Caesarean rates are rising, but how much do we really understand about the role of induction of labour? The answer may lie in what happens between the decision to induce and the eventual birth. In this article, Dr Veronika Dobiasova explores why induction pathways deserve closer scrutiny, from cervical-ripening choices and the time allowed for labour to establish, to communication, support and women’s experiences of care. Rather than blaming induction or treating caesarean birth as a failure, the focus is on how maternity services can use better data and more individualised, woman-centred care to improve outcomes and experiences.
Caesarean rates are rising — but what role does induction really play? The answer may lie not only in the final mode of birth, but in the pathway that follows the decision to induce. [1,6]
The uncomfortable question
When caesarean rates rise, it is reasonable to look closely at the role of induction within maternity care pathways. Induction is visible, measurable and, for women who have experienced a long process followed by an emergency caesarean, it can feel closely connected to an outcome that was never part of their hoped-for birth plan. [2,6]
This article is not an argument against induction, nor an attempt to minimise women’s difficult experience. It asks a more demanding question: once the decision to induce has been made, do maternity services provide enough information, clinically appropriate time, practical support and meaningful review? [4]
Induction is not one thing. If we reduce it to a single label in a dataset, we risk missing the parts of the pathway that matter most — both to clinical outcomes and to women’s experience of care. [2,4,6]
The missing link in the caesarean data
Caesarean birth rates in England have risen markedly since 2019 — a trend that does not appear to be mirrored to the same extent in comparable countries. The reasons are likely to be complex, reflecting changes in the health and characteristics of the maternity population as well as the wider context of maternity care. [1]
So where does induction fit into that picture?
The latest detailed National Maternity and Perinatal Audit snapshot, based on births in NHS maternity services in England, Scotland and Wales in 2023, found that „33.9% of women and birthing people experienced induction of labour“. This makes induction an important part of the maternity-care picture. It does not, however, show how individual induction pathways unfolded or how far they contributed to the overall caesarean rate. [2]
Women offered induction are not a random group. Their pregnancies may have reached a point at which continuing expectant management carries a different balance of risk. The clinically meaningful comparison is therefore rarely induction versus spontaneous labour. It is more often induction now versus expectant management. [3,4]
A caesarean following induction cannot automatically be interpreted as evidence that induction caused it, or that the decision to induce was inappropriate. The more useful question is what happened between the decision to induce and the eventual mode of birth. [3,6]
National figures can show the final outcome, but not always the journey behind it: why induction was recommended, the cervical-ripening method used, how long the pathway lasted, where key decisions were made or how the woman experienced the process. The NMPA has identified limitations in available induction data, including inconsistent coding of unsuccessful induction, which makes variation in pathways and outcomes difficult to interpret. Until services examine those details, induction will remain partly a black box in caesarean data. [2,6]
Induction is not one thing
An induction pathway can look very different depending on the woman’s clinical circumstances and the condition of her cervix at the outset. A favourable cervix may allow induction to begin with amniotomy, followed by intravenous oxytocin where needed. A less favourable cervix may require cervical ripening first, with repeated assessment and a potentially longer period before labour becomes established. [4]
Both may be recorded simply as “induction of labour”. In reality, they can be entirely different journeys. [2,4]
Outcomes may be shaped by cervical readiness, the method selected, the time allowed for ripening and labour to establish, the care setting, monitoring requirements, pain management, the ability to eat, sleep and mobilise, staffing levels, access to labour ward and the way decisions are communicated. These variables also shape whether a woman feels involved in care or carried along by a process she cannot influence. [2,4,5]
If we treat induction as one uniform intervention, we cannot properly understand why some women progress smoothly while others face a long, increasingly medicalised pathway towards assisted birth or caesarean birth. [2,4,6]
Cervical ripening is part of the pathway
Cervical ripening is not a technical footnote at the start of induction. It is a clinically relevant part of the pathway that can influence uterine activity, monitoring needs, comfort, mobility, rest and a woman’s sense of control during what may be a prolonged and uncertain process. [4,5]
NICE includes osmotic cervical dilators among mechanical options for women with a Bishop score of 6 or less. Mechanical methods are associated with a lower likelihood of uterine hyperstimulation than pharmacological methods. [4]
Synthetic osmotic cervical dilators, such as DILAPAN-S, illustrate why this choice matters. In randomised comparison with dinoprostone, they have shown similar vaginal birth outcomes with fewer episodes of uterine hyperstimulation. Importantly, women using DILAPAN-S also reported higher satisfaction with the cervical-ripening process, including less pain and a greater ability to rest and sleep. For a woman facing an uncertain and potentially prolonged induction, these are not minor details: they can shape how she copes with the process and how much control she feels able to retain. [5]
The point is not that one method is right for everyone. It is that cervical ripening should be treated as a meaningful clinical choice within an individualised induction pathway — selected with attention not only to cervical change and safety, but also to the woman’s comfort, practical needs and experience. [4,5]
When “failed induction” hides more than it reveals
An emergency caesarean following induction may be the safest and most appropriate decision. Caesarean birth should never be framed as a failure of the woman, the midwife, the obstetric team or the method used to begin induction. [4]
Yet the phrase “failed induction” deserves more scrutiny than it often receives.
