Predictors of Induction of Labor and Success Rate Among

Mothers Giving Birth at Jimma University Medical Centre

South West Ethiopia: Unmatched Case Control Study
Enatfanta Sewmehon, Fantaye Chemir, Lakew Abebe, and
Admasu Belay Gizaw

BACKGROUND: Induction of labor is defined as the process of artificially stimulating the uterus to
start labor. It is the stimulation of uterine contractions during pregnancy before labor begins on its
own. In spite of the unquestionable reputation of labor induction for ending pregnancies, there is a risk
to the mother and/or the fetus. Studies from both developed and developing countries are reporting
increase in rate of labor induction with additional cases of cesarean section and fetal distress.
OBJECTIVE: The main aim of this study is to assess Predictors of induction of labor and success rate
among mothers giving birth at Jimma University Medical Centre Southwest Ethiopia.
METHODS: Facility based unmatched case control quantitative study design was done among 694
(cases = 347 & controls = 347) mothers. Systematic random sampling technique was used to select both
cases and controls from the registration delivery log book. Standard document review checklist was
used to collect data. Multivariate binary logistic regression analysis was done to identify predictors of
the outcome the variable.
RESULTS: The study findings revealed the success rate of induction of Labor in this study was 73.8%.
Mothers with still birth history were three times more likely to be induced compared with mothers
without still birth history. Mothers with abortion history were seven times more likely to be induced
compared with mothers without abortion history. Mothers with gestational age >=42 weeks were 17
times more likely to be induced compared with mothers with gestational age 38–41 weeks and mothers
who had no antenatal care follow up are seven times more likely to be induced compared with mothers
who had antenatal care follow up.
CONCLUSION: Maternal age, gestational age, history of abortion and history of still birth were signifi-
cant predictors of induction of Labor which was claimed to increases the rate of uterine rupture, cesar-
ean section and admission to neonatal Intensive Care Unit.
KEYWORDS: induction of labor; neonatal outcome; maternal outcome; birth outcome; Ethiopia

AQ2 INTRODUCTION administering mechanical and pharmacologic agents

such as use of oxytocin and prostaglandins (misopro-
Initiation (Induction) of labor is defined as the process stol), intrauterine placement of catheters, or the use of
of artificially stimulating the uterus to start labor by osmotic dilators and artificial rupture of the membranes

