Dr. Rebecca Dekker – 00:00:00:

Hi everyone. On today’s podcast, we’re going to talk about the evidence on inducing labor at 41 weeks or later. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi, everyone. Today, I am so excited to bring you today’s podcast all about the evidence on induction of labor at 41 weeks or later. 

So today, along with my co-host, Dr. Sara Ailshire, we have a lot of brand new evidence-based information to bring to you. So Sara is a member of the EBB research team, and she has come onto the podcast many times to share her research updates. And today, Dr. Sara is here to talk about our latest Signature Article, all about the research on inductions at late term and further beyond in pregnancy. So this episode is a companion podcast episode to our earlier podcast on the evidence, “What is a Due Date,” episode 384, which came out in January of 2026. So Sara, welcome back to being a co-host on the podcast with me.

Dr. Sara Ailshire – 00:01:29:

Hi, thank you so much for having me back on. It’s always good to be back and get on the pod and talk about what we’ve been up to. So I’m really excited to talk about everything that we’ve added to this article, the latest research on the topic, and to finish up our two-part series about due dates and induction at 41 weeks and beyond. So we’ve been working on these for a really long time. And now that we’re recording this podcast, it means that we’re at the finish line. It’s always a great feeling when these big projects come to an end and we get to share what we’ve learned with everybody.

Dr. Rebecca Dekker – 00:01:59:

Yes. And now all this work that we’ve put into the many hours you’ve put in, I’ve been helping edit. We get to the point where we can share it with everyone. And we love being able to share the evidence with you. So if you want any of the materials or scientific references that go along with this episode, it’s super simple to access. Just go to ebbirth.com/inducingduedates. And everything there is waiting for you. So just to rewind a little bit, I originally published the Evidence on Due Dates here at Evidence Based Birth® in the year 2015. And then we updated that article in 2020. And we now have a lot of new content here at Evidence-Based Birth about due dates and induction. I want to point out that in the past, we called this Signature Article the evidence on inducing for due dates. But we’re changing the title of this article to the evidence on inducing for 41 weeks or later. And that’s because after the 39-week time point, which we cover in a separate podcast and article all about the ARRIVE Trial, 41 weeks or one week past your due date is the next time point that researchers focus on. There is surprisingly very little research about being induced for your actual due date of 40 weeks. But there’s been a ton of research recently on being induced at 41 weeks. And so that’s why we’re focusing on 41 weeks in the Signature Article and on this podcast. As a content note, in this episode, we will discuss the risk of stillbirth, which is the loss of a baby at or beyond 20 weeks of pregnancy. We will also talk about the risk of newborn death. Stillbirth and newborn loss touches the lives of many parents, birth workers, and providers all around the world. And in the show notes, we will share some resources that honor the babies lost and support parents and families affected by this type of loss. Now, last time on the podcast, when Dr. Sara was here, we talked about the science behind due dates so we could understand where that 40-week number comes from, what that estimate gets right and gets wrong. We also talked a little bit about why providers may get concerned when a pregnancy goes past term or past the due date. In this episode, we’re specifically focusing on 41 weeks, which is one week past the due date. And we’re going to also focus on why providers might recommend or at least start talking about inducing at 41 weeks once you’ve gone past your due date. So if you’re pregnant or you’re hoping to become pregnant and you want to learn more about what to expect, if you go past your due date, or if you’re a birth worker, maybe a doula, childbirth educator, your clients have questions about induction at the end of pregnancy, especially if they really wanted to go into labor on their own. Hopefully today we can help you out. We want to cover why someone might start hearing from providers that they need to be induced after they go past their due date, the difference between a medically indicated induction and an elective induction. We’re going to talk a lot about what the research says, what the health outcomes are when labor is induced at 41 weeks instead of waiting for labor to begin on its own, which is also called expectant management. We are going to summarize the benefits and the risks of induction at 41 weeks and beyond. And we’re going to talk about what the professional guidelines say on this topic. We’re going to answer some frequently asked questions about these topics. And of course, we’ll end by giving you the bottom line. So, Sara, can you start us off by explaining how common is it for someone to be induced for going past their estimated due date?

Dr. Sara Ailshire – 00:05:58:

Yeah, that’s a great question. That’s where we start in the article. In 2022, which is some of the most recent data that we have, the total induction rate in the United States was 31.8%. And this comes from a review of American birth certificate data that was published in 2024. But that number might be inaccurate because research suggests that induction of labor is probably underreported in the federal vital statistics that we get so much of our information about pregnancy, childbirth, and birth outcomes from. Also, specific details about induction are not recorded in standard U.S. birth certificate data. So we cannot know for sure how often people may have different types of inductions or why inductions are carried out, for example. However, there are researchers who are trying to help answer this question. We do know, for example, that 40% of participants in the Listening to Mothers in California survey that was published in 2018 reported that their care provider tried to induce their labor. The researchers then were able to ask the participants in the study for the reasons why they were induced. And two of the most common reasons for induction were, one, out of everybody who was induced, 35% of those said that they were induced because their baby was full term. And close to the due date. And then another 22% of those who said that they were induced said that they were induced because their healthcare provider was concerned that they were overdue. So induction can be a really helpful tool if there’s something that’s happening in pregnancy that can put the parent or the baby at risk. I think I’ve told my story on the podcast before I was induced for preeclampsia, for example, and I’m really grateful that, you know, I got the care I needed to have a healthy birth and, you know, be doing well today. And there’s some people who choose induction for themselves at term. They think it’s the best option for them. They’re ready, you know, it’s their free choice. However, in the research from Listing the Mothers in California data that we have, we see that some providers consider being overdue or being past your due date, a medical reason for why somebody might need an induction.

Dr. Rebecca Dekker – 00:08:09:

Yeah, while you were talking, it’s reminding me of how frustrated you and I were at trying to find information on how often labor is induced for going past the due date, because it seems like it’s something that we don’t really have documented anywhere, at least on a national basis. And I know we were able to look at a few countries, but worldwide, it just seems like we’re just kind of guessing how often induction happens for going past your due date. We get a lot of comments from doulas in particular who say like almost all of my patients are getting pressure to be induced at 39, 40 or 41 weeks. And I’m just affirming that this was a difficult subject to find data on.

Dr. Sara Ailshire – 00:08:49:

Yeah, absolutely. You know, we can find information about induction, even if that information, which like other researchers have documented, might be a little bit imperfect. But you know, if we had our wish list of all the data that we could have, it’d be really nice to have a little bit more insight into this and be able to really understand, you know, do people’s experiences, like birth professionals experiences, does that align with, you know, what the numbers are, but we don’t have them. So Rebecca, would you mind walking us through the distinction between a medically indicated induction and an elective induction when it comes to going past your due date?

