Comparative Effectiveness, Safety, and Cost-Effectiveness of Labour Induction Methods: A Systematic Review

Abstract

Labour induction is a common obstetric intervention, most often undertaken at term in women with an unfavourable cervix, and its rising global use underscores the need to identify optimal strategies that balance effectiveness, safety, and cost-effectiveness. This systematic review aimed to evaluate the comparative effectiveness, safety, and cost-effectiveness of pharmacological, mechanical, and combined methods of induction in term pregnancies, including both nulliparous and multiparous women undergoing elective or indicated induction. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of PubMed, Scopus, Web of Science, and Embase was performed for randomized controlled trials (RCTs) published between 2015 and 2025. Ten RCTs were included and assessed for risk of bias using the Cochrane RoB 2 tool. A narrative synthesis was performed due to clinical and methodological heterogeneity. Across 10 RCTs (n=8,683 participants), oral misoprostol and Foley catheter demonstrated comparable effectiveness and safety for cervical ripening and induction. Combination methods (e.g., misoprostol plus Foley catheter) significantly shortened induction-to-delivery intervals and increased the likelihood of vaginal birth within 24 hours compared with single methods. Safety outcomes were generally favourable, although higher rates of infectious morbidity were reported with mechanical methods in women with prelabour rupture of membranes. Cost analyses indicated that misoprostol and Foley catheter incur similar inpatient costs, while outpatient Foley catheter ripening provides substantial savings. Additionally, induction at 41 weeks was more cost-effective than expectant management until 42 weeks, particularly for nulliparous women. The evidence suggests that oral misoprostol and Foley catheter are equally effective first-line options, while combination methods and outpatient strategies may optimize outcomes depending on parity, cervical status, and healthcare setting.