INTERNATIONAL JOURNAL OF CHILDBIRTH Volume 12, Issue 4, 2022

© 2022 Springer Publishing Company, LLC www.​springerpub.​com
https://dx.doi.org/10.1891/IJC-2022-0043 1
 2 Predictors of Induction of Labor and Success Rate Sewmehon et al.
AQ3 (Tandu-Umba et al., 2013; Goh et al., 2017). It is the
stimulation of uterine contractions during pregnancy
before labor begins on its own and commonly prac-
ticed in modern day obstetrics to decrease and if pos-
sible avoid major maternal and or fetal complications
associated with pre-eclampsia, premature rupture of
membrane (PROM), Intrauterine Growth Retardation
(IUGR) and post-term pregnancy (Al-Shaikh et al.,
2012).
The incidence of labor induction has continued
to increase over the past several years globally. The pro-
portion of mothers undergoing an induction of labor is
estimated to be greater than 20% in developed countries
while the average range in Africa was estimated to be
4.4% (1.4% in Niger to 6.8% in Algeria) (Boshomane
et al., 2019; Veerapen, 2016, Vogel et al., 2013).
In spite of the unquestionable reputation of labor
induction for ending pregnancies, there is a risk to the
mother and/or the fetus. This intervention may result in
undesirable effects. World Health Organization (WHO)
recommends induction of labor to be performed with a
clear indication like pre-eclampsia, ante-partum hemor-
rhage, chorioamnionitis, suspected fetal compromise,
post-term pregnancy, uncomplicated twin pregnancy,
diabetes mellitus, intrauterine growth restriction, oli-
gohydramnios, and intrauterine fetal death, near term
(Guerra et al., 2009) report about Global Survey on
Maternal and Perinatal Health showed trial of labor
(ToL) after previous caesarean section (CS) is an impor-
tant strategy to reduce short- and long-term morbidity
associated with repeated CS (Kalisa et al., 2017).
When successful induction of labor results in
vaginal delivery, but sometimes fails with probable risks
of increased rate of operative delivery, cesarean section,
extreme uterine activity, abnormal patterns in fetal heart
rate, rupture of the uterus, intoxication, preterm deliv-
ery and possibly cord prolapse. Induction of labor is said
to fail when vaginal delivery is not achieved within 24 to
48 hour (Lawani et al., 2014).
Assessing success rate of induction of Labor and
its predictors would help clinicians and policy makers to
determine the benefits and define a reasonable role for
induction of labor in current obstetric practice (Debele
et al., 2021). However, majority of the studies were
focusing on failed induction and associated factors with
cross-sectional design without comparison groups. So,
little is known about success rate of induction of Labor
and its predictors in Ethiopia and particularly in the
study area. Therefore, this study aimed to assess success
rate of induction of labor and its predictors in the study
area to minimize existing gaps.
METHODS AND MATERIALS
Study Area and Period
The study was conducted in Medical Centre. The center
is the only teaching and referral hospital in the south-
western part of the country with catchment population
of around 4,269,746 and giving referral service for the
whole South-Western part. From the total female popu-
lations, 753,377 women were categorized in the child-
bearing age group. Induction of labor is performed on
average of 3 occasions per day equates to around 2,190
within a 2-year periods.
Study Design
Facility based unmatched case control quantitative
study design was done among 694 (cases = 347& con-
trols = 347) mothers who delivered at Jimma Medical
Centre (JMC). From these, cases were mothers who
gave birth with induction of labor and controls were all
mothers who gave birth without induction.
Sampling Procedure
The sample size was determined by Epi info version 7
by considering 38.4% prevalence of cesarean section
among induced mothers on study done in Hawassa,
Ethiopia (14) and 28.1% overall prevalence of C/S
among mothers who gave birth at JMC (18) considering
5% margin of error of at 95% confidence level, ratio of
cases to controls: 1:1 and power: 80%. The final sample
size taken was 694 (cases: 347, controls: 347). Systematic
random sampling technique was used to select both
cases and controls from the registration delivery log-
book of the year 2014–2015 among mothers who had
delivered at Jimma Medical Center with induction and
without induction respectively.
Data Collection Tools
The data for this study was collected using semi struc-
tured record review checklist which was adapted and
developed after reviewing different literature. The
checklist contains items on socio-demographic charac-
teristics, indication for induction, method of induction,
mode of delivery, complications of induction like uter-
ine hyper stimulation, neonatal outcome and maternal
outcome for both cases and controls. The record review
checklist was pre-tested by considering 5% of the sample
 Predictors of Induction of Labor and Success Rate Sewmehon et al. 3

size in the other hospital out of Jimma Medical Center
and necessary editorial and contextual modification in
the record review checklist was made based on the exist-
ing guidelines and expert opinion. Data was entered
into Epi-data software and was cleaned and checked for
outliers, missing values and any inconsistencies.
Data Collectors and Data Collection Procedures
The data was collected by two diploma midwives from
another hospital using validated record review checklist
from women’s record. Supervision of the data collection
was done by one first degree holder midwife and the
principal investigator. To ensure the quality of data, two
days training was given for data collectors and supervi-
sors on the objective and relevance of the study, how to
gather the appropriate information, procedures of data
collection techniques and the whole contents of the
record review check list.
and predictors of the outcome variable. Accordingly, the
variables selected to be a candidate for multivariate logis-
tic regression include age of mothers, history still birth,
gestational age, history of abortion and antenatal care
follow up. Secondly, variables with p-value less than 0.05
in multivariate analysis were considered as significant
predictors for induction of labor. In the binary logistic
regression, all the variables were entered into bivari-
ate analysis and those variables with a p value < 0.25
in crude odds ratio was considered as a candidate for
multivariate analysis and those variables with a p value <
.05 in multivariate analysis was considered as significant
predictor of induction of labor. Finally, the results were
presented in texts, tables and graphs.
RESULTS
Socio Demographic Characteristics of the Study
Participants

Data Processing & Analysis Procedure
Each questionnaire was coded and entered into Epi-data
software and was exported to SPSS version 20.1 for anal-
ysis. Descriptive statistics and multivariable regressions
analysis were done. Bivariate and multivariate binary
logistic regression analysis was done to identify candidate
The total numbers of mother’s medical record files
included in the study were 694 of which 347 were cases
and 347 were controls. One hundred eighteen (34%) of
the cases and 125 (36%) controls belong to the age group
ranging from 25 to 29 years. The mean age of mothers
who enrolled as cases and controls were 27 and 25 years
respectively (Table 1).

