r hypertension), differences in availability of resources, as well as to unexplained differences in opinion and practice. Nevertheless, there is no agreement or evidence to suggest an ideal rate [13] . The number of women whose labours are induced has risen dramatically over the past two decades. Rates in the USA and the UK currently exceed 20% of all births [3] [5] [14] [15] . Even further, in some units in the USA, up to 50% of all births follow IOL [15] . However, researchers reporting from African countries have noted rates of <10%; albeit showing the same worldwide trend of progressive increase [12] [16] .

In this study, 442 participants (51.8%) were aware of CR and IOL. However, the overall knowledge was sub-optimal; especially regarding membrane sweeping [only 85 women out of 442 (19.2%) heard about it], and use of vaginal misoprostol [only 84 women (19.0%) were aware of it]. Perception was also sub-optimal as 84 out of 442 respondents (19.0%) were not aware of the indications of CR and IOL, and only 219 (49.5%) believed that IOL prevents CS.

Antenatal healthcare givers constitute a major source of awareness of and knowledge about CR and IOL for pregnant women. Shortage of their services, combined with low level of women’s education, is to be blamed for the relatively low level of awareness exhibited in this study. Poor knowledge of specific procedures and methods, and incorrect perceptions may also be related to difficulties of participants’ recall, inadequate content of health education sessions or clinic consultation and lack of previous exposure [17] . The later may also explain why, in this study, knowledge was higher in women with a previous history of CR and IOL.

In this study, the most well-known method of IOL was intravenous Oxytocin which is also the commonest agent used for IOL worldwide. It has been used alone, in combination with ARM or following CR with other pharmacological or non-pharmacological methods. Prior to the introduction of prostaglandin agents, Oxytocin was used as a cervical ripening agent as well. In developed countries Oxytocin alone is more commonly used in the presence of ruptured membranes whether spontaneous or artificial. In developing countries where the incidence of HIV is high, delaying ARM in labor reduces vertical transmission rates and hence the use of Oxytocin with intact membranes warrants further investigation [18] [19] .

The majority of participating women in this study were not aware of Misoprostol use for CR and IOL despite its widespread use among Obstetricians and Gynaecologists in Egypt [20] [21] . Misoprostol is a synthetic form of prostaglandin E1 analogue which has gained popularity in obstetrics and gynaecology worldwide. Although not licensed for CR and IOL in many parts of the world, Misoprostol is licensed for this indication in Egypt. However, the drug is not without complications. Rates of uterine hyper-stimulation, uterine rupture, serious CTG abnormalities, meconium stained liquor and neonatal hypoxic ischemic encephalopathy were increased with Misoprostol use especially at doses above 25 µg [22] .

In this study, 189 participants out of 442 (42.8%) considered that labour following IOL was more painful. This perception may be due to one or more of several reasons. Only limited choices of pain relief in labor are available in Egypt; a developing country with limited resources. Induced labor significantly differs from the physiological spontaneous onset labor, with a longer and often painful latent phase. Prostaglandins may be associated with significant discomfort. Simple analgesia may suffice, but some women will require stronger opiate or epidural analgesia [23] .

In Egypt, use of different methods of pain relief in labor has been extensively investigated. It was noted that women who had IOL equally benefited from the available limited options of pain relief in labor as those who came in spontaneous labor. Nevertheless, there is still an unmet need for obstetric analgesia among many women all-over the country. Large governmental maternity hospitals in Egypt are facing serious challenges in providing care that is of consistently high quality in a rapidly changing and unstable environment. [11] [24] .

Women who are induced tend to be less satisfied with their experience of childbirth [25] . In this context, and with increasing pressure on healthcare resources, it is particularly important to address questions about how to provide safe IOL in settings and ways that are acceptable to women, and in the most possible cost-effective way [15] . Counselling about the cascade of events following IOL and its complications has been perceived as inadequate by parturients [25] [26] . Heimstad et al., found that women who had IOL were not satisfied with the information they were given and desired more participation in decision-making [27] . The finding which was reported by the majority of respondents [311 out of 442 (70.4%)] in this study of willingness to accept IOL in the index pregnancy or recommend it to somebody else despite concerns about pain and harm to baby and mother, is perplexing. Especially in developing countries, there is the possibility that willingness to re-experience a procedure is influenced by the recommendations of medical staff members whose knowledge and guidance may completely overwhelm maternal wishes [2] . Maternal autonomy has been noted to be influenced by fear of physician’s negative attitude and reaction to refusal, the probability of occurrence of adverse consequences and/or abandonment of care should doctors’ advice and recommendations be not followed [28] .

