Acta Obstetricia et Gynecologica.

2010; 89: 10031010

MAIN RESEARCH ARTICLE

Maternal risk factors for postterm pregnancy and cesarean delivery

following labor induction

NATHALIE ROOS1, LENA SAHLIN1, GUNVOR EKMAN-ORDEBERG1, HELLE KIELER2 &

OLOF STEPHANSSON1,2
1
Department of Womens and Childrens Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, Stockholm,
Sweden, and 2Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden

Abstract
Objective. To investigate risk factors associated with postterm pregnancy and cesarean delivery following labor induction.
Design. Population-based cohort study. Setting. Sweden. Population. From the Swedish Medical Birth Register, a total of
1,176,131 singletons births from gestational week 37 and onwards, between 1992 and 2006. Methods. Unconditional logistic
regression analysis. Main outcome measures. Risk of postterm pregnancy (delivery at 42 weeks) and cesarean delivery following
labor induction. Results. Among 1,176,131 births, 8.94% were delivered postterm. Compared to normal weight women, the
risk of postterm pregnancy in obese women was almost doubled (adjusted OR: 1.63, 95% CI 1.591.67). The risk of postterm
pregnancy increased with increasing maternal age and was higher among primiparous women. The risk of cesarean section
(CS) following labor induction postterm, increased with maternal age and BMI, and was more than doubled among women
35 years and older (adjusted OR 2.28, 95% CI 2.042.56). A vefold risk of CS was seen among nulliparous women (adjusted
OR 5.05, 95% CI 4.715.42). Parous women with a previous CS undergoing labor induction had a sevenfold increased risk
of CS postterm (adjusted OR 7.19, 95% CI 5.938.71). Conclusions. Nulliparity, advanced maternal age and obesity were
the strongest risk factors for postterm pregnancy and CS following labor induction in postterm pregnancy. Including maternal
risk factors to the cervical assessment may improve prediction of vaginal delivery following labor induction in postterm
pregnancy.

Key words: Prolonged, pregnancy, risk factors, induced, cesarean section

Introduction The best time for labor induction remains a con-

The prevalence of postterm pregnancy, dened as
delivery at or beyond 42 weeks of gestation (1), varies
worldwide but is estimated to be 510% (2). The
introduction of routine ultrasound for gestational age
dating has signicantly reduced the incidence of post-
term pregnancy (3). An increased risk of perinatal
mortality and morbidity (4), together with a higher
risk of maternal obstetrical complications (5), makes
the management of the condition an important issue
in modern obstetrics. Few studies have focused on the
etiology of postterm pregnancy, but some risk factors
have been identied.
troversy. Earlier induction may result in a higher
proportion of induction failure followed by cesarean
section (CS), whereas the risk of poor maternal and
fetal outcome increases with gestational age (6). The
rate of labor induction is increasing worldwide, and in
the United States the proportion has increased from
9.5 to 22.5% between 1990 and 2006 (7). The rise in
CS has partly been attributed to the increased rate of
labor induction (8). Digital and transvaginal ultra-
sound (TVU) cervical assessment appear to be poor
predictors of vaginal delivery after labor induction in
postterm pregnancy (9,10). Few studies have inves-
tigated maternal characteristics (i.e. BMI, parity and

Correspondence: Nathalie Roos, Department of Womens and Childrens Health, Division of Obstetrics and Gynaecology, H2:01, Karolinska University
Hospital, Karolinska Institutet, SE-171 76 Stockholm, Sweden. E-mail: nathalie.roos@karolinska.se

(Received 7 September 2009; accepted 10 March 2010)

