As doulas, most of us are very familiar with the ARRIVE Study. In fact, many of us have found it difficult to support clients desiring a natural birth since the ARRIVE study was published. Anecdotally, many of us felt induction of labor increases risk of c-section. However, it was difficult to navigate our anecdotal experience with the study.
Well, a new retrospective cohort study published in the journal Birth: Issues in Perinatal Care found a correlation between an induction of labor and increased risk of c-section birth.
Induction of labor and cesarean birth in lower-risk nulliparous women at term: A retrospective cohort study was published in January 2024.
What is The ARRIVE Study?
For those who complete our comprehensive birth doula training, you have already learned about the ARRIVE study. If you are not an IDI trained doula, or you have not yet reached that part in your training, here is what you should know about the ARRIVE study:
The ARRIVE study was published in the New England Journal of Medicine in 2018. Since its publication, many first-time parents have found themselves encouraged to schedule an induction of labor to reduce their risk of a c-section birth.
The ARRIVE study concluded:
“Induction of labor at 39 weeks in low-risk nulliparous women did not result in a significantly lower frequency of a composite adverse perinatal outcome, but it did result in a significantly lower frequency of cesarean delivery.”
However, anecdotally, many birth workers did not experience the same outcome as the study. To understand more about why not all providers promote elective induction at 39 weeks based on the ARRIVE study, you may find the response from the American College of Nurse Midwives helpful.
They state: “The American College of Nurse-Midwives (ACNM) affirms its support for the promotion of normal healthy physiologic birth and a women’s right to self-determination as we acknowledge the publication of the ARRIVE trial…” read the full response here: ACNM Responds to Release of ARRIVE Trial Study Results (midwife.org)
We share more information about the ARRVE study in our comprehensive training. It is also important to note than an increased risk is by no means a guarantee. An increased risk also does not mean likely, just that it is a higher risk than the control.
New Study: Induction of Labor Increases Risk of C-Section
Researchers looked at data from Victorian Perinatal Data Collection to assess outcomes on every birth in Victoria, Australia greater than 20 weeks gestation. The study says:
“Given the widespread recommendation to offer IOL at 41 weeks, we were interested in assessing whether any relationship between IOL and CB was consistent over gestational weeks at term, including at 41 weeks.”
Research has previously shown that there is a potential benefit to induction of labor at 41 weeks and beyond. Inducing labor at 41 weeks versus waiting for spontaneous labor is associated with improved perinatal outcomes. However, was induction of labor at 39, 39, and 40 weeks associated with improved outcomes?
The ARRIVE study found induction of labor at 39 weeks might be associated with a reduced risk of c-section birth. However, this was a study with assigned induction versus spontaneous labor. This was not necessarily representative of clinical practice.
With the retrospective study, researchers were able to look at numbers based on everyday clinical practice. Unlike the ARRIVE study, researchers did not see a reduced risk of c-section birth among those induced. In fact, they found the opposite.
Induction of Labor Increases Risk of C-Section Birth
The study conclusion:
“In a contemporary lower-risk nulliparous population in Victoria, Australia, we replicated and enhanced an influential retrospective cohort study, Stock 2012, which examined the relationship between IOL and CB.
“In contrast, in our study, the adjusted odds of CB were increased by 23%–43% following IOL at all gestations from 38 weeks. Perinatal mortality was rare in both the IOL and the expectantly managed groups. It was lower with IOL, but this reduction reached statistical significance only for IOL at 40 or more weeks.
“These results suggest that IOL in a lower-risk population may be associated with inherent risks. Consequently, maternity care providers should ensure women are informed of all potential risks and benefits of the non-medically indicated IOL.”
In layman’s terms, an induction of labor was associated with an increased risk of c-section. Only after 40 weeks was the induction of labor (for non-medical reasons) associated with a reduction in perinatal mortality.
What does this mean for birthing families and doulas?
This study provides evidence for families to ask more questions. When presented with the option of an elective induction of labor, they can use BRAIN:
Benefit – to me? to baby?
Risks – to me? to baby?
Alternatives – what alternatives do we have?
Intuition – what is my gut feeling?
Nothing – what are the risks/benefits to doing nothing right now?
It is important to note that the outcomes reviewed here were for inductions of labor not associated with already known complications.
Often, the ARRIVE study was used to schedule an induction of labor rather than waiting for spontaneous labor. These studies did not look at induction with medical indication such as preeclampsia, IUGR, placental or cord abnormalities, infection, etc.
If a birthing person prefers to wait for spontaneous labor, this study can be reassuring that it is a safe option. For those desiring an induction of labor rather than waiting, it provides insight to the potential risks.
Each study we see provides another piece of the puzzle for families to make informed decisions about their care.
Author: Aliza Juliette Bancoff
Aliza Juliette Bancoff is a well-known doula and doula trainer who has been providing doula services to families for over a decade. She is the founder of Main Line Doulas, a doula group providing doula support in the great Philadelphia area for the last decade, the International Doula Institute, which provides online doula training and lactation training and certification programs and the International Breastfeeding Institute which provides lactation training and certification. She is the co-founder of United Birth, a company devoted to increasing access to doulas across the country to make the perinatal time safer both physically and emotionally. “Every birthing person deserves access to quality doula support. And we are working to make that a reality across the country. The work we are doing to get doulas to every birthing person will decrease the black infant and maternal mortality rate significantly by 2030.” Says Bancoff. Aliza is known for her compassionate and empowering approach to doula work, and she has been featured in numerous media outlets, including United Nations Maternal Health Report, Parent Magazine, CafeMom, theBump and many more. Aliza's journey into doula work began when she gave birth to her first child and felt a strong calling...