Labor Induction Not Linked to Higher Cesarean Rates in Midwife-Led Births

The Takeaway: A retrospective review of more than 7,300 midwife attended births in three Colorado hospitals found that labor induction did not increase the likelihood of cesarean birth compared to expectant management. Researchers from the CU Anschutz College of Nursing found that prolonged pregnancy beyond 41 weeks – not induction itself – was associated with higher C-section rates. The study also highlights how integrated midwifery care may contribute to strong maternal and newborn outcomes.

Inducing labor does not increase the likelihood of cesarean birth, according to a retrospective review of more than 7,300 births overseen by midwives across three Colorado hospitals.

Labor induction rates in recent years have significantly increased said the study’s lead author, Denise Colter Smith, PhD, CNM, assistant professor in the CU Anschutz College of Nursing. And while research funding for midwife-led studies is limited nationwide, she and her team are committed to answering the most pressing questions in the field by applying rigorous methodology to more widely accessible retrospective data.

“Midwives attend nearly half of the births at UCHealth University of Colorado Hospital, and this study is a great example of what midwifery care can do at scale,” Smith said.

In the following Q&A, Smith discusses what the study reveals about induction, spontaneous labor and the role of midwives in supporting safe births.

What prompted a study of labor induction outcomes in integrated midwifery care?

One of the big questions in maternity care right now is labor induction – what are the positives, what are the negatives and what actually happens to patients who are induced? Labor induction rates have risen significantly since the publication of the ARRIVE clinical trial, which in 2018 concluded that for healthy first-time mothers at 39 weeks, elective induction did not increase risks for babies and was associated with a slightly lower rate of C-sections compared with waiting for labor to begin naturally.

Integrated midwifery care is a model in which midwives work alongside physicians and specialists within a hospital system. As midwives, we place high value on spontaneous labor and birth because it often has the most straightforward outcome. But more and more people have a medical reason for induction and sometimes request one. So the question became: What are the outcomes for those patients, and how can we best counsel them about what to expect? We wanted to understand what induction outcomes look like specifically in a large midwifery practice, because most existing studies are based mostly on physician-led care.

Key points:

Labor induction did not increase cesarean birth risk in midwife-led care, according to an analysis of more than 7,300 births in three Colorado hospitals.

Pregnancy beyond 41 weeks was linked to higher C-section rates.

Length of stay in the hospital was significantly longer for those being induced, an important consideration for many families.

Researchers emphasized that care setting and organizational culture influence birth outcomes.

Integrated midwifery care can support safe, evidence-based maternity care at scale.

What did your study find about induction and C-section risk?

The biggest takeaway from our retrospective review is that, in a setting like ours where midwives are providing hospital-based care, labor induction itself did not increase the risk of cesarean birth. In our setting, newborn outcomes were also good. One outcome of importance that was significantly different was the length of time spent admitted to the hospital labor unit, which was in some cases three times longer for those being induced. This is especially meaningful for families who need to plan for their older children's care or when spouses need to work.

So, if you need to be induced – especially for a medical reason – you shouldn’t automatically worry that induction is going to lead to a C-section. What stood out was that prolonged pregnancy, or being pregnant past 41 weeks, was associated with a higher rate of cesarean birth. It wasn’t the induction itself.

Do patients who choose midwife care tend to be healthier and at a lower risk than the general population?

No, and that’s really important. People often hear “midwife” and assume the patients are all exceptionally healthy or seeking some specific kind of birth experience. But our sample was very representative of the overall population.

We had patients with hypertension, diabetes, fetal growth restriction and other complications. In some health systems, midwifery care is a foundational access point for maternity care. Many patients simply come to us because we are the first-line provider available to them. In addition, midwives are trained to provide evidence-based care for complications of pregnancy and to provide collaborative care with physician colleagues, as needed, for complications beyond their scope of practice.

Why do women choose midwife care?

Midwives provide whole-person care. We focus on how you’re doing mentally, physically and within your family unit, because we believe relationships are foundational to care.

Our primary goal is maintaining the health of both mother and baby, and we believe one of the best ways to do that is through vaginal birth but not at any cost. It’s not that we think C-sections are wrong. It’s that C-sections are not medically necessary as often as people assume.

Definitions:

Labor induction: The process of using medications or medical techniques to start labor before it begins naturally.

Cesarean birth: A cesarean birth, or C-section, is a surgical procedure used to deliver a baby through incisions in the abdomen and uterus.

Retrospective review: A retrospective review is an analysis of existing patient data and medical records to study outcomes after care has already occurred.

Integrated midwifery care: Integrated midwifery care refers to midwives working collaboratively within a hospital-based healthcare system alongside physicians and specialists.

Why do C-section rates matter?

When we look at C-sections retrospectively, people often don’t question whether it was the right decision because they trust their providers. And in retrospect, it’s very hard to tell someone they shouldn’t have had one.

Here’s what we do know: C-sections are a major surgery. When someone already has complications like hypertension, obesity or clotting disorders, surgery on top of those conditions can become a tipping point that leads to poor outcomes.

So when we talk about lowering unnecessary cesarean birth, we’re talking about maintaining health and avoiding adding more risk when it isn’t medically necessary.

What does this study say about health systems with integrated midwifery care?

Where you choose to give birth matters. One thing this study underscores is that context matters. We’ve heard providers or systems say their patients are sicker and that’s why their outcomes aren’t as good. But it’s not just patient's health driving outcomes. It’s also the organizational culture and the people who work in the facility. In a health system with integrated midwifery care, outcomes are better than population estimates and regional birth outcomes.

Related: U.S. News & World Report names CU Anschutz Nursing's Midwifery Program as #1 in the nation.

What are common misconceptions about midwives?

Some people think midwives are outdated or somehow separate from evidence-based medicine, and that’s just not true. Midwives follow evidence. Historically, from the earliest outcomes data in colonial America to today, midwives have had outcomes equal to or better than physicians. Choosing midwifery care does not mean rejecting modern medicine.

C-sections can be thought of as an advancement in maternity care – and they certainly have their place. When we see higher C-section rates, we might assume it’s medical progress, but the data don’t really support that. When maternal and newborn outcomes improved dramatically in the mid-20th century, the cesarean birth rate was still only around 5%. The largest advances came from handwashing and medications to treat hemorrhage. Meanwhile today, we’re seeing increasing cesarean rates alongside increasing maternal morbidity and mortality. So more C-sections do not automatically mean better outcomes.

What should pregnant patients understand about induction and C-section risk?

Again, context matters. In settings such as those in this study, where we’ve integrated midwifery care, you can be reassured that an induction itself isn’t likely to increase your risk of cesarean birth. When you’re choosing a place to give birth, it’s the people providing the care and how they approach labor and birth that matter most. If a care setting has good outcomes, the induction itself isn’t going to lead to an increased risk of cesarean birth.