Keeping birth normal by reducing inductions

1474603690_19d77024fdDespite attempts to convince us that induction of labour reduces the caesarean section rate, those of us who have worked within hospitals know from experience that induction of labour poses a real threat to a woman’s chance of giving birth to her baby herself. Sometimes, the potential benefits of induction outweigh this and other risks, but I know many midwives and doctors who think that the current induction rate is far too high.

I’m always sweeping the literature for snippets and studies that relate to the question of how we can help more women to have a normal birth and, with more Recipes for Normal Birth workshops coming up, I was interested to see the publication of research from Sweden (Ekéus & Lindgren 2016) which looked specifically at the impact of induction on unplanned caesarean and vacuum extraction. Even better, the researchers controlled for medical complications, which allows us to see whether having a complication changes the situation for women. This is retrospective research, so it has pros and cons in relation to what we are able to gather from it, but we know from some of the systematic reviews of the randomised controlled trials in this area that the data from these are subject to human interpretation and their results are not always the best way of seeing what is happening in reality.

The Swedish research includes data from over a million births and it confirms that, for most women, having labour induced means they are two or three times more likely to have an unplanned caesarean section. (The exceptions to this were women who had already had a baby whose labours were induced early because they had a problem, but this is a fairly specific group, and the majority of women who undergo induction do not fall into this group).  Women having their labour induced were also more likely to have a vacuum extraction, although the chance of this happening was less than the chance of their being told they needed a caesarean section.

The data are particularly stark for women who do not have a medical complication, which includes those whose labours are induced simply because they have reached a certain point in pregnancy. For these women, having their labour induced in weeks 39, 40 or 41 of their pregnancy meant they were three times more likely to end up with a caesarean section than the women whose labour began spontaneously.

RNB March 2016I am increasingly passionate about getting details about this kind of data out there for midwives, doctors, birth folk and women, through workshops and courses as well as through my website. We need to have good information to discuss with women and their families, we need to be confident in sharing this information and we need to pool our ideas about how we can bring about change. And yes, we also need to think about how we can help those women who truly do need interventions and consider whether there are things we can do to increase their chance of a normal birth.

 

Ekéus C and Lindgren H (2016). Induced Labor in Sweden, 1999–2012: A Population-Based Cohort Study. Birth. Early online, DOI: 10.1111/birt.12220

 

The Research…

Background: Previous studies show contradictory results about the impact of induced labor on the cesarean delivery rate and few studies have investigated the risk of vacuum extraction subsequent to induced labor. The aims of the present study were to describe the rate of induced labor in Sweden from 1999 to 2012, and to assess the risk of unplanned cesarean delivery and vacuum extraction after induced labor in relation to medical complications and length of gestation.

Methods: A register-based cohort study was conducted, including 1,078,536 women with spontaneous or induced onset of labor who gave birth by noninstrumental vaginal delivery, unplanned cesarean delivery, or vacuum extraction in gestational week 37 + 0 to 41 + 6. Logistic regression was used to study the association between induced labor and instrumental delivery.

Results: The rate of induced labor increased from 7.7 to 12.9 percent among primiparous and from 7.5 to 11.8 percent among multiparous women. Induced labor was associated with 2–3 times greater risk of unplanned cesarean delivery among all women, except multiparas in gestational week 37–38, and with a 20–50 percent higher risk of vacuum extraction after the adjustment for confounding factors. Among women without a recognized medical complication, induced labor was associated with a threefold increased risk of cesarean delivery in gestational week 39–41 and a 40 percent increase in gestational week 37–38 compared with women with spontaneous onset of labor.

Conclusions: The proportion of induced labors increased substantially during the 14-year study period and was associated with an increased risk of both cesarean delivery and vacuum extraction, even in women without a documented medical complication. The increased risk of instrumental delivery should be taken into account when counseling about the risks and benefits of induced labor.

 

Post-term pregnancy course slide purple

If you’d like to learn more about post-term pregnancy and build your confidence with the evidence, I’d love to welcome you to my online course on this topic 😀  And you can keep up with my research postings via my free updates and monthly Birth Information Update.

photo credit: happy family via photopin (license)

7 comments for “Keeping birth normal by reducing inductions

  1. February 4, 2016 at 10:40 am

    I’m a birth worker in central south of England. Our local maternity hospital ran an induction audit throughout 2010 and for the first 4 months of 2011. Just looking at first time mums, around 27% were induced over all. Of these around 39% were induced for being “post term” with no other medical reason.

    Outcomes for all inductions for first time mums were: caesarean approx 37%, instrumental birth approx 31%, normal birth approx 31%.

