Is anyone else feeling disgruntled at the ongoing trend in the research literature towards attempting to justify earlier and earlier induction of labour? A year or so ago, I unpacked a meta-analysis which claimed that, contrary to the experience of midwives and a significant volume of research, induction of labour actually reduces the chance of caesarean section (Wickham 2014). In case you missed that article, I argued that the findings are questionable, mainly because of the lumping together of data from a wide range of trials carried out over a long time span and including very different groups of women with different indications for and methods of induction. But whether or not the research methods are valid and robust, we are seeing more and more studies which are seeking to justify more and more intervention in the course of normal pregnancy and birth.
Many of these studies, including the paper that I discuss below, are coming out of the USA, but I know UK midwives who are concerned about moves towards inducing labour in certain groups of women, including those who are older or larger than is considered ideal. As the number of women in both of these groups is growing, we could well end up in a situation where more women’s labours are being induced than not. This is very worrying, because almost every paper I read on keeping birth normal clearly points outs that one of the most important keys to reducing the caesarean section rate is for as many women as possible to experience spontaneous onset of labour.
The title of one recent paper that is concerning me is, “A risk of waiting: the weekly incidence of hypertensive disorders and associated maternal and neonatal morbidity in low risk term pregnancies” (Gibson et al 2015). You can probably imagine the results, and you can probably imagine that they look rather different when appraised by someone who trusts women and birth, but I am more concerned here with the approach taken in writing up this study. The title, for instance, is rather provocative. It reads more like a tabloid headline than the lead-in to an objective analysis of a research question, and anyone appraising this paper would suspect within seconds in which direction its authors were leaning.
This intrinsic bias is further reinforced in the abstract, which contains more provocative language. By discussing the presumed benefits of normal pregnancy, and the maternal risks of expectant management, are the authors deliberately expressing doubt about a process which has worked for millennia, while simultaneously defining pregnancy and birth in relation to their management decisions rather than women’s agency and the abilities of their bodies?
In the next line, the researchers refer to the women in their study as “low-risk gravid” and continue using such language throughout the paper. This may, in fairness, be due to the stance of the journal and wider medical linguistic trends rather than their personal viewpoint but this doesn’t make it any less disempowering to those women who feel objectified and frustrated that their caregivers express such doubt about the ability of their bodies to grow and birth babies.
In any case, what happened to the precautionary principle; the ethical approach wherein, if we don’t know whether an action or policy or intervention is safe or not, then the burden of proof that it is not harmful falls on those recommending the action or intervention? This is not the only article to be flying in the face of that principle. This paper is part of a trend, and it may be something that those of us who care about and work with birthing women need to discuss with our colleagues, especially when we are asked to go along with guidelines and practices based on this kind of research.
Discussing the doubt
I don’t imagine for a moment that the authors of such articles will stop this practice just because I ranted about it in TPM. But I know that many readers of this article are practising in areas and systems which may be affected by these research findings, and, if nothing else, I’d like to help other midwives find ways of speaking about such studies and papers. To me, the precautionary principle is a great starting point. The sentence, “what happened to the precautionary principle?” is one of my favourite ways of pointing out that, ethically, medical intervention has to prove itself against nature. Not the other way around.
Gibson K, Waters TP & Bailit JL (2015). A risk of waiting: the weekly incidence of hypertensive disorders and associated maternal and neonatal morbidity in low risk term pregnancies. AJOG, in press. doi:10.1016/j.ajog.2015.09.095
Wickham S (2014). Does induction really reduce the likelihood of caesarean section? TPM 17(8):39-40.
And if you’re interested in learning more or discussing the issues around induction, check out post-term pregnancy: exploring evidence, inspiring confidence!