Comment on “Outpatient Versus Inpatient Induction of Labor With Oral Misoprostol: A Multicentre Randomized-controlled Trial”

Induction of labor (IOL) is increasingly common. Norway has seen a 2-fold increase in IOL over 15 years, reaching 30% of pregnancies. This increase is due to several factors, including updated guidelines and postpartum management and a larger proportion of pregnancies complicated by gestational diabetes, hypertensive disorders, and higher maternal age and body mass index. As IOL rates increase, safe and efficient implementation, appropriate use of hospital resources, and women’s experiences of care are key considerations. Low-dose misoprostol is one pharmaceutical method of achieving cervical ripening. Endorsed by the World Health Organization and National Institute for Health and Care Excellence, it is a self-administered option associated with high vaginal delivery rates and a low risk of uterine hyperstimulation. Compared with mechanical methods, misoprostol requires fewer clinical resources in already constrained maternity units. Although IOL has traditionally been managed in inpatient settings, outpatient IOL is increasingly used and considered safe and effective. However, there have been conflicting results in studies on childbirth satisfaction with outpatient IOL, and knowledge about oral misoprostol in an outpatient setting is sparse. The aim of this study was to compare outpatient and inpatient induction of labor on childbirth satisfaction and obstetrical outcomes. This was a randomized-controlled trial conducted at 8 hospitals in Norway between January 2022 and April 2023. Included were nulliparous and multiparous women with single, cephalic pregnancies at term, no uterine scar, who were scheduled for IOL. All study participants were induced with oral misoprostol (25 μg tablets), receiving their first dose in the hospital. Outpatient participants were given 11 tablets of misoprostol to self-administer, if there were no complications after the first dose, and provided with an appointment for admission to the hospital after 48 hours. Inpatient participants received misoprostol tablets administered by an on-call midwife according to protocol. The primary outcome was maternal childbirth experience, based on the Childbirth Experience Questionnaire (CEQ) and Experience with Induction Tool (EXIT) questionnaire. A total of 283 women were included in the per-protocol analysis, with 152 women managed as outpatients and 131 as inpatients. The outpatient group had a CEQ score of 3.1, while the inpatient group had a score of 3.0 (mean difference, 0.14; 95% CI, 0.02-0.25, P = 0.02). From the EXIT questionnaire, 89% of outpatients and 71% of inpatients said they would prefer to use the same IOL again, and 89% of outpatients and 67% of inpatients said they would recommend outpatient IOL to a friend. Obstetrical outcomes, including rates of cesarean delivery, operative vaginal deliveries, and postpartum hemorrhage, were similar with no cases of hyperstimulation. Overall, the maternal childbirth experience with oral misoprostol administered in either outpatient or inpatient settings was positive. Outpatients were more likely than inpatients to prefer to use the same IOL in subsequent pregnancies and recommend it to a friend. (Summarized from Austad FE, Kessler J, Balstad Magnussen E, et al. Outpatient versus inpatient induction of labor with oral misoprostol: A multicentre randomized-controlled trial. BJOG. 2025;132:1562-1573. doi: 10.1111/1471-0528.18296).