In this study, all participating women wanted IOL to be included among antenatal health education topics. However, the matter should be thoroughly studied in order to determine the content of the IOL educational messages since untested information about risks of CR and IOL may scare women from the procedures when they are genuinely indicated [2] . Nevertheless, the messages must address the issues of safety and woman’s refusal since 280 out of 442 respondents (63.3%), in this study, perceived IOL as dangerous to mother, 234 (52.9%) considered it dangerous to baby and 131 (29.6%) would refuse CR and IOL even when indicated. All participants in this study desired to be told the specific indication for IOL when indicated for the purpose of their satisfaction. The reported dislike of women to IOL in this study may not be due to fear of the procedure as such, but it may represent a reflection of their wishes to have spontaneous onset of labor which they deem natural. This desire has been expressed by women both in developing and developed countries [29] [30] .

In this study, women who has not had a previous IOL were more than five times unaware about CR and IOL (OR: 5.19; 95% CI: 1.6 - 11.23; p = 0.001*). This is in agreement with Enabor et al., who noted that participants who had a previous IOL were more than six times more aware about CR and IOL (OR: 6.70; 95% CI: 1.41 - 31.88, p = 0.02) [2] .

5. Conclusion

This study has shown that a slightly more than half of participants were aware of CR and IOL, and the overall knowledge and perception were sub-optimal. Nevertheless, the attitudes towards CR and IOL were positive, if the procedures were indicated. Women’s knowledge of specific methods of CR and IOL and their indications should be further enhanced by improving antenatal clinic services. This health education duty can be achieved through parent craft classes, patient information leaflets and the different multimedia tools. Emphasis should be given to securing enough time for counselling sessions targeting women who are more likely to undergo CR and IOL, with information being part of their birth preparedness plan. Communication skills of medical, midwifery and nursing staff should be continuously developed for this purpose. With the increased use of Misoprostol in obstetrics, women should be given more information about its indications and possible complications. More options of obstetric analgesia, in the context of available resources, should be offered to women in order to dispel their fears of pain and improve their level of satisfaction with the birth process.


The authors would like to thank junior medical, midwifery and nursing staff of Obstetrics and Gynecology Department at ZUH for their contribution to collection of the data of this study.

Declaration of Interest

The authors report no conflicts of interest.

Role of the Funding Source

The authors alone were responsible for funding this work. They have not received any grants, financial support or any other source of funding.

Cite this paper

Ahmed MohamedNooh,Mohamed El-SayedMohamed, (2015) Cervical Ripening and Induction of Labor: Awareness, Knowledge, Perception and Attitude of Antenatal Care-Seeking Women at Zagazig University Hospital, Zagazig, Egypt. Open Journal of Obstetrics and Gynecology,05,626-634. doi: 10.4236/ojog.2015.511088


  1. 1. Stephenson, M.L. and Wing, D.A. (2015) A Novel Misoprostol Delivery System for Induction of Labor: Clinical Utility and Patient Considerations. Drug Design, Development and Therapy, 9, 2321-2327.

  2. 2. Enabor, O.O., Olayemi, O.O., Bello, F.A., et al. (2012) Cervical Ripening and Induction of Labour-Awareness, Knowledge and Perception of Antenatal Attendees in Ibadan, Nigeria. Journal of Obstetrics and Gynaecology, 32, 652-656.

  3. 3. Carbone, J.F., Tuuli, M.G., Fogertey, P.J., et al. (2013) Combination of Foley Bulb and Vaginal Misoprostol Compared with Vaginal Misoprostol Alone for Cervical Ripening and Labor Induction: A Randomized Controlled Trial. Obstetrics & Gynecology, 121, 247-252.

  4. 4. Austin, S.C., Sanchez-Ramos, L. and Adair, C.D. (2010) Labor Induction with Intravaginal Misoprostol Compared with the Dinoprostone Vaginal Insert: A Systematic Review and Meta-Analysis. American Journal of Obstetrics and Gynaecology, 202, 624.e1-624.e9.

  5. 5. Hofmeyr, G.J. (2003) Induction of Labour with an Unfavourable Cervix. Best Practice and Research Clinical Obstetrics and Gynaecology, 17, 777-794.

  6. 6. Olson, D.M. (2003) The Role of Prostaglandins in the Initiation of Parturition. Best Practice and Research Clinical Obstetrics and Gynaecology, 17, 717-730.

  7. 7. Talaulikar, V.S. and Arulkumaran, S. (2011) Failed Induction of Labor: Strategies to Improve the Success Rates. Obstetrical & Gynecological Survey, 66, 717-728.

  8. 8. Mealing, N.M., Roberts, C.L., Ford, J.B., et al. (2009) Trends in Induction of Labour, 1998-2007: A Population-Based Study. Australian and New Zealand Journal of Obstetrics and Gynaecology, 49, 599-605.

  9. 9. Kolas, T., Hofoss, D., Daltveit, A.K., et al. (2003) Indications for Cesarean Deliveries in Norway. American Journal of Obstetrics & Gynecology, 188, 864-870.

  10. 10. Spong, C.Y., Berghella, V., Wenstrom, K.D., et al. (2012) Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstetrics & Gynecology, 120, 1181-1193.

