Is Spontaneous Labor Really Better Than Being Induced? Here’s What the Research Says
On the day of my appointment, I waddled into the maternity ward in no hurry and with no incident. I was given Misoprostol, to “ripen” my cervix. Later, I had a Foley balloon inserted to help dilation and I got an IV to administer Pitocin, a hormone that causes uterine contractions. After 12 hours, six loops of my labor playlist, one last-minute epidural, and maybe a little swearing, I was holding my happy, healthy baby girl. I gave the whole experience an A-plus.
So, when I was pregnant with my second, I started planning for another induction. But by then, I’d made a wealth of mom friends, and when I mentioned my plan, their reactions were mixed.
Some raved about their own elective inductions, saying it was a safe way to get peace of mind about where and when they delivered. Plus, they talked about how inductions helped avoid fetal risks that are more common later in pregnancy.
Others couldn’t believe I would sign up to be induced. One said that the process increased the chances of a caesarian section, while another said her induction was much more painful than her other births. “Why not just let the baby come when she’s ready?” my friend asked with a shrug. “She’ll know when it’s time.”
I wasn’t sure what to do. My first induction went smoothly, but after hearing horror stories from other moms, I wondered if I’d just been lucky.
Why inductions get a bad rap
The truth is, inductions have had a bad reputation for years. For one thing, my friend’s claim that induction caused higher rates of c-sections was a widely accepted theory for decades. Research from the 1970s, and even into 1999 and 2000, seemed to connect induction with the invasive surgery. However, a 2013 study found that the previous research failed to account for birth complications. Inductions, it turns out, actually help avoid c-sections.
Another long-standing concern is that induction could affect the health of the baby. While many people are pregnant for 40 or 41 weeks, elective inductions are widely available starting at 39 weeks gestation, which is considered full-term. However, some worry that not giving the fetus those extra days, or weeks, in the womb could be detrimental to its health.
But the often-cited ARRIVE trial, which was published by the New England Journal of Medicine in 2018, found that delivery at 39 weeks did not increase complications for babies. In fact, letting a pregnancy go into post-term (42 weeks or later) is associated with a number of risks for the fetus, including stillbirth, meconium aspiration (when the fetus has their first bowel movement while in the womb and ingests it), and decreased amniotic fluid (which can lead to a restricted flow of oxygen to the fetus).
Obstetrician Lauren Beaven, MD, FACOG, of Axia Women’s Health in Lexington, Kentucky, explains, “Fetuses at 39 weeks have reached maximum development of their lungs and brains, meaning that waiting until 40 weeks or after does not improve newborn respiratory capability, feeding, or temperature control. Babies born electively at 39 weeks have developed to their full potential and past 40 weeks this does not improve any further.”
She notes that risks increase for babies born before 39 weeks but explains that elective inductions shouldn’t be performed before that point anyway. Any induction performed before full term would only be done out of medical necessity. “We expect that respiratory temperature and feeding behaviors may be less developed in those [premature] babies, but the benefit of delivering them due to medical complications of the pregnancy outweighs those risks,” she says.
Another common worry is that inductions make labor more painful. However, in one study, parents who were induced reported less pain during labor and claimed they felt “more perceived control during childbirth.”
The real risks of inducing labor
There are some rare risks to induction. For one thing, it doesn’t always work, which could mean another induction or even a c-section. Some methods of induction can increase the risk of infection. Plus, induction increases the risk that the uterine muscles won't properly contract after birth, which could lead to heavy bleeding after delivery.
Sometimes Pitocin, which is often given during induction, can cause the fetal heart rate to drop, though Dr. Beaven shares that this can also happen during spontaneous labor. “If this occurs with Pitocin, the medication can be turned off and there are methods that are used immediately to try to bring the baby’s heart rate back to normal,” she explains.
Figuring out what’s right for your birth plan
Even with these risks in mind, I felt sure that another induction would be safe, and even beneficial. But I wondered if it was truly my preference. Lots of parents talk about the convenience of going through the early stages of labor at home. And because I didn’t want to leave my clingy toddler with grandparents for days and days, I even considered a home birth.
Tara Kenny, a certified professional midwife, certified lactation counselor, and doula based in Boston, acknowledges that there are many benefits to inductions. However, she doesn’t want pregnant people to feel unnecessarily pressured to induce.
“The ARRIVE trial has kind of tipped a lot of providers into the camp of ‘let’s induce people earlier’ because they tend to have fewer complications,” she says. “But I don’t think it’s fair or appropriate to say that to every pregnant person. I think that it should be more of an informed choice.”
Kenny adds that while a medically-indicated induction can be life-saving for those who need it, she hopes pregnant people know that most people who wait for spontaneous labor have perfectly healthy births. “I think that we’re losing sight of the fact that, statistically speaking, it’s normal to be pregnant up until 41 weeks and a few days,” she says.
She adds that while studies show that induction can provide a safer birth experience for the parent and baby, the statistical differences are marginal. One study published in the New England Journal of Medicine in 2016 revealed that the women who were induced had 3 percent fewer c-sections than those who weren’t. So, while inducing may benefit some, it’s not a cure-all.
“I think as a midwife, it is our responsibility to present all the information and ultimately let the patients be the one to decide,” Kenny says.
"It is our responsibility to present all the information and ultimately let the patients be the one to decide." —Midwife Tara Kenny
Physician William Grobman, MD, MBA, the lead researcher on the 2018 article “Labor Induction versus Expectant Management in Low-Risk Nulliparous Women,” echoes Kenny’s claim that, with the margin being so small, it should be about the pregnant person’s preference. “I feel very strongly that people should have the option to induce or not induce and that this should be a person-centered decision,” he states.
When it came to delivering my second daughter, I didn’t have a chance to decide on induction or not. At 37 weeks I was diagnosed with preeclampsia, a potentially life-threatening condition that causes high blood pressure during pregnancy and is remedied by giving birth. My induction was started within the hour. Once again, I was administered Misoprostol, I had a Foley balloon, and got Pitocin. The induction methods were the same, but this time, labor seemed much harder and lasted twice as long. My epidural fell out twice and I spent the whole time nervous about my blood pressure. But all turned out well, and in the end, I got to hold my new baby girl. I give it an A-plus.
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