As the childbirth movement of the 1970s influenced laboring women to resist narcotic and anesthesia use, avoid the sterile delivery room for a birthing room, refuse leather hand restraints and leg stirrups, and bring fathers to the birthing room, women are now challenged to weigh in on another obstetrical intervention: elective induction of labor (IOL) at 39 weeks gestation. The ARRIVE trial (Grobman et al., 2018) has generated much discussion among childbearing women and those who care for women during pregnancy, labor, and birth. In this multicenter randomized controlled trial, 6,101 low-risk nulliparous women were randomized to elective IOL between 39 weeks and 39 weeks and 4 days or to expectant management, which included an agreement not to have an elective induction before 40 weeks and 5 days, and to give birth no later than 42 weeks and 2 days. There were no differences between groups for the primary study outcome, which was a composite of perinatal adverse events. There was a difference in one of the key secondary outcomes: method of birth. The rate of cesarean birth was lower (18.6%) in the IOL group than the expectant management group (22.2%) (Grobman et al.). This finding has led some to conclude that elective IOL at 39 weeks is an ideal way to decrease risk of cesarean birth for healthy women.

The Society for Maternal-Fetal Medicine (SMFM, in press) immediately published a response, which was endorced by the American College of Obstetricians and Gynecologists (ACOG). They conclude it is reasonable to offer elective IOL to low-risk, nulliparous women at or beyond 39 weeks for women meeting eligibility criteria used in the trial, and recommend against offering elective IOL to women inconsistent with the study protocol unless part of research or quality improvement activity. It is important to remember that the study protocol did not consider an IOL to have "failed" unless at least 12 hours had elapsed since both rupture of membranes and use of a uterine stimulant, and the woman remained in the latent phase of the first stage of labor (Grobman et al., 2018). Thus, cesarean birth was not done until after ample time for labor progress based on the study protocol.

In contrast to these recommendations, ACOG has recently authored two documents promoting physiologic birth in low-risk women. The Committee Opinion Approaches to Limit Intervention During Labor and Birth (ACOG, 2017) delineates numerous low-interventional practices and was published despite multiple retrospective studies prior to, and with similar in findings of, the ARRIVE (Grobman et al., 2018) study. The ACOG and SMFM (2014) Obstetric Care Consensus on Safe Prevention of the Primary Cesarean Delivery acknowledges that one of the most effective tools to improve birth outcomes is the continuous presence of supportive personnel or a doula. Does advocating nonmedical interventions for improved outcomes contradict the position that induction at 39 weeks is a "reasonable" standard of care?

Limitations of the ARRIVE trial (Grobman et al., 2018) include low interest to enroll as recruitment occurred at 41 hospitals over 3 years. Of the 22,533 eligible low-risk nulliparous women, only 27% agreed to participate, suggesting selection bias. Unavailable data include: epidural or narcotic use; childbirth education classes; presence of a doula; and 1:1 care by a registered nurse for women receiving oxytocin. Variances to care include: admitting provider approach and management style (94% physician and 6% midwife); type of induction method (left to discretion); and oxytocin protocol. An inability to generalize findings is due to participants' characteristics such as average age ~24 years old; 44% white; 59% single; 48% nonemployed; and 45% without private insurance. Inductions were conducted in academic teaching centers compared with community-based or rural hospitals. Women were queried via the Labor Agentry Scale (LAS) and a Likert assessment of labor pain. The LAS, developed in 80s, elicits one dimension: perceived personal control during pregnancy and childbirth. It is not surprising the labor induction group scored high positive on perceived control as they desired induction compared with 16,427 eligible women that chose not to participate in the study. Labor pain scores were not correlated to epidural or narcotic use.

Of significant concern are institutional implications. What costs are associated with increased need for labor beds and surgical rooms to accommodate potential physician and consumer demand for 39-week elective IOL? If requested and the labor unit is at capacity, is there increased professional liability as findings suggest decreased incidence of cesarean birth, less maternal hypertension, and fewer newborn respiratory consequences? What is the cost for an increase in nurse staffing to provide 1:1 nursing care for women in labor being induced with oxytocin as recommended by the Association of Women's Health, Obstetric, and Neonatal Nurses (2010) Guidelines for Professional Registered Nurse Staffing for Perinatal Units and the American Academy of Pediatricians and ACOG (2017) in the Guidelines for Perinatal Care? Will there be increased legal risk related to imprudent use of oxytocin, the most common obstetric medication associated with harm (Clark, Belfort, Byrum, Meyers, & Perlin, 2008)?

What about women's experience of induction? In the Listening to Mothers III survey, 15% of mothers reported experiencing pressure from a care provider to have labor induced without a medical indication, 53% experienced attempted labor induction, and 30% had a medically induced labor (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2014). It is likely this situation will become more common as pregnant women are vulnerable to making uninformed decisions about induction when there is not a medical reason. In a study of 3,337 nulliparous women, physicians offered the option of elective induction to 69.5% (n = 937) of survey participants (Simpson, Newman, & Chirino, 2010). This was a factor in women's decisions; 43.2% (n = 404) of those offered the option had elective induction, whereas 90.8% (n = 374) of those not offered the option did not have elective induction. Women were given explicit information in prepared childbirth classes about the potential risks and associated interventions involved with elective IOL; however, many women felt their physician would not be offering the option of elective induction unless it was in their best interests; the offer was generally interpreted to be a recommendation (Simpson et al.). Women often describe induction as exhausting and results in a disempowering experience (Declercq et al.).

In the midst of the United States addressing the highest rate of maternal mortality of all high-income countries in the world, it appears disingenuous that the two professional societies representing physicians overseeing the majority of births suggest that intervening with normal physiology is reasonable action to improve maternal outcomes while ignoring due diligence to examine implications for already overtaxed facilities and rising staffing fatigue. Much more data are needed before, if ever, elective IOL can be recommended as routine for low-risk women.

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