Rates of Induction of Labor and Cesarean Birth for Low-Risk Nulliparous Women (NTSV) in the United States, 2016 to 2024

Interventions during labor and birth in the United States have continued to increase (Simpson, 2023; Simpson, 2024a,2024b). Induction of labor and cesarean birth have risen for all women, but especially for low-risk women (nulliparous at term with a singleton vertex fetus [NTSV]). It is likely that the increase in elective induction of labor for NTSV patients in the United States is due in part to publication of the ARRIVE trial (Grobman et al., 2018) as physicians and maternity services are offering the procedure as one aspect of a strategy to improve birth outcomes (American College of Obstetricians and Gynecologists [ACOG], 2025). Before elective induction of labor becomes standard care for all low-risk nulliparous women in the United States, a review of the evidence, changes in clinical practices, and natality outcomes is warranted. As per ACOG (2025, p. e1), since publication of the ARRIVE trial, several retrospective cohort studies with larger populations have shown mixed outcomes in cesarean birth reduction and “concerning maternal and neonatal morbidities” with elective induction of labor at 39 weeks gestation; however, they were not randomized clinical trials. If the influence of the findings of the ARRIVE trial (Grobman et al., 2018) is sufficient to affect US natality data on the induction of labor rate for NTSV patients (Graph), a similar influence on the cesarean birth rate could be expected; however, the cesarean birth rate for NTSV patients and all others remains stubbornly the same or slightly higher (Table). A potential factor in not realizing a corresponding decrease in cesareans in US natality data is the estimation from Grobman et al. (2018) that 28 low-risk nulliparous women would need to plan to be electively induced at 39 weeks gestation to avoid 1 cesarean birth. It is possible that some maternity services offering elective induction at 39 weeks do not have in place labor management protocols designed to promote vaginal birth (e.g., cervical ripening for an unfavorable cervix [modified Bishop score <5]; at least 12 hours for latent phase labor after cervical ripening; rupture of membranes; and oxytocin administration before considering the induction of labor to have “failed”) as suggested for clinical sites in the ARRIVE trial (Grobman et al., 2018). Costs of antepartum care were lower in the induction group, with fewer routine prenatal visits, fewer emergency/triage, or unplanned visits, and fewer admissions compared to the expectant management group in the ARRIVE trial (Grobman et al., 2018). The bulk of these fewer visits were prenatal visits and OB triage visits that did not occur since the patients instead were induced during week 39 (Grobman et al., 2020). Einerson et al. (2024) reported similar costs overall between the two groups in the five hospitals in Utah that participated in the ARRIVE trial, but higher costs for some patients related to use of ultrasound, cervical ripening, oxytocin and fetal scalp electrodes and occurrence of maternal complications (postpartum hemorrhage infection, third- and fourth-degree lacerations), cesarean birth, and longer length of stay. Women who were randomized to the elective induction of labor group had an average of 20 hours in labor and delivery compared to 14 hours in the expectant management group in the ARRIVE trial (Grobman et al., 2018). The extra 6 hours of intrapartum nursing care can negatively affect unit operations and bed capacity (Mann & James, 2025) and be quite expensive, as induction of labor with oxytocin requires a nurse-to-patient ratio of 1 registered nurse to 1 woman in labor (American Academy of Pediatrics & ACOG, 2017; Association of Women's Health, Obstetric and Neonatal Nurses [AWHONN], 2022). Findings from a new study emphasize the importance of following the AWHONN nurse staffing standards. Lyndon et al. (2025) reported cesarean rates were lower and vaginal birth after cesarean rates were higher in hospitals that staffed during labor and birth according to the AWHONN (2022) standards. Nurse staffing per national standards is an important strategy to promote vaginal birth (Lyndon et al., 2025) and does not involve increasing labor and birth interventions. Adding interventions to the childbirth process without associated positive changes in outcomes is not in the best interests of patients or health care system finances. Costs of longer labor are generally assumed by the hospital since insurance reimbursement for birth is based on type of birth (vaginal or cesarean), not length of labor. A full review of the AWHONN (2022) nurse staffing document includes a comprehensive discussion of the evidence linking nurse staffing to patient morbidity and mortality and other outcomes such as exclusive breastfeeding during the birth hospitalization (Lyndon et al., 2022). The staffing standards (AWHONN, 2022) serve as a resource for the rationale maternity nurse, midwife, and physician leaders can use for budgeting for and promoting appropriate nurse staffing to allow nurses to attend to women and their fetuses during and birth labor as they deserve and desire.Figure: Induction and Augmentation of Labor Low Risk Nulliparous Women (NTSV) United States 2016 to 2024 - Cesarean Birth Rates by Type 2016 to 2024 2016 2017 2018 2019 2020 2021 2022 2023 2024 All 31.9 32.0 31.9 31.7 31.8 32.1 32.1 32.3 32.4 NTSV 25.7 26.0 25.9 25.6 25.9 26.3 26.3 26.6 26.7 Primary 21.9 21.7 21.6 21.9 22.3 22.5 22.5 22.8 22.9 ∗NTSV = nulliparous women at term pregnancy with a singleton fetus in a vertex presentation.Data compiled from Centers for Disease Control and Prevention & National Center for Health Statistics (2025a, 2025b).