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WHO recommendations on outpatient settings for induction of labour. Geneva: World Health Organization; 2022.

Cover of WHO recommendations on outpatient settings for induction of labour

WHO recommendations on outpatient settings for induction of labour.

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3Recommendations and supporting evidence

This section presents the updated recommendation on outpatient settings for induction of labour that was formulated by the GDG, followed by the corresponding narrative summary of the evidence. To ensure that the recommendation is correctly understood and appropriately implemented in practice, additional remarks reflecting the summary of the discussion by the GDG are included after the recommendation.

RECOMMENDATION 1Routine outpatient induction of labour is not recommended for improving birth outcomes (low-certainty evidence)

Remarks

  • The evidence reviewed for this recommendation was derived from high-income country settings and defined the outpatient setting as the “home”, where home induction is defined as cervical ripening at home. Most commonly, after the induction agents have been administered in a hospital/health-care facility, the woman spends time at home before being admitted back to the facility once in labour. Inpatient inductions are defined as induction in health-care facilities (hospitals or birth centres, or midwife-led units), such that the woman remains there following induction while awaiting the start of labour.
  • The GDG noted that outpatient induction of labour might not be expected to improve birth outcomes. Low-certainty evidence in the systematic review found no difference in birth outcomes when comparing labour induction between inpatient and home settings.
  • The GDG noted that in some settings, women considered to be at low risk for complications during induction are offered outpatient induction of labour when they have good transportation options and live near the delivery facility. Considering the potential preference of pregnant women to return to their home setting following placement of a cervical ripening agent or initiation of induction, outpatient induction of labour may be undertaken where feasible, following shared decision-making between the provider and the woman. If outpatient induction of labour is considered, this should be in the context of a well organized programme with adequate staff resources available to remotely monitor/assess and/or reassure women at home. Women should have suitable arrangements in place to return rapidly to the hospital/ facility if and when needed.

3.1. Summary of the evidence

Effects (desirable and undesirable)

The evidence on the effectiveness and safety of outpatient settings for induction of labour was derived from a Cochrane systematic review updated in 2020 (15). The review included three new trials, providing evidence from an additional 238 women, such that the evidence base now includes seven RCTs, six of which provide data on 1610 women and their babies, while one trial provided no usable data. The interventions examined in all of the studies involved induction and initial monitoring in hospital, with subsequent discharge home to await the start of labour or for a fixed period of time for women in the home induction group. The comparators were all with induction, labour and birth in the hospital. The evidence is summarized in GRADE tables presented as part of the EtD framework in the Web Annex.

Values and preferences

Considering the benefits and risks of outpatient induction of labour in a home setting, the GDG considers it unlikely that there would be important variability in how women value the outcomes of interest (see Annex 2). During induction of labour women value the ability to move about freely and to have privacy and a sense of security. This allows them to feel more in control and maintain their dignity. Feeling secure was enhanced by: having a support person present; systems that enabled this support to continue from induction to delivery; and having rapid access to the clinical expertise and equipment that might be needed.

Resource use and costs

The resources required to implement the routine induction of labour are primarily the costs of training skilled health personnel. Evidence for resource use and costs is very limited; information from one trial-based primary study and data from a study included within the systematic review on effectiveness was available. Together, they described aspects of cost, resource usage, budget impact and value for money, when considering induction of labour (15, 18, 19).

Equity

The equity domain was discussed at length by the GDG members as they formulated this recommendation. It is likely that women from low- and middle-income settings, or from disadvantaged groups within a high-income setting, may also experience greater barriers to participation in health-care decision-making about labour induction than indicated in the QES findings.1

Acceptability

The evidence for acceptability of methods for induction of labour was derived from a synthesis of a published QES and additional primary studies (21–28). When there is a recognized need to avert harm to the baby, labour induction is widely acceptable to women. Acceptability varies according to women’s trust in their health-care provider, their perception of birth as a natural process, their need for certainty, and the duration of waiting. The QES authors found that “outpatient labour induction is not preferable for all women, and individuals will have preferences about what constitutes a comfortable and safe environment for labour” (21–28).1 There is limited evidence available on the acceptability of labour induction to clinicians. Health practitioners report lack of clear evidence on the risks and benefits of labour induction to guide their decision-making. They were particularly concerned about neonatal safety and the potential for medical litigation (29).

Feasibility

The feasibility of implementing these recommendations was considered by the GDG. WHO general principles for performing labour induction state (5, 6):

  • Wherever induction of labour is carried out, facilities should be available for assessing maternal and fetal well-being.
  • Women receiving oxytocin, misoprostol or other prostaglandins should never be left unattended.
  • Wherever possible, induction of labour should be carried out in facilities where caesarean sections can be performed.

Performing induction of labour safely requires availability of appropriate medicines or mechanical devices, monitoring equipment and access to facilities for safe caesarean section. Inconsistent supply or lack of medicines, medical equipment and appropriate facilities may be an issue in some settings. The GDG considered outpatient induction of labour in this context.

Note: The EtD table – which summarizes the balance between the desirable and undesirable effects and the overall certainty of the supporting evidence, values and preferences of stakeholders, resource requirements, cost-effectiveness, equity, acceptability and feasibility that were considered by the GDG in determining the strength and direction of the recommendation – is presented in the EtD framework (Web Annex).

Footnotes

1

Murano M, Chou D, Costa do Nascimento ML, Turner T. Using the WHO-INTEGRATE evidence to decision framework to develop induction of labour recommendations. Health Res Policy Syst. 2022 (in press).

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