ISSN 0001-6349 print/ISSN 1600-0412 online  2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.3109/00016349.2010.500009
1004 N. Roos et al.
age), besides cervical assessment, as independent
predictors for failed labor induction (11). Integrating
maternal risk factors for failed labor induction with
cervical assessment may improve the prediction
of vaginal delivery after labor induction postterm.
The aim of the present study was to investigate risk
factors associated with postterm pregnancy and fail-
ure of induction of labor in postterm pregnancies
using the population-based Swedish Medical Birth
Register.
Material and methods
The Swedish Medical Birth Register (MBR), which
includes information on more than 98% of all births in
Sweden, recorded 1,442,675 singleton births between
1 January 1992 and 31 December 2006. The Birth
Register includes demographic data and prospectively
collected information on reproductive history and
complications that occur during pregnancy, delivery
and the neonatal period. In Sweden, maternal char-
acteristics are recorded in a standardized manner
during a womans rst visit for antenatal care, which
occurs before the 15th week of gestation in more than
95% of the pregnancies. From height and weight
measurements at the rst visit we calculated each
womans body-mass index (BMI) dened as weight
in kilograms divided by the square of the height in
meters (kg/m2). The women were categorized accord-
ing to the BMI as lean (BMI less than 20.0), normal
(BMI 20.024.9), overweight (BMI 25.029.9) and
obese (BMI of 30.0 or more). Smoking habits were
recorded and the women were categorized as non-
smokers, moderate smokers (19 cigarettes per day),
or heavy smokers (at least 10 cigarettes per day).
Maternal age was dened as age in completed years
at the time of delivery and parity as the number of
previous births, including stillbirths at 28 weeks of
gestation or later. Maternal age was categorized as less
than 20 years, 2024 years, 2529 years, 3034 years
or 35 years and older. Parity was categorized into
nulliparous or parous women. For socioeconomic
status measurement we used information on whether
the woman was cohabiting with the babys father or
not. Through linkage with the Education Register,
information on the number of years of formal educa-
tion completed as of 1 January 2008, was obtained
and categorized as 11 years or less or 12 years or more.
Mode of delivery (vaginal or CS), information on
induction of labor and maternal diseases such as
preeclampsia and gestational diabetes are recorded
when the woman is discharged from the hospital.
Ultrasound for determination of gestational length
has been offered to all pregnant women in Sweden
since 1990 and about 95% of the women agree to
undergo ultrasound dating of gestational length (12).
Accordingly, gestational age was primarily based
on prenatal ultrasound measurement if present or
otherwise estimated on the recorded date of the rst
day of the last menstrual period. We dened term
pregnancy as labor at 3741 completed weeks of
gestation and postterm pregnancy as labor at 42 weeks
of gestation and onwards.
From the study base (n = 1,442,675) we excluded
1,868 births with unknown gestational age and
73,919 preterm births (gestational age before
37 completed weeks). The nal dataset included
1,366,888 births (Figure 1).
For the study on maternal risk factors for postterm
pregnancy, we excluded 74,778 pregnancies with
Total number of singleton pregnancies during
19922006
n = 1,442,675
Excluding unknown gestational age
n = 1,868
n = 1,440,807
Excluding pre term births
n = 73,919
n = 1,366,888
Excluding elective cesarean births <42 weeks
n = 74,778
n = 1,292,110
Elective induction of labor before 42 weeks
n = 90,047
n = 1,202,063
Unknown mode of initiation of labor before
42 weeks
n = 25,932
Final data set
n = 1,176,131
Figure 1. Study sample design from the Swedish Medical Birth
Register between 1992 and 2002.

