AOGS O R I G I N A L R E S E A R C H A R T I C L E

Inter-hospital variations in labor induction and outcomes

for nullipara: an Australian population-based linkage study
TANYA A. NIPPITA1,2,3, JUDY A. TREVENA1, JILLIAN A. PATTERSON1,2, JANE B. FORD1,2,
JONATHAN M. MORRIS1,2 & CHRISTINE L. ROBERTS1,2
1
Clinical and Population Perinatal Health Research, Kolling Institute, Northern Sydney Local Health District, 2Sydney
Medical School-Northern, University of Sydney, and 3Department of Obstetrics and Gynecology, Royal North Shore
Hospital, Northern Sydney Local Health District, St Leonards, NSW, Australia

Key words Abstract

Labor, induction, term nullipara, maternal
outcome, neonatal outcome, cesarean section
Correspondence
Tanya Nippita, Clinical and Population
Perinatal Health Research, Kolling Institute of
Medical Research, Level 2, Building 52, Royal
North Shore Hospital, St Leonards, NSW
2065, Australia.
E-mail: tanya.nippita@sydney.edu.au
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Please cite this
article as: Nippita TA, Trevena JA, Patterson
JA, Ford JB, Morris JM, Roberts CL. Inter-
hospital variations in labor induction and
outcomes for nullipara: an Australian
population-based linkage study. Acta Obstet
Gynecol Scand 2016; 95:411–419.
Received: 22 October 2015
Accepted: 18 January 2016
Introduction. This study aimed to describe variation in inter-hospital induction
of labor (IOL) rates, determine whether variation is explained by individual
and hospital factors and examine birth outcomes. Material and methods. Nulli-
para at term with a singleton cephalic birth were identified using linked hospi-
tal discharge and birth data for 66 hospitals in New South Wales, Australia,
2010–2011. Random effects multilevel logistic regression models were fitted for
early term, full term, and late term births, adjusting for individual and hospital
factors. Hospital intrapartum cesarean rates, and severe maternal and neona-
tal morbidity outcomes were determined according to hospital IOL rate.
Results. Of 69 549 nullipara, 24 673 (35%) had an IOL. For early term births,
adjusted hospital IOL (aIOL) rates varied (3.3–13.9%), with 11 of 66 (17%)
hospitals having aIOL rates significantly different from the average aIOL rate.
For births at full term, the hospital aIOL rates varied (10.6–32.6%), with 29
hospitals (44%) having aIOL rates significantly different from the average aIOL
rate. For late term births, the hospital aIOL rates varied (45.1–67.5%), with 11
hospitals (17%) having aIOL rates significantly different from the overall aver-
age aIOL rate for women with late term births. There was generally no rela-
tionship between higher or lower hospital IOL rates and intrapartum cesarean
section rates, or maternal or neonatal adverse outcomes. Conclusions. Inter-
hospital IOL rates for nullipara with a singleton cephalic term birth had high
unexplained variation, with no clear association with intrapartum cesarean
section rates, or maternal or neonatal adverse outcomes.

DOI: 10.1111/aogs.12854 Abbreviations: aIOL, adjusted induction of labor; CS, cesarean section; IOL,
induction of labor.

Introduction Key Message

Internationally, increasing rates of intervention in child-
birth have focused attention on induction of labor (IOL).
The importance of IOL rates for nullipara is such that
these rates are included in national benchmarking stan-
dards to monitor maternity care (1). The focus on nulli-
para is because of the consequences of delivery for the
first birth on subsequent births and differences in risks
Despite high unexplained variation in hospital induc-
tion rates, there were no differences in adverse birth
outcomes for term nullipara. Therefore, reducing
labor induction rates in hospitals with high rates,
especially for nullipara at full term, can be safely
attempted.

ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 411–419 411
Variations in IOL for nullipara
for delivery outcomes of nulliparous compared with mul-
tiparous births (2).
Variations in medical interventions such as IOL may
indicate over-provision of health care, or an unmet need
for health care in other areas (3). Consequently, varia-
tions in intervention rates have performance, health, and
economic implications for healthcare systems.
There have been no studies investigating hospital IOL
rates and their outcomes for nullipara. A recent popula-
tion-based study found high variation in hospital IOL
rates for nullipara, but the associated outcomes were not
assessed (4). On the other hand, previous studies investi-
gating the relationship between inter-hospital rates of IOL
and outcomes did not differentiate between nullipara and
multipara (5,6). The purpose of this study was to describe
inter-hospital variation in IOL rates and associated preg-
nancy outcomes for nullipara with singleton cephalic
pregnancies, who gave birth ≥37 weeks of gestation.
Material and methods
The study population included all pregnancies resulting
in a singleton birth in cephalic presentation to nullipara
at ≥37 weeks of gestation in a hospital that had facilities
to conduct IOL in New South Wales, Australia from 1
January 2010 to 31 December 2011 (see Supplementary
material, Figure S1). Population data and study variables
were obtained from the NSW Perinatal Data Collection
and the Admitted Patients Data Collection. The NSW
Perinatal Data Collection is a legislated population-based
surveillance system of all births in NSW including all
births of at least 20 weeks gestation or at least 400 g
birthweight. Validated information from the birth record
includes demographic, pregnancy, labor and birth charac-
teristics of the mother and perinatal outcomes, which are
recorded by the attending midwife or doctor (7). The
Admitted Patients Data Collection is a census of all
admissions to NSW public and private hospitals, and has
additional information on maternal conditions, and
infant and maternal outcomes. Records were linked longi-
tudinally to improve ascertainment of maternal, birth,
and infant characteristics. Probabilistic linkage of the data
sets was performed by the Centre for Record Linkage,
and researchers were provided with anonymized data.
Quality assurance data for this study show false-positive
and false-negative rates of linkage of 0.3% and <0.5%,
respectively.
Potential predictors for IOL were divided into charac-
teristics of the individual woman and the hospital she
attended. Individual factors included demographic, preg-
nancy, and pre-existing maternal conditions (Table 1).
Hospital factors included annual number of births;
available neonatal care facilities; region (urban or
412 ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 411–419
T.A. Nippita et al.
regional); type of obstetric training (primary referring to
tertiary obstetric training hospitals, secondary referring
to large district and rural hospitals that host obstetric
registrars, and nontraining hospitals); hospital rates of
prelabor cesarean section (CS), spontaneous labor,
induction/augmentation of labor, instrumental delivery,
third-/fourth-degree perineal tears, CS performed under
general anesthetic and the proportion of births in which
regional analgesia is used (as indicators of anesthetic
service).
Statistical analysis
Births were classified into prespecified induction groups:
early term (37–38 weeks of gestation), full term (39–
40 weeks of gestation), late term (41 or more weeks of
gestation) (8). For each hospital, the primary outcome
was the rate of women in each group who had labor
induced among all pregnant women at risk of IOL; a
woman was considered ‘at risk’ of having an IOL during
a gestational period if she was still pregnant at the start
of the period.
Multilevel logistic regression models were used to
examine inter-hospital variation in IOL rates for early-,
full-, and late term births; hospital-specific IOL rates were
determined. Modeling was performed in three hierarchi-
cal stages, separately for each induction group. As previ-
ously described (9), first, the unadjusted model was
fitted; second, individual factors significantly associated
with induction were included; lastly, hospital factors were
added.
Among hospitals, the proportion of variance explained
by individual and hospital factors was calculated as the
change in variance from the previous to more adjusted
models, as a proportion of the variance of the unadjusted
model. The percentage of hospitals in each group that
were significantly different from the state average rate was
used as an additional indicator of variability.
The associations between hospital rates of induction
and adverse pregnancy outcomes were then determined.
Within each induction group (early, full and late term),
hospitals were divided into quintiles according to their
adjusted hospital IOL rates. Severe maternal and neonatal
outcomes were measured using composite indicators (in-
cluding life-threatening conditions, e.g. shock, significant
birth trauma, and procedures associated with severe mor-
bidity, e.g. blood transfusion, surgical procedures) that
have been developed and validated for use in routinely
collected data (10,11). Multilevel logistic regression was
used to determine the adjusted odds ratios of maternal
and neonatal morbidity and intrapartum CS for each
quintile of hospital IOL rates. Adjusted maternal and
neonatal morbidity and intrapartum CS rates were also
T.A. Nippita et al. Variations in IOL for nullipara

Table 1. Maternal and pregnancy characteristics of nullipara with cephalic singletons ≥37 weeks, by gestational age, New South Wales, 2010–
2011.

Early term Full term Late term

(37–38 weeks) (39–40 weeks) (≥ 41 weeks) Total

(n = 14 804) (n = 40 304) (n = 14 362) (n = 69 470)

n (%) n (%) n (%) n (%)

