of those who experienced labor reported walking around after they were admitted to the hospital and were having regular contractions (Declercq et al. 2013). · In a study of birthing people in California, 39% of birthing people who experienced labor reported walking around after they were admitted to the hospital (Sakala et al. 2018).	· There is no monetary cost to moving around during labor.	· A Cochrane review found that birthing people who were in an upright position (walking, sitting, standing, kneeling) during the first stage of labor had a 29% decrease in the risk of having a Cesarean compared to those who were in recumbent positions (lying on their backs, lying with the head of the bed raise, or side-lying) (Lawrence et al. 2013).	· Birthing people with an epidural also have options for movement during labor and are often encouraged to switch positions every 30 to 60 minutes. · To learn more, check out EBB’s Signature Article, Evidence On: Birthing Positions.
Use a peanut ball (peanut-shaped birth ball) to assist with positioning if you have an epidural or have to stay in bed during labor.	· The percentage of people who use a peanut ball in labor is unknown.	· Many (but not all) birth settings have peanut balls that can be used by patients in labor at no extra cost. · For someone who wants to own their own peanut ball, a set of 3 balls typically costs less than $100.	· A small, randomized trial conducted in the U.S. found a lower rate of Cesareans in those who used peanut balls during labor compared to those who did not (10% vs. 21%) (Tussey et al. 2015). · A NNT was calculated from this study and found that 1 Cesarean could be avoided for every 10 people who used a peanut ball (Tussey et al. 2015). · A US study of birthing people who had epidurals found that those who used a peanut ball cut their odds of having a Cesarean in half (21% vs. 27%) (Hickey and Savage 2019). · A 2021 systematic review that included 6 randomized trials found no difference in Cesarean rates between those who used a peanut ball and those who did not. However, the evidence was rated as being very poor and researchers note that higher quality studies are needed on this topic (Ahmadpour et al. 2021).	· To learn more, check out EBB Podcast Episode 45: How do peanut balls support labor?
Don’t lay on your back during labor.	· Most people labor and birth while lying on their backs (sometimes called supine, lithotomy, or recumbent), despite evidence showing the benefits of upright positions (e.g., walking, sitting, standing, kneeling). · A study in England found that only 16% of people gave birth in an upright position (Care Quality Commission 2022). · A study in the U.S. found that very few people gave birth in upright positions, such as squatting or sitting (4%) or on hands-and-knees (1%) (Declercq et al. 2013). · In movies and television shows, the most shown labor and birth position is laying on your back in bed.	· There is no monetary cost for laboring or birthing in an upright position or out of bed.	· A Cochrane review found that birthing people who were in an upright position (walking, sitting, standing, kneeling) during the first stage of labor had a 29% decrease in the relative risk of having a Cesarean compared to those who were in recumbent positions (lying on their backs, lying with the head of the bed raise, or side-lying) (Lawrence et al. 2013).	· Upright birthing positions are possible with both medicated and unmedicated births. · To learn more, check out EBB’s Signature Article, Evidence On: Birthing Positions.
Receive intermittent fetal auscultation (hands-on listening) instead of electronic fetal monitoring.	· Continuous electronic fetal monitoring (EFM), sometimes called cardiotocography or CTG, is the most common type of fetal monitoring and routinely used in hospitals. · Intermittent fetal auscultation (using a Doppler ultrasound or special stethoscope to listen to the fetal heartbeat at regular time intervals) is less common. · In a study of birthing people in the US, only 11% reported receiving hands-on listening (Declercq et al. 2014)	· Where available, birth settings do not typically charge extra for hands-on listening. Hands-on listening may require closer nursing care and may not be possible in a setting where each labor nurse has multiple clients.	· A systematic review and meta-analysis found that there was a 17% decrease in the relative risk of Cesarean for those who had hands-on listening compared to CTG (Wattar et al. 2021) · A Cochrane review found a 39% decrease in the relative risk of Cesarean for those with hands-on listening compared to continuous EFM. However, the researchers noted that the Cesarean rate in the included studies was not reflective of current rates. They estimated that with a modern Cesarean rate, those with continuous EFM would have a rate of about 24% compared to 15% among those with hands-on listening. Using these more realistic estimates, they calculated a NNT and found that for every 11 people with continuous EFM, there would be one additional Cesarean (Alfirevic et al. 2017).	· Hands-on listening may lower the Cesarean rate because it has a lower rate of “false positives” and so fewer emergency Cesareans are performed. · It also gives birthing people more freedom of movement during labor. · For more information on fetal monitoring, check out EBB’s Signature Article, Evidence on: Fetal Monitoring.