elective CS at term, 90,047 with elective induction at
term (<42 weeks), and 25,932 women who were
excluded due to lack of information on the mode of
initiation of labor (i.e. spontaneous or labor induc-
tion). The nal consisted of 1,176,131 births from
which 105,197 were postterm (Figure 1). The analysis
was performed by comparing postterm pregnant
women with term pregnant women with spontaneous
onset of labor concerning maternal risk factors (age,
parity, cigarette smoking, pre-pregnancy BMI, whe-
ther the woman was living with the babys father,
country of birth and years of formal education).
For the second part of the study, the study population
consisted of 36,498 women with labor induction at
postterm. We compared 28,435 women with vaginal
delivery with 8,063 women with CS following labor
induction with regard to maternal age, parity, ciga-
rette smoking, pre-pregnancy BMI, cohabiting status,
country of origin and years of formal education.
Data on previous CS were introduced into the
Medical Birth Register in 1999. In a sub-analysis
we included 8,983 parous women undergoing labor
induction postterm from 1999 to 2006. A total of
1,075 women with failed induction were compared
to 7,908 women with successful labor inductions
with regard to maternal risk factors as previously
described, including previous CS.
Statistical analysis
We used unconditional logistic regression analysis
with adjusted odds ratios (OR) and 95% condence
intervals (CI) to analyze the risk of postterm preg-
nancy and failed induction associated with maternal
characteristics. Each estimate was adjusted for other
assessed estimates such as maternal age, parity, edu-
cation, BMI, smoking, country of origin and if the
mother was living with the babys father or not.
All analyses were performed using the statistical
software SAS version 9.1 (SAS Institute Inc., Cary,
NC, USA).
Ethics and consent
The study was approved by one of the local
research ethics committees in Stockholm, Sweden.
The research committee did not require the women to
provide informed consent.
Results
The annual rate of postterm pregnancy remained
relatively unchanged during the study period
Postterm pregnancy and cesarean section risk 1005
(mean 8.94%). The rate of postterm pregnancy
increased with increasing maternal age and BMI.
Rates were higher among primiparous compared
with parous women, and among women with a higher
educational level compared with lower educational
level. Women who were not living with the babys
father had higher rates when compared with coha-
biting women. Cigarette smokers experienced lower
rates of postterm pregnancy compared with non-
smokers (Table 1).
In the multivariate analysis, a more than 50%
increase in risk of postterm pregnancy was found
among women with advanced maternal age and
among primiparous women (Table 1). Compared
to normal weight women, the risk of postterm preg-
nancy was about 60% higher among obese women
(adjusted OR: 1.63, 95% CI 1.591.67). Lean women
had an approximately 25% lower risk of postterm
pregnancy (adjusted OR: 0.74, 95% CI 0.720.76)
than normal weight women. A slight risk reduction of
postterm delivery was observed in heavy smokers
compared with non-smokers. Being of non-Nordic
origin marginally decreased the risk of postterm
pregnancy (Table 1). Excluding women with pre-
eclampsia, gestational and prior diabetes did not alter
the results for the estimates for risk of postterm
pregnancy (data not shown).
Labor induction in postterm pregnancy increased
from 28 to 46% (Figure 2), and the proportion of CS
following labor induction increased from 14 to 26%
between 1992 and 2006 (Figure 2). The rate of CS
following induction of labor in postterm pregnancy
increased with maternal age and increasing BMI
(Table 2). The risk of CS following labor induction
was more than doubled among women 35 years and
older compared to women between 20 and 24 years of
age (OR 2.28, 95% CI 2.042.56). The rate of CS
following labor induction among parous women was
10.49% compared with 31.76% among nulliparous
women with an OR of 5.05 (95%CI 4.715.42).
Overweight and obese women had higher risks
of CS than normal weight women accounting for
about 50% of all CS following labor induction. There
was no association between socioeconomic status
measured as years of formal education and the mother
cohabiting with the babys father or not and CS fol-
lowing labor induction. Cigarette smokers compared
to non-smokers were at increased risk for CS follow-
ing labor induction in a dose-dependent manner.
Being of non-Nordic origin (adjusted OR 1.33, 95%
CI 1.221.45) was associated with an increased risk
of CS following labor induction (Table 2).
In a sub-analysis of parous women (n = 8,983) from
1999 onwards undergoing labor induction for post-
term pregnancy, the rate of CS was 37.5%. Parous
1006 N. Roos et al.