Maternal characteristics
Maternal age
<20 years 933 (6.3) 2500 (6.2) 995 (6.9) 4428 (6.4)
20–34 years 11 353 (76.7) 31 819 (79.0) 11 347 (79.0) 54 519 (78.5)
≥35 years 2518 (17.0) 5978 (14.8) 2017 (14.0) 10 513 (15.1)
Born in Australia 8875 (60.0) 25 526 (63.3) 9973 (69.4) 44 374 (63.9)
Smoking during pregnancy 1425 (9.6) 3371 (8.4) 1273 (8.9) 6069 (8.7)
Socio-economic status quintile
1 (most disadvantaged) 2246 (15.2) 5999 (14.9) 2379 (16.6) 10 624 (15.3)
2 2605 (17.6) 6799 (16.9) 2528 (17.6) 11 932 (17.2)
3 2724 (18.4) 7395 (18.4) 2848 (19.8) 12 967 (18.7)
4 3519 (23.8) 9508 (23.6) 3112 (21.7) 16 139 (23.2)
5 (least disadvantaged) 3567 (24.1) 10 220 (25.4) 3369 (23.5) 17 156 (24.7)
Type of care
Private, private hospital 4356 (29.4) 11 246 (27.9) 2494 (17.4) 18 096 (26.0)
Private, public hospital 1415 (9.6) 3471 (8.6) 1067 (7.4) 5953 (8.6)
Public, public hospital 9033 (61.0) 25 587 (63.5) 10 801 (75.2) 45 421 (65.4)
Antenatal visit pre-20 weeks 13 273 (89.7) 36 382 (90.3) 12 993 (90.5) 62 648 (90.2)
Pregnancy characteristics
Infant size (centile)
(SGA) <3 605 (4.1) 1436 (3.6) 471 (3.3) 2512 (3.6)
3–10 1399 (9.5) 3534 (8.8) 1225 (8.5) 6158 (8.9)
10–90 11 800 (79.7) 32 439 (80.5) 11 598 (80.8) 55 837 (80.4)
90–97 727 (4.9) 2067 (5.1) 752 (5.2) 3546 (5.1)
(LGA) >97 268 (1.8) 818 (2.0) 314 (2.2) 1400 (2.0)
Diabetes 1635 (11.0) 2684 (6.7) 299 (2.1) 4618 (6.6)
Hypertension 2102 (14.2) 3579 (8.9) 922 (6.4) 6603 (9.5)
Any chronic condition 538 (3.6) 602 (1.5) 115 (0.8) 1255 (1.8)
Antepartum hemorrhage 209 (1.4) 404 (1.0) 84 (0.6) 697 (1.0)
Hospital characteristics
Hospital facilities
NICU 4618 (31.2) 12 636 (31.4) 4909 (34.2) 22 163 (31.9)
CPAP 2161 (14.6) 5351 (13.3) 2093 (14.6) 9605 (13.8)
Neither 8025 (54.2) 22 317 (55.4) 7360 (51.3) 37 702 (54.3)
Hospital region
Urban 12 532 (84.7) 33 128 (82.2) 11 117 (77.4) 56 777 (81.7)
Regional 2272 (15.4) 7176 (17.8) 3245 (22.6) 12 693 (18.3)
Obstetric training
No training 5311 (35.9) 14 554 (36.1) 4010 (27.9) 23 875 (34.4)
Primary training 5098 (34.4) 13 805 (34.3) 5352 (37.3) 24 255 (34.9)
Secondary training 4395 (29.7) 11 945 (29.6) 5000 (34.8) 21 340 (30.7)

CPAP continuous positive airway pressure; LGA large for gestational age; NICU neonatal intensive care unit; SGA small for gestational age.

determined by quintile. Statistical analyses were per-

formed with SAS version 9.3 (SAS Institute, Cary, NC,
USA).
Ethical approval for this study was obtained from the
NSW Population and Health Services Research Ethics
Committee (2012/12/430) in 2012.
Results
The study population consisted of 69 470 births of single-
ton infants in cephalic presentation, born to nullipara
≥37 weeks gestation at 66 NSW hospitals in 2010–2011.
Of these births, 24 650 (35.5%) followed IOL. The overall

ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 411–419 413
Variations in IOL for nullipara T.A. Nippita et al.

crude IOL rate at different hospitals ranged from 12.4%
to 49.0% (interquartile range 29.8–40.0%). Among nulli-
para ‘at risk’, the induction rate was 5.9% at early term,
18.9% at full term and 59.1% at or beyond 41 weeks.
Pregnancy and maternal characteristics of these births are
shown in Table 1, by gestation. There were 112 stillbirths
in the population (0.16%), with 41, 54, and 17 stillbirths
occurring in early, full, and late term groups, respectively
(Table 2); as numbers of stillbirths were small, associa-
tions between stillbirths and hospital IOL rates were not
determined.
Variation in hospital IOL rates
For early term nullipara, the unadjusted hospital IOL rate
ranged from 3.2% to 14.8%. Adjusting for individual fac-
tors reduced the variation in hospital IOL rates by 7%
[adjusted IOL (aIOL) rates 3.6–14.3%], with maternal
medical conditions and birthweight below the 10th centile
associated with an increased odds of IOL at these gesta-
tions. Hospital factors reduced the variation in hospital
IOL rates by a further 43% (aIOL rates 3.6–13.0%)
(Table 3, Figure 1). Overall, 50% of the variation in hos-
pital IOL rates for nullipara at early term could be
explained. After adjustment, only 11 of the 66 hospitals
had IOL rates significantly different from the state average
(Table 3).
For full term nullipara, the unadjusted hospital IOL
rate ranged from 6.8% to 31.2%. Adjusting for individual
factors reduced the variation in hospital IOL rates by
15% (aIOL rate 8.0–32.5%), and adjusting for hospital
factors reduced the variation by a further 20% (aIOL
rates 10.6–32.0%) (Table 3, Figure 1). Nullipara with pri-
vate care, whether in a private or public hospital, had sig-
nificantly higher odds of having an IOL at full term
compared with nullipara having public care. Additionally,
nullipara at full term delivering in hospitals with sec-
ondary obstetric training were more likely to have an IOL
compared with nullipara delivering in hospitals without
any obstetric training (see Supplementary material,
Table S1). Overall, 35% of the variation in hospital IOL
rates for nullipara at full term could be explained. Even
after accounting for these factors, 44% of hospitals
(n = 29) had IOL rates that were significantly different
from the state average (Table 3).
For late term nullipara, unadjusted hospital IOL rates
varied from 44.6% to 67.9%. Adjusting for individual fac-
tors reduced the variation in hospital IOL rates by 7%
(aIOL rates 45.3–67.7%), with hospital factors reducing
the variation by a further 12% (aIOL rates 47.1–66.2%)
(Table 3, Figure 1). Again, nullipara having private care
whether in a private or public hospital had an increased
odds of IOL compared with nullipara with public care
(see Supplementary material, Table S1). Also, nullipara
delivering in regional hospitals had a reduced odds of
IOL compared with nullipara delivering in urban hospi-
tals (see Supplementary material, Table S1). Overall, 19%
of the variation in hospital IOL rates could be explained
with 17% (n = 11) of hospitals having IOL rates that
were different from the state average (Table 3) after
adjusting for relevant factors.
Pregnancy outcomes following IOL
Severe maternal morbidity rates, adjusted for individual
factors, were 2.4% (95% CI 1.9–2.9%) for nullipara at
term (Table 4). For each of the three induction groups,
there were no differences in maternal morbidity rates

