. At around 41 weeks, women were randomly assigned to either induction of labour or expectant management. In the induction group, labour was induced within four days, and women received cervical ripening (if the cervix was less than 3 cm dilated), followed by intravenous oxytocin and/or artificial rupture of membranes. In the expectant management group, women were taught how to do kick count monitoring, had three non-stress tests per week, and underwent amniotic fluid measurement two to three times per week. Labour was induced if the non-stress test was nonreactive or showed decelerations, if there was low amniotic fluid (deepest pocket less than 3 cm), if complications developed, if the mother requested an induction, or if the mother did not go into labour on her own by 44 weeks. If an induction occurred in the expectant management group, mothers did not receive cervical ripening— instead, they either had their water broken and/or oxytocin, or had a Caesarean without labour.
Hannah et al.’s findings on Caesarean rates differ, depending on how the groups were analysed. Using intent-to-treat analysis with the two original groups (random assignment to either induction or monitoring), the overall Caesarean rate was lower in the induction group (21.2% vs. 24.5%), even after taking into account parity, maternal age, cervical dilation at the time of study entry, and race (Table 1).40 However, there were high cross-over rates between groups. When Hannah et al. conducted a secondary data analysis to find out what actually happened to women in the two assigned groups, a different finding emerged (Table 1).41 Nulliparous women who went into spontaneous labour had an overall Caesarean rate of only 25.7%, regardless of which group they were originally assigned. The Caesarean rate of women in the induction group who were induced was not statistically different than the Caesarean rate of women who went into spontaneous labour from either group. However, nulliparous women in the expectant management group who had an induction experienced a significantly higher Caesarean rate than all of the other groups— 42%. The same pattern held true when the researchers examined data from multiparous women