Table 1. Adjusted odds ratios for delivery of postterm birth associated with maternal characteristics between 1992 and 2006.
No. of births No. of postterm births Rate, % Adjusted odds
Characteristic (n = 1,176,131) (n = 105,197) (8.94%) ratio (95% CI) p-Valuea
Age (years) <0.0001
19 24,377 1,861 7.72 0.90 (0.840.95)
2024b 190,683 14,669 7.80 Ref.
2529 415,674 34,854 8.55 1.20 (1.181.23)
3034 372,426 34,223 9.40 1.44 (1.401.47)
35 172,225 17,361 10.36 1.67 (1.631.72)
Data missing 746 64
Parity <0.0001
0 507,610 54,042 10.65 1.65 (1.631.68)
1b 668,502 51,153 7.65 Ref.
Data missing 19 2
Body-mass index (BMI) <0.0001
19.9 105,643 6,486 6.22 0.74 (0.720.76)
20.024.9b 560,677 46,323 8.40 Ref.
25.029.9 224,550 22,834 10.42 1.31 (1.291.33)
30.0 82,013 9,845 12.42 1.63 (1.591.67)
Data missing 203,248 17,943
Education (years) 0.40
11 674,976 58,709 8.70 0.99 (0.981.01)
12b 483,207 44,755 9.26 Ref.
Data missing 17,948 1,733
Living with the babys father <0.0001
Yesb 1,044,098 93,478 8.95 Ref.
No 56,508 5,670 10.03 1.10 (1.071.14)
Data missing 75,525 6,049
Cigarette smoking <0.0001
Noneb 958,222 86,931 9.07 Ref.
19 cigarettes/day 101,243 8,905 8.80 0.99 (0.971.02)
10 cigarettes/day 49,309 4,002 8.12 0.90 (0.870.94)
Data missing 67,357 5,359
Country of birth <0.0001
Nordicb 991,996 89,651 9.04 Ref.
Non-Nordic 168,667 14,065 8.34 0.93 (0.910.95)
Data missing 15,468 1,481
a
Wald test of the overall effect (test of general heterogeneity).
b
The births with this characteristic served as the reference group. Adjusted for maternal age, parity, BMI, years of education, living with the
babys father, cigarette smoking and country of birth.

women with a previous CS had a sevenfold
increased risk of CS following labor induction
(adjusted OR 7.19, 95% CI 5.938.71) compared
with parous women with no previous CS. Because
the cohort included women with repeated preg-
nancies, we performed additional analyses restricted
to primiparous and parous women, respectively.
The results from the analyses did not inuence the
ndings based on the full model.
Discussion
The main nding of the study was that overweight and
obesity, nulliparity and advanced maternal age were
associated with increased risk of postterm pregnancy
and CS following labor. A previous CS was strongly
correlated to CS following labor induction in
postterm pregnancy. Over the past two decades the
rate of labor inductions postterm in Sweden has
almost doubled together with the rate of CS following
labor induction.
We observed that the rate of postterm pregnancy
increased with increasing maternal age in a dose-
dependent manner which is supported by most pre-
vious studies (13,14). However, maternal age did not
inuence risk of postterm pregnancy in a Danish
study by Olesen et al. (15). Advanced maternal age
>35 years more than doubled the risk of CS following
labor induction in postterm pregnancy. Similar ndings
have been reported in studies of failure of induction not
restricted to postterm pregnancies (16), whereas this
was not observed in a study by Cnattingius et al. (17).
Advanced maternal age is an independent risk factor
for CS independently of labor starting spontaneously
or by induction (18). Older parturients have a higher
 Postterm pregnancy and cesarean section risk 1007

50

45

40

35
Labor induction
Frequency %

30 postterm

25

20
Failed labor
15 induction postterm

10

01
99

00
92

96
93

98

02

03

06
94

04

05
95

97

20
19

20
19

19

20
19

19

20

20
19

20

20
19

19

Figure 2. Induction and cesarean section rates following labor induction among singleton postterm births excluding women with elective
cesarean sections in Sweden between 1992 and 2006.