TABLE 1. Socio Demographic and Obstetric Characteristics of the Mothers Who Delivered in JMC
CHARACTERISTICS CASE N (%) CONTROLS N (%)
Age 15–19 22 (6.3) 27 (7.8)
20–24 103 (29.7) 122 (35.2)
25–29 118 (34) 125 (36)
30–-34 65 (18.7) 46 (13.3)
35–49 39 (11.2) 27 (7.8)
Total 347 (100) 347 (100)
Residence Jimma 135 (38.9) 139 (40.1)
Other areas 212 (61.1) 208 (59.9)
Total 347 (100) 347 (100)
Parity Primi para 153 (44.1) 154 (44.4)
Multi para 194 (55.9) 193 (55.6)
Total 347 (100) 347 (100)
Still birth Yes 16 (4.6) 5 (1.4)
No 331 (95.4) 342 (98.6)
total 347 (100) 347 (100)
Abortion history Yes 65 (18.7) 11 (3.2)
No 282 (81.3) 336 (96.8)
Total 347 (100) 347 (100)
ANC follow up Yes 275 (79.3) 335 (96.5)
No 72 (20.7) 12 (3.5)
total 347 (100) 347 (100)
Mode of delivery Vaginal 256 (73.8) 300 (86.5)
C.S 91 (26.2) 47 (13.5)
Total 347 (100) 347 (100)
4 Predictors of Induction of Labor and Success Rate Sewmehon et al.

Obstetric Characteristics of the Study Participants
More than half of the mother was multi para from both
cases and controls accounting 194 (55.9%) and 193
(55.6%) respectively. Sixteen (4.6%) of the mothers who
gave birth with induction and 5 (1.4%) of the mothers
who gave birth without induction found to have a his-
tory of still birth. Majority of the mothers from cases
275 (79.3%) and controls 72 (20.7) have a history of
ANC follow up. The mean gestational age was 38.57
(±2.876) for cases and 37.61 (±2.268) for controls. The
mean birth weight of neonates of induced mothers was
3,139 gram (±563) and 3,102 gram (±546) for neonates
of non-induced mothers (Table 1).
Indication and Method for Induction of Labor
The success rate of induction of Labor in this study was
256 (73.8%). The findings of this study also identified
the most common indication for induction of labor were
PROM 131 (37.8%) with gestational age below 42 weeks,
hypertensive disorders of pregnancy 98 (28.2%) with
gestational age 34–37 weeks and post term pregnancy 76
(21.9%) or pregnancy with gestational age greater than
42 weeks. The dominant method used for induction of
labor in this study was intravenous oxytocin infusion
250 (72%) and the rest were complementary methods
93 (26.8%) and amniotomy 4 (1.2%).
Birth Outcome
The variables used in this study for the measure of birth
outcome were mode of delivery, presence or absence
of uterine rupture and admission to NICU. Among
induced mothers, 156 (45%) of them gave birth by
spontaneous vaginal delivery followed by those who
gave birth with instrument assisted vaginal delivery
100 (28.8%) and cesarean section 91 (26.2%). While
among controls, the mode of deliveries was found to be
spontaneous vaginal delivery 247 (71.2%), instrumen-
tal assisted vaginal delivery 53 (15.3%) and cesarean
section 47 (13.5%). The main indication for cesarean
section for cases was failed induction 65 (71.4%) and
the rest were fetal distress 8 (8.8%), and mal position 5
(5.5%). The primary reason for cesarean section among
controls was cephalopelvic disproportion 17 (36.2%)
followed by mal position 14 (29.8%) and fetal distress
5 (10.6%). The number of mothers who developed
uterine rupture was 0.9% among cases and 4.4 among
controls.
Meconium-stained amniotic fluid was observed
among 78 (22.5%) deliveries (control 7 (2%)). The mean
of 1st minute and 5th minute APGAR score for the cases
was 6.68 (±0.88) 8.84 (±0.78). While the mean of 1st
minute and 5th minute APGAR score for the control
was 6.75 (±0.9) and 8.77 (±0.78) respectively. Non-
Reassuring Fetal Heart Rate (NRFHR) was detected
among 77 (22.2%) cases and 340 (98%) controls. Intera
Uterine Fetal Distress (IUFD) among case was 32 (9.2%)
while it was 18 (5.2%) among controls.
The rate of NICU admission among cases was 23
(6.6%) with the reason for admission to NICU were
respiratory problems 9 (39.1%), neonatal asphyxia 9
(39.1%) and very low birth weight 5 (21.7%). The
rate of NICU admission among control was 17 (5.2%)
(Table 2).

