DOI: 10.1111/1471-0528.

13805 Intrapartum care

www.bjog.org

Elective induction of labour and maternal

request: a national population-based study
B Coulm,a B Blondel,a S Alexander,b M Boulvain,c C Le Raya,d
a
INSERM UMR 1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team, Centre for Epidemiology and Statistics (U1153),
DHU Risk in Pregnancy, Paris-Descartes University, Paris, France b Perinatal Epidemiology and Reproductive Health Unit, Ecole de Sant
e
Publique, Universit
e Libre de Bruxelles, Brussels, Belgium c Department of Obstetrics and Gynaecology, University Hospitals of Geneva,
Geneva, Switzerland d Maternit
e Port Royal, H^ opital Cochin Saint-Vincent-de-Paul, Assistance Publique Hôpitaux de Paris, Paris-Descartes
University, Paris, France
Correspondence: B Coulm, INSERM U1153, Obstetrical, Perinatal and Paediatric Epidemiology Research Team, Maternit
e Port-Royal,
53 avenue de l’Observatoire, 75014 Paris, France. Email benedicte.coulm@inserm.fr

Accepted 13 October 2015. Published Online 30 November 2015.

Objective To estimate the rate of elective inductions in France
and the proportion of them that were maternally requested, and
to study the factors associated with elective inductions that were
or were not requested by women.
Design Cross-sectional population-based study.
Setting All maternity units in France.
Population About 14 681 women from the 2010 French National
Perinatal Survey of a representative sample of births.
Methods Inductions were classified as elective based on their
indications and maternal and fetal characteristics, collected from
medical records. Elective inductions requested by women were
identified from the mother’s postpartum interviews. Polytomous
logistic regression analysis was used to study the determinants of
inductions that were or were not maternally requested. Women
with spontaneous labour served as the comparison group.
Main outcome measure Rate of elective inductions.
Results The induction rate was 22.6, 13.9% elective. Among
elective inductions, 47.3% were requested by women. The
characteristics of mothers, pregnancies, and maternity units were
similar in both groups of elective inductions. The main associated
factors were parity 2 or more [adjusted odds ratio (OR) 4.7, 95%
confidence interval (CI) 3.1–7.2 for maternally requested
inductions and aOR of 1.8 (95% CI1.2–2.7) for unrequested
inductions, compared with parity 0] and private hospital status
[aOR 4.5 95% (CI 3.3–6.0) for maternally requested inductions
and aOR 3.7 (95% CI 2.8–4.9) for inductions not requested by
the mother]. We found no association between maternal social
characteristics and type of elective induction.
Conclusion Parity and organisational factors appear to influence
the decision about elective inductions. It would be interesting to
determine how obstetricians and women make this decision and
for what reasons.
Keywords Determinants, elective, France, induction of labour,
maternal request.
Tweetable abstract About 13.9% of inductions of labour were
elective in France, 47.3% of these requested by women.
Linked article This article is commented on by JE Norman and SJ
Stock, p. 2198 in this issue. To view this mini commentary visit
http://dx.doi.org/10.1111/1471-0528.13871.

Please cite this paper as: Coulm B, Blondel B, Alexander S, Boulvain M, Le Ray C. Elective induction of labour and maternal request: a national population-
based study. BJOG 2016;123:2191–2197.

guidelines list diseases and conditions that justify induc-

Introduction
In Western countries, induction of labour has increased
over the past 20 years.1–4 Rates of 22.6% in France,3 and
21.0% in England2 in 2010, and a rate of 22.8% in the
USA in 20131 show that inductions are performed for a
significant proportion of deliveries.
When they are performed for medical indications, induc-
tions for labour are associated with a reduction in maternal
and neonatal morbidity.5–7 Numerous clinical practice
tion.8–11 In the absence of medical indications, there is cur-
rently no strong evidence for or against elective induction.
Some observational studies have shown an increased risk of
caesarean deliveries during labour5,12–14 and maternal mor-
bidity15,16 after elective induction, but other studies that
have used a more appropriate comparison group of women
who were ‘expectantly managed’ have reported no
increased risk of caesarean deliveries.17–21 However, most
of these latter studies were performed in academic centres