Stay well-hydrated during labor	· A combination of unrestricted access to oral fluids and IV fluids of 250 mL/hr have been shown to reduce the risk of Cesarean, possibly by helping to shorten labor and reduce the likelihood of being diagnosed with “failure to progress” (Ehsainipoor et al. 2017; Dawood et al. 2013). · In a study in the US, 62% of people reported receiving a continuous drip of intravenous (IV) fluids during labor (Declercq et al. 2014). · A study of birthing people in California found that 76% received IV fluids during labor with midwives and 87% with an obstetrician (Declercq et al. 2020). · In a survey of birthing people in the US, 60% reported not drinking during labor and 80% reported not eating (Declercq et al. 2014). · A Canadian study found that 60% of people without epidurals and 83% with epidurals were restricted from eating or drinking anything in labor besides ice chips and clear fluids (Chackowicz et al. 2016).	· Use of IV fluids during labor is often routine in hospital settings. · In some birth settings, people may be told they cannot eat or drink in labor (other than clear liquids). However, many professional organizations recommend that people be able to choose whether they want to eat and drink during labor.	· A meta-analysis comparing IV fluid intake found a 30% decrease in the relative risk of Cesarean among those who received IV fluids at 250 mL/hr compared to 125 mL/h in hospital settings (Ehsanipoor et al. 2017). · The authors calculated an NNT and estimated that treating 18 people with IV fluids at a rate of 250 mL/hr could prevent 1 Cesarean (Ehsanipoor et al. 2017). · Low-risk people who give birth out-of-hospital who have free access to oral fluids and food (instead of routine IV fluids) also experience low rates of Cesarean (5-6%) (Cheyney et al. 2014; Stapleton et al. 2013).	· Although large volumes of IV fluids (250 mL/hr) may help shorten labor and reduce the risk of Cesarean birth, a higher amount of fluids may lead to an artificial drop in newborn weight and possible painful chest swelling, which may negatively impact breast- or chestfeeding. · If you are not receiving IV fluids, another alternative is to ensure that you are taking in at least 240 mL (1 cup) of oral fluids per hour. · For more information on IV fluids and eating or drinking during labor, check out EBB’s Signature Articles, Evidence on: Eating or Drinking During Labor.
For breech births, consider an external cephalic version (ECV) or vaginal birth	· Breech position (bottom first) occurs in 3-4% of term pregnancies and most (93%) in the U.S. are born by Cesarean (ACOG 2020). · An external cephalic version (ECV), or procedure done by a care provider to help turn the baby into a head-down position, was only done with 0.2% of births in the U.S. in 2019 (CDC 2019). · The success rate of these ECV procedures was 49%. Of these successes, 72% went on to have a spontaneous vaginal birth while 24% had a Cesarean. These data suggest that more than a third of people with term breech pregnancies could avoid a Cesarean if everyone attempted an ECV (CDC 2019). · ACOG estimates that 20-30% of people in the US who are eligible for an ECV are not offered it (ACOG 2020).	· In the U.S., ECVs are considered a part of regular, routine prenatal care covered by insurance. · However, ECVs take extra time and resources (e.g., possible medications, extra monitoring), and birth settings and care providers may not be reimbursed for some of these resources in the U.S. This may be why birth settings and care providers do not often offer them. · A study on cost-effectiveness found that those with successful ECVs who had vaginal deliveries had cost savings of 35% in the total cost of their deliveries. In their study the total cost of care for those without ECV was over $6.6 million dollars, compared with $4.3 million in those who had ECV (Bangalore et al. 2021).	· A Cochrane review found that attempting an ECV at term decreased the relative risk of Cesarean by 43%. However, these data are from older studies, when breech vaginal births were more common. If these trials were replicated today, they might find even larger reductions in the risk of Cesarean (Hofmeyr et al. 2015). · We calculated an NNT based on this Cochrane review and found that 1 Cesarean could be avoided for every 8 ECV attempts with breech positioning.	· Note that ECV and breech vaginal birth are different options, and each has its own risks and benefits. Also, some health care providers may be skilled in ECV but not in breech vaginal birth. · For more information on breech births and ECV, check out: · EBB’s Signature Article, EBB Podcast Episode #173 “Evidence on External Cephalic Version for Breech Positioned Babies” · EBB Podcast Episode #296 “Evidence on Breech Birth”, · EBB Podcast Episode #297 “Frequently Asked Questions about Breech”
Have patient health care providers who provide you with enough time in labor and while pushing.	· Some care providers may not give birthing people enough time in labor before diagnosing them with failure to progress, a first or second stage labor arrest, or a failed induction of labor. · These are common reasons for Cesareans, and one article states that 25% to 55% of all Cesareans are because of “slow labor” (Lefevre et al. 2021). · In a study from the US, researchers found that 73% of Cesareans that were carried out because of a “failed induction” or “labor arrest” did not actually follow recommended guidelines for diagnosing these issues (Alrais et al. 2019).	· Professional guidelines encourage care providers to give birthing people adequate time during labor. · However, this extra time can be more costly for birth settings in terms of extra resources, hospital beds, and staff needed to support longer labors.	· A study from Italy looked at Cesarean rates among those who received a model of care based on updated labor guidelines. These updated guidelines (meant to prevent unnecessary Cesareans) discourage providers from diagnosing labor arrests and failed inductions unless specific criteria are met. They also recommend giving birthing people more time during labor and while pushing (Ragusa et al. 2016). · They found that birthing people receiving this updated model of care had half the rate of Cesareans compared to those receiving the old model of care (10% vs. 22%) (Ragusa et al. 2016).	· It’s normal for labors that are induced to take 2-4 days. · Professional organizations have recommendations for how long someone should be given in labor before being diagnosed with first or second stage labor arrests or with a failed induction. You can find out more about these at the end of this article about the ARRIVE trial. · To learn more, check out EBB’s Signature Article: Evidence on Failure to Progress, ACOG’s article on “EBB Podcast Episode #159 “Failure to Progress”