  11. 11. Abdel-Ghani, R.M. and Berggren, V. (2011) Parturient Needs during Labor: Egyptian Women’s Perspective toward Childbirth Experience, a Step toward an Excellence in Clinical Practice. Journal of Basic and Applied Scientific Research, 1, 2935-2943.

  12. 12. Abdel-Aleem, H. (2011) Misoprostol for Cervical Ripening and Induction of Labour: RHL Commentary. The WHO Reproductive Health Library, World Health Organization (WHO), Geneva.

  13. 13. Nooh, A., Baghdadi, S. and Raouf, S. (2005) Induction of Labour: How Close to the Evidence-Based Guidelines Are We? Journal of Obstetrics and Gynaecology, 25, 451-454.

  14. 14. Hamilton, B.E., Martin, J.A. and Ventura, S.J. (2013) Births: Preliminary Data for 2012. National Vital Statistics Reports, 62, 1-20.

  15. 15. Dowswell, T., Kelly, A.J., Livio, S., Norman, J.E. and Alfirevic, Z. (2010) Different Methods for the Induction of Labour in Outpatient Settings. Cochrane Database of Systematic Reviews, No. 8, Article ID: CD007701.

  16. 16. Afolabi, B.B., Oyeneyin, O.L. and Ogendengbe, O.K. (2005) Intravaginal Misoprostol versus Foley Catheter for Cervical Ripening and Induction of Labour. International Journal of Gynaecology and Obstetrics, 89, 263-267.

  17. 17. Al-Ateeq, M.A. and Al-Rusaiess, A.A. (2015) Health Education during Antenatal Care: The Need for More. International Journal of Women’s Health, 7, 239-242.

  18. 18. Alfirevic, Z., Kelly, A.J. and Dowswell, T. (2009) Intravenous Oxytocin Alone for Cervical Ripening and Induction of Labour. Cochrane Database of Systematic Reviews, No. 4, Article ID: CD003246.

  19. 19. Kelly, A.J. and Tan, B. (2001) Intravenous Oxytocin Alone for Cervical Ripening and Induction of Labour. Cochrane Database of Systematic Reviews, No. 3, Article ID: CD003246.

  20. 20. Abdellah, M.S., Hussien, M. and Aboalhassan, A. (2011) Intravaginal Administration of Isosorbidemononitrate and Misoprostol for Cervical Ripening and Induction of Labour: A Randomized Controlled Trial. Archives of Gynecology and Obstetrics, 284, 25-30.

  21. 21. Habib, S.M., Emam, S.S. and Saber, A.S. (2008) Outpatient Cervical Ripening with Nitric Oxide Donor Isosorbidemononitrate Prior to Induction of Labor. International Journal of Gynecology & Obstetrics, 101, 57-61.

  22. 22. Elati, A. and Weeks, A. (2009) The Use of Misoprostol in Obstetrics and Gynaecology. BJOG, 116, 61-69.

  23. 23. Goel, K., Gedam, J.K., Rajput, D.A. and Bhalerao, M.V. (2014) Induction of Labor: A Review. Indian Journal of Clinical Practice, 24, 1057-1064.

  24. 24. Abdel-Barr, T., Elshalakany, N.A. and Shafik, Y.M. (2014) Single Dose Spinal Analgesia: Is It a Good Alternative to Epidural Analgesia in Controlling Labour Pain? Egyptian Journal of Anaesthesia, 30, 241-246.

  25. 25. Shetty, A., Burt, R., Rice, P. and Templeton, A. (2005) Women’s Perceptions, Expectations and Satisfaction with Induced Labour—A Questionnaire-Based Study. European Journal of Obstetrics & Gynecology and Reproductive Biology, 123, 56-61.

  26. 26. Simpson, K.R. and Atterbury, J. (2003) Trends and Issues in Labour Induction in the United States: Implications for Clinical Practice. Journal of Obstetric Gynaecological and Neonatal Nursing, 32, 767-769.

  27. 27. Heimstad, R., Romundstad, P.R., Hyett, J., Mattsson, L.-A. and Salvesen, K.A. (2007) Women’s Experiences and Attitudes towards Expectant Management and Induction. Acta Obstetrics and Gynaecology Scandinavia, 86, 950-956.

  28. 28. Chigbu, C.O. and Ezenyeaku, C.C. (2008) Women’s Opinions and Experiences with Induction of Labour and Caesarean Delivery on Request in South Eastern Nigeria. International Journal of Gynaecology and Obstetrics, 103, 158-161.

  29. 29. Aziken, M., Omo-Aghoja, L. and Okonofua, F. (2007) Perceptions and Attitudes of Pregnant Women towards Caesarean Section in Urban Nigeria. Acta Obstetrics and Gynaecology Scandinavia, 86, 42-47.

  30. 30. Angeja, A.C., Washington, A.E., Vargas, J.E., Gomez, R., Rojas, I. and Caughey, A.B. (2006) Chilean Women’s Preferences Regarding Mode of Delivery: Which Do They Prefer and Why? BJOG, 113, 1253-1258.


*Corresponding author.

Journal Menu >>