ª 2015 Royal College of Obstetricians and Gynaecologists 2191

 Coulm et al.
and their conclusions cannot be extended to all maternity
units. Because there is still a lack of conclusive evidence
and prospective trials in the general population to conclude
that inductions are not associated with a higher risk of cae-
sarean delivery or maternal morbidity, performing an elec-
tive induction of labour should be considered, at or after
39–40 weeks of gestational age, only in circumstances spec-
ified in national guidelines.8,9,11
Measuring the elective induction rate would be useful
for monitoring trends in this practice and comparing it
between different hospitals and between different countries.
The population-based estimates of this rate are not well
known at present.22 Studies suggest there may be wide vari-
ations between hospitals or regions, as the proportion of
inductions without medical indication range from 14 to
25–30% of all inductions,23–25 and from 21 to 51% of
inductions in term pregnancies.26–28 In addition, the cir-
cumstances of elective inductions, especially the respective
roles of obstetricians and women in the decision, are not
known, and very few studies have analysed the determi-
nants of this decision.26,27
Our objective was to estimate the rate of elective induc-
tions and the proportion of those performed at maternal
request in France. We also investigated whether maternal
and maternity unit characteristics were associated with
inductions on maternal request and with elective induc-
tions for other reasons.
Methods
In France, National Perinatal Surveys have been conducted
periodically since 1995 to produce statistics about perinatal
indicators. These surveys include all births (live births and
stillbirths) at a gestational age of 22 weeks or more or with
a birthweight of at least 500 g in every maternity unit in
France for a complete 1-week period.3 Midwives interview
mothers before discharge to obtain data on maternal social
and demographic characteristics, prenatal care, and deliv-
ery. Medical data about the pregnancy, delivery, and new-
borns are collected from medical records. In addition, each
maternity unit completes a questionnaire providing infor-
mation about its characteristics. The last survey, conducted
in 2010, included an overall sample of 14 681 women in
the 535 maternity units in France.
The 2010 data collection form contained eight precoded
indications for induction of labour: (1) post-term preg-
nancy or prevention of post-term pregnancy, (2) premature
rupture of the membranes (PROM), (3) non-reassuring
fetal status, (4) suspected macrosomia, (5) diabetes mellitus
(gestational or pre-existing), (6) other maternal disease, (7)
no medical indication or (8) other. Specific details were to
be provided for the last category; in most cases, these
details comprised additional information on the maternal
2192
or fetal conditions that led to the decision to induce. For
each induction, the clinician was asked to choose one or
two of these indications. In addition, data were collected
on maternal complications or hospitalisation during preg-
nancy, gestational age, number of fetuses, fetal presenta-
tion, and neonatal status at birth. In the face-to-face
postpartum interview, women whose labour was induced
were asked: ‘Was this induction done at your request?’
A group of five European perinatal epidemiologists from
three countries (France, Switzerland, Belgium) whose
research interests focus on obstetric interventions, deter-
mined which inductions were elective (i.e. had no medical
indication). They first classified each induction indepen-
dently, using information on the induction indications,
maternal and fetal characteristics, and any pregnancy com-
plications. They subsequently met to reach a consensus
about the cases where there was disagreement.
To be considered elective, an induction had to be per-
formed in a woman with a singleton fetus in cephalic presen-
tation alive at the onset of labour, between 37+0 and
40+6 weeks’ gestational age (GA), for one of the following
indications (without any other associated indication): no
medical indication, prevention of post-term (but before
41 weeks’ gestation) or for one of the two following reasons
mentioned under indication 8 (other) above: maternal fati-
gue/tiredness or painful ‘false labour’ contractions. In addi-
tion, an induction was not considered elective when women
had diseases that could have justified induction (pre-existing
insulin-dependent diabetes, gestational insulin-dependent dia-
betes mellitus, pre-eclampsia). An elective induction was con-
sidered to be at the mother’s request if she confirmed that.
To study the determinants of elective inductions, we
defined a comparison group of all the women who went
into labour spontaneously between 37+0 and 40+6 weeks’
gestation, with a singleton newborn alive at the onset of
labour, and no pregnancy complications that could have
justified induction, according to the same criteria used to
select elective deliveries.
We analysed the following characteristics of women and
pregnancies: age, parity, pre-pregnancy body mass index
(BMI), country of birth, educational level, family status,
fertility treatment, prenatal care, and gestational age at
delivery. Prenatal care was considered intensive when the
number of visits was at least twice the minimum set out in
the national regulations (seven visits for a pregnancy of
40 weeks for both nulliparas and multiparas). To study
geographical accessibility to the maternity unit, we used the
time taken to reach the centre for the delivery as reported
by the women. Size and status (public or private) of the
maternity unit were noted.
In France all maternity units are legally required to deli-
ver at least 300 newborns a year and to have an operating
room for caesarean deliveries. Legislation also requires that
ª 2015 Royal College of Obstetricians and Gynaecologists