 

First Author (Year)	Study Population	Methods	Findings	Notes
Nethery (2023)	First-time birthing people who were pregnant with a single, head-down baby and who were at least 39 weeks pregnant.	·   Data from 13 hospitals in the Pacific Northwest U.S. ·   Interrupted time-series analysis that looked at immediate changes and long-term trends in rates of induction, elective induction, unplanned Cesareans, pregnancy-related high blood pressure, serious health issues for babies, and NICU admission. ·   This type of analysis controls for underlying changes in things like elective inductions or changes in the population over time using specific statistical methods. So, this study “mimics” a randomized control trial while using observational data. ·   Compared rates before and after the ARRIVE trial. ·   The pre-ARRIVE period included 15,208 births from January 2016 – July 2018. ·   The post-ARRIVE period included 13,048 births from August 2018 – December 2020.	·   The overall rate of induction was 39% and increased from 35% pre-ARRIVE to 43% post-ARRIVE. ·   The rate of elective induction was 7% and increased from 4% pre-ARRIVE to 11% post-ARRIVE. ·   There were no differences in rates of unplanned Cesarean births (27% pre-ARRIVE and 26% post-ARRIVE), hypertensive disorders of pregnancy (pre-eclampsia, eclampsia, or gestational hypertension) (8% pre-ARRIVE and 10% post-ARRIVE), or NICU admission (7% pre- and post-ARRIVE). ·   There were no immediate changes in serious health issues for babies, but there was a 3% relative increase over time.	The researchers noted that their study may not have included enough elective inductions to see a true difference in Cesarean rates or pregnancy-related high blood pressure.
Wood (2023)	First-time birthing people who were pregnant with a single, head-down baby with no congenital conditions and born at 39 weeks or later.   They did not include birthing people with chronic high blood pressure or diabetes.	·   Data from U.S. birth certificates. ·   Interrupted time-series analysis to look at immediate changes and long-term trends in rates of 39-week inductions (not elective inductions specifically) and Cesareans. ·   Compared rates before and after the ARRIVE trial. ·   The pre-ARRIVE group included 2,860,942 births from January 2016 – July 2018. ·   The post-ARRIVE group included 971,343 births from November 2018 – March 2020.	·   The rate of 39-week inductions immediately increased, to a rate of 15.0% versus an expected 13.8% (expected based on trends before the ARRIVE trial was published). ·   Cesarean rates decreased over time (25.1% pre-ARRIVE versus 24.7% post-ARRIVE) and were lower than expected based on trends before the ARRIVE trial.	·   Birth certificates do not include the reason for induction. ·   The decrease in Cesarean rates was statistically significant, but small. Large studies are more likely to have significant findings because of something called power. This is where more observations (or data from a much larger number of participants) make it easier for the statistical tests to have mathematically significant results.
Atwani (2024)	First-time birthing people who gave birth between 39 and 42 weeks.   They did not include birthing people with chronic high blood pressure, diabetes, or babies with congenital conditions.	·   Data from U.S. birth certificates. ·   Interrupted time-series analysis to look at immediate changes and long-term trends in rates of inductions and Cesarean births. ·   Grouped participants by BMI and looked at changes in those with a BMI > 40 kg/m2 and those with a BMI < 40 kg/m2. ·   Compared rates before and after the ARRIVE trial. ·   The pre-ARRIVE group included 1,087,832 births from August 2016 – July 2018. ·   The post-ARRIVE group included 1,038,435 births from January 2019-December 2020.	·   Overall rate of inductions and inductions at 39 weeks increased for both groups of birthing people (those with BMI < 40 and with BMI > 40). ·   The relative risk of Cesarean decreased by 2% for those with BMI < 40, but did not change for those with BMI > 40.	Birth certificates do not include the reason for induction.
Gilroy (2022)	First-time birthing people who were pregnant with a single baby, who started prenatal care by the 12th week of pregnancy, and whose babies were born between 39 weeks to 42 weeks and 6 days.   They did not include birthing people with chronic high blood pressure or pre-pregnancy diabetes, or whose babies had congenital conditions.	·   Data from U.S. birth certificates. ·   Examined changes in Cesarean rates and health outcomes for birthing people (blood transfusions, ICU admission) and babies (breathing assistance, Apgar score < 3 at 5 minutes, NICU admission, seizures, and whether surfactants were used – a medication to help with breathing issues). ·   Compared outcomes between those with inductions at or beyond 39 weeks of pregnancy and those with spontaneous labors. ·   Compared rates before and after the ARRIVE trial. ·   The pre-ARRIVE group included 1,966,870 births from January 2015 – December 2017. ·   The post-ARRIVE group included 609,322 from January 2019 – December 2019.	·   Rate of induction at or beyond 39 weeks increased from 30% to 36%, and the odds of induction increased by 36% in the post-ARRIVE period. ·   Cesarean rates decreased slightly (27.9% pre-ARRIVE versus 27.3% post-ARRIVE). ·   Birthing people in the post-ARRIVE group were more likely to be admitted to the maternal ICU (0.09% versus 0.08%) and more likely to have infants who needed immediate assisted breathing support (3.5% versus 2.8%). ·   Compared to spontaneous labors, inductions had a higher risk of most health issues for babies, except for surfactant use.	·   Birth certificates do not include the reason for induction. This is why their induction group included both elective and medically indicated inductions. ·   Depending on the reason for the medically indicated induction, it would be more common to see health issues in babies with these types of inductions. Some of these inductions likely occurred because there was a maternal health condition that affected the baby, or a problem with the baby in utero. This means that in some cases, there was a pre-existing health condition rather than the induction causing a health issue in the baby.
Futterman (2023)	First-time birthing people whose babies were born between 39 weeks to 41 weeks and 6 days.   They did not include birthing people with chronic high blood pressure or pre-pregnancy diabetes, or who had insufficient prenatal care.	·   Data from U.S. birth certificates. ·   Looked at changes in pregnancy-related high blood pressure. ·   Compared trends in people with and without inductions at 39 weeks (elective or medically indicated). ·   They compared rates before and after the ARRIVE trial. ·   The pre-ARRIVE Group included 1,610,594 births from January 2015 to December 2017. ·   The post-ARRIVE group included 987,494 births from January 2019 to December 2020.	·   Pregnancy-related high blood pressure increased overall among all births (4.9% pre-ARRIVE versus 6.3% post-ARRIVE). ·   However, pregnancy-related high blood pressure decreased among those induced at 39-weeks (14.7% pre-ARRIVE versus 14.1% post-ARRIVE) and decreased gradually each year. ·   The rate of pregnancy-related high blood pressure was higher in the induction group, because this group included both medically indicated and elective inductions. However, this rate decreased in the post-ARRIVE period. ·   Researchers suggest that this decrease may have been because of an increase in elective inductions at 39 weeks.	·   Birth certificates do not include the reason for induction. ·   Researchers concluded that because we’re seeing increasing rates of high blood pressure in term pregnancies, elective inductions at 39 weeks could help lower this risk. ·   Note from EBB: If the reduction of pregnancy-related high blood pressure that we saw in the ARRIVE was real and can be applied to the general population, and elective inductions at 39 weeks have been adopted widely, then it is interesting that we are continuing to see an overall rise in pregnancy-related high blood pressure. This may be because we are attempting to solve this problem with elective inductions, rather than getting at the root cause of the increase in high blood pressure.