TABLE 2. Birth Outcome in the Study of Predictors of Induction of Labor Among Mothers Who Gave Birth in JMC
BIRTH OUTCOME RESPONSE OPTIONS
Mode of delivery Cases Control
n % n %
Spontaneous Yes 156 45 247 71.2
No 191 55 100 28.8
Instrument Yes 100 28.8 53 15.3
No 247 71.2 294 84.7
CS Yes 91 26.2 47 13.5%
No 256 73.8 300 86.5
Uterine rupture Yes 3 0.9 15 4.3
No 344 99.1 332 95.7
Admission to NICU Yes 23 6.6 17 5.2
No 324 93.4 330 94.8
 Predictors of Induction of Labor and Success Rate Sewmehon et al. 5

Predictors of Induction of Labor
Gestational age, stillbirth history; abortion history and
antenatal care follow up were identified as indepen-
dent predictors of induction of labor among the study
participants. It was found that mothers who undergo
induction of labor were likely to be: Those with still
birth history (AOR = 3.90, 95% CI: 1.32, 11.50), those
with abortion history (AOR = 7.10, 95% CI: 3.57,14.12),
those with gestational age ≥42 weeks (AOR = 17.8, 95%
CI: 6.93,45.77) and those with no history of ANC follow
up (AOR = 7.41, 95% CI: 3.82,14.37) as compared to
their respective counterparts (Table 3).
Outcome Comparison
Binary logistic regression analysis was also employed with
uterine rupture, admission to NICU and cesarean section
an outcome variable (variable of interest). The variables
which were found to be significant predictors of uterine
rupture in the multivariate analysis were induction of
labor and antenatal care follow up history. Accordingly,
women who face uterine rupture are likely to be those
with induced labor (AOR = 4.96, 95% CI: 1.59, 15.46)
and those with no history of ANC follow up (AOR = 11.2,
95% CI: 4.88, 25.76) compared to their counter parts.
The findings of this study also revealed as still
birth history is significantly associated with induction
of labor. Neonates of induced mothers were three times
(AOR = 2.98, 95% CI: 1.66, 5. 34) more likely to be
admitted to NICU as compared with neonates of control
group. Neonates of mothers with still birth history were
also three times (AOR = 3.13, 95% CI: 1.15, 8. 56) more
likely to be admitted to NICU as compared to neonates
of mothers without still birth history.
Induction of labor, abortion history and history
of ANC follow up were the significant predictor for
cesarean section. Accordingly, women with induced
labor were two times more likely to deliver by cesarean
section as compared to non-induced ones. Mothers with
abortion history are three times more likely to deliver
by cesarean section as compared with mothers without
history of abortion. Mothers who had a history of ANC
visit were two times more likely to deliver by cesarean
section as compared with mothers who had no ANC
follow up (Table 4).

TABLE 3. Predictors of Induction of Labor Among Mothers Who Gave Birth in JMC
VARIABLE CASES N (%) CONTROLS N (%) AOR (95% C.I)
Still birth Yes 16 (4.6) 5 (1.4) 3.894 (1.319,11.495)
No 331 (95.4) 342 (98.6)
Gestational age category 28–37 119 (34.3) 171 (49.3) 0.709 (0.499,1.006)
38–41 146 (42.1) 171 (49.3) 1
>=42 82 (23.6) 5 (1.4) 17.8 (6.933,45.768)
Abortion history Yes 65 (18.7) 11 (3.2) 7.099 (3.568,14.12)
No 282 (81.3) 336 (96.8) 1
ANC Yes 275 (79.3) 335 (96.5) 1
No 72 (20.7) 12 (3.5) 7.405 (3.815,14.373)