Dr. Rebecca Dekker – 00:09:25:

Yeah. So you mentioned having a medically indicated induction a few minutes ago. So in general, inductions are considered to be medically indicated when there are medical problems or pregnancy complications present that make it less safe to continue the pregnancy. Medically indicated inductions typically refer to inductions where the motivation for attempting to induce labor is either to respond to a medical condition that could threaten your health or the well-being of your baby or a situation where giving birth could help resolve a medical condition before it becomes worse, such as with preeclampsia. So medically indicated inductions can happen anytime during pregnancy. They can happen well before your due date. If there’s a medical indication, it can even happen before viability or the age where a fetus can be born and have a chance of surviving outside the womb. So we do have a reference list and you can access that for descriptions of medical conditions in which preterm or early term birth via induction and or Cesarean may be recommended by providers. So, you know, we can have medical complications that maybe call for an induction all the way to like, we need this induction to save your life and everything in between. Now, labor inductions that do not have a clear medical reason or indication for taking place are called elective inductions. So elective inductions might occur for preference reasons or for social reasons. If you or your healthcare provider want the birth to happen when a specific provider is on duty, for example, or maybe you need to schedule the birth around the availability of a partner or support person. Maybe they’re about to be deployed and you want to have the baby before they leave. Inductions that are elective might also occur for reasons like wanting to be done with an uncomfortable pregnancy, or maybe you live a long distance from the hospital. So you feel like it’s safer to induce rather than risk going into labor and having the baby in the car on the way there. Or maybe there’s an upcoming blizzard or hurricane, or you’re trying to plan care around other children or dependents. So there are a lot of reasons why someone might choose an elective induction. Now, opinions can differ on, you know, what is the best, most inclusive term to use when we’re referring to inductions that don’t have a clear medical indication, including when inductions are done for reaching your due date. So there is controversy over what would we call an induction simply for reaching 41 weeks, for example. So in the Signature Article, we chose to use the term elective induction when we’re talking about situations like that, that don’t have a clear medical indication, because it’s the term most commonly used in research. And we’re writing about this topic for a general audience. And we also try to use the terms that researchers use to ensure we’re accurately representing their work. So in the United States, elective inductions typically do not occur earlier than 39 weeks and zero days. And this is sometimes referred to as the 39-week rule. And that’s because in 2009, there was a set of guidelines published by the American College Obstetricians and Gynecologists known as ACOG and the Society for Maternal and Fetal Medicine, where they advised against elective inductions prior to 39 weeks of pregnancy due to the known increased risk of complications for infants who are born in that early term period between 37 weeks, zero days and 38 weeks, six days. But sometimes the lines between an elective versus a medically indicated induction are blurred and not always clear. So some providers consider being induced for late term pregnancy, which is considered 41 weeks, zero days to 41 weeks, six days, or post term pregnancy, which is considered to be 42 weeks, zero days and later to be medically indicated because of the increased risk of complications that come with longer pregnancies. While others might refer to it as an elective induction if there are no existing health problems at that time. And as I mentioned earlier, to stay consistent, and because this is what the term most of the researchers use, we will call those inductions at 41 and 42 weeks when there’s no other health problems, we’ll call those elective inductions. Now, when someone gets closer or past their due date, they might start facing that question. Should we induce labor or should we wait for labor to start on its own? Or maybe you don’t want to wait forever, but you’re willing to wait just a few more days or maybe one more week. Another way of referring to waiting for labor to start on its own, usually with fetal monitoring to monitor the baby’s status is called expectant management. And expectant management can sometimes result in spontaneous labor where you went into labor on your own, and it can sometimes result in choosing an elective induction later or having a medically indicated induction later. That is often compared in the research with a more active management style where labor is induced electively for getting close to reaching or passing the due date without any other health problems indicating a need for induction. So there is a lot of research comparing the benefits and risks of this more active management style using an elective induction at certain time points versus expectant management. And that research kind of spans the length of time from 39 weeks to 42 weeks and beyond. So, Sara, I think now let’s turn to that research. You know, what does the research say about outcomes when labor is induced primarily at 41 weeks? Because that’s what we’re going to focus on today in this podcast. Instead of waiting for labor to begin on its own.

Dr. Sara Ailshire – 00:15:24:

Absolutely. So before we get into that, though, I wanted to talk a little bit about some of the limits of the research evidence that we have that compares induction at 41 or 42 weeks with waiting for labor to start on its own. And just as a disclaimer, research is not a perfect process. And the fact that we can talk about some of these issues from previous research studies means that researchers know about this and can account for this in future studies as they design new randomized controlled trials or as they study existing medical records doing observational research. So we have identified four of these things to keep in mind. First, many of the clinical trials on induction versus expectant management were carried out in countries or during time periods with comparatively lower Cesarean rates than you might find in another country or today, depending where you are in the world. These research findings on Cesarean rates and inductions might not apply, you know, to people who are giving birth in hospitals that have high Cesarean rates. You know, the setting of birth would matter a lot. And if you’re giving birth in a hospital, that puts a really strict time limit on the length of labor that discourages mobility and position changing. Or, you know, if you have epidural doesn’t provide assistance with, you know, moving you around as you might need, you might have a very different experience with an induction than somebody who’s induced in a hospital where birthing people have freedom of movement. They’re able to rest. There’s greater shared decision making. We hope that research is sort of like generally applicable. That’s the goal. But circumstances can matter and can maybe impact how applicable, you know, a study might be to your circumstances. Another limitation is that the correct comparison group for elective induction includes people who are induced later in pregnancy, as well as those who go into labor spontaneously. Most researchers, though, only report the results of the two study groups as they originally are defined or as people are originally assigned. Those who are meant to have the management or the induction versus those who are meant to have expected management. But it can be more helpful to look at the results for people who were actually induced or who actually went into spontaneous labor. 

For example, in the Signature Article, we spend some time talking about an older study from the 1990s, the Hanna Post-Term Trial, which is a very important research study, even though I think it’s like over 30 years old at this point. Even saying it remains one of the biggest studies about induction for reaching 42 weeks. In this trial, about one third of mothers who were assigned to the induction group went into labor spontaneously before the induction. So when you look at the breakdown of what actually happened to the people in the two research groups, as we do in the article, it becomes apparent that the Cesarean rates only increased with expected management when induction occurred in the pregnancy later and not when mothers went into spontaneous labor later in the pregnancy. The third thing to consider is that in most studies, people in the expected management group have more fetal testing while they’re waiting for labor to begin. And some of these tests might have shown possible signs of distress. And some of those results could have been false positives. So extra fetal testing could possibly lead to higher rates of Cesarean for suspected fetal distress during labor in an expected management group. And the last point to consider is that induction protocols can vary from study to study, and sometimes they can even vary within the studies themselves. So this was another issue in the Hannah Post-Term study. People in the active management group first received drugs to ripen their cervix and then got drugs to induce labor, while the people in the expected management group who ended up with an induction did not have cervical ripening. So it’s known that if you have an induction without cervical ripening, you are more likely to have a Cesarean as an outcome. So in this case, the expected management group would have been at increased risk of Cesarean compared to the active management group.