Table 2. Delivery and birth outcomes of nullipara with cephalic singletons ≥ 37 weeks, by gestational age, New South Wales, 2010–2011.

Early term Full term Late term

(37–38 weeks) (39–40 weeks) (≥ 41 weeks) Total

(n = 14 804) (n = 40 304) (n = 14 362) (n = 69 470)

n (%) n (%) n (%) n (%)

Induction of labor 4917 (33.2) 11 296 (28.0) 8437 (58.8) 24 650 (35.5)
Cesarean sections
Prelabor 2215 (15.0) 2657 (6.6) 356 (2.5) 5228 (7.5)
Intrapartum 2383 (16.1) 7838 (19.5) 4505 (31.4) 14 726 (21.2)
Vaginal births 10 205 (68.9) 29 795 (73.9) 9500 (66.2) 49 500 (71.3)
Severe maternal morbidity 284 (1.9) 705 (1.7) 405 (2.8) 1394 (2.0)
Resuscitation 944 (6.4) 2606 (6.5) 1236 (8.6) 4786 (6.9)
Apgar < 4 at 1 min 300 (2.0) 801 (2.0) 398 (2.8) 1499 (2.2)
Apgar < 7 at 5 min 245 (1.7) 575 (1.4) 265 (1.9) 1085 (1.6)
Stillbirth 41 (0.3) 54 (0.1) 17 (0.1) 112 (0.2)
Severe neonatal morbidity 541 (3.7) 1113 (2.8) 558 (4) 2212 (3)

414 ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 411–419
T.A. Nippita et al.
Table 3. Rates of induction and measures of inter-hospital variation, for nullipara with single cephalic pregnancies, by gestational age, NSW,
2010–2011.
Overall %a of % of variance
Induction “at risk” explained by case
Group induced mix
Early term: 5.9 7 43
37–
38 weeks
Full term: 39 18.9 15
–40 weeks
Late term: 59.1 7 12
≥ 41 weeks
a
Rates refer to adjusted rates.
b
Proportion of hospitals for which the 95% confidence interval of the adjusted hospital induction rate does not cross the overall predicted state
rate.
according to the quintiles of adjusted hospital IOL rates,
except for late term nullipara, where there was maternal
morbidity was lowest for the lowest hospital quintile of
adjusted IOL rates (maternal morbidity rate of 2.2%,
95% CI 1.7–2.7%; adjusted odds ratios 0.65, 95% CI
0.52–0.82) (Table 4; see Supplementary material, Fig-
ure S2).
Severe neonatal morbidity rates, adjusted for individual
factors, were 3.1% (95% CI 1.0–5.2%) for babies born to
nullipara at term. There was no difference in neonatal
morbidity rates for each of the three hospital induction
groups according to the quintiles of adjusted hospital IOL
rates, except for early term nullipara, where the second
highest quintile of hospital induction rates had the high-
est neonatal morbidity (3.7%, 95% CI 1.6–6.0%; adjusted
odds ratios 1.51, 95% CI 1.08–2.11) (Table 4; see Supple-
mentary material, Figure S3).
The overall crude rate for CS across all groups was
34.5%. For each of the three IOL groups, there were no
differences in hospital intrapartum CS rates following
IOL for any of the quintiles of hospital IOL rates adjusted
for individual factors, with overall intrapartum CS rates
being 28.7% (95% CI 21.7–35.6%), 32.5% (95% CI 22.4–
43.0%), and 38.8% (95% CI 31.5–46.0%) for early, full,
and late term, respectively (Table 4; see Supplementary
material, Figure S4).
Discussion
Over one-third of nullipara at ≥37 weeks gestation with a
singleton, cephalic birth had an IOL in NSW from 2010
to 2011. The greatest amount of variation in hospital
IOL rates was explained at early term (50% of variance
explained), followed by full term (35% of vari-
ance explained). Nevertheless, at full term, 44% of hospi-
tals had an adjusted IOL rate that was significantly
ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 411–419
Variations in IOL for nullipara
% of remaining variance Minimum Maximum % (n) of hospitals with
explained by hospital hospital rate hospital rate rates different from
factors (%) (%) overallb
3.6 13.0 17% (11)
20 10.6 32.0 44% (29)
47.1 66.2 17% (11)
different from the state average. Surprisingly, hospital fac-
tors explained more of the variation in hospital IOL rates
than individual factors, perhaps suggesting that culture,
facilities, or other characteristics of the hospital play a
substantial role in decision-making. Generally, there was
no clear association between hospital IOL rates and intra-
partum CS, or maternal or neonatal morbidity, although
there was a slightly higher risk of neonatal morbidity at
early term births among hospitals with high IOL rates.
Measures to reduce rates of IOL in those hospitals within
higher IOL rate quintiles should not result in adverse
birth outcomes.
The strengths of this study include the use of a recent,
validated, population data set with reliably collected
information on pregnancy and birth characteristics. We
used random effects multilevel modeling, enabling adjust-
ment for individual and hospital factors, while also
adjusting for clustering of women within hospitals and
random fluctuations due to small sample sizes in some
hospitals. We also used validated composite maternal and
neonatal outcomes, specifically developed for use in pop-
ulation data analysis. However, residual confounding is a
potential limitation as we are unable to adjust for all
pregnancy factors or clinician and/or patient preferences.
Small hospitals with low-risk maternity populations were
excluded if they did not have the facilities to perform
IOL or did not perform IOL. Women attending these
hospitals who required IOL would be transferred to
another hospital, but the small numbers would not be
expected to overly influence IOL rates at the receiving
hospital. Additionally, the population had too few still-
births to examine differences in stillbirth outcomes.
Babies born at early term (compared with full term)
have increased morbidity (12), so clinicians would be
expected to intervene only if there were compelling
maternal or perinatal conditions that warranted early
415
Variations in IOL for nullipara T.A. Nippita et al.

