Pregnant women often fear that having their labor induced will lead to a c-section. In her bestselling book, Expecting Better, Emily Oster cites fear of a c-section as the primary reason she opted not to have her labor induced. Other reputable sources like the Mayo Clinic Online and March of Dimes claim that inductions increase the odds of a c-section.
But, according to the latest scientific research, these fears are unfounded. Past 39 weeks, labor inductions do not appear to raise the risk of having a c-section. Instead, being induced lowers your chances of a c-section by about 20%.
How did we get this so wrong? Until about 5 years ago, almost all the evidence on inductions and c-sections came from observational studies, which were all subtly biased, because they compared women who went into labor on their own with women who were induced.
What was wrong with this comparison?
Observational studies typically control for gestational age. This means that, in effect, they match women by the week they delivered, because the risks associated with giving birth climb as pregnancies continue past 39 weeks. Women who went into labor spontaneously at 39 weeks were compared to women who were induced at 39 weeks, and so on.
And, when matched by delivery week, women who go into labor spontaneously are less likely to have c-sections.
So what’s the problem? Pregnancies that go into labor spontaneously by a certain week are different from those that don’t.
Think about it this way: What is choice women actually face past 39 weeks? Women cannot will themselves into labor, or there would be a lot fewer pregnancies going past 40 weeks. Instead, pregnant women can only choose either to be induced or to wait it out.
So the proper study design compares these two options: being induced versus waiting it out. This is the approach taken by recent randomized controlled trials on inductions.
In these trials, pregnant women are randomly assigned to be induced past a certain point in pregnancy, for example, at 41 weeks, or to wait it out. Women assigned to wait may go into labor on their own or be induced at a later date. Using this approach, studies find, almost without exception, that relative to waiting and delivering at a later point in pregnancy, inducing labor leads to a lower chance of a c-section.
A 2009 meta-analysis (combined analysis of multiple studies) was the first to convincingly reveal the problem.
The analysis compared the results of observational studies and randomized controlled trials (RCTs). The observational studies found a roughly 20% increase in the risk of c-section following inductions; the better-designed RCTs found a roughly 20% reduction in the risk.