units with more than 1500 deliveries per year have at least
one anaesthesiologist and one obstetrician present on site
24 hours per day, 7 days per week. In all units a paediatri-
cian must also be on call for all units, although not neces-
sarily present on site in the smallest units. There are no
midwife-led units. All pregnant women have access to
health insurance, which routinely covers medical costs dur-
ing delivery, regardless of the maternity unit status (private
or public). Some private units charge supplemental fees for
interventions, but in 2010, 81% of women had supplemen-
tary insurance3 that at least in part reimburses these fees.
In most private units, women are delivered by the obstetri-
cian who performed the prenatal care; in contrast, in public
units, women are delivered by the team on duty, i.e. a mid-
wife for uncomplicated deliveries and an obstetrician in
complicated cases.
We first estimated the frequency of elective inductions of
labour in the whole population and the proportion of those
performed on maternal request. Subsequently, those per-
formed on maternal request and those that were not were
analysed separately. In the bivariate analysis, we compared
each category of elective induction with the comparison
group. All factors associated with a P-value of ≤0.20 with
either or both types of elective induction in bivariate analy-
sis were included in a polytomous logistic regression model.
We also described the mode of delivery in the two groups
of elective inductions (requested and non-requested).
Data were analysed with SAS 9.3 software.29 Differences
in distributions of variables by mode of onset of labour
were examined with chi-squared tests. Statistical signifi-
cance was set at P < 0.05.
Results
Of the 14 625 women with known mode of onset of
labour, 9720 (66.5%) went into labour spontaneously, 3312
(22.6%) had labour induced, and 1593 (10.9%) had cae-
sareans before labour (Figure 1). Of the 3266 inductions
with known indications, 459 were considered to be elective
(13.9%); these accounted for 3.1% of all births. Among all
elective inductions, 217 (47.3%) were performed on mater-
nal request. The overall distribution of inductions by gesta-
tional age was 2.8% at 37 weeks, 18.7% at 38 weeks, 36.2%
at 39 weeks, and 42.3% at 40 weeks. However, maternally
requested inductions took place more frequently at
39 weeks than did the others (P < 0.001) (Table 1). The
rates of caesarean delivery during labour were 5.1% among
women who had requested elective induction and 10.8%
among women with unrequested elective inductions, with-
out significant difference (P = 0.48).
In the bivariate analysis, the characteristics of mothers
and pregnancies associated with both types of elective
inductions were gestational age, parity, and intensive pre-
ª 2015 Royal College of Obstetricians and Gynaecologists
Elective induction of labour and maternal request
natal care (Table 1). Maternal age ≥35 years, low educa-
tional level, and longer distance from the hospital were
associated only with maternally requested induction. Only
obesity was associated with non-requested elective induc-
tion. Deliveries in private maternity units and units per-
forming fewer than 1500 deliveries by year were more
frequent in both types of elective inductions.
After adjustment for women, pregnancy, and maternity
unit characteristics, the risk of having an elective induction
was higher at 39 weeks than at 40 weeks for inductions
requested by women, and lower at 39 weeks than at
40 weeks in inductions not requested by women. Parity
was strongly associated with elective inductions: in women
of parity 2 or more, the adjusted OR (aOR) was 4.7 [95%
confidence interval (CI) 3.1–7.2] for maternally requested
elective inductions and aOR 1.8 (95% CI 1.2–2.7) for elec-
tive inductions that were not requested, compared with
nulliparous women (Table 2). Women with a high number
of visits were also more likely to have be in one of the cate-
gories of elective induction. Obesity was associated only
with unrequested elective inductions. Private status and
small size of maternity units remained associated with both
types of elective inductions. The aOR for private units was
4.6 (95% CI 3.4–6.1) for those requested by mothers and
3.7 (95% CI 2.8–5.0) for those that not requested.
Discussion
Main findings
In 2010, about 14% of all inductions in France were elec-
tive, and only half were performed on maternal request.
Total number of women
(N = 14 681)
• No information on the mode of onset of
labour N = 56
• Cesarean delivery before labour
N = 1593
Induction of labour Spontaneous onset of
(N = 3312) labour
No information on the indication
for induction N = 46
Non-elective induction Elective induction1,2
(N = 2807) (N = 459)
No information on women
Comparison group
request: N = 24
37+0 to 40+6 weeks
Singleton
Cephalic presentation
Alive at the onset of
Maternal request Not requested by women labour 2
(N = 217) (N = 218) (N = 7605)
Figure 1. Identification and classification of elective inductions
requested by women and elective inductions not requested by women.
1
37+0 to 40+6 weeks, singleton, cephalic presentation, alive at the
onset of labour and one of the following registered indications: no
medical indication, prevention of post-term pregnancy, other non-
medical maternal reasons (Induction for maternal fatigue/tiredness or
painful “false labour” contractions). 2 No major pregnancy complication.
2193
 Coulm et al.