20 Early term (37–38 weeks)

18

Adjusted rate of induction (%)

16
14
12
10
8
6
4
2
0
Hospital

45 Full term (39–40 weeks)

40
Adjusted rate of induction (%)

35
30
25
20
15
10
5
0
Hospital

Late term (41+ weeks)

80

70
Adjusted rate of induction (%)

60

50

40

30

20

10

0
Hospital

Figure 1. Hospital-specific induction rates (women induced as a % of all women still pregnant at the start of the period), adjusted for all
significant individual and hospital-level predictors separately for three induction groups, New South Wales, 2010–2011. (The dotted line
represents the overall predicted rate for each group; note that the y-axis for each graph is different).

delivery. Consistent with this, nullipara in this group have
the highest prevalence of maternal medical conditions.
However, individual patient factors explained less varia-
tion than hospital factors in this group.
The largest variation across hospitals for adjusted IOL
rates were for full term nullipara. Although 35% of the
variation was explained by individual and hospital factors,
44% of hospital aIOL rates were significantly different
from the average; more than three-fold difference in
hospital aIOL rates. Consistent with the findings of a
European study (13), we found that nullipara who had
private care were more likely to have a full term IOL
compared with nullipara receiving public care. Conse-
quently, women giving birth in countries with public and
private care available should be informed that private care
is associated with an increased rate of IOL, especially
given that almost one-third of women with IOL at full
term have an intrapartum CS. The increased variation in
hospital IOL rates may be related to differences in thresh-
olds for intervening on the part of both women and

416 ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 411–419
T.A. Nippita et al. Variations in IOL for nullipara

Table 4. Maternal morbidity outcomes, neonatal adverse outcomes and intrapartum cesarean section (CS) rates (following labor induction for
those gestational weeks) by quintiles of adjusted hospital induction of labor (IOL) rate for each gestational age group.

Maternal morbiditya Neonatal morbidityb Intrapartum CSc

Hospital IOL quintile Rate (%) (95% CI) OR (95% CI) Rate (%) (95% CI) OR (95% CI) Rate (%) (95% CI) OR (95% CI)

