Written By: Dr Ummay Kulsoom

The final weeks of pregnancy have the mix feelings of  the silence before a storm and anxiety before an exam. It is filled with expectations, blooming with excitement and intimidating with a thousand questions.

One of the greatest dilemma remains whether to wait for spontaneous labor or consider elective induction?

Every third pregnant female in USA and England undergoes induction of labor.  Since the publication of the ARRIVE trial (2018) more inductions are now being performed in the U.S. but there has not been an overall improvement in maternal or newborn health outcomes.  The trial stated that it is possible to achieve low Cesarean rates with 39-week elective inductions in low-risk, first-time birthing people who have accurately estimated due dates. 

The  trial reported that people assigned to elective induction at 39 weeks had a Cesarean rate of 19% compared to a rate of 22% among those assigned to expectant management, resulting in a relative risk reduction of 16% with elective induction but the absolute risk being only 3% lower!

Though this trial had many limitations, notably it used different protocols in the subjects which are not routinely used in general population (like waiting 12 hours after induction before labelling it as failed induction).

It also had ethnic bias and age bias and parameters like birth satisfaction were not included. With respectful maternity care, both safe care and the mother’s experiences during labor and birth are important health outcomes. 

Still, based on this study many guidelines were revised:

ACOG 2018 (Reaffirmed 2023) concluded that it is reasonable to offer elective induction to low-risk, first-time birthing people at 39 weeks of pregnancy.

NICE 2021, recommended that health care providers ask birthing people if they would like a membrane sweep at visits after 39 weeks  but give them every opportunity to go into spontaneous labor if they have uncomplicated pregnancy. 

Studies have repeatedly shown that more interventions during birth are associated with more symptoms of trauma (Creedy et al. 2000; Soet et al. 2003). Inductions of labor have also been associated with lower childbirth satisfaction and worse experiences compared to spontaneous labor (Adler et al. 2020; Falk et al. 2019) especially for mothers who desire a birth with freedom of movement and/or freedom to eat and drink during their labor. The right  to move and eat/drink at will can be more difficult to advocate for and obtain during inductions because of hospital policies. The “cascade of interventions” or the “domino effect "that often come along with an induction can also interfere with a mother’s desires and preferences during labor and birth. Induction is actually meant to fight what is natural and it changes the timing and  length of labor, and the way that labor unfolds. 

And after all this comes the possible disadvantages like failure of induction, longer labor duration, medicalization of birth, decreased breastfeeding rate etc. 

 In contrast to this trial and guidelines, there are many other alternative methods that have shown to  significantly reduce the risk of cesarean like: 

  1. Randomized  trials have found that when mothers  who receive continuous support during labor (such as with a doula), they are 25% less likely to have a Cesarean (Bohren et al. 2017)
  1. less-invasive type of fetal monitoring (also known as intermittent auscultation),  can lead to  39% less Cesarean compared to those who receive continuous electronic fetal monitoring (Alfirevic et al. 2017).
  1. walking around during labor and staying hydrated, have been shown in randomized trials to lower your risk of Cesarean by more than 16%

Having said all that, it is to be noted that not all Cesareans are preventable, and Cesareans can be medically necessary or even lifesaving at times for both mother and baby. 

Studies like the ARRIVE trial have been used by health care providers to push and coerce pregnant mothers into interventions. They may provide biased and misleading information, sometimes accusing couples  who refuse induction of “not caring about their baby.”

A Californian study described how 1 in 6 women who planned to have a vaginal birth reported feeling pressured by their care provider to have an induction.

The presence of pressure or coercion cancels informed consent, because there is no free will left in it. This accounts for a type of obstetric mistreatment and obstetric violence which can be mitigated if there is proper discussion and the patient makes the final, uncoerced decision about each step of their care.

So, induction of labor for reducing the risk of cesarean only and in absence of any medical indication is not a good bargain in exchange of spontaneous labor.  

When labor starts naturally, your body and baby are working together in perfect harmony. 

There is no single “right way” to welcome your baby whether you choose to wait for labor to start naturally or plan an elective induction, what truly matters is that it is your choice, made with love, knowledge, responsibility and care.

Take time, think wisely, do your research, talk openly with your doctor, ask every question, understand the pros and cons, and most importantly listen to your heart and intuition . Your body, your baby, and your comfort should always guide the decision.

Because birth is not just a medical procedure, it is a life changing, powerful and sacred turning point, and a memory that lasts forever. You deserve to step into it feeling strong, supported, and sure of your path because it’s you who has to live with the consequences.