Dr. Rebecca Dekker – 00:19:27:

Yeah. So you mentioned the Hannah Post-Term trial that came out in the 1990s that had a really big impact. I think people used to think you just let people go on as long, you know, they’ll go into labor when they go into labor and you shouldn’t really induce them. And then after the Hannah Post-Term trial, the 42-week point kind of became the point that everybody was like, all right, this is where it’s safer to be induced. And there are some limitations, as you mentioned, to the Hannah Post-Term trial, and you can learn more about it in the Signature Article. But then what happened next was in the late 2010s, there were two big trials that came out of Northern Europe on the 41-week time point. There was INDEX that was published out of the Netherlands and SWEPIS from Sweden. So, Sara, should we start with kind of breaking down the INDEX trial?

Dr. Sara Ailshire – 00:20:18:

Yeah, absolutely. So the INDEX trial is named for the acronym that the researchers used to stand in for the full title of their study, which was Induction at 41 Weeks, Expectant Management at 42 Weeks, so INDEX. This was a multi-center trial that was conducted at 123 midwifery practices in 45 hospitals in the Netherlands, where midwives are lead professionals for most pregnancies and births. The researchers randomly assigned a total of 1,801 pregnant people to either being induced at 41 weeks and 0 to 1 days. Or to expected management and then an induction if needed at 42 weeks and zero days, if labor had not started on its own by that point. In the Netherlands, at least at the time of the study, labor is not usually induced before 42 weeks with an uncomplicated pregnancy. So they were able to get the ethical approvals they needed to conduct a study. In the U.S., for example, it is not standard practice in many practices to continue expected management for as long as 42 weeks. So it might have been more difficult to get the same ethical approvals needed to do that study here, for example. Pregnant people were enrolled into the study between 2012 and 2016. The mothers had to be healthy and pregnant with single head down babies. Everybody had to have a gestational age that was estimated with ultrasound before 16 weeks of pregnancy to ensure that they had the most accurate estimate of how far along they were in their pregnancy. They excluded anybody from the trial who had a previous Cesarean, who had a high blood pressure disorder, who had expected or known problems with the baby’s growth, whose baby had an abnormal fetal heart rate, or where there were known fetal malformations or other known complications of the pregnancy. In both of the research groups, cervical ripening and induction methods depended on local protocols. So thinking back to some of the issues we talked about in research, this is one that continued. It’s an important weakness in the INDEX study because, again, like that big Hannah Post-Term trial, individual providers in the INDEX trial might have managed labor inductions differently depending on group assignment. The variation in induction methods used in the study also limits the study’s generalizability or the ability to apply the results to the population at large, since care providers lack an induction protocol that they could replicate, that they could kind of follow to hopefully see the same results. In the elective induction group, 29% of the participants had spontaneous labor before their induction, and 71% were induced. In the expected management group, 74% of the participants had spontaneous labor before their planned induction, and 26% were induced. Interestingly, the median decrease in length of pregnancy between the two groups was only two days. So, in other words, the median pregnancy was only two days shorter in the elective induction group compared to the expected management group.

Dr. Rebecca Dekker – 00:23:25:

I always find that fascinating when they’re like, this group is going to be induced and then this group is going to have expectant management and it’s supposed to be a week’s difference, but it’s just really two days. So we’re looking at the difference of average pregnancy length of like, what does it do when you make a pregnancy two days shorter at this time point? So what do they find?

Dr. Sara Ailshire – 00:23:48:

Yeah. So for the mothers, the findings were that there’s no difference in Cesarean rates across the two groups. It was about 11% of birthing people in each group had a Cesarean. There was also no difference in combined measure of bad outcomes for mothers. It was about 11 to 14% in both groups. This outcome was called by the researchers, the maternal composite adverse outcome rate. And what they did was they grouped a bunch of negative outcomes that you would hope not to see together. You know, I mean, they also looked at those outcomes individually, but they put them in a group together just to see sort of generally what were these undesirable outcomes that happened. In total, and these included excessive bleeding after birth or requiring a manual removal of the placenta, severe tears or admission to the intensive care unit, or maternal death. There were no maternal deaths that occurred in either group in the study, and the researchers did not report on the rate of uterine rupture in either group. The other major outcome they looked at were how were things for the babies? So babies in the elective induction group had a lower composite adverse outcome rate of 1.7% in the induction group versus 3.1% in the expectant management group, and this combined negative outcome, same thing as, same sort of name as for the mothers, but included different negative outcomes, and these were perinatal death, an APGAR score of less than seven at five minutes, a measure of umbilical blood that identifies there’s a problem of low oxygen, meconium aspiration syndrome, nerve injury, brain bleeds, or admission to the newborn intensive care unit, or NICU. It was mostly the lower rate of APGAR score of less than 7 at 5 minutes that contributed to the lower combined adverse outcome with the elective induction group. 1.2% with the elective induction versus 2.6% with expected management. The researchers noted, though, that there were no difference in rates of APGAR score of less than 4 at 5 minutes. However, the combined outcome was still significantly lower in the elective induction group if using APGAR score of less than 4 at 5 minutes and excluding fetal malformations. There was one stillbirth that occurred in the elective induction group at 40 weeks and six days before the mother was induced. And there were two stillbirths that occurred in the expected management group while the mothers were waiting for labor. One stillbirth was to a first-time mother. It occurred at 41 weeks and three days, and her baby was small for gestational age. The other stillbirth occurred to a woman who had had previous births. It took place at 41 weeks and four days, and her placenta showed signs of infections. There were no newborn deaths in either group. And I should note that this concern about a small for gestational age infant is something that we talked about in the previous podcasts, and we cover it a little bit more in depth in the companion Signature Article on what is a due date. But just for our audience who might not have seen those or might not have listened to the last podcast, when a baby is small for gestational age, meaning that they’re estimated to be at or below the 10th percentile for weight, it doesn’t necessarily mean that something is wrong because sometimes people are small and they have small babies. However, sometimes a baby being very, very small can mean that there’s something that has gone wrong, either due to an underlying genetic condition or another problem in pregnancy, maybe with the placenta or the umbilical cord, that has negatively impacted their growth and could have potentially contributed to their death in utero. And finally, for the group of babies in the study, there was no protocol for fetal monitoring. Like the protocol for induction, it varied from place to place. But in general, fetal monitoring and assessment of amniotic fluid levels was typically performed between 41 and 42 weeks for research participants. So in summary, the INDEX trial found that elective induction at 41 weeks resulted in similar Cesarean rates and fewer overall bad outcomes for babies compared to waiting for labor until 42 weeks. The absolute risk of a bad outcome, a combined measure of perinatal death, intensive care admission, or APGAR score of less than four at five minutes, was low in both groups. 1.7% in the induction group versus 3.1% in the expected management group.

Dr. Rebecca Dekker – 00:28:30:

So has there been any more research about this that’s come out since INDEX?

Dr. Sara Ailshire – 00:28:36:

Yeah, so something else that was interesting was that three years after the INDEX study was published, the researchers also published a companion study in 2022. This companion study was inspired by the fact that not everyone who was asked to participate in the INDEX trial agreed to take part. In fact, about 69% of those who were invited to participate in the trial declined because they did not want to be randomly assigned to one group or the other. So in this companion study, researchers followed the labor and birth outcomes of those who declined to participate in the INDEX trial in order to see if characteristics and health outcomes differed between those who were in the trial versus those who declined to participate. So they looked at people who gave birth at 90 midwifery practices and 12 hospitals in the Netherlands between 2012 and 2016. And they were able to recruit 3,642 women who met the same requirements as those who were enrolled in the INDEX study. And for the purposes of analysis, the participants were grouped into three categories according to their preferences for either one, induction, two, expectant management, or three, if the researchers couldn’t identify a preference. And they called them the unknown preference group.