Langen (2023)	First-time birthing people who were pregnant with a single, head-down baby and who were at least 39 weeks pregnant.   They did not include birthing people with an uncertain gestational age, those with pre-pregnancy diabetes or high blood pressure.	·   Data from 68 hospitals across Michigan. ·   Compared Cesarean rates and health outcomes between those with elective induction at 39 weeks and expectant management. ·   Birthing people outcomes included: included differences in operative vaginal deliveries (births with forceps or vacuum), maternal ICU admission, chorioamnionitis (infection in the placenta or amniotic fluid), and perineal tears. They also compared Bishop scores at the time of hospital admission (< 5 and ≥ 5). This score can help predict how close a pregnant person is to labor. ·   Baby outcomes included: birth weight, 5-minute Apgar score, NICU admission, arterial cord pH (the pH of blood in the umbilical cord), and shoulder dystocia. ·   Data were from January 1, 2020 to December 31, 2020 and included 1,558 people in the elective induction group and 12,374 people in the expectant management group. ·   Conducted a general, unmatched analysis and an analysis where they matched participants on key factors like age, race, and health status.	·   In unmatched analyses, Cesarean rates were higher in the elective induction group (30.1% versus 23.6%). The elective induction group spent more time in labor (25 hours versus 16 hours) and had slightly higher rates of postpartum hemorrhage (10.1% versus 8.3%), forceps- or vacuum-assisted birth (11.4% versus 9.3%), and shoulder dystocia (4.1% versus 3.0%). ·   In matched analyses, there were no differences in Cesarean rates. Those who were induced had longer labors (24.7 hours versus 20.1 hours) and slightly higher rates of shoulder dystocia (4.1% versus 2.5%). Babies born in the expectant management group had slightly higher birthweights (3,493 grams versus 3,429 grams).	·   In this “real world” look at induction and expectant management, they found that the two unmatched study groups were different at baseline. ·   For example, birthing people in the elective induction group were more likely to be at least 35 years old, identify as white and non-Hispanic, and have private insurance. This finding suggests there are real-world differences in who gets recommended for an elective induction at 39 weeks and/or who chooses to have an elective induction. ·   Fewer people in the elective induction group had favorable Bishop scores at hospital admission (15%) compared to those in the expected management group (54%). This means that almost 9 out of 10 people in the elective induction group were not at all close to being in labor when they were admitted for their induction.
Jelks (2023)	All deliveries occurring at or beyond 36 weeks of pregnancy.   They included people giving birth for the first time and those who had given birth before, as well as both low-risk and high-risk birthing people.	·   Data from one hospital in California. ·   Looked at changes in outcomes before and after starting a new labor induction policy allowing 39-week inductions. It was left up to the attending health care provider to decide who they felt would be a good candidate for induction. ·   Primary outcome was gestational age, delivery reasons, rates of induction and elective induction, and time from admission to birth. ·   Also looked at Cesarean rates, reasons for Cesareans, and maternal and newborn health issues. ·   The pre-policy group included 2672 births from March 2019 to February 2020. ·   The post-policy group included 2526 births from May 2020 to April 2021.	·   Rates of elective deliveries at or beyond 39 weeks increased overall (19.2% pre-policy versus 40.0% post-policy). ·   Rates of elective inductions at 39 weeks increased for low-risk people giving birth for the first time (5.6% pre-policy versus 28.3% post-policy) and low-risk people who had given birth before (8.3% versus 32.3%). ·   No changes in Cesarean rates overall or among low-risk birthing people (neither first-time birthing or those who had given birth before). ·   No changes in maternal and newborn health issues, aside from chorioamnionitis, which increased (8.0% pre-policy versus 9.6% post-policy). ·   The time from admission to birth increased (median of 12.8 hours pre-policy versus 15.6 hours post-policy) and this was driven by longer labors among those with elective inductions at or beyond 39 weeks.	·   Researchers in this study found an increase in 39-week inductions and elective induction at 39 weeks among low- and high-risk people and among those who were giving birth for the first time and who had given birth before. ·   This study looking at the impact of a nonrestrictive induction policy at one hospital suggest that in the “real world”, health care providers may be more likely to perform inductions at 39 weeks or recommend elective inductions at 39 weeks to all birthing people. ·   This is important because the ARRIVE trial and current research on the impact of elective inductions at 39 weeks has only been done with low-risk first-time birthing people.
Muller (2023)	Low-risk birthing people.   They did not include birthing people who had health issues that could have been known before 39 weeks of pregnancy or who had risk factors that would have made it difficult for them to receive expectant management (e.g., pre-eclampsia).	·   Data from the National Health Service (NHS) in England. ·   Compared severe infant health issues between those who had an induction at 39 weeks and those with expectant management. ·   Primary outcome was a single indicator that combined stillbirth, neonatal death (an infant death within 28 days of birth) and 15 other diagnoses or 7 procedures for infants that have been associated with hospitalization and death in the year after birth. ·   Also compared differences in outcomes based on socio-economic status and ethnicity. ·   Data were from January 2018 to March 2021. ·   The induction group included 47,352 people and the expectant management group included 453,720 people.	·   The risk of death and severe health issues for babies was lower in the induction group (3.28% versus 3.64%). ·   Those in the induction group had a lower risk of stillbirth (0.01% versus 0.07%) but a higher risk of newborn death (0.10% versus 0.04%). ·   This slightly lower risk in the induction group remained even after the researchers considered other factors that could impact this risk (e.g., maternal age). ·   This reduced risk was greatest for first-time birthing people and those with low socio-economic status and was not different by race or ethnicity. ·   Estimated that there would need to be 360 inductions at 39 weeks to avoid 1 of these outcomes (or 210 for those with disadvantaged socio-economic status and 186 for first-time birthing people).

