Induction of labor at 39 weeks of gestation versus expectant management for low-risk nulliparous women: a cost-effectiveness analysis

Published:February 12, 2019DOI:


      A large, recent multicenter trial found that induction of labor at 39 weeks for low-risk nulliparous women was not associated with an increased risk of cesarean delivery or adverse neonatal outcomes.


      We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks vs expectant management for low-risk nulliparous women in the United States.

      Study Design

      A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks vs expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the United States annually that are considered low risk. Outcomes included mode of delivery, hypertensive disorders of pregnancy, macrosomia, stillbirth, permanent brachial plexus injury, and neonatal death, in addition to cost and quality-adjusted life years for both the woman and neonate. Model inputs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/quality-adjusted life years.


      In our theoretical cohort of 1.6 million women, induction of labor resulted in 54,498 fewer cesarean deliveries and 79,152 fewer cases of hypertensive disorders of pregnancy. We also found that induction of labor resulted in 795 fewer cases of stillbirth and 11 fewer neonatal deaths, despite 86 additional cases of brachial plexus injury. Induction of labor resulted in increased costs but increased quality-adjusted life years with an incremental cost-effectiveness ratio of $87,691.91 per quality-adjusted life year. In sensitivity analysis, if the cost of induction of labor was increased by $180, elective induction would no longer be cost effective. Similarly, we found that if the rate of cesarean delivery was the same in both strategies, elective induction of labor at 39 weeks would not be a cost-effective strategy. In probabilistic sensitivity analysis via Monte Carlo simulation, we found that induction of labor was cost effective only 65% of the time.


      In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes but increased costs. The incremental cost-effectiveness ratio was marginally cost effective but would lead to an additional 2 billion dollars of healthcare costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity, careful evaluation and allocation of healthcare resources, and patient preferences.

      Key words

      cesarean delivery, decision analysis, healthcare resources, induction of labor, low-risk nulliparous women, mode of delivery, obstetric outcomes
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Darney B.G.
        • Snowden J.M.
        • Cheng Y.W.
        • et al.
        Elective induction of labor at term compared with expectant management.
        Obstet Gynecol. 2013; 122: 761-769
        • Osterman M.J.K.
        • Martin J.A.
        Recent declines in induction of labor by gestational age.
        NCHS Data Brief. 2014; 155: 1-8
        • Murthy K.
        • Grobman W.A.
        • Lee T.A.
        • Holl J.L.
        Trends in induction of labor at early-term gestation.
        Am J Obstet Gynecol. 2011; 204: 435.e1-435.e6
        • Caughey A.B.
        • Nicholson J.M.
        • Cheng Y.W.
        • Lyell D.J.
        • Washington A.E.
        Induction of labor and cesarean delivery by gestational age.
        Am J Obstet Gynecol. 2006; 195: 700-705
        • Stock S.J.
        • Ferguson E.
        • Duffy A.
        • Ford I.
        • Chalmers J.
        • Norman J.E.
        Outcomes of elective induction of labour compared with expectant management: population based study.
        BMJ. 2012; 344
        • Caughey A.B.
        • Sundaram V.
        • Kaimal A.J.
        • et al.
        Maternal and neonatal outcomes of elective induction of labor.
        Evid Rep Technol Assess (Full Rep). 2009; 176: 1-257
        • Caughey A.B.
        • Sudaram V.
        • Kaimal A.J.
        • et al.
        Systematic review: elective induction of labor versus expectant management of pregnancy.
        Ann Intern Med. 2009; 151: 252-263
        • Amano K.
        • Saito K.
        • Shoda T.
        • Tani A.
        • Yoshihara H.
        • Nishijima M.
        Elective induction of labor at 39 weeks of gestation: a randomized trial.
        J Obstet Gynaecol Res. 1999; 25: 33-37
        • Martin D.
        • Thompson W.
        • Pinkerton J.
        • Watson J.
        A randomized controlled trial of selective planned delivery.
        Br J Obstet Gynaecol. 1978; 85: 109-113
        • Nielsen P.
        • Howard B.
        • Hill C.
        • Larson P.
        • Holland R.
        • Smith P.
        Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial.
        J Matern Fetal Neonatal Med. 2005; 18: 59-64
        • Dyson D.
        • Miller P.
        • Armstron M.
        Management of prolonged pregnancy: induction of labor versus antepartum fetal testing.
        Am J Obs Gynecol. 1987; 156: 928-934
        • Gelisen O.
        • Caliskan E.
        • Dilbaz S.
        • Ozdas E.
        • Dilbaz B.
        • Ozdas E.
        Induction of labor with three different techniques at 41 weeks of gestation or spontaneous follow-up until 42 weeks in women with definitely unfavorable cervical scores.
        Eur J Obs Gynecol Reprod Biol. 2005; 120: 164-169
        • Hannah M.
        • Hannah W.
        • Hellmann J.
        • Hewson S.
        • Milner R.
        • Willan A.
        Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian multicenter post-term pregnancy trial group.
        N Engl J Med. 1992; 326: 1587-1592
        • Heimstad R.
        • Skogvoll E.
        • Mattsson L.-A.
        • Johansen O.
        • Eik-Nes S.
        • Salvesen K.
        Induction of labor or serial antenatal fetal monitoring in postterm pregnancy: a randomized controlled trial.
        Obstet Gynecol. 2007; 109: 609-617
        • Grobman W.A.
        • Rice M.M.
        • Reddy U.M.
        • et al.
        Labor Induction versus expectant management in low-risk nulliparous women.
        N Engl J Med. 2018; 379: 513-523
        • Martin J.
        • Hamilton B.
        • Osterman M.
        • Driscoll A.
        • Drake P.
        Births: final data for 2016.
        Natl Vital Stat Rep. 2018; 67: 1-50
        • Caughey A.B.
        • Cahill A.G.
        • Guise J.M.
        • Rouse D.J.
        Safe prevention of the primary cesarean delivery.
        Am J Obstet Gynecol. 2014; 210: 179-193
        • Yao R.
        • Ananth C.
        • Park B.
        • Pereira L.
        • Plante L.
        31: Obesity and the risk of stillbirth: a population-based cohort study.
        Am J Obstet Gynecol. 2014; 210: S21
      1. United States Department of Health and Human Services (USDHHS), Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), Department of Vital Statistics. Public-use data on CDC WONDER Online Database, for years 2007-2016.