Table 1. Characteristics of women, pregnancies, and maternity units associated with the mode of onset of labour and maternal request

Elective induction of labour Spontaneous

onset of labour
Requested P* Not requested P**

Gestational age (weeks) 217 218 7535

37 4.2 <10 2
1.4 <10 2
6.8
38 19.8 18.8 18.1
39 44.2 28.4 33.1
40 31.8 51.4 42.0
Maternal age (years)
<25 12.0 0.02 16.5 0.09 18.2
25–34 66.4 61.5 65.4
≥35 21.7 22.0 16.4
Parity 217 216 7543
0 20.3 <10 4
37.5 0.01 42.4
1 41.9 32.4 36.4
2 or more 37.8 30.1 21.2
BMI 213 214 7137
<25 75.1 0.79 70.6 0.03 77.1
25–29 16.9 17.8 15.6
≥30 8.0 11.7 7.3
Country of birth 216 218 7317
France 88.9 0.09 78.4 0.30 82.7
Europe 1.4 5.1 4.0
North Africa 6.0 8.7 6.4
Sub-saharan Africa 1.9 5.5 3.8
Other country 1.9 2.3 3.1
Educational level 217 217 7327
Middle school or less 30.0 0.02 26.7 0.69 27.8
High school 24.9 16.1 18.8
Some college 15.2 24.4 22.2
College or postgraduate 30.0 32.7 31.3
Family status 217 218 7307
Cohabiting 92.6 0.78 94.5 0.43 93.1
Single 7.4 5.5 6.9
High number of visits*** 213 213 7038
Yes 36.6 0.01 37.1 0.01 28.2
No 63.4 62.9 71.8
Travel time to reach maternity unit (minutes) 216 218 7219
≤30 84.3 0.01 89.9 0.08 90.3
31–45 11.6 6.0 7.1
>45 4.2 4.1 2.5
Maternity unit status 217 218 7603
Public 36.9 <10 4
42.2 <10 4
72.3
Private 63.1 57.8 27.7
Maternity unit size (deliveries/year) 217 218 7603
<1500 49.8 <10 3
50.0 <10 3
39.1
1500–2499 30.9 31.2 29.9
≥2500 19.4 18.8 31.0

*Comparison: elective induction requested by women versus spontaneous onset of labour.