 

A 2020 Cochrane review was carried out to compare the effect of policies for labor induction at or beyond 37 weeks of pregnancy versus policies of expectant management (Middleton et al. 2020). In contrast to the observational studies we summarized in Table 3 (above), this Cochrane review is made up of randomized, controlled trials with low-risk participants.

The researchers identified 34 trials with a total of 21,563 low-risk birthing people. One of these included trials was the ARRIVE trial, which made up 28% of the participants in the analysis. Most of the studies took place in high-income countries, and most included a mixture of first-time birthing people and people who had given birth before. The majority of studies were testing policies of induction after 41 weeks of pregnancy (20 out of 34 trials). The other studies looked at policies of induction between 40-41 weeks (6 out of 34 trials) or before 40 weeks (8 out of 34 trials).

What did they find? They compared the timing of induction in each of these groups (before 40 weeks, between 40 to 41 weeks, and after 41 weeks) and found no differences in health outcomes. However, the researchers note that they didn’t have enough study power, or enough participants in each of these groups, to accurately tell whether there were differences. When looking at all studies (combining all gestational ages from 37 to 41+ weeks), they did see some differences in outcomes. This means that the results below do not apply specifically to 39-week elective induction, but to policies of elective induction in general.

When looking at the impact of inductions on infant health, they found that induction of labor overall was associated with fewer infant deaths. There were 4 deaths in the labor induction group (0.4 deaths per 1,000 people) and 25 in the expectant management group (3 deaths per 1,000 people). The majority of deaths in the expectant management group occurred at or beyond 41 weeks of pregnancy (19 deaths). Those with an induction had a 69% lower relative risk of infant death compared to those with expectant management. The researchers calculated a number needed to treat (NNT) and found that 544 inductions would need to be conducted to prevent one infant death.

The induction group also had a 70% lower relative risk of stillbirths – there were two stillbirths in the induction group and 16 in the expectant management group. Most (12 out of 16) of the stillbirths in the expectant management happened at or beyond 41 weeks of pregnancy. Babies born to people who were induced had a 12% lower relative risk of NICU admission and 27% lower relative risk of an Apgar score less than seven at five minutes. Babies born to people in the induction group also had a 25% lower relative risk of meconium aspiration syndrome. Babies in the induction group also tended to have a lower birthweight compared to those born to people in the expectant management group and had a 28% lower relative risk of macrosomia (being a “big baby”, defined in this study as a birthweight greater than 4000 grams). They did not find any difference in the risk of brain damage, lack of oxygen during the birth, seizures or use of anti-seizure medications, or physical trauma to the baby.

When looking at the impact of inductions on the health of birthing people, the researchers concluded that induction probably lowers the risk of Cesareans. There was a 10% lower relative risk of Cesarean birth in the induction group. They did not find any difference in operative vaginal births (with forceps or vacuum), use of epidural or regional analgesia, severe perineal tears, prolonged labor, postpartum hemorrhage, breastfeeding, or length of hospital stay.

Remember, these findings represent the combined impact of induction policies ranging from 37 weeks all the way to 41+ weeks (not 39-week elective induction alone), with most studies focusing on 41 weeks or later. So, the results from this Cochrane review cannot be applied to a policy of elective induction at 39 weeks. There is clear evidence that the risk of newborn death increases in the late-term (41 weeks 0 to 6 days) and post-term period (42 weeks and beyond), which explains why most of the stillbirths and infant deaths in this analysis occurred after 41 weeks (Muglu et al. 2019).

Also, elective inductions at 37 to 38 weeks are rarely done anymore because researchers have found an increased risk of NICU admission and newborn death with early elective inductions (at 37-38 weeks) (Parikh et al. 2015; Clark et al. 2009).

They found that overall (including participants who were giving birth for the first time and those who had given birth before) elective inductions at 39 weeks were associated with a 37% lower likelihood of perineal injury and 13% lower likelihood of forceps- or vacuum-assisted vaginal birth. There were no differences in rates of postpartum hemorrhage or emergency Cesareans between the two groups. In looking at overall infant outcomes, they found that those with elective inductions at 39 weeks had a 38% lower likelihood of a low 5-minute Apgar score and a 34% lower likelihood of macrosomia (being a “big baby”). There were no differences in shoulder dystocia or NICU admissions.

They also looked at these outcomes separately for first-time birthing people and for those who had given birth before. Among first-time birthing people who were electively induced at 39 weeks, they found a 20% lower likelihood of unplanned Cesarean birth and a 25% lower likelihood of NICU admission for babies. They found a 22% increased likelihood of shoulder dystocia among the induction group. They did not find a difference in any of the other outcomes.