Dr. Rebecca Dekker – 00:29:52:

So I guess in the study, which was observational, Sara, they’re just trying to observe the outcomes when people fall into one of these groups naturally, either induction at 41 weeks or expectant management up until 42 weeks, correct?

Dr. Sara Ailshire – 00:30:06:

Absolutely. Yeah. And so, and I’ll talk a little bit now about what the researchers found. So for the mothers, they found that the overall C-section rate was 10.5% in the induction group and 8.9% in the expectant management group. And for people who were giving birth for the first time, the Cesarean rate was also lower in the expected management group compared to the induction group. The combined measure of poor health outcomes for mothers was similar in both groups, 11.6% in the induction group versus 11.4% in the expectant management group. And again, this was that same maternal composite adverse outcome rate. One maternal death occurred in the expectant management group from an amniotic fluid embolism. An amniotic fluid embolism is a very rare complication in pregnancy that occurs close to or shortly after birth. When the birthing person’s bloodstream is exposed to amniotic fluid and they have a severe reaction, this type of exposure is really common in pregnancy, especially during late term and birth. There’s all sorts of fluid interchange between a birthing person and a baby. So researchers are trying to understand why this occurs in some people, but it doesn’t occur in most others. Aside from that very serious and tragic outcome, five other women were admitted to the intensive care unit, four from the unknown preference group, and one from the expectant management group. And most of those admissions to the ICU were due to severe postpartum hemorrhage. So for the babies, the findings in this study were that babies in the elective induction group had a lower composite adverse outcome rate of 1.1% versus 1.9% in the expected management group. No stillbirths occurred in this study, while one neonatal death occurred the day of birth in the unknown preference group. And the infant who died was born to somebody who went into spontaneous labor at 41 weeks, two days, and experienced a sudden excessive loss of blood after their water broke. The baby’s heart rate slowed, they had an emergency Cesarean, and the baby died later due to complications of a lack of oxygen. So in summary, this companion study to the INDEX trial found a lower rate of Cesareans for those who chose expectant management. They also observed a similar rate of poor maternal health outcomes with induction versus expectant management. Those who chose an elective induction at 41 weeks had fewer overall adverse outcomes for newborns. However, the absolute risk for adverse newborn outcomes was low in both groups, and interestingly, it was lower than the rates that they observed at the original INDEX trial. So that was the INDEX trial. It was one of the big, important, recent studies that came out on this topic. Rebecca, would you like to walk us through SWEPIS?

Dr. Rebecca Dekker – 00:32:51:

Yeah, so SWEPIS is the other really large randomized control-trial on induction at 41 weeks, and it stands for the Swedish Post-Term Induction Study. S-W-E-P-I-S is the acronym. It gained a lot of media attention when it was published. There were headlines such as Post-Term pregnancy research canceled after six babies die. And, the truth is, you know, there were serious things that happened during this study. The researchers planned to enroll 10,000 mothers from multiple healthcare centers across Sweden, but they ended up stopping the study early with about 1,380 people in each group after their data safety and monitoring board found a significant difference in stillbirths and newborn deaths between groups. So similar to the Netherlands, when INDEX was trialed out, midwives in Sweden at this time did not typically induce labor before 42 weeks and healthy pregnancies. And also like the Netherlands, midwives in Sweden manage most pregnancies and births. So the investigators for SWEPIS wanted to compare elective induction at 41 weeks and zero to two days versus expectant management and induction at 42 weeks and zero to one day if the person still had not gone into labor. So they enrolled mothers between 2015 and 2018. Being in the study, you had to be healthy, pregnant with a single head down baby. And gestational age was required to be estimated with an ultrasound from the first or second trimester. They excluded lots of people such as those with prior Cesarean or those who had complications such as diabetes, high blood pressure, small for gestational age babies and other complications. So because the stillbirth rate in Sweden is so low, they typically have really good outcomes there. They thought they would need about 10,000 people overall to see a difference in these two interventions, but they ended up not needing that many people to see a difference in outcomes. And that’s why the study was stopped early. So a big strength of the SWEPIS trial is that they did define their induction protocol and they use the same protocol in both groups. So if you had an induction in the elective induction group or in the expectant management group, you would have similar protocols for the induction. And that included if your cervix was already ripened and ready for labor, then they would simply break your water and start synthetic oxytocin, aka pitocin. If your cervix was not ripe or your baby’s head was not engaged, then they would do cervical ripening first. They might use mechanical methods or medications, and then they would give the synthetic oxytocin after the cervix was ripened. So in the elective induction group, the people who are supposed to have that induction, 14% did go into labor on their own before their scheduled induction, and 86% actually had the induction. And in the expectant management group, 67% went into labor spontaneously before their planned induction date and 33% were induced. So similar to the INDEX trial, the median decrease in the length of pregnancy between the groups was very short. So pregnancy in the elective induction group was in general only about three days shorter than those who had expectant management.

Dr. Sara Ailshire – 00:36:23:

Oh, wow. That’s so interesting. So like in the INDEX study, the elective induction group gave birth only a few days earlier than average. So Rebecca, what did the SWEPIS investigators find?

Dr. Rebecca Dekker – 00:36:35:

So as I mentioned earlier, the study was stopped early. There were five stillbirths and one early newborn death in the expectant management group out of 1,379 participants in that group. That gives us a death rate of 4.4 deaths per 1,000 deliveries. In contrast, there were zero deaths in the elective induction group out of 1,381 participants in that group. All five of the stillbirths in the expectant management group occurred between 41 weeks, two days, and 41 weeks, six days. Three of those five stillbirths had no known explanation. One stillbirth had a baby who was small for gestational age, which we already discussed can be a risk factor for stillbirth. And the other stillbirth was a baby who had a heart birth defect. And then the one newborn death occurred four days after birth due to multiple organ failure and a baby who was born large for gestational age. So the authors were trying to kind of talk about what happened here. And they mentioned that, you know, when there might be complications present in the pregnancy, maybe something with the placenta or the umbilical cord, that those differences might become increasingly important as the days of pregnancy progress past 41 weeks, leading to that higher death rate with expectant management past the 41-week time point. And another thing to note is that all of these perinatal deaths, all of these losses were babies who are being born to first-time mothers, which suggests that a 41-week induction might be especially beneficial if you’re giving birth to your first baby. And they calculated that it would take only 230 elective inductions at 41 weeks to prevent one stillbirth or newborn death. And this is a much lower number than previously thought. It doesn’t take as many inductions to save one life. Now, I know, Sara, when you were talking about the INDEX trial, they did not find a significant difference in perinatal death between the induction group and the expectant management group. And I think some of the reasons why they did see a difference in SWEPIS is SWEPIS was a larger study, so it’s better able to detect rare outcomes such as death. And it also could be that in the INDEX trial, they had better fetal monitoring going on during that 41-week time period when people were waiting up until 42 weeks to have their baby, possibly leading to fewer perinatal deaths. It can’t be certain because there were no published fetal monitoring protocols in either trial. Finally, the participants in the SWEPIS expectant management group tended to give birth a little bit later than the participants in the INDEX expectant management group, and that might help explain the higher perinatal death rate in SWEPIS. When they looked at the combined perinatal outcome of severe health outcomes in babies or death, there was no significant difference between the two groups. It was about 2.2 to 2.4% in both groups. However, there was that significant difference in just looking at the death rate. The elective induction group babies were less likely to be admitted to the NICU, 4% versus 5.9%, had fewer cases of jaundice, 1.2% versus 2.3%, and there were fewer big babies in the elective induction group, 4.9% versus 8.3%. For mothers in SWEPIS, there was no meaningful difference in Cesarean rates between groups. It was about 10% to 11% in both groups. More mothers in the elective induction group had a type of infection called endometritis, which is inflammation of the inner lining of the uterus. That was 1.3% versus 0.4%. Meanwhile, there were more mothers in the expectant management group that developed high blood pressure disorders at the end of pregnancy, 3% versus 1.4%. There were no cases of uterine rupture in either group. And when they asked people about their experiences, they found that people in the expectant management group struggled more with negative thoughts. They described feeling in limbo or kind of stuck while they waited for labor or 42-week induction. And as I mentioned, the fetal monitoring in SWEPIS was done per local guidelines because there was no published study protocol for how to monitor the fetus while you’re waiting for labor. However, the mothers recruited in the Stockholm region of Sweden, which was about half the people in the study, did have a specific protocol because that’s what was typically done in that area where they measured amniotic fluid volume and abdominal diameter right at 41 weeks. And that assessment was not really done in the other parts of the country where the study was taking place. And so important to note from the study is that none of the six deaths occurred in the Stockholm region of Sweden where they were doing this type of prenatal fetal monitoring. So this could mean that the results of this study might not apply equally to a place that’s doing more intensive fetal monitoring to make sure everything’s okay with the fetus while you wait for labor to begin. Also, since all of the perinatal deaths were happening in cases where it was a first-time birth and the mother had not given birth before, the study results might not apply to those who have given birth before.

Dr. Sara Ailshire – 00:41:59:

Yeah, I thought the results of this study were really interesting. And of course, it garnered so much attention for some of the outcomes that occurred. Could you share with the listeners what, if any, impact the study had on induction of labor in the country where the study took place, Sweden?

Dr. Rebecca Dekker – 00:42:17:

Yeah. So there has been follow-up research on induction in Sweden after SWEPIS, on this really ignited debate in Sweden, but also in other places around the world about, you know, when should we induce labor? Is this 41 week time point really important? And in Sweden, they changed their guidelines to recommend an induction at 41 weeks to offer that to everyone or to have an individual plan aiming at birth or inducing labor by 42 weeks. And so there was a study published in 2025 comparing outcomes like pre and post these guidelines change. So they looked at all of the births that happened pre-SWEPIS and then all of the births that happened post-SWEPIS. And they were primarily interested in rates of stillbirth and newborn death, as well as overall other bad health outcomes for babies and Cesarean rates. Overall, they found that the risk of stillbirth and newborn death to babies born at or beyond 41 weeks decreased from pre-SWEPIS to post-SWEPIS from about 1.7 per 1,000 infants down to 0.9 per 1,000 infants. And there were also lower rates of birth trauma and a lower risk of stillbirth and newborn death for babies who were born in the 39 to 40 week time period. Meanwhile, they did see induction rates go up slightly. The rate of severe tears went down slightly and women’s experiences of childbirth were slightly better post-SWEPIS. So a little bit mixed results, but overall it seemed like this research did translate into better outcomes for babies after the guidelines were changed. So we’ve gone over INDEX and SWEPIS and some of like the results we’ve seen from those major studies and their follow-up studies. There are also a few other smaller studies that you can see if you review the full Signature Article, as well as a table in the Signature Article that kind of goes over each of the individual studies. So if you want to dive in and learn more, all of the data are there for you. So I thought now, Sara, we could go over the benefits and risks of induction focusing at that 41 week time point. And if it’s okay with you, I’ll read the potential benefits and you can share the potential risks. Sound good?

Dr. Sara Ailshire – 00:44:39:

Sounds great.

Dr. Rebecca Dekker – 00:44:40:

Okay. So when we’re looking at scheduling and induction at 41 weeks, the research does show that one of the main benefits is a lower risk of stillbirth, especially among those who have risk factors for stillbirth. One of those risk factors is being pregnant with your first baby. And the overall or absolute risk of stillbirth is four out of 10,000 pregnancies at 39 weeks, seven out of 10,000 pregnancies at 40 weeks, 17 out of 10,000 pregnancies at 41 weeks, and 32 out of 10,000 pregnancies at 42 weeks. So you can see how that inducing labor closer to that 41 week zero time point would be important because of that increased in risk in the 41st week of pregnancy. Other potential benefits include a lower risk of a baby needing intensive care unit admission, a lower risk of the baby experiencing jaundice, the lower chances of giving birth to a big baby, potentially a lower risk of Cesarean, depending on the practice setting and how well the practitioners do with providing inductions and lowering the risk of Cesarean with inductions. Another consistent finding in the research is that there’s a lower risk of developing a high blood pressure disorder at the end of pregnancy. And cognitive benefits for babies during a continued pregnancy appear to increase until about 40 to 41 weeks of pregnancy. So you’re getting kind of like the full benefit of the baby’s development in the womb if you go up to 41 weeks. And that’s another reason researchers think that is a good time point to go ahead and do an elective induction. And then finally, a lot of people find that a potential benefit for them is the convenience and also the ability to end pregnancy once you’re becoming really uncomfortable. And researchers have found that in general, satisfaction tends to go up when the timing of birth is 41 weeks rather than 42 weeks.

Dr. Sara Ailshire – 00:46:34:

Okay. So those were the pros. And now I’ll talk a little bit about the cons. So some of the cons that we identified from the research was that one, a potential for the medicalization of birth because of the induction. So continuous fetal monitoring, sometimes what people refer to as a cascade of interventions that could occur. Two, the potential for a failed induction leading to a Cesarean. The potential for uterine tachycystole, more than five contractions in 10 minutes average over a 30-minute window, a potential increase in risk of uterine rupture with medical induction, especially among those who have had a previous Cesarean. Missing out on the hormonal benefits of spontaneous labor, increased risk of the mother experiencing the inflammation of the inner lining of the uterus, that endometritis infection that Rebecca referenced earlier. And medically induced contractions can potentially increase pain and make it more likely that a person would choose to also use an epidural.

Dr. Rebecca Dekker – 00:47:37:

Sara, I know you also updated the section on this article about, you know, what did the published guidelines say about induction? Past your due date, can you share some of those guideline recommendations with us?