**Comparison: Elective induction not requested by women versus spontaneous onset of labour.
***Defined as a number of prenatal visits that are twice that in the national guidelines.

The main factors associated with both types of elective Strengths and limitations
inductions of labour were high parity and private status of To the best of our knowledge, our study is one of the first
maternity units. to collect information about women’s requests for labour

2194 ª 2015 Royal College of Obstetricians and Gynaecologists

 Elective induction of labour and maternal request

induction. We used a list of indications for induction (in-

Table 2. Maternal and organisational determinants of elective
inductions requested and not requested by women cluding ‘none’) selected by clinicians as the principal basis
for identifying elective inductions. The data on medical
Elective induction of labour P complications were used mainly to verify the indications
and to limit classification errors as much as possible. In
Requested by Not requested
women by women
contrast, in most other studies selection was based on the
absence on birth certificates or hospital discharge data of
aOR* 95% CI aOR* 95% CI specific conditions or complications during pregnancy that
are possible indications for induction,20,22,23,28 without the
Gestational age (weeks) certainty that these inductions had no medical indications.
37 0.5 0.2–1.2 0.1 0.1–0.5 <10 4
Because the study was conducted in all maternity units and
38 1.3 0.9–2.0 0.8 0.5–1.2 covered a representative sample of births,3,30 our results are
39 1.8 1.3–2.4 0.7 0.5–0.9
generalisable to the overall French population. The missing
40 1 1
data rate was quite small for both medical characteristics
Maternal age (years)
and women’s requests.
<25 0.9 0.6–1.5 1.3 0.9–2.0 0.62
25–34 1 1
Our study is subject to some limitations. Classification
≥35 0.8 0.6–1.2 1.1 0.8–1.6 uncertainties remain possible. It is not always conceptually
Parity clear whether an induction of labour is elective or not. For
0 1 1 <10 4 example, our decision to include inductions because of
1 2.6 1.8–3.9 1.0 0.7–1.4 ‘painful contractions and maternal fatigue’ in the elective
2 or more 4.7 3.1–7.2 1.8 1.2–2.7 category is debatable; some obstetricians might have con-
BMI sidered those to be medical indications. Moreover, some
<25 1 1 0.26
women might have found it difficult to decide whether
25–29 1.0 0.7–1.5 1.2 0.8–1.7
≥30 1.0 0.6–1.7 1.7 1.1–2.7
they requested the induction, because the decision often
Country of birth resulted from discussion with the physician,31,32 who may
France 1 1 0.1 have influenced their choice.33 Finally, women were inter-
Europe 0.4 0.1–1.2 1.6 0.9–3.1 viewed after delivery and they may have been reluctant to
North Africa 0.8 0.4–1.5 1.4 0.8–2.4 declare that the induction was done at their request if their
Sub-Saharan Africa 0.6 0.2–1.5 1.9 0.9–3.6 childbirth experience and perinatal outcomes were poor.
Other country 0.7 0.3–2.0 1.0 0.4–2.5
This could have led to an underestimation of the elective
Educational level inductions performed on maternal request. Another limita-
Middle school 1 1 0.06
tion was our sample size: given the size, we cannot show
or less
High school 1.2 0.8–1.8 0.8 0.5–1.3
moderate associations with some of the characteristics we
Some college 0.6 0.4–1.0 1.2 0.8–1.8 studied.
College or 0.9 0.6–1.4 1.3 0.9–1.9
postgraduate Interpretation
High number of visits** The rate of elective inductions in different countries is gen-
Yes 1.5 1.1–2.0 1.5 1.1–2.0 <10 2
erally unavailable both because there is no consensus about
No 1 1
their definition and because the reasons for inductions are
Travel time to reach maternity unit (minutes)
≤30 1 1 0.22
rarely known in large population-based studies. Currently,
31–45 1.2 0.8–2.0 0.8 0.4–1.4 most studies of elective inductions have focused on the
>45 1.7 0.9–3.5 1.7 0.8–3.4 effects of these elective inductions on maternal and neona-
Maternity unit status tal health among all term deliveries.17,18,28 Our study
Public 1 1 <10 4
reports that 14% of all inductions performed in France in
Private 4.6 3.4–6.1 3.7 2.8–5.0 2010 were elective and that they accounted for 3.1% of all
Maternity unit size (del/year)
deliveries. Data from a study in New York in 1998–99 indi-
<1500 1.7 1.2–2.5 1.9 1.3–2.7 <10 2