Early term: 37–38 weeks of gestation

1st quintile (low) 2.3 (2.0–2.6) 0.82 (0.60–1.12) 2.6 (1.0–4.2) 0.86 (0.58–1.27) 29.2 (24.4–34.0) 1.14 (0.73–1.79)
2nd quintile 2.3 (2.0–2.5) 0.83 (0.62–1.11) 2.9 (1.2–4.6) 1.05 (0.73–1.51) 28.0 (22.9–33.1) 0.81 (0.54–1.23)
3rd quintile 2.4 (2.1–2.6) 1 (ref) 2.8 (0.9–4.7) 1 (ref) 28.8 (21.2–36.4) 1 (ref)
4th quintile 2.4 (1.5–3.3) 1.03 (0.81–1.30) 3.7 (1.6–5.8) 1.51 (1.08–2.11) 27.4 (19.0–35.8) 0.86 (0.63–1.18)
5th quintile (high) 2.4 (2.0–2.8) 1.06 (0.85–1.32) 3.5 (1.0–5.9) 1.35 (0.98–1.86) 29.8 (21.9–37.7) 1.07 (0.80–1.43)
Overall 2.4 (1.9–2.9) 3.1 (1.0–5.2) 28.7 (21.7–35.6)
Full term: 39–40 weeks of gestation
1st quintile (low) 2.3 (2.0–2.5) 0.83 (0.64–1.09) 3.0 (0.8–5.2) 0.78 (0.54–1.13) 32.0 (26.2–37.8) 0.85 (0.61–1.18)
2nd quintile 2.3 (2.1–2.5) 0.87 (0.66–1.14) 3.1 (1.3–4.8) 0.85 (0.58–1.23) 32.9 (26.1–39.6) 0.93 (0.68–1.26)
3rd quintile 2.4 (1.7–3.0) 1 (ref) 3.5 (1.5–5.5) 1 (ref) 33.7 (19.0–48.3) 1 (ref)
4th quintile 2.4 (1.7–3.2) 1.07 (0.86–1.33) 2.9 (1.1–4.7) 0.78 (0.55–1.10) 31.1 (18.9–43.3) 0.85 (0.64–1.12)
5th quintile (high) 2.4 (2.1–2.8) 1.13 (0.91–1.41) 3.1 (0.4–5.7) 0.82 (0.57–1.16) 33.7 (23.6–43.9) 1.00 (0.75–1.32)
Overall 2.4 (1.9–2.9) 3.1 (1.0–5.2) 32.7 (22.4–43.0)
Late term: ≥ 41 weeks of gestation
1st quintile (low) 2.2 (1.7–2.7) 0.65 (0.52–0.82) 3.0 (0.6–5.3) 0.99 (0.67–1.45) 38.2 (33.4–42.9) 0.90 (0.70–1.14)
2nd quintile 2.3 (2.0–2.7) 0.85 (0.68–1.05) 3.2 (1.6–4.9) 1.20 (0.82–1.74) 37.3 (28.6–45.9) 0.83 (0.66–1.05)
3rd quintile 2.5 (1.8–3.2) 1 (ref) 3.0 (0.7–5.3) 1 (ref) 39.3 (34.2–44.5) 1 (ref)
4th quintile 2.3 (2.0–2.7) 0.87 (0.70–1.07) 3.1 (1.7–4.6) 1.14 (0.78–1.66) 39.0 (32.0–45.9) 0.99 (0.78–1.25)
5th quintile (high) 2.5 (2.1–2.8) 0.99 (0.82–1.20) 3.2 (0.5–5.9) 1.09 (0.76–1.57) 40.0 (30.6–49.3) 1.06 (0.86–1.32)
Overall 2.4 (1.9–2.9) 3.1 (1.0–5.2) 38.8 (31.5–46.0)

a
Maternal morbidity measured using the Maternal Morbidity Outcome Index (MMOI).
b
Neonatal morbidity measured using the Neonatal Adverse Outcome Index (NAOI).
c
Hospital intrapartum cesarean rate following IOL for women in the group.

clinicians. Perhaps this is not surprising as international
recommendations differ, with some national guidelines
suggesting planned delivery from 39 weeks of gestation
(14) and others from 41 weeks of gestation (15).
As expected, our study found higher hospital IOL rates
for late term nullipara (aIOL rates 47.1–66.2%), with the
least amount of variation explained by individual and
hospital factors; only 11 hospitals’ (17%) IOL rate dif-
fered from the average. The simple fact of belonging in
the group (reaching the gestational age of 41 weeks), as
opposed to individual or hospital factors, was driving the
IOL rates. Regional hospitals were less likely to induce
late term nullipara than urban hospitals. A Canadian
study found that rural women were more likely to be
induced compared with urban women (16), whereas an
American study found the opposite (17). Urban and rural
differences may warrant further exploration regarding
knowledge of guidelines in NSW rural hospitals.
Although the IOL rate for nullipara (reflective of the
overall IOL rate in NSW of 27.3%) (18) in this study is
high compared to other countries in northern Europe,
there is marked variation in IOL rates between and
within European countries (1,19) with rates of overall
IOL ranging from 6.8% to 33%. The marked variation
found in hospital IOL rates in our setting may be gener-
alizable to other jurisdictions internationally, even if abso-
lute rates are not. Further investigation into the reasons
for differences in international rates of IOL is recom-
mended.
There was no clear association between hospital IOL
rates and outcomes of maternal morbidity, neonatal mor-
bidity, or intrapartum CS rates. High rates of neonatal
morbidity for nullipara at 37–38 weeks of gestation in the
fourth and fifth quintiles may reflect the reason for IOL,
such as growth restriction. However, another study found
no difference in adverse neonatal outcomes and differ-
ences in hospital IOL rates after adjustment for individual
factors (5).
Similar to our study, Canadian research found no dif-
ferences in CS rates for hospitals with differing rates of
IOL from 41 weeks of gestation (20), in contrast with an
English report (1) showing a two-fold difference in
adjusted hospital rates of CS following IOL for nullipara
from ≥37 weeks of gestation. The disparity in findings
may be due to the English report examining all term
births as a single group (nullipara with a singleton cepha-
lic pregnancy ≥37 weeks who had an IOL). Variation in
intrapartum CS rates following IOL for nullipara was also

ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 411–419 417
Variations in IOL for nullipara
found using data from NSW (21) when nullipara
≥37 weeks of gestation was analyzed. However, the pre-
sent study acknowledged the difference within this group
by dividing term births into early term, full term, and late
term groups, and found differences in CS rates between
(but not within) each group. Consistent with other stud-
ies investigating IOL and intrapartum CS rates when
using an “at-risk” population (22), this study found grad-
ually increasing rates of CS (28.7%, 32.7%, and 38.8%,
respectively) as gestation advanced. Of concern, the over-
all NSW CS rate (34.5%) following IOL has increased
(23) and is high compared with international rates (1,24),
although reasons for the difference are unclear.
When trying to reduce IOL rates, a concern is the
potential increase in stillbirth. A retrospective study sug-
gested that reducing elective delivery before 39 weeks was
associated with an increase in stillbirths at 37 and
38 weeks (25). Although the current study had too few
stillbirths to make meaningful comparisons between ges-
tational age groups and hospital IOL rates, a large Ameri-
can study using National Health Statistics data found the
reduction in early term births (probably from the reduc-
tion in elective IOL before 39 weeks of gestation) has not
resulted in an increase in term stillbirths (26), with still-
births decreasing at later gestational ages, except after
41 weeks of gestation. Although the US reports a national
IOL rate (26) lower than that of NSW and Australia (18),
reported rates of term stillbirth (0.1–0.2%) (26) are simi-
lar to our study. A Norwegian study described a similar
perinatal mortality risk of 0.18% (27) for singleton births
from 37 weeks of gestation compared with Australia, and
yet Norway reported a much lower IOL rate of 13.7%
during that time (2005/6) (28). Although these interna-
tional ecological comparisons should be viewed with cau-
tion, it does not appear that liberal use of IOL in NSW
was associated with lower stillbirths at later gestational
ages.
Many reports raise concerns about increasing health-
care costs; a suggestion to improve value to the commu-
nity is by decreasing unexplained variation in healthcare
practice (3). For women <41 weeks, elective IOL com-
pared with expectant management appears to result in
longer labor (29) and may be associated with increased
costs (30). This study illustrates that hospitals with high
rates of IOL have similar maternal and neonatal out-
comes compared with hospitals with lower rates of IOL,
indicating a potential avenue to reduce costs. Further
investigation of differences in the hospitals with low and
high IOL rates, such as exploration of patient and clini-
cian preferences that contribute to these differences, may
assist in decreasing unexplained variation in IOL rates.
In conclusion, the most variation in hospital induction
rates was for nullipara at full term, but for all nullipara
418 ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 411–419
T.A. Nippita et al.
≥37 weeks of gestation, hospital factors explained more
variation than individual factors. Across all groups of nul-
lipara ≥37 weeks of gestation with a singleton, cephalic
fetus, there were no clear medical harms or benefits (such
as differences in intrapartum CS rates, or in neonatal or
maternal outcomes) across hospitals with different IOL
rates.
Acknowledgments
We thank the NSW Ministry of Health for access to the
population health data and the Centre for Health Record
Linkage for linkage of the data sets.
Funding
CLR is supported by an NHMRC Senior Research Fellow-
ship (APP1021025) and JBF by an Australian Research
Council Future Fellowship (FT120100069). JAT was
employed by the NSW Ministry of Health on the NSW
Biostatistical Officer Training Program at the time this
work was conducted.
References
1. RCOG. Patterns of maternity care in English NHS
Hospitals 2011/12. London: Royal College of Obstetricians
and Gynaecologists, 2013.
2. Lee YY, Roberts CL, Patterson JA, Simpson JM, Nicholl
MC, Morris JM, et al. Unexplained variation in hospital
caesarean section rates. Med J Aust. 2013;199:348–53.
3. Newhouse JP, Garber AM, Graham RP, McCoy MA,
Mancher M, Kibria A. Variation in health care spending:
target decision making, not geography. Committee on
Geographic Variation in Health Care Spending and
Promotion of High-Value Care, Institute of Medicine,
National Academy of Sciences, editors. Washington, D.C.:
The National Academies Press, 2013.
4. Nippita TA, Trevena JA, Patterson JA, Ford JB, Morris JM,
Roberts CL. Variation in hospital rates of induction of
labour: a population-based record linkage study. BMJ
Open. 2015;5:e008755.
5. Glantz JC. Rates of labor induction and primary cesarean
delivery do not correlate with rates of adverse neonatal
outcome in level I hospitals. J Matern Fetal Neonatal Med.
2011;24:636–42.
6. Glantz JC. Labor induction rate variation in upstate New
York: what is the difference? Birth. 2003;30:168–74.
7. Roberts CL, Bell JC, Ford JB, Morris JM. Monitoring the
quality of maternity care: how well are labour and delivery
events reported in population health data? Paediatr Perinat
Epidemiol. 2009;23:144–52.