Dr. Sara Ailshire – 00:47:49:

So for this update, we found recent guideline recommendations about induction at 41 weeks or later from the American College of Obstetricians and Gynecologists, the American College of Nurse Midwives, the Society of Obstetricians and Gynecologists of Canada, the Association of Ontario Midwives, and the National Institute for Healthcare Excellence guidelines in the UK. You can see the actual breakdown by publication in the Signature Article, but the overall trends were that as a pregnancy continues beyond 41 weeks, Most guidelines begin to recommend that providers have discussions with their patients about the benefits and risks of inducing labor versus expected management. They also began to recommend increased fetal monitoring if expected management is chosen at 41 weeks and later. The recommendations for 42 weeks trend towards recommending induction if labor has not yet started on its own. If a patient chooses expected management at 42 weeks or later in pregnancy, recommendations then suggest regular fetal monitoring until birth. Fetal monitoring cannot always prevent complications for occurring, nor will it always catch a complication as it’s happening. But the hope with that recommendation is that providers can interpret these results and share this information with their clients to promote informed choice and to promote shared decision making. So Rebecca, do we have time to do a couple frequently asked questions that we get on this topic?

Dr. Rebecca Dekker – 00:49:18:

Yeah, let’s do two. So one question that comes up on this topic is what about induction for going past your due date in someone who is planning a VBAC? So we hear this a lot, but many people who are planning a vaginal birth after Cesarean or VBAC are told they must go into labor by 39 weeks, or maybe they’re told 40 or 41 weeks, or they’re required to have a repeat Cesarean, or sometimes they’ll say you can have an induction, but not always. Sometimes it’s just you have to have a Cesarean. So researchers have found that only about 10% of people who reach term will spontaneously give birth by 39 weeks and zero days. So if a hospital is mandating, you know, you have to have a repeat Cesarean if you haven’t gone into labor by your 39th week, this means that 90% of people planning a VBAC at that particular facility will be disqualified from having a spontaneous VBAC labor. Also, some hospitals and providers will refuse to provide an induction with VBAC because there is a higher risk of uterine rupture if you have had prior uterine surgery with an induction. So that means some people who reach their required deadline will only have one option, and that’s a repeat Cesarean. There’s actually no evidence supporting these hard stop rules that you must give birth by 39 weeks or you must give birth by 40 weeks if you’re having a VBAC. The first large meta-analysis to specifically look at the link between weeks of pregnancy and likelihood of VBAC was published in 2019. They included 94 observational studies with nearly 240,000 people attempting labor for a VBAC. And interestingly, they found that gestational week at birth was not linked to your odds of having a VBAC. So whether you gave birth at 37 weeks, 39 weeks, or 41 weeks, it didn’t make a difference as to whether someone was having a VBAC or not. And in another study, researchers looked at more than 12,000 people who were electively induced at 39 weeks who were having a VBAC and compared them to those who were having expectant management beyond that date. They found that elective induction at 39 weeks was associated with a higher chance of ending up with a VBAC, 74% versus about 60% for those who had expectant management. But there was also a higher chance of uterine rupture in the elective induction group. So in the induction group, the rate of uterine rupture was 1.4% versus 0.4 to 0.6% in those who chose expectant management. And importantly, the risk of uterine rupture did not go up for those who had expectant management and chose not to be induced. So at 39 weeks during labor, the risk was 0.5%. At 40 weeks, it was 0.6%. At 41 weeks, it was 0.4%. 0.4%, that’s the evidence we have on that. Another question is, are there any benefits to going past your due date? Sara, do you want to take that one?

Dr. Sara Ailshire – 00:52:20:

Yeah. So we talked a little bit about that earlier, but it’s nice to be able to take some more time and really kind of dive in here. So one of the benefits to going past your due date and waiting for spontaneous labor, if that’s your preference, is that you can avoid the potential risks of an induction and associated interventions by having a lower intervention labor and birth. The American College of Obstetricians and Gynecologists, in partnership with the American College of Nurse Midwives, wrote in a committee opinion that titled Approaches to Limit Intervention During Labor and Birth, if you’re interested in looking at it, that some common obstetric practices are of limited or uncertain benefit for low-risk people in spontaneous labor. So if you don’t have an induction, for example, you’re not going to be exposed to certain risks that can come of that particular intervention, like having a failed induction, for example, uterine tachysystole, the uterine contractions are too close together, having an increased need for an epidural, things like that. One of the potential benefit of going past your due date and waiting for spontaneous start of labor is that you might experience hormonal benefits for allowing the normal process of labor to take place. And that’s something that Dr. Sara Buckley covers in her work, The Hormonal Physiology of Childbearing. Based on the available evidence, Dr. Buckley concluded that, quote, Overall, consistent and coherent evidence from physiologic understandings and human and animal studies finds that the innate hormonal physiology of mothers and babies, when it’s promoted, supported, and protected, has significant benefits, both in childbearing, and likely into the future by optimizing labor and birth, newborn transitions, breastfeeding, maternal adaptations, and maternal infant attachment. Also, so another benefit that we’ve heard about anecdotally is that later term and post-term babies have an easier time with breastfeeding. There’s not a lot of research on the subject, but we did find a recent study from New Zealand of around 1,087 women that compared labor and neonatal outcomes based on when an induction took place. You can see the details in the Signature Article, but what they found was that as babies were born later and later, they compared babies born early term, full term, and then late term. So 37 to 38 weeks, 39 to 40 weeks. And then 41 weeks later, the babies born late term, 41 weeks and later, were most likely of the three categories to initiate and sustain breastfeeding. There might also be cognitive benefits for babies when pregnancy is allowed to continue to 40 and 41 weeks. There was one study that we found that showed, again, a progressive benefit in cognitive outcomes several years after birth until 41 weeks. There might also be cognitive benefits for babies when pregnancy continues to 40 or 41 weeks. A study of Scottish schoolchildren found that the need for special education was highest among children born before 37 weeks. And there was a continuous decrease in that need for special education, using that as sort of a proxy for neurodevelopmental outcomes until 41 weeks, after which point the risk quickly increased again. And the recent Cochrane review called for more research on this topic to be an important thing to consider. I do want to note here that these benefits or these potential benefits are with going past your due date are associated with going past your due date in a single uncomplicated pregnancy. And we cover a lot more in the article, and we’ve really kind of only scratched the surface here. I’m really excited to share this review of the recent research because I know our readers and our professional members are especially so interested in the studies that they can look up and read for themselves. But I think we’re at the end here, Rebecca. And because we’re at the end, I feel like I should ask you, Rebecca, what’s the bottom line?