1500–2499 1.4 0.9–2.0 1.4 1.0–2.2

cate that 4.8% of all deliveries could be estimated to have
≥2500 1 1 occurred after elective inductions.22
We found higher rates of elective inductions among
Comparison group: spontaneous onset of labour. multiparas, as previously reported in two North American
*Odds ratios adjusted for all characteristics listed in the table.
studies.23,26 There may be several explanations for this find-
**Defined as a number of prenatal visits that is twice that in the
national guidelines. ing. Multiparas may be more inclined to request induction
because this planning facilitates family organisation. Also,

ª 2015 Royal College of Obstetricians and Gynaecologists 2195

 Coulm et al.
their cervix is more often ripe at the end of pregnancy,
which encourages obstetricians to choose to induce labour
or accept the request of the woman. Finally, obstetricians
may also choose induction for multiparas for fear that
rapid labour might result in delivery before arrival at the
hospital and thus increase the risk for both mother and
child.34
Requested elective inductions were also more frequent
among women with a very high number of prenatal visits.
This association may be explained by medical factors not
considered in our study (for example, history of poor preg-
nancy outcome, including fetal loss). It may also reflect
women’s anxiety or their preferences for both more prena-
tal visits and obstetrical interventions. We also found
higher rates of unrequested elective inductions among
obese women. One explanation may be that obstetricians
are aware of the increased risk with these women of obstet-
ric and anaesthesia complications related to caesareans in
labour,35–37 and prefer to plan the delivery for a time when
the complete obstetric team is available.
Elective inductions were more frequent in private units
as previously reported.23 Women at these facilities might
agree to or request induction more often, to be sure of
their obstetrician’s presence. These obstetricians, in turn,
may also be more sensitive to women’s requests, percep-
tions, and feelings.38,39 Moreover, they might find induc-
tion a way of regulating their workload and improving
their working conditions, by reducing the number of deliv-
eries at night, on weekends, and during office hours.
In small maternity units, induction may also make it
possible to ensure that an anaesthesiologist is present for
epidurals if requested, and that, if relevant, safety is opti-
mised by timing deliveries during periods when all the
team (anaesthesiologists, paediatricians, and obstetricians)
is present.
Conclusion
The frequency of inductions without medical indications
was quite low in France, and half of them were performed
on maternal request. This suggests a major role for other
factors associated with the organisation of care. Under-
standing how women and their obstetricians make the
decision electively to induce labour and the reasons for
these choices is an area for further research.
Disclosure of interests
None declared. Completed disclosure of interests form
available to view online as supporting information.
Contribution to authorship
BC carried out the statistical analysis and wrote the first
draft of the manuscript. CLR designed the study. BB is the
2196
scientific coordinator of the 2010 National Perinatal Sur-
vey. BB and CLR made significant revisions to the first
draft. BC, BB, MB, SA and CLR contributed to the design
and execution of the classification and to the interpretation
of the results. All authors revised successive versions of the
article and approved the final article.
Details of ethics approval
The survey was approved by the National Council on Sta-
tistical Information and the French Commission on Infor-
mation Technology and Liberties (CNIL) (registration
number 909003, 12 June 2009).
Funding
The French National Perinatal Survey was funded by the
Ministry of Health and was coordinated by the National
Institute of Health and Medical Research (INSERM) Unit
U1153 (Paris, France). Our study was supported by the
French Ministry of Health, the National Health Insurance
Fund for Salaried Workers (CNAMTS), and the National
Institute for Prevention and Health Education (INPES)
through a grant from the French Institute for Public Health
Research (IReSP).
Acknowledgements
Inserm Unit 1153 has received a grant from the Betten-
court Foundation (Coups d’
elan pour la Recherche
francßaise) in support of its research activities. &
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