8. Nippita TA, Khambalia AZ, Seeho SK, Trevena JA,
Patterson JA, Ford JB, et al. Methods of classification for
T.A. Nippita et al.
women undergoing induction of labour: a systematic
review and novel classification system. BJOG.
2015;122:1284–93.
9. Synnes AR, Macnab YC, Qiu Z, Ohlsson A, Gustafson P,
Dean CB, et al. Neonatal intensive care unit characteristics
affect the incidence of severe intraventricular hemorrhage.
Med Care. 2006;44:754–9.
10. Lain SJ, Algert CS, Nassar N, Bowen JR, Roberts CL.
Incidence of severe adverse neonatal outcomes: use of a
composite indicator in a population cohort. Matern Child
Health J. 2012;16:600–8.
11. Roberts CL, Cameron CA, Bell JC, Algert CS, Morris JM.
Measuring maternal morbidity in routinely collected health
data: development and validation of a maternal morbidity
outcome indicator. Med Care. 2008;46:786–94.
12. Parikh LI, Reddy UM, Mannisto T, Mendola P, Sjaarda L,
Hinkle S, et al. Neonatal outcomes in early term birth. Am
J Obstet Gynecol. 2014;211:265 e1–e11.
13. Coulm B, Le Ray C, Lelong N, Drewniak N, Zeitlin J,
Blondel B. Obstetric interventions for low-risk pregnant
women in france: do maternity unit characteristics make a
difference? Birth. 2012;39:183–91.
14. ACOG Committee on Practice Bulletins- Obstetrics.
ACOG Practice Bulletin No. 107: induction of labor.
Obstet Gynecol. 2009;114(2 Pt 1):386–97.
15. WHO. WHO recommendations for induction of labour.
Geneva, Switzerland: WHO Press, 2011.
16. Kornelsen J, Moola S, Grzybowski S. Does distance matter?
Increased induction rates for rural women who have to
travel for intrapartum care. J Obstet Gynaecol Can.
2009;31:21–7.
17. Kozhimannil KB, Hung P, Prasad S, Casey M, Moscovice
I. Rural-urban differences in obstetric care, 2002–2010,
and implications for the future. Med Care. 2014;52:4–9.
18. Hilder L ZZ, Parker M, Jahan S, Chambers GM. Australia’s
mothers and babies 2012. Perinatal statistics series no. 30.
Cat. no. PER 69. Canberra, Australia: AIHW, 2014.
19. EURO-PERISTAT Project with SCPE and EUROCAT.
European Perinatal Health Report. The health and care of
pregnant women and babies in Europe in 2010. May 2013.
20. Hutcheon J, Harper S, Strumpf E, Lee L, Marquette G.
Using inter-institutional practice variation to understand
the risks and benefits of routine labour induction at 41
weeks. BJOG. 2015;122:1200–6.
21. Nippita T, Lee Y, Patterson J, Ford J, Morris J, Nicholl M,
et al. Variation in hospital caesarean section rates and
obstetric outcomes among nulliparae at term: a
population-based cohort study. BJOG. 2015;122:702–11.
22. Darney BG, Caughey AB. Elective induction of labor
symposium: nomenclature, research methodological issues,
and outcomes. Clin Obstet Gynecol. 2014;57:343–62.
23. Patterson JA, Roberts CL, Ford JB, Morris JM. Trends and
outcomes of induction of labour among nullipara at term.
Aust N Z J Obstet Gynaecol. 2011;51:510–7.
ª 2016 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 95 (2016) 411–419
Variations in IOL for nullipara
24. Vogel JP, Betran AP, Vindevoghel N, Souza JP, Torloni
MR, Zhang J, et al. Use of the Robson classification to
assess caesarean section trends in 21 countries: a secondary
analysis of two WHO multicountry surveys. Lancet Glob
Health. 2015;3:e260–70.
25. Ehrenthal DB, Hoffman MK, Jiang X, Ostrum G. Neonatal
outcomes after implementation of guidelines limiting
elective delivery before 39 weeks of gestation. Obstet
Gynecol. 2011;118:1047–55.
26. MacDorman MF, Reddy UM, Silver RM. Trends in
stillbirth by gestational age in the United States, 2006–
2012. Obstet Gynecol. 2015;126:1146–50.
27. Morken NH, Klungsoyr K, Skjaerven R. Perinatal mortality
by gestational week and size at birth in singleton
pregnancies at and beyond term: a nationwide population-
based cohort study. BMC Pregnancy Childbirth.
2014;14:172.
28. Division of Epidemiology. The medical birth register:
births in Norway 2005–2006. Norwegian Institute of Public
Health, 2009. Available at: http://www.fhi.no/eway/default.
aspx?pid=239&trg=Content_6465&Main_6157=
6261:0:25,6747&Content_6465=6259:106177::0:6269:2:::0:0
[Accessed 30 November 2015]
29. Bailit JL, Grobman W, Zhao Y, Wapner RJ, Reddy UM,
Varner MW, et al. Nonmedically indicated induction vs
expectant treatment in term nulliparous women. Am J
Obstet Gynecol. 2015;212:103.e1–7.
30. Fahy M, Doyle O, Denny K, McAuliffe FM, Robson M.
Economics of childbirth. Acta Obstet Gynecol Scand.
2013;92:508–16.
Supporting information
Additional Supporting Information may be found in the
online version of this article:
Table S1. Among nullipara with cephalic presenting
term fetus, crude odds ratios (cOR) and 95% CI from
univariate regression, and adjusted odds ratios (aOR) and
95% CI, for hospital IOL by gestational age group.
Figure S1. Flow chart of the included population of nulli-
para with a single cephalic pregnancy at ≥37 weeks for
analysis.
Figure S2. Maternal morbidity following induction of
labor for nulliparous women with a singleton, cephalic
fetus, by gestational age group.
Figure S3. Neonatal morbidity following induction of
labor for nulliparous women with a singleton, cephalic
fetus, by gestation age group.
Figure S4. Intrapartum cesarean section rates following
induction of labor for nulliparous women with a single-
ton cephalic fetus, by gestational age group.
419