TABLE 4. Predictors Uterine Rupture Among Mothers Who Gave Birth in JUMC
VARIABLE UTERINE RUPTURE N (%) AOR (95%C.I)
YES NO
Induction Yes 27(87.1) 320(48.3) 4.958(1.59,15,46)
No 4(12.9) 343(51.7) 1
Residence Jimma 5(16.1) 269(40.6) 1
Outside Jimma 26(83.9) 394(59.4) 2.73(.978,7,65)
Gestational age 28–37 19(61.3) 271(40.9) .498(.21, 1.18)
38–41 10(32.3) 307(46.3)
>=42 2(2.3) 85(97.7) 3.53(.71, 17.5)
ANC visit Yes 11(35.5) 599(90.3) 1
No 20(64.5) 64(9.7) 11.2(4.879, 25.758)
 6 Predictors of Induction of Labor and Success Rate Sewmehon et al.
TABLE 5. Outcomes of Induction of Labor Among Mothers Who Gave Birth in JUMC
UTERINE RUPTURE
VARIABLE AOR(95% C.I)
Induction of labor Yes 4.958 (1.59,15,46)
No 1 1
In general, induction of labor was found to
be a significant predictor of uterine rupture (AOR
= 4.96, 95% CI: 1.59, 15, 46), admission to NICU
(AOR = 2.98, 95% CI: 1.66, 5. 34) and cesarean section
(AOR = 1.91, 95% CI: 1.23, 2. 96) (Table 5).
DISCUSSION
The success rate of induction of Labor in this study was
73.8 % among cases. This is similar with the 2005 WHO
global survey analysis findings of Latin American coun-
tries (70%) (Guerra et al., 2009), but it is slightly lower
than the study done at the kingdom of Saudi Arabia
(84%) (Al-Shaikh et al., 2012). The inconsistency might
be due to the difference in method used for induction
(misoprostol in Saudi Arabian study while oxytocin).
The indication for induction of Labor in this study
was PROM (37.8%) followed by hypertensive disorders
of pregnancy (28.2%) and post-term pregnancy (21.9%).
This finding was in line with other studies done at
Hawassa, Ethiopia and with the 2005 WHO global sur-
vey of Latin American countries (Guerra et al., 2009;
AQ4 Hurissa et al., 2015). However, the commonest indica-
tion for induction of labor on a study done in Nigeria
and Nepal was post-term pregnancy (Lawani et al.,
2014; Rayamajhi et al., 2009). Accurate determination
of gestational age to ascertain a postdate pregnancy may
sometimes be difficult due to unsure date of the last
menstrual period and non-availability of early dating
ultrasound scan in resource poor settings.
The most commonly utilized methods of induc-
tion of labor in the study was oxytocin infusion (72%)
which is in much higher than the study done at
University of Gondar Specialized Hospital (24.4%)
(Tadesse et al., 2022). In contrary, the primary method
of induction of labor at South Africa and Saudi Arabia
hospital was misoprostol (86.7%) which may be due to
the difference in the protocol among setups or physi-
cal facilities of labor and delivery units and the issue of
availability (Al-Shaikh et al., 2012; Mbele et al., 2007).
In this study, the first reason for cesarean section
among induced mothers was failed induction (71.4%)
followed by fetal distress (8.8%), and mal position
(5.5%). This finding is different to a study undertaken
ADMISSION TO NICU CESAREAN SECTION
AOR(95% C.I) AOR(95% C.I)
2.978 (1.661,5.339) 1.908 (1.229,2.96)
1
in Democratic Republics of Congo (DRC) where the
leading cause of cesarean section among induced moth-
ers in the study done in DRC was fetal distress (38.2%)
followed by failed induction (26.5%) and feto pelvic dis-
proportion (17.6%) (Tandu-Umba et al., 2013). The dif-
ference might be due to the level of quality of maternity
care and induction protocol utilized in this study and
different hospitals in Democratic Republics of Congo.
This means the labor induction protocol and level of
utilizing these protocol might be different in this study
and studies in Democratic Republics of Congo.
The Rate of newborn admission to NICU in this
study was relatively higher induction of labor among
cases (6.6%) than controls (5.2%) which is comparable
with the study done in Latin America and Scotland
where the rate of admission to newborn unit is higher
among induced mothers in this study (Guerra et al.,
2009; Stock et al., 2012). This might be related to indi-
cation for induction of labor which affects the fetal
adjustment to extra uterine life or the fetal adjustments
will help the fetus to cope the effects of indications of
induction of labor after birth.
In this study mothers with still birth were more
likely to be induced compared with mothers without
still birth. Systematic review report of Hussain AA et.al
indicated lack of statistically significant association
between still birth and induction of labor; though, the
review focuses on possible impact of induction of labor
for post-term pregnancies (Hussain et al., 2011). In
this study it was also observed that women with GA ≥
42 (post-term) were more likely to undergo induction
than those with GA 38–41 (term). This may be due to
increased maternal and fetal complications as the preg-
nancy progresses beyond term. However, this finding
was not in line with a study conducted in South Africa
where GA and labor induction have no significant asso-
ciation (Mbele et al., 2007).
The results of this study also indicated that moth-
ers who underwent induction of Labor were five times
more likely to develop uterine rupture as compared with
those in the non-induced group. This is consistent with
a prospective cohort study conducted by Landon MB
et.al where the risk of uterine rupture in induced moth-
ers was three folds compared with spontaneous Labor
(Landon et al., 2004). Induction of labor was found to
 Predictors of Induction of Labor and Success Rate Sewmehon et al.
increase the likelihood of cesarean section. This is in
line with a study done in Korea hospital where cesarean
section and instrument assisted vaginal delivery rates
were significantly higher among induced mothers (Lee
et al., 2015).
Now a day’s induction of labor is becoming increas-
ingly popular in all hospitals of Ethiopia including JUSH
(Bayou et al., 2016). Though success rate is found to be
higher (73.8 %) in this study; there were significant rate
of unsuccessful labor induction. Induction of labor is
also found to be associated with poorer maternal and
perinatal outcomes than spontaneous labor where it was
claimed to increase the rate of uterine rupture, cesarean
section and admission to neonatal ICU Taye and Yuya
(2015). The indication for labor induction and the
resources available at the institution for maternal care
and newborn infant are factors that should be taken
into consideration when considering and deciding labor
induction.
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8(6), e65612.
 8 Predictors of Induction of Labor and Success Rate Sewmehon et al.