Among those who had given birth before who were electively induced at 39 weeks, they found a 39% lower likelihood of unplanned Cesarean birth, a 31% lower likelihood of macrosomia (“big baby”), and a 27% lower likelihood of perineal injury. They did not see a difference in any of the other outcomes.

The researchers concluded that “This review… found that elective induction of labor at 39 weeks of gestation compared with expectant management was associated with improved labor-related outcomes, including a 37% reduction in perineal injury risk… elective induction of labor at 39 weeks of gestation is likely to be safe and beneficial for some women…” However, since they were comparing two unequal groups—a lower-risk group and a higher-risk group—this conclusion is not justified by their methods.

In 2023, a group of researchers carried out a systematic review and meta-analysis comparing health outcomes between elective induction at 39 weeks and expectant management (Hong et al. 2023). In their search for papers, the researchers included both randomized controlled trials and observational studies.

The researchers included 14 studies – 13 of these were observational studies and one was a randomized controlled trial (the ARRIVE trial). These studies represented a total of 1,625,899 birthing people who were pregnant with a single baby, including 86,555 who appeared to have been electively induced at 39 weeks. Participants in these studies included both first-time birthing people and those who had given birth before. Hong et al. excluded studies if the induction group included people with medical reasons for induction, if the study only included people pregnant with multiples (pregnant with more than one baby), or if the methods for determining gestational age (length of pregnancy) were unclear.

The researchers compared differences in health outcomes between those with elective induction at 39 weeks and those with expectant management. For health outcomes among birthing people, the researchers compared rates of emergency Cesareans, perineal injury, postpartum hemorrhage, and operative vaginal birth (with forceps or vacuum). For health outcomes among babies, they compared rates of NICU admission, 5-minute Apgar scores (<7), macrosomia or a big baby, and shoulder dystocia.

Note: The authors of this analysis live in Australia and refer to Cesareans as “emergency Cesareans”, because this is a common way of referring to an unplanned Caesarean in Australia. However, in other countries (like the U.S.), emergency Cesareans and unplanned Cesareans are referred to as separate and distinct things. An unplanned Cesarean is one that is not scheduled in advance and may be due to medical reasons or provider or parent preference. In contrast, an emergency Cesarean is when there is an urgent and immediate threat to the health of the birthing person or baby. Although Hong et al. refer to “emergency Cesareans”, the original studies they are citing all refer to these as Cesarean deliveries.

This review by Hong et al. had an important drawback that severely limits any conclusions one can draw. Most of the data came from large retrospective (looking back in time) observational studies. When our team at EBB looked at the original studies, the participants in the “elective induction groups” and the participants in the “expectant management groups” were quite different from one another. This is because there are real-world differences in who is offered an elective induction. For example, in Darney et al. (2013), the 3rd largest study in this analysis, the expectant management group was more likely to be younger, Black, not completed high school, not initiate prenatal care in the 1st trimester, and more likely to have no insurance or deliver at a teaching hospital. In contrast, the elective induction group was more likely to be older, White, have a high school education, initiate prenatal care in the 1^st trimester, have insurance, and not deliver at a teaching hospital. These are what we call “confounding factors”, or factors that can distort the results and make it impossible to determine a cause-and-effect relationship between elective induction and health outcomes such as Cesarean rates.

One way that researchers can account for these differences is to use statistical strategies to control for the confounding factors. The original investigators all controlled for at least some confounding factors in their papers, but Hong et al. did not control for any confounding factors when they combined all the data in their meta-analysis. This is not clear from reading the Hong et al. paper but was confirmed via personal correspondence with Dr. R. Hastie (October 7, 2024), who clarified that because each of the original studies measured different confounding factors, it was not possible to combine that data.

While this is understandable, it also means that the findings from this meta-analysis cannot be used to determine the health impact of elective inductions at 39 weeks.

There is no such thing as an exact “due date,” based on a person going into spontaneous labor exactly at 40 weeks. Studies exploring how long it takes the average person to go into spontaneous labor suggest there’s a range of time in which most people give birth. Research suggests that most people will go into spontaneous labor around 5 days AFTER 40 weeks. Specifically, about half of all first-time pregnant people will go into labor on their own by 40 weeks and 5 days, while about half of those who have given birth before will go into labor by 40 weeks and 3 days. (Smith et al. 2001; Jukic et al. 2013)

We explain more about this in the EBB Signature Articles, Evidence On: Due Dates and Evidence On: Inducing for Due Dates.

Some researchers consider babies to be “big” at birth if they weigh 4,000 grams (8 lbs. 13 oz.) or more, while others say a baby is big if they weigh 4,500 grams (9 lbs. 15 oz) or more. Elective inductions at 39 weeks may reduce the risk of macrosomia (big babies), as this risk increases as pregnancy goes on. However, a big baby can only be truly diagnosed after birth, and that ultrasounds are wrong about half the time at predicting a big baby.

Some providers may say that elective inductions lower the risk of shoulder, which occurs in 7 to 15% of births to big babies. However, two studies we reviewed for this Signature Article found a slightly increased risk of shoulder dystocia in the 39-week elective induction groups (Langen et al. 2023; Gilroy et al. 2022).

A Cochrane Review also looked at the impact of induction at or near the end of a term pregnancy (37 to 40 weeks) for suspected big babies compared to expectant management (Boulvain & Thornton, 2023). The researchers only found four randomized trials, representing 1,190 birthing people, to include in their review. All the participants in this review were non-diabetic.