incidence of non-progressive labor and more often
require oxytocin in higher doses and for longer
periods of time to achieve vaginal delivery compared
to younger women (19). Mean maternal age at birth
has increased in Sweden and most other developed
countries due to postponement of childbearing due to
social, economic and educational factors. In the USA,
the birth rate for women aged 3539 years has risen
nearly 50% since 1990 (7).
Nulliparity was an independent risk factor for pro-
longed pregnancy consistent with previous ndings
(15,20). Nulliparity was associated with a vefold
increased risk for CS following labor induction
among postterm pregnancies constituting almost
one-third of all failures. This is in line with prior
studies on term pregnancies (16,17,2124). Nullipa-
rous women often require oxytocin augmentation to
achieve a vaginal delivery (19). A previous pregnancy
may have induced a higher number of gap junctions in
the myometrium, giving rise to a shorter second stage
of labor in parous women (21).
In the present study obese and overweight women
accounted for almost 20% of all postterm pregnancies
and approximately 45% of all CS following labor
induction. High maternal BMI was found to be the
second strongest risk factor for CS following labor
induction postterm and the risk increased in a dose-
dependent manner. There has been an increase in the
prevalence of overweight and obesity in women of
childbearing age in Sweden and most other developed
countries during the last decades. In the United
States, the prevalence of overweight in women has
increased from 22.5 in 1988 to 32.2% in 2004 (25,26).
Several studies have found an association between
increased risk of CS following labor induction and
high maternal BMI (16). Overweight and obesity are
not only associated with increased risk of post-
term pregnancy and CS following labor induction
postterm but also associated with adverse maternal
and fetal outcome (27). Strategies for reducing over-
weight and obesity is an important issue since it is
probably the most preventable risk factor for adverse
pregnancy outcome.
Our nding that smoking was associated with a
lower risk of postterm pregnancy has been reported
in a previous study based on Swedish data by
Denison et al. (14). However, the study did not
include a multivariate analysis taking confounding
factors into account. In a large population-based
USA study by Kistka et al. there was no association
between maternal smoking and risk of postterm preg-
nancy (13). Smoking is associated with preterm birth,
but the mechanisms are poorly understood (28).
A possible explanation is that cigarette smoke inhibits
the synthesis and/or the release of progesterone which
has been demonstrated in in vitro studies with human
granulosa cells, luteal cells and trophoblasts (29).
Heavy smokers had marginally higher rates of CS
following labor induction postterm although cigarette
smoking diminished the risk of postterm pregnancy.
The biological rationale for this possible association
remains unexplained.
In the study by Kistka et al. low socioeconomic
status was associated with a higher risk of postterm
1008 N. Roos et al.

