I was due with my first baby on Christmas. When he didn’t come, for five more long days, my OBGYN asked if I wanted to be induced. It was barely the first time I’d heard the word, let alone considered the decision. Without any more explanation, or considerations of the risks or rewards, she raised her eyebrows awaiting my answer. I hesitated. “You mean, like, now?” I said. She said yes, or otherwise I’d have to wait until after the holidays, maybe even until January 2 or 3, as staffing was lower in the timeframe, she said. Her body language was impatient, and I didn’t feel like I should ask any questions, given the tension in the room, and my excitement to meet my first child. So I said yes.
Four kids and almost eight years later, I look back on that situation with disgust. As a first-time mom, this should have been at least a 20-minute discussion, possibly with an overnight period to think about it afterward, in which I would have been presented with research to help inform the decision. Now, I know more.
Parents, new and experienced alike, face this same conversation every day across the U.S. — with some providers doing an excellent job at educating their patients and others avoiding the conversation completely. According to 2020 statistics, induction rates have risen from around 10% of births to nearly 26%, between 1990 and 2018. Of those, a third were elective inductions, meaning they were chosen not because of any medical reason to begin labor. Instead, elective inductions are sometimes offered beginning at 39 weeks for purposes such as planning childcare for other children while parents are in the hospital, coordinating time off work, and other personal reasons.
The induction conversation, and research around it, is a messy dilemma with lots at stake — parents and baby’s lives, birth stories, and comfort level in their medical decisions. So how on earth is an expectant mom supposed to navigate this, especially amid the discomfort and anticipation of the last days of pregnancy?
Unfortunately, my holiday induction story is far from unique. It was a tough first pregnancy lesson that taught me to advocate for myself in future induction conversations, and led me down a path to learn much more about my options.As I head into my fifth pregnancy, I researched the progress made, and that still needs to be made, in shared decision making with patients and parents, much unlike my first birth.
Unclear research on a difficult, personal choice
There has been a great deal of research into whether it’s safer to induce or wait until labor begins on its own — depending on how overdue a woman is and how “ready” her body is for labor. In 2018, previous recommendations to wait for labor, and not to induce for the most part unless there was a medical reason, changed with the findings of the “ARRIVE trial,” a 2018 study published in the New England Journal of Medicine.
“That’s changed our thinking dramatically,” Dr. Holly Puritz told me, explaining that it said it was ok to offer the option of induction at 39 weeks, as long as the patient’s preferences were considered and the hospital had the staffing. Of course, not every expectant mom will research the study to decipher what the findings mean for them.
Puritz said that one drawback of inductions is that it can take a while to deliver the baby, leading to multiple days in a hospital bed, which is completely uncomfortable and exhausting. “Length of time has a big role in ability to withstand pain and discomfort,” she explained.
To determine who is a best candidate for an elective induction, OBGYNs consider a patient’s “Bishop score,” which considers factors like how low the baby’s head is, how dilated they are, and if the cervix is effaced. In Puritz’ personal opinion, she equates pregnancy past 41 weeks to a common phrase she uses with teenagers: “Nothing good happens after midnight.” For her, 41 weeks is midnight, and the risks aren’t worth the benefits, as the placenta’s quality and ability to sustain the baby can start deteriorating.
An induction decision tool to educate patients, alleviate confusion
That’s what inspired Dr. Ann Peralta to create a “decision tree” for patients. She is the founder of Partner to Decide, a non-profit organization dedicated to increasing equitable access to shared decision-making in maternity care. The chart, available in three languages, breaks down the research and facts surrounding inductions. It answers some common questions like: How many people are still pregnant five days after their due date? What about two weeks after? Who chooses if I get induced or not? What are the similarities and differences between the choices?
Peralta was faced with this decision multiple times, as she had late babies, and alway felt pressure to induce. She didn’t want others to have to be in the health field to have access to the data, but more importantly, the context around it they might not get from reading one study.
“That was what inspired me to try to make a tool that provided the access to the actual data.”
Bridging the gap for underserved populations
As a white, college-educated health and parenting journalist, my distinct advantage in navigating these discussions with providers isn’t lost on me. I can’t imagine making such decisions with a provider I don’t trust, or a language barrier, as they are complicated enough. Not only are some non-English speaking patients unable to access a full discussion about the induction decision, but underserved populations such as Black and brown women might not fully trust what their doctor is saying.
And with good reason: “It’s clear if you have Black or brown skin, if you are low income, if you have a lower education level, you are much less likely to experience shared decision making, or any kind of decision making on this topic,” says Jade Kearney, founder of SheMatters, a digital health platform supporting Black mothers. Dr. Erica Montes, a bi-lingual English/Spanish OB-GYN (known on Instagram as The Modern Mujer), pointed out that only 5.8 percent of all US physicians are Latinos, and about 5 percent of practicing physicians are Black. Black women are more than three times more likely to die in pregnancy and postpartum than white women.
How to have “real talk” with your provider
It’s unlikely your doctor will present you with this brand-new induction conversation tool, simply because it’s not a widespread resource yet. But you can print it yourself and use it as a conversation guide with your provider. Our experts had additional conversation starters you can use to ensure you are having shared decision-making with your provider including:
- Is this mandatory?
- What are the risks and benefits, for me and the baby?
- I think I want an induction — why shouldn’t I have it?
- I don’t think I want one, why should I?
Finally, Kearney says if you are working with a provider who isn’t giving you enough time or you don’t feel heard, it’s never too late to switch.
This is exactly what I did after my third baby resulted in an even longer, more terrible induction than the first one. At my new provider, who delivered my fourth baby just short of 41 weeks, without needing induced that time, I was able to have the above conversations. And most importantly, I wasn’t rushed into a decision, pushed into revolving my baby’s birth around a holiday, or met with any raised eyebrows. That’s how it should be for everyone, every time, whether they want an elective induction, don’t, or aren’t sure.
Alexandra Frost is a Cincinnati-based freelance journalist, content marketing writer, copywriter, and editor focusing on health and wellness, parenting, real estate, business, education, and lifestyle. Away from the keyboard, Alex is also mom to her four sons under age 7, who keep things chaotic, fun, and interesting. For over a decade she has been helping publications and companies connect with readers and bring high-quality information and research to them in a relatable voice. She has been published in the Washington Post, Huffington Post, Glamour, Shape, Today's Parent, Reader's Digest, Parents, Women's Health, and Insider.