AQ5 Disclosure. The authors have no relevant financial interest or of existing data. However, confidentiality of the information
affiliations with any commercial interests related to the sub- gathered was ensured by not recording the name of the client
jects discussed within this article. or other identifiers on the record review checklist.
Acknowledgements. We would like to acknowledge Jimma Data Availability. All the supportive material will be available
University covering the survey cost. We also acknowledge the at the hands of corresponding author at any time when it is
data collectors and the staffs of Jimma University Medical Centre. necessary.
Authors’ Contributions. All authors made extensive contri- Abbreviations
butions to commencement and design, acquisition of data,
ANC: Antenatal care
or analysis and interpretation of data; participated in drafting
AOR: Adjusted odds ratio
the article or revising it critically for important intellectual
IOL: Induction of labor
content; agreed to submit to this journal; approved to be pub-
IUFD: Intrauterine Fetal Death
lished; and agree to be accountable for all aspects of the work.
IUGR: Intrauterine Fetal Growth Restriction
Funding. The authors do not receive any funding for this spe- JUTH: Jimma University Teaching Hospital
cific study, but the survey cost is covered by Jimma University. NICU: Neonatal intensive care unit
PROM: Premature Rupture of Membrane
Ethical Considerations. Ethical clearance to conduct the
SNNPR: Southern Nation, Nationalities and Peoples’ Region
study was obtained from institutional review board (IRB)
WHO: World health organization. AQ6
of Institute of health, Jimma University. A formal letter of
cooperation was taken from JUMC prior to data collection. Correspondence regarding this article should be directed AQ1
Participant consent was taken ahead of starting data collec- to Admasu Belay Gizaw, School of Nursing and Midwifery
tion procedure in line with the national ethics review guide- Institute of Health Jimma University South West Ethiopia.
line of Ethiopia for research involving the collection or study E-mail: admasu.belay@ju.edu.et
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