Table 2. Adjusted odds ratios for risk of cesarean section following labor induction in postterm pregnancies associated with maternal
characteristics, in Sweden between 1992 and 2006.
No. of labor inductions No. of cesarean sections Rate, % Adjusted odds
Characteristic (n = 36,498) (n = 8,063) (22.09%) ratio (95% CI) p-Valuea
Age (years) <0.0001
19 584 115 19.69 0.90 (0.691.16)
2024b 4,764 954 20.02 Ref.
2529 11,903 2,519 21.16 1.38 (1.251.52)
3034 12,492 2,894 23.17 1.88 (1.702.08)
35 6,726 1,574 23.40 2.28 (2.042.56)
Data missing 29 7
Parity <0.0001
0 19,912 6,324 31.76 5.05 (4.715.42)
1b 16,585 1,739 10.49 Ref.
Data missing 1 0
Body-mass index (BMI) <0.0001
19.9 1,945 296 15.22 0.66 (0.580.76)
20.024.9b 15,537 3,087 19.87 Ref.
25.029.9 8,874 2,172 24.48 1.45 (1.361.55)
30.0 4,194 1,141 27.21 1.87 (1.712.04)
Data missing 5,948 1,367
Education (years) 0.65
11 20,525 4,251 20.71 0.99 (0.931.05)
12b 15,361 3,697 24.07 Ref.
Data missing 612 115
Living with the babys father 0.57
Yesb 32,383 7,092 21.90 Ref.
No 2,037 436 22.73 0.96 (0.851.10)
Data missing 2,078 508
Cigarette smoking 0.057
Noneb 30,087 6,624 22.02 Ref.
19 cigarettes/day 3,140 653 20.80 1.05 (0.941.17)
10 cigarettes/day 1,341 277 20.66 1.21 (1.031.42)
Data missing 7,784 1,462
Country of birth <0.0001
Nordicb 30,808 6,759 21.94 Ref.
Non-Nordic 5,211 1,218 23.37 1.33 (1.221.45)
Data missing 479 86
a
Wald test of the overall effect (test of general heterogeneity).
b
The births with this characteristic served as the reference group. Adjusted for maternal age, parity, BMI, years of education, living with the
babys father, cigarette smoking and country of birth.

pregnancy in an American (USA) population, and use
of antenatal care reduced the risk (13). We could,
however, not nd any correlation between the socio-
economic indicators and risk for postterm preg-
nancy or with failure of induction in our study.
This could be due to smaller social differences in
Sweden compared to the United States (30). Addi-
tionally, in Sweden all women have equal access to
antenatal and obstetric care, free of charge. In the
present study, we did not have any information on
lifestyle and environmental factors such as drug use,
alcohol consumption, and caffeine use during preg-
nancy which may constitute possible confounding
factors for prolonged pregnancy.
An important challenge in modern obstetrics is to
foresee which women will undergo CS following labor
induction. CS following labor induction is associated
with an increased risk of complications for both
neonate and mother, not least in overweight and
obese parturients (6,31,32). Cervical assessment prior
to labor induction is used to predict the likelihood
of vaginal delivery. We could not study the inuence
of the method used for labor induction or of the
cervical Bishop Score. Both digital and TVU cervical
assessment have, however, a limited predictive value
for vaginal delivery following labor induction at
term (9,33). Few studies have investigated the fai-
lure of labor induction in postterm pregnancies by
taking maternal characteristics as well as cervical
assessment into account (16,24). Information about
risk factors for postterm pregnancy and failure of
labor induction may be used in addition to the
Bishop score in the assessment of the woman prior
to labor induction.

Major strengths of this study include the large size
of the study population and the prospective recording
of data on maternal risk factors such as smoking,
height and weight. Sweden, along with the other
Nordic countries, is an exceptional country for this
kind of study with a large proportion of pregnancies
dated by a routine ultrasound examination (98%) in
second trimester and misclassication of gestational
age is consequently unlikely to have a substantial
inuence on our ndings (34). We did not have
any information on the indications for CS (labor
dystocia, fetal asphyxia, infection, etc.), which is a
weakness of the study.
In summary, we found that nulliparity, advanced
maternal age and obesity were strong risk factors
for postterm pregnancy and failed labor induction.
Knowledge about these risk factors is important when
counseling and assessing women who go past term on
the likely mode of delivery and labor induction. Our
study did not include information about cervical
assessment (Bishop score) and method of induction
which would be of great value for future studies taking
risk factors for failed labor induction into account to
improve the management of this condition.
Acknowledgements
This study received nancial support from The
Swedish Research Council (projects 73X-20137 (LS)
73X-14612 (GE)) and The Board of Post Graduate
Education at Karolinska Institutet, Stockholm, Sweden
(KID-funding). Financial support was also provided
through the regional agreement on medical training
and clinical research (ALF) between Stockholm
County Council and Karolinska Institutet.
Declaration of interest: The authors report no
conicts of interest. The authors alone are responsible
for the content and writing of the paper.
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