Dr. Rebecca Dekker – 00:56:14:

So what’s the bottom line about inducing labor for reaching 41 weeks? Well, elective induction at 41 weeks and zero days could help reduce stillbirths and lower the risk of poor health outcomes for babies, especially among first-time mothers. So importantly, we have two large randomized controlled trials published in 2019 that both found benefits to elective induction at 41 weeks instead of continuing to wait for labor until 42 weeks. Both of these trials took place in countries that follow the midwifery model of care and the overall Cesarean rates were low amongst everybody in the study, generally about 10 to 11%. One of these two studies found that there were fewer newborn deaths and stillbirths with 41-week induction. And the other study did not find a difference in deaths, but it found fewer poor health outcomes for babies with 41-week induction as compared to waiting for one more week. If it seems like you’re going past your due date, it’s important to talk with your care provider about the potential benefits and risks of having an elective induction at different time points versus waiting for spontaneous labor for a certain period of time and then perhaps having an induction later if needed. So any conversation about induction should take into account your preferences, your personal birth history, risk factors for stillbirths such as small for gestational age, which is a very important risk factor or it being your first birth, the chances of the induction being successful, including how ripe your cervix is, your hospital’s Cesarean rate with inductions, how well do they do at lowering the Cesarean risk with inductions, and what are some alternatives to the induction? I also think the bottom line includes that non-medical factors are very real when it comes to individual decision making. For example, for some people, the experience of being induced might include potentially more painful contractions leading to being tethered for monitoring and IV fluids more likely to need an epidural or being confined to bed. And those interventions might not make much of a difference to someone who’s already planning to have multiple interventions in their birth, but it could make a big difference to someone who is planning to use movement, freedom of movement, freedom of eating and drinking and other comfort measures with an unmedicated birth. Another example of how individual preferences can come into play is if someone has experienced miscarriages or stillbirth in the past or has important risk factors for stillbirth. They may have a strong preference for elective induction in order to lower the overall risk of stillbirth by any means necessary. And I want to affirm that all these experiences and preferences are valid. So here at EBB, I hope you found this research helpful, all about the evidence on inducing labor for when you go past your due date and reach 41 weeks. We also cover 42 weeks in the article as well as another time point. Just go to ebbirth.com/inducingduedates and you can download a free handout all about the evidence on inducing for 41 weeks. And we have a lot of other resources available. All of the references, you can just click on the link and go straight to the studies that we talk about and resources that we share in there for stillbirth and newborn loss. So thank you, Sara, for your hard work on this article. And I’m excited that we’re getting it into everybody’s hands and their ears today.

Dr. Sara Ailshire – 00:59:41:

Thank you. It’s so much fun to get to talk about this. And I’m so excited for people to read and I hope it is helpful.

Dr. Rebecca Dekker – 00:59:49:

Today’s podcast was brought to you by the Signature Articles at Evidence-Based Birth®. Did you know that we have more than 20 peer-reviewed articles peer-reviewed articles summarizing the evidence on childbirth topics available for free at evidencebasedbirth.com. It takes six to nine months on average for our research team to write an article from start to finish. And we then make those articles freely available to the public on our blog. Check out our topics ranging from advanced maternal age to circumcision, due dates, big babies, Pitocin, vitamin K, and more. Our mission is to get research evidence on childbirth into the hands of families and communities around the world. Just go to evidencebasedbirth.com, click on blog. And click on the filter to look at just the EBB Signature Articles.

For many years, the common belief was that elective inductions doubled the Cesarean rate, especially in first-time mothers.

However, in the 2000s and 2010s, some researchers began to dispute the claim that elective induction doubles the risk of Cesarean (Caughey et al. 2006; Einerson & Grobman 2020). They argued that earlier studies—where elective induction showed a doubling in Cesarean rates—were flawed.

In the earlier studies, elective induction was compared only to spontaneous labor: people who were electively induced versus people who went into spontaneous labor. Excluded from these two groups were people who were not electively induced but waited for labor and then ended up having inductions later on, some of which were medically necessary (and, thus, linked to a higher rate of Cesareans). For an example of this earlier flawed research, see this article by Yeast et al. 1999 [https://pubmed.ncbi.nlm.nih.gov/10076139/].

Previous studies compared Cesarean rates of these two groups only:

New researchers pointed out that we need to compare people who have elective inductions with the whole group of those who wait for spontaneous labor—whether or not they actually do have spontaneous labor.

This is a subtle difference, but an important one, because not everyone who waits for labor will actually have a spontaneous labor. Some will develop complications that lead to an induction and increase their risk for Cesarean. The researchers argued that the comparison group must include these people as well.

So, with this new understanding, someone in the wait-for-labor group who ends up being induced later in the pregnancy would not be considered inappropriate crossover between groups. This is because induction later in the pregnancy is a possible outcome with expectant management, just like going into spontaneous labor is a possible outcome.

This graphic shows how you would look at the two groups: the elective induction group versus the entire group of people who were not electively induced at that time—some of whom would, in fact, end up being induced later in the pregnancy.

Since the 2010s, researchers said studies should include all groups:

Because of this flaw in the earlier studies, the researchers argued, those studies don’t give us a true picture of the risks and benefits of elective induction between 39-41 weeks versus waiting for labor to start on its own (“expectant management”).

A: After 41 weeks, concerns begin to grow about the potential for increased risk for stillbirth, as well as the increased risk of poor outcomes for the birthing person or baby. Most guidelines will recommend that someone who has not gone into labor on their own by 42 weeks should be induced. However, neither these concerns nor the existing guidelines have created a hard and fast rule about when a person should be induced to have the best possible chance of avoiding potentially negative outcomes while also maximizing the benefits of carrying a pregnancy to term and allowing the body to begin labor on its own without induction.

The authors of a systematic review from 2019 raise concerns that routine induction prior to post-term puts a large number of pregnant people at risk of harmful side effects from induction (Rydahl et al. 2019a). This review came out too early to include the SWEPIS and INDEX trials.

Unlike the Middleton et al. (2020) Cochrane review, Rydahl et al. applied stricter criteria to the studies they included. They restricted studies to only those published within the last 20 years, with low-risk participants, and compared routine induction at 41 weeks and 0 to 6 days versus routine induction at 42 weeks and 0 to 6 days. Altogether, they included three observational studies, two randomized controlled trials (RCTs), and two “quasi-experimental” studies (which means they compare groups in a way that isn’t truly random).

Combining the two RCTs with the two quasi-experimental studies, there was one perinatal death in the 41-week induction group and six deaths in the 42-week induction group (a perinatal death rate of 0.4 versus 2.4 per 1,000). The finding was not statistically significant. These same studies showed no difference in Cesarean rates between groups; however, the authors did report that one observational study found an increase in the Cesarean rate with the 41-week induction group.

Back in 2011, Denmark changed its national policy from recommending induction at 42 weeks 0 days, to 41 weeks 3 to 5 days. A recently published study compared birth outcomes before the change in policy (2000-2010) versus after the change (2012-2016) (Rydahl et al. 2019b). The study looked back at all births in Denmark between 41 weeks 3 days and 45 weeks 0 days of pregnancy. Over 150,000 births were included in the dataset.

They did not find any difference in stillbirths, perinatal death, or low Apgar scores comparing the period before versus after the policy change. Perinatal death was already declining before the policy change in 2011, and it continued the downward trend without an additional impact from the 2011 policy change. There was also no impact on the rate of Cesareans or the use of forceps/vacuum.

