Evidence Library · Induction

Does induction cause cesareans? Not against the real alternative.

The old claim came from the wrong comparison.

Women were told for years that induction doubles the risk of cesarean. That came from comparing induced women with women who went into labor spontaneously, which is not the choice anyone faces. The real choice is between inducing now and continuing the pregnancy.

In a study of 166,559 births, comparing induction with spontaneous labor gave relative risks of cesarean 1.6 to 2.1 times higher. Comparing induction with continued pregnancy, the correct comparison, gave risks at or below 1.0 at most weeks.

The ARRIVE trial randomized 6,106 low-risk first-time mothers to induction at 39 weeks or continued pregnancy. Cesarean occurred in 18.6% of the induction group and 22.2% of the expectant group. A review of 34 trials and more than 21,000 women found induction at or beyond 37 weeks lowered both cesarean rates and perinatal death.

Where the debate still isWhether the ARRIVE results hold outside a research setting, and whether inducing every low-risk woman at 39 weeks is a good policy, are genuinely contested. What is no longer defensible is the old claim that induction doubles the risk of a cesarean. Measured against the real alternative, which is continuing the pregnancy, it does not.

Where this comes from:

184. Grobman WA, Rice MM, Reddy UM, Tita ATN, Silver RM, Mallett G, et al. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379(6):513-523.

185. Middleton P, Shepherd E, Morris J, Crowther CA, Gomersall JC. Induction of labour at or beyond 37 weeks' gestation. Cochrane Database Syst Rev. 2020;(7):CD004945.

186. Danilack VA, Triche EW, Dore DD, Muri JH, Phipps MG, Savitz DA. Comparing expectant management and spontaneous labor approaches in studying the effect of labor induction on cesarean delivery. Ann Epidemiol. 2016;26(6):405-410.

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