They found that the relative risk of shoulder dystocia was lowered by about 40% for those with an induction. They also had an 80% lower relative risk of any type of fracture. Something to note is that in the largest trial included in this review (representing 822 out of the total 1,190 birthing people), inductions were conducted between 37 weeks and 38 weeks 6 days.

They did not find any difference between induction or expectant management regarding the risk of NICU admission, brachial plexus injury (injury to the baby’s nerves that carry signals between the arm and brain), Cesarean, or instrumental birth (with forceps or a vacuum). Ultimately, the authors concluded that there are advantages to induction for those with suspected big babies, but there also some drawbacks with being induced before term.

These and other researchers state that more research is needed to confidently recommend that birthing people with a suspected big baby be induced. There is a randomized trial being conducted in the UK on this topic (“The Big Baby Trial”), so keep an eye out for these results when they are published (Ewington et al. 2022).

You can learn more about the research on big babies in the EBB Signature Article, Evidence On: Induction or Cesarean for a Big Baby.

Advanced maternal age (AMA) is often defined in the U.S. as giving birth at age 35 or older, which carries an increased risk of some issues during pregnancy and childbirth.

The ARRIVE Trial included some birthing people older than age 35. However, this percentage was quite small, especially compared to the birthing population in the U.S., where more people are now having babies at older ages (Martinez and Daniels 2023). About 4% of participants the induction group and 4.5% in the EM group were 35 or older. Today, about 20% of all births in the U.S. are to birthing people who are 35 or older (Osterman 2024). The average age of participants in the ARRIVE trial was between 23 and 24, while the average of someone giving birth for the first time in the U.S. is now 27 (Osterman 2024).

A meta-analysis published in 2015 looked at different outcomes between birthing people older than 35 who were either induced or had expectant management (Walker et al. 2015). They found four studies that included over 2,500 birthing people and found no difference in Cesarean rates between the two groups. A clinical trial published in 2016 included over 600 people at least 35 years old and looked at the impact of induction at 39 weeks on some outcomes (Walker et al. 2016). They also found no difference in Cesarean birth rates and no differences in health issues for birthing people or babies.

You can learn more about the research on AMA by reading the EBB Signature Article Evidence on: Advanced Maternal Age.

When pregnancies are conceived through IVF, there are increased risks of some pregnancy and birth issues such as placental abruption, Cesarean, and stillbirth (Jackson et al. 2004; ACOG 2016, Reaffirmed 2024). However, these risks are typically higher when someone is pregnant with multiple babies versus one baby, and the absolute risk of some of these issues is low. Still, because of these risks, some care providers might recommend an induction at 39 weeks for their IVF patients. Studies show that there are higher rates of induction among birthing people with IVF compared to those with spontaneous or non-IVF pregnancies (Karavani et al. 2022).

In 2022, the Society for Maternal Fetal Medicine (SMFM) stated we do not know whether elective induction at 39 weeks reduces the risk of maternal death and health issues in babies for IVF pregnancies compared to expectant management (Ghidini et al. 2022). They recommend that people who become pregnant through IVF talk with their care providers about elective induction at 39 weeks and decide together whether this intervention is right for them.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) also does not believe that there is enough evidence to support inducing pregnancies conceived through assisted reproductive technologies, like IVF (Robinson et al. 2023).

If you’re feeling pressured to have an induction at 39 weeks, it’s important to know that you have the right to say yes or no. You also have the right to ask questions, and have those questions answered with accurate information. If you choose an induction, you have the right to help decide which induction methods will be used. You can also request more information about how the induction will unfold, like whether and what cervical ripening methods might be used, how long your health care provider will wait before starting other methods to stimulate contractions, and other processes they might use. You can also ask the induction procedures to be stopped at anytime.

Fear tactics may be used by care providers to pressure someone into having or not having an induction. An example of a fear tactic for an induction is a care provider only discussing relative risks (not absolute risks) and saying, “You have a 50% higher chance of stillbirth if you don’t have an induction right now!” If you feel that your care provider is using fear tactics or pressuring you into an induction, consider switching to a care provider who fully supports informed consent and refusal.

If your care provider recommends an elective induction at 39 weeks, consider asking the following questions:

• Why do you recommend that I have an elective induction?
• What percentage of your clients are induced? Out of the last 10 births that you attended, how many of them were induced?
• What is your Cesarean rate with inductions? OR Out of the last 10 inductions that you did, how many ended in Cesareans?
• What are your preferred methods for induction?
• Do you do cervical ripening, and what methods do you use?
• Are you open to my using a natural approach to cervical ripening, if I prefer that? What about outpatient cervical ripening?
• Would you support my right to accept or refuse this induction?
• What I decline the induction now and choose to wait 1 week? Can I reconsider if I haven’t started by labor by 40 weeks? 41 weeks?
• What exactly do your professional guidelines state about elective induction? Can I see a copy of the guidelines you are referencing? Does your hospital policy differ from these guidelines?
• Can I see your hospital’s policy for inductions? Do they permit walking around and eating during an induction?

The BRAIN acronym can also be helpful to remember.

• B – Benefits. What are the benefits of an induction at 39 weeks?
• R – Risks. What are the risks of an induction at 39 weeks?
• A – Alternatives. What are other options?
• I – Intuition or instinct. What is your gut telling you?
• N – Nothing. What would happen if I chose to do nothing, or waited to make to a decision?

EBB has a Pocket Guide to Labor Inductions with more information on reasons for induction, medical and natural induction methods, and other ways to discuss elective and medical inductions with your care provider.

It can be helpful to begin thinking early in your pregnancy about whether you are interested in an elective induction at 39 weeks. You can have a conversation with your care provider early on to learn more about their position on elective inductions and whether this is something they can offer you.