    Outcomes for inductions for being “post term” for first time mums were: caesarean approx 39%, instrumental birth approx 32%, normal birth approx 27%.

    I was at the meeting where these stats (along with others) were presented and I remember a consultant midwife expressing surprise regarding the caesarean rate as NICE insists induction does not raise the rate of caesarean. This is so clearly not the case! I’ve spoken with other birth educators and it seems, anecdotally, that there’s a similar picture across the country.

    I too am sad when women tell me they “have” to be induced. Women are told the “risks” of remaining pregnant beyond 42 weeks (“your placenta might stop working properly and there’s an increased risk of your baby dying”) but aren’t told the risks related to induction. They aren’t told the actual figures relating to perinatal death, just that it “triples”. Neither are they told that induction is a choice. Even when they understand choice they’re often, by then, too scared to refuse induction because of a) going against the wishes of their care-giver and b) what if the increased risk happens to them? Now they know the “additional risks”, what if….? Many women aren’t even told about the extra care that should be offered if they choose to decline induction – having baby listened to more often and ultrasound scan.

    Sorry – this is a bit of a hobby-horse for me. Thank you, Sarah, for all you do to raise awareness of the difficulties women face (pregnant women and midwives!) and those inherent within our system, and for campaigning for change.

    Zana

    • February 4, 2016 at 3:20 pm

      I share all of those concerns, Zana, and am working on a new workshop which I hope will help a tiny bit. Thanks for your comments; the stats that you and others have shared on social media really help to illustrate the problem…

      Update: the online course is now available … details at http://www.sarawickham.com/workshops

    • becky coolidge
      March 1, 2016 at 2:48 am

      was postterm defined as after 42 weeks?

      • March 1, 2016 at 7:18 pm

        Good question! On the results tables, which is all I have, it just says “post-term” without qualifying this. I imagine it would be 40 +10 or +12 as this is when women are “offered” induction (although most are unaware it is an “offer”). In fact a quick look at a locally produced Propess info sheet (introduced after the audit was carried out) says that induction is “recommended to all women between 41 and 42 weeks of pregnancy”.

  2. Gillian Somerville
    February 8, 2016 at 12:55 am

    I’m a first time mum, who had a very healthy pregnancy, no signs of complications. Only problem was I was past my due date. I was induced a few days before I reached 42 weeks. When I arrived in the labour ward they put the monitor on and to my surprise and delight said ‘oh you’re actually in Labour naturally – we can see your contractions have started’. But because the contractions stopped after a good few hours they went ahead and induced me anyway. After 40 hours of being in Labour I ended up in theatre only just narrowly avoiding a c section (they were prepping me for one) i ended up with forseps and episiotomy in a scary ER style. I found it very frightening and felt disconnected from it all. (I’ll leave it that). When I first arrived in the labour ward my instinct was telling me i was going into Labour myself just give me a bit longer. But it’s only in hindsight now that I wish I’d been more informed. Knowing what I know now, I’d urge all expectant women to consider workshops on positive birthing and be as informed as you can be about all your options. I was too scared to go against the protocol. But must say my community midwives were incredible and I was so well looked after. They did everything they could. I think it the system that is failing women and their birthing experience.

  3. Sheherazade
    March 1, 2016 at 4:42 am

    Hi, I found this really interesting just wanted to give my view as a new mum. I did feel pressure to agree to an induction in the event that the midwives should feel it was needed even though I wasn’t even at term when asked and specifically said I didn’t want induction when asked. When I said in my birth choices that I didn’t want anything to start labour the midwife tried to talk me round with “soft” options such as aromatherapy and sweeps. It frustrates me that the medical professional is happy to say all babies are different when it suits them and yet we have to conform to dates in other ways e.g. Birth dates, weaning. In the event my baby came naturally at 38 weeks but reading this would have helped me stick to my guns if I had gone longer.

  4. March 26, 2016 at 5:29 pm

    Zana, I echo everything that you have said. It is also one of my ” hobby horses” too…..

    In my ideal world we will stop offering induction of labour as a routine procedure for post dates, (without medical concerns). I think that one we will look back and say, ” didn’t we unnecessarily bring too many babies into the world that weren’t ready to be born… ” a bit like in the 1970’s and 1980’s when most mothers were given a shave, emema and episiotomy as routine. Babies brains are still growing in those final weeks…..

    If I had a penny for every mother that tells me, she didnt know that she had a choice about induction ,( amongst many other things….)

    Keep up all the brilliant work that you do Sara Wickham…..I recommend A.I.M.S booklets to anyone that will listen. x

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