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\begin{document}

\title{Induction of labour and caesarean delivery rates: The need for a
national and international consensus}



\author[1]{Eric Jauniaux}%
\affil[1]{University College London}%


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  \date{May 21, 2024}


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Commentary for manuscript BJOG 2022 Gurol-Urganci et al
(10.1111/1471-0528.17193)

\textbf{Induction of labour and caesarean delivery rates: The need for a
national and international consensus}

In high- and middle-income countries (HMIC), induction of labour are
common obstetric interventions often based on guidelines and hospital
protocols aimed at starting the labor for specific medical circumstances
or initiate it in post-term pregnancy. In low-income countries (LIC),
inductions are rarely available to pregnant patients due to lack of
maternity resources. By contrast, cesarean delivery (CD) rates are more
volatile and continue to increase in most HMIC with little improvement
in perinatal outcomes (Betran et al., BJOG; 206;123:667-70) whereas CD
rates have remained low in most sub-Saharan African countries (Boatin et
al., BMJ, 2018;360:k55) but maternal and perinatal deaths following CD
are disproportionately high (Sobhy et al., Lancet, 2019;393:1973-82) due
to inadequate access to emergency obstetric care facilities.

There is little controversy regarding induction of labour at any
gestational age to prevent perinatal morbidity and mortality in case of
pregnancy complications. Conversely, the timing of induction for
post-term pregnancies has been recently challenged. A large trial from
the United States, found no significant difference in perinatal outcome
in nulliparous patients induced between 39 weeks+0 and 39 weeks+4 days
compared to expectant management up to 41 weeks+0 days but reported a
significantly lower incidence of CD in the early induction group
(Grobman et al., NEJM, 2018;379:513-230). A Swedish trial comparing
induction at 41 versus 42 weeks was stopped due to a significantly
higher rate of perinatal mortality in the expectant management group
(Wennerholm et al., BMJ,2019;367:I6131).

Overall, CD rates have increased by 400\% between 1966 and 1997 in most
HICs (Glantz and McNamley, Obstet Gynecol Surv. 1997;52:497505). This
trend expends even more rapidly in MICs where attempt at stemming it
have so far failed (Hussein et al., BJOG, 2021;128:807). A recent
analysis of the 2010-2018 world data from 154 countries covering 94.5\%
of live births shows that 21.1\% of pregnant patients gave birth by CD
(Betran et al., BMJ Glob Health. 2021;6:e005671). The authors estimate
that by 2030, 28.5\% of patients worldwide will be delivered by
caesarean section with the greatest increase predicted to be in Eastern
Asia.

The recent publication of a national review of maternity safety has
identified a ``culture to keep CD rates low at all costs'' in some UK
maternities with poor perinatal outcomes
(www.gov.uk/publications/Okenden review/2022). In this issue of the
journal, Gurol-Urganci et al (BJOG,2022: in press) report on rates of
induction of labour and emergency CD in the English National Health
Service (NHS) between April 2015 and March 2017. The authors found
considerable in between-hospital variation in the use of both procedures
and hospitals with a higher induction rate presented with a lower risk
of adverse birth outcomes but no similar association was found for CD
rates. The UK has a unique national system of evidence-based guidelines
for clinical care (www.nice.org.uk/guidance). The recommendations
proposed in these guidelines are intended to decrease variations in
clinical practice to optimize patients care and are developed involving
patients. Their implementation should focus on patient needs and
preferences and not be influenced by local socio-economic, medico-legal
or cultural factors.

\textbf{Word count} : 500

\textbf{Disclosure of interests}

The author has no conflicting of interest to declare.

Eric Jauniaux MD, PhD, FRCOG

EGA Institute for Women's Health, University College London Faculty of
Population Health Sciences,~University~College~London, London, UK.
(e.jauniaux@ucl.ac.uk).

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