        • Overland E.
        • Vatten L.
        • Eskild A.
        Pregnancy week at delivery and the risk of shoulder dystocia: a population study of 2,014,956 deliveries.
        BJOG. 2014; 121: 34-41
        • Christoffersson M.
        • Rydhstroem H.
        Shoulder dystocia and brachial plexus injury: a population-based study.
        Gynecol Obste Invest. 2002; 53: 42-47
        • FRED Economic Data
        Consumer Price Index For All Urban Consumers: Medical Care [CPIMEDSL]: 2018.
        (Available at:) (Accessed July 1, 2018)
        • Sanders G.
        • Neumann P.
        • Basu A.
        • Al E.
        Recommendations for conduct, methodological practices, and reporting of cost-effectiveness analyses: second panel on cost-effectiveness in health and medicine.
        JAMA. 2016; 316: 1093-1103
        • Song K.
        • Musci T.J.
        • Caughey A.B.
        Clinical utility and cost of non-invasive prenatal testing with cfDNA analysis in high-risk women based on a US population.
        J Matern Neonatal Med. 2013; 26: 1180-1185
        • Tilden E.L.
        • Lee V.R.
        • Allen A.J.
        • Griffin E.E.
        • Caughey A.B.
        Cost-effectiveness analysis of latent versus active labor hospital admission for medically low-risk, term women.
        Birth. 2015; 42: 219-226
        • Grobman W.A.
        2: Resource utilization among low-risk nulliparas randomized to elective induction at 39 weeks or expectant management.
        Am J Obstet Gynecol. 2019; 220: S2-S3
        • Bost B.
        Cesarean delivery on demand: what will it cost?.
        Am J Obstet Gynecol. 2003; 188: 1418-1421
        • Werner E.F.
        • Hauspurg A.K.
        • Rouse D.J.
        A cost-benefit analysis of low-dose aspirin prophylaxis for the prevention of preeclampsia in the United States.
        Obstet Gynecol. 2015; 126: 1245-1250
        • Brauer C.
        • Waters P.
        An economic analysis of the timing of microsurgical reconstruction in brachial plexus birth palsy.
        J Bone Jt Surg. 2007; 89: 970
      2. Waitzman N, Romano P, Scheffler R. Estimates of the economic costs of birth defects. Inquiry 2994;31:188-205.

        • Angeja A.
        • Washington A.
        • Vargas J.
        • Gomez R.
        • Rojas I.
        • Caughey A.B.
        Chilean women’s preferences regarding mode of delivery: which do they prefer and why?.
        BJOG. 2006; 113: 1253-1258
        • National Center for Health Statistics. Health, United States 2015
        With Special Feature on Racial and Ethnic Disparities. U.S. Department of Health and Human Services.
        (Available at:)
        • Kaimal A.J.
        • Little S.E.
        • Odibo A.O.
        • et al.
        Cost-effectiveness of elective induction of labor at 41 weeks in nulliparous women.
        Am J Obstet Gynecol. 2011; 204: 137.e1-137.e9
        • Phibbs C.S.
        • Schmitt S.K.
        Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants.
        Early Hum Dev. 2006; 82: 85-95
        • Carroll A.E.
        • Downs S.M.
        Comprehensive cost-utility analysis of newborn screening strategies.
        Pediatrics. 2006; 117: S287-S295
        • Grobman W.A.
        • Dooley S.L.
        • Welshman E.E.
        • Pergament E.
        • Calhoun E.A.
        Preference assessment of prenatal diagnosis for Down syndrome: is 35 years a rational cutoff ?.
        Prenat Diagn. 2002; 22: 1195-1200

      Linked Article

      • June 2019 (vol. 220, no. 6, pages 590.e1-10)
        American Journal of Obstetrics & GynecologyVol. 223Issue 2
        • Preview
          Hersh AR, Skeith AE, Sargent JA, Caughey AB. Induction of labor at 39 weeks of gestation versus expectant management for low-risk nulliparous women: a cost-effectiveness analysis. Am J Obstet Gynecol 2019;220:590.e1-10.
        • Full-Text
        • PDF