After the policy change in 2011, however, they did see a significant increase in labor inductions and uterine ruptures. During 2011, the rate of people induced at 41 weeks 3 days jumped from 41% to 65%, and the rate of uterine rupture went from 2.6 to 4.2 cases per 1,000. Most of these uterine ruptures (73%) occurred among mothers with a previous Cesarean. Unfortunately, we can’t tell from this study whether the uterine ruptures are occurring among people with a prior Cesarean who are being induced—only that the rate of uterine rupture increased after the policy change, and that most occurred among mothers with a previous Cesarean.

The researchers expressed concern about the increase in harm without evidence of benefits from a policy of earlier induction. Why did the intervention fail to lower perinatal deaths in Denmark? It could be that the rate was already low in Denmark (and on a downward trend) so there was little opportunity to prevent additional deaths. It could also be that waiting until 41 weeks, 3 days to induce was a few days too late to make a difference. The SWEPIS and INDEX trials found that even a few days after 41 weeks made a significant difference in birth outcomes.

A: Many people who are planning a vaginal birth after Cesarean (VBAC) are told they must go into labor by 39, 40, or 41 weeks or they will be required to have a repeat Cesarean or induction.

Research has shown that only about 10% of people who reach term will spontaneously give birth by 39 weeks (Smith 2001; Jukic et al. 2013). So, if a hospital or physician mandates repeat Cesareans for people who have not gone into labor by 39 weeks, this means that 90% of people planning a VBAC with that hospital or physician will be disqualified from having a spontaneous VBAC. Also, some hospitals and providers will not provide inductions with VBACs, which means some people who reach the required deadline will only have one option– repeat Cesarean.

There is actually no evidence supporting hard-stop “must-give-birth-by-39-weeks” or “give-birth-by-4o-weeks” rules for people planning a VBAC.

In 2015, researchers looked at 12,676 people who were electively induced at 39 weeks for a VBAC or had expectant management for a VBAC (Palatnik & Grobman 2015).

Elective induction at 39 weeks was associated with a higher chance of VBAC compared to expectant management (73.8% versus 60-62%), but there was also a higher rate of uterine rupture in the elective induction group (1.4% versus 0.4-0.6%).

For people who chose not to be induced, the risk of uterine rupture was fairly steady at 39 weeks (0.5% uterine rupture rate), to 40 weeks (0.6%), to 41 weeks (0.4%).

The first large meta-analysis to specifically look at the link between weeks of pregnancy and likelihood of VBAC was published in 2019 (Wu et al. 2019). It included 94 observational studies with nearly 240,000 people attempting labor for a VBAC. Interestingly, they found that gestational week at birth was not linked to having a VBAC— whether someone gave birth at 37 weeks, 39 weeks, or 41 weeks—it didn’t make a difference to whether someone had a VBAC or a Cesarean birth after Cesarean.

A: One of the major benefits of going past your due date and awaiting the spontaneous start of labor is the hormonal benefit of experiencing spontaneous labor. In her book Hormonal Physiology of Childbearing (free full text available here), Dr. Sarah Buckley reviewed the research on the hormonal benefits of spontaneous labor.

Based on the available evidence, Dr. Buckley concluded that:

“Overall, consistent and coherent evidence from physiologic understandings and human and animal studies finds that that the innate, hormonal physiology of mothers and babies—when promoted, supported, and protected—has significant benefits for both in childbearing, and likely into the future, by optimizing labor and birth, newborn transitions, breastfeeding, maternal adaptations, and maternal-infant attachment” (Executive Summary, page 9).

Another benefit of going past your due date and experiencing spontaneous labor is that you can avoid the potential risks of a medical induction, which may include experiencing a failed induction (possibly leading to a Cesarean), uterine tachysystole (uterine contractions that are too close together and may decrease blood flow to the baby), and adverse effects of other interventions that often occur with an induction, such as epidural anesthesia and continuous fetal monitoring (NICE 2021).

Anecdotally it has been said that late- and post-term babies have an easier time with breastfeeding. While there is not much research on the subject, a recent study did examine the relationship with gestational age at birth and breastfeeding outcomes among women who were induced at different points at the end of pregnancy. This New Zealand study (Carlhäll et al. 2024) of 1,087 women compared labor and neonatal outcomes based on when an induction took place. In terms of timing, 266 participants had an induction at early term (37-38 weeks), 480 at full term (39-40 weeks), and 341 at late term (41 weeks or later). The researchers found that the rate of exclusive breastfeeding at discharge increased with increasing gestational age at birth, from 67.2% of those induced at early term, 76.4% of those induced at full term, and 81.4% of those induced at late term. However, only the women induced at late term were more likely to exclusively breastfeed after taking into account, age, BMI, whether this was someone’s first time giving birth, and the actual induction method.

There may be cognitive benefits for babies when the pregnancy continues to 40-41 weeks (Murray et al. 2017). A study of Scottish schoolchildren found that the need for special education was highest among children born before 37 weeks (preterm babies), and then there was a continuous decrease in the need for special education until a low point at 41 weeks, after which the risk quickly rose again (MacKay et al. 2010). Middleton et al. (2020) in their review of the research did not find any studies that investigated the relationship between gestational age at birth and neurodevelopmental outcomes but identified this as an important area for future research.

A: When someone goes past their estimated due date, it is appropriate to talk with their care provider about the benefits and risks of elective induction and expectant management.

Most research articles and guidelines say that because there are benefits and risks to both options, the pregnant person’s values, goals, and preferences should play a part in the decision-making process.

It is important for expectant families to be aware of the growing research evidence showing worse health outcomes for those who wait for labor instead of being induced closer to 41 weeks 0 days, especially among first-time mothers and those with additional risk factors for stillbirth.

Ultimately, after receiving accurate, evidence-based information and guidance from their health care provider, pregnant people have the right to decide whether they prefer to induce labor or wait for spontaneous labor with appropriate fetal monitoring.

A: It can be difficult for health care providers and expectant parents to discuss the risk of stillbirth. Research on health care decision-making suggests that one of the best ways to frame the risk of stillbirth is to use the following techniques (Perneger & Agoritsas 2011; Fagerlin et al. 2011).

1. Present risks in actual or “absolute” numbers (as opposed to relative risk)
2. Talk about both potential gains and losses
3. Offer a visual if possible
4. Focus on the absolute difference between two risks

So, using data from Muglu et al. (2019) in a real-life situation, this might look like:

“At 41 weeks, out of 10,000 pregnant people, about 17 will have a stillbirth. This means 9,983 won’t have a stillbirth.

In comparison, at 42 weeks, out of 10,000 pregnant people, about 32 will have a stillbirth. This means 9,968 won’t have a stillbirth. Here is a picture to help give you an idea of what this means.

So, an extra 15 people out of 10,000 might avoid a stillbirth by being induced at 41 weeks. For the other 9,985 women, it won’t make a difference.”

Then circle/highlight the additional 15 to show the difference.

1. Alkmark, M., Keulen, J. K. J., Kortekaas, J. C., et al. (2020). “Induction of labour at 41 weeks or expectant management until 42 weeks: A systematic review and an individual participant data meta-analysis of randomised trials.” PLoS Med 17(12):e1003436. https://pubmed.ncbi.nlm.nih.gov/33290410/
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