Some care providers might not offer elective inductions because they do not have the resources or time elective inductions often require. Remember that inductions can sometimes take days, requiring additional hospital resources and staff. Some care providers want to make sure that they are at your birth, and a very long induction can make this more difficult, particularly in a birth setting where shifts are rotated between providers.

If you’re planning a birth in a birth center or at home, you can talk with your care provider about whether and how they like to encourage labor to get started. In some states in the U.S., midwives cannot legally attend home births or freestanding birth center births before or after a certain gestational period (for example, before 37 weeks or after 42 weeks). So, someone who lives in one of these places (and desires a home birth or freestanding birth) may be especially interested in ways to get labor started as they get closer to 41 weeks.

Note that community midwives do not use medical methods to induce labor. So, if a medical induction is something you want, you will need to plan a hospital birth with a health care provider who can attend your birth in that setting.

If you are interested in having an elective induction and this is not something your care provider can do for you, finding out early gives you more time to look for a care provider who does perform elective inductions.

A stillbirth is the death of a fetus after 20 weeks of pregnancy until birth, classified as early (between 20-27 weeks), late (28-36 weeks), or term (more than 37 weeks) (CDC 2022). The rate of stillbirths in the U.S. declined significantly in the 1990s and early 2000s, before increasing a bit in 2010s. Since then, the rate has stayed about the same, and was 5.8 deaths per 1,000 births in 2020 (Ananth et al. 2022). Overall, the rate hasn’t changed much in the years before or after the ARRIVE trial.

When looking at the most recent data available for perinatal and early newborn deaths, there also hasn’t been much of a change. Perinatal deaths include the death of a fetus after 28 weeks and infant deaths younger than 7 days old. The rate of perinatal death in 2020 was 5.64 deaths per 1,000 deliveries and in 2021 was 5.54 deaths per 1,000 deliveries. Early newborn deaths include the death of an infant within the first 7 days of life, and these decreased by 4% between 2020 (2.86 deaths per 1,000 live births) and 2021 (2.75 deaths per 1,000 live births) (Valenzuela et al. 2023).

Overall, the U.S. has not seen much of a decrease or change in these rates since the ARRIVE trial was published.

Research is mixed, but findings seem to suggest that induction at 39 weeks is only cost effective for hospitals if Cesarean rates among induced patients are lower than with expectant management (Hersh et al. 2019). Labor and delivery costs appear to be higher for elective inductions, which usually involve a longer time in labor and more medications and interventions. However, postpartum costs might be lower with an elective induction, because of shorter postpartum and newborn stays after birth (Einerson et al. 2020).

In one study, researchers used a theoretical cohort of 1.6 million birthing people to compare health and cost outcomes between those who were induced at 39 weeks and those who had expectant management (Hersh et al. 2019). This was a “theoretical cohort” because these people did not actually exist – they were hypothetical and modeled after data from large studies and data from the U.S. Centers for Disease Control. In their analysis, they were able to predict the likelihood of outcomes like inductions and Cesarean births.

The researchers predicted that induction would have higher financial costs, but it increased something called “Quality-Adjusted Life Years” (QALYs), which is a measure of how well different kinds of medical treatments improve and lengthen patients’ lives. Based on this, elective induction could be considered cost-effective. However, they found that it was only cost-effective about 65% of the time, and this cost-effectiveness depended on the cost of the induction and the Cesarean rate among those induced. Specifically, they found that if the cost of elective inductions were to go up by $180 USD, then it would no longer be cost effective. It would also no longer be cost effective if the Cesarean rate among those who were induced was 22%, or equal to the rate found in the expectant management group in the ARRIVE Trial (the Cesarean birth rate in the induction group in the ARRIVE trial was 19%) (Hersh et al. 2019).

In another study, researchers conducted an economic analysis of patients from five hospitals in Utah who had participated in the ARRIVE trial. They had cost data for around 1,200 patients (608 who were induced and 623 who had expectant management). The cost data included the total cost of maternal and newborn care from the time the patients were randomized in the study up until 8 weeks postpartum. This study found that there was no difference in total cost between elective induction and expectant management. Maternal outpatient costs (from time of study enrollment until they were admitted for labor) were lower among those who were induced, but their inpatient delivery and care costs were higher. Costs also did not vary by maternal age, BMI during pregnancy, or the need for cervical ripening (Einerson et al. 2020).

Some of the original researchers from the ARRIVE trial conducted their own analysis looking at how health resource use (not actual costs) differed between those with induction versus expectant management (Grobman et al. 2020). They looked at medical records and interviews with ARRIVE Trial participants that captured information on outpatient visits and inpatient hospital admissions before delivery and up to 8 weeks postpartum. Those in the induction group used fewer health resources (had less visits and needed less care) before delivery. During labor and delivery, those in the induction group had longer labors and more often needed cervical ripening methods, synthetic oxytocin, and an internal device called an intrauterine pressure catheter (IUPC). Their babies spent less time in the hospital, though, and needed less respiratory support.

When looking at postpartum and newborn care, there weren’t many differences between those who were electively induced and those with expectant management. Babies whose parents had been induced were more likely to have extra outpatient care beyond routine newborn visits. The researchers in this study conclude that elective induction does not cost more than expectant management, based primarily on their findings that those who were induced used fewer resources before labor and delivery and that resource use was about the same during labor and delivery and the postpartum period. A limitation of this study was that they weren’t able to compare actual costs, only resources used (interventions needed, inpatient and outpatient care), because hospital costs can vary, and some hospitals do not share cost information.  (Grobman et al. 2020).