What does it mean in a particular unit? Was there a clear and individualised plan from the outset? Were likely timeframes explained honestly? Was the woman given clinically appropriate time for cervical ripening and labour to establish? Was there repeated review as the clinical picture changed? Did she understand why the plan changed, or did the decision for theatre feel abrupt and unexplained? [2,4]
These questions do not imply that every induction should be prolonged. Safety must always guide care, and there are situations in which delay is neither safe nor appropriate. But a pathway should be able to show how and why it moved from one stage to another. [4]
A woman should not leave maternity care believing that her body “failed” because a process designed around organisational pressures, limited capacity or inconsistent thresholds did not work for her. [2,4]
Women experience the pathway, not the guideline
Women do not experience an induction as a guideline, a protocol or an intervention rate.
They experience waiting. They experience the uncertainty of not knowing whether anything is happening. They experience interrupted sleep, repeated vaginal examinations, unfamiliar staff, pain that may be difficult to anticipate and the emotional shift when a hoped-for plan becomes something else. [4,5]
They also experience the language used around them.
“Nothing is happening.”
“We need to speed things up.”
“You have failed to progress.”
“It is time to move to theatre.”
Each phrase may have a clinical rationale behind it. But without explanation, context and compassionate communication, it can leave a woman feeling passive in decisions about her own birth.
Informed choice is not a form signed before cervical ripening begins. It is an ongoing conversation. Women need clear, individualised information about why induction is recommended, what waiting may involve, what each stage of the process could look like, when the plan will be reviewed and what might lead to a change of direction.
For midwives, this is central rather than peripheral work. Advocacy, expectation-setting, honest explanation and continuity of communication can make the difference between a woman feeling that induction was done to her and feeling that she remained an active participant in a changing clinical plan.
Move induction out of the shadows — and into the audit room
The final mode of birth tells us too little.
If maternity services genuinely want to understand their caesarean rates, they need to audit the pathways behind them. Not to reduce caesareans at any cost, and not to judge individual clinicians or units through a single headline figure, but to identify avoidable variation and opportunities to improve care. [1,2,6]
The questions should be practical:
What proportion of emergency caesareans in our unit follows induction of labour?
Which women are most likely to experience caesarean after induction, and what are their indications and clinical characteristics?
Which cervical-ripening methods are used, in which circumstances, and with what outcomes?
How long are women spending in the pathway before active labour is established?
What prompts escalation, and are those thresholds clear and consistently applied?
What do women report about information, pain, sleep, mobility, privacy, support and agency during induction?
These answers will not produce one neat answer. They may reveal genuine differences in population needs, clinical complexity and local service configuration. But they can also expose areas where a pathway is being shaped more by capacity than by individual need.
That is where meaningful improvement begins.
Induction is neither the villain nor the saviour. Caesarean birth is neither proof of failure nor a statistic to be reduced at all costs. The real test is whether a woman entering an induction pathway receives individualised information, clinically appropriate time, meaningful choice and practical support. Achieving this is not about asking individual midwives to do more within already stretched services; it is about designing pathways, data and decision-making processes that make woman-centred care easier to deliver. [2,4,6]
References
1. Ambia J, Alderdice F, Knight M, Rowe R, Sanders J, Carson C. Short report: International comparison of caesarean birth rates, 2020–2025. Oxford: National Perinatal Epidemiology Unit, Nuffield Department of Women’s and Reproductive Health, University of Oxford; 2026. doi:10.5287/ora-z6obzn5pq.hmc.ox.ac+1
2. NMPA Project Team. National Maternity and Perinatal Audit: Induction of Labour Snapshot Audit. Based on births in NHS maternity services in England, Scotland and Wales during 2023. London: Royal College of Obstetricians and Gynaecologists; 2025.
3. Grobman WA, Rice MM, Reddy UM, et al. Labor induction versus expectant management in low-risk nulliparous women. N Engl J Med. 2018;379(6):513–523. doi:10.1056/NEJMoa1800566.
4. National Institute for Health and Care Excellence. Inducing labour. NICE guideline NG207. London: NICE; 2021.
5. Gupta JK, Maher A, Stubbs C, Brocklehurst P, Daniels JP, Hardy P; Synthetic Osmotic Cervical Dilator for Induction of Labor in Comparison to Dinoprostone Vaginal Insert (SOLVE) Collaborative Group. A randomised trial of synthetic osmotic cervical dilator for induction of labor versus dinoprostone vaginal insert. Am J Obstet Gynecol MFM. 2022;4(4):100628. doi:10.1016/j.ajogmf.2022.100628.
6. Gurol-Urganci I, Cromwell DA, Edozien LC, et al. Use of induction of labour and emergency caesarean section and perinatal outcomes in English maternity services: a national hospital-level study. BJOG. 2022;129(11):1899–1906. doi:10.1111/1471-0528.17193.
Dr Veronika Dobiasova
Medical Writer in Women’s Health, Labour Induction & Cervical Ripening | International Product Manager for MEDICEM
October 2026