May 2021 saw the publication of a draft NICE guideline on inducing labour. NICE stands for the National Institute for Health and Care Excellence. It is the body that provides national guidance and advice to inform health and social care in the UK.
This guideline “concerns the circumstances, methods and monitoring for inducing labour in pregnant women.”
The draft NICE guideline on inducing labour can be seen here. It is currently out for consultation and a final version is likely to be published in October 2021.
I wrote this blog post because I received so many requests for help from organisations and individuals who wished to comment on the guideline. My hope was that this blog post might help point people who wished to respond towards useful points and evidence. The deadline for responses has now passed, but I have left the post here for anyone seeking more knowledge about the guideline. We’ll update it when the final version is published.
I offer links to many blog posts on this site and externally, many with useful references. There is also a lot of information and references in my two books on this topic: In Your Own Time, which I wrote after the draft guidance was published, and Inducing Labour: making informed decisions, which is a classic book that talks you through the process of induction and helps you make the decisions that are right for you. Both are bestsellers, and both are available electronically for a number of devices if you need something quickly.
A sea change
The draft 2021 NICE guideline on inducing labour encompasses a significant shift towards discussing induction with all women and to recommending earlier induction. This is on top of concerns about shifts in practice that have occurred during the coronavirus pandemic.
One element of the sea change can be seen in the removal of a key line from the 2008 guideline.
“Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour.” (NICE 2008).
In the draft 2021 guideline, NICE state that:
“This recommendation has been deleted because the next recommendation states which women with uncomplicated pregnancies should be offered induction, and so the committee agreed this recommendation was unnecessary.” (NICE 2021).
The recommended increase to interfere in uncomplicated pregnancy (which always carries risks and downsides) can be seen in many other places in the draft guidance. Examples include the recommendation that membrane sweeping should be offered routinely from 39 weeks without enough discussion about the possible disadvantages of this approach.
Worry and concern
The draft NICE guideline on inducing labour has been met with worry and concern in many quarters, for several reasons. Recommendations do not seem to have taken into account some of the wider issues or the numerous valuable studies available.
In some cases, statements about “the evidence” are not supported with a reference. When one clicks the links in the document in an attempt to see the evidence used to support changes and recommendations, the recommendation turns out to be based on the “knowledge and experience” of the panel. Which is very different from robust evidence.
Here, I highlight ten of the most significant concerns.
1. Due dates aren’t accurate
Suggested changes to the offer of induction in later pregnancy ignore evidence around the inaccuracy of due dates. Pregnancy length varies, and the offer of earlier induction means that more babies will be born before they are ready. As I discuss in point 5, they will be at risk of long-term health consequences as a result.
Many women report that their ‘due date’ was changed following the result of a scan. In some cases, they are certain that they couldn’t possibly have conceived within the timeframe that the technology suggests. Although there is some research to demonstrate that this happens, it is ignored by policymakers
2. The complexity of the post-term pregnancy debate is not considered
As my book on this topic shows, this is a complicated issue. There is concern that the risk of stillbirth increases when pregnancy is prolonged. However, the evidence on induction for post-term pregnancy isn’t as clear-cut as some would like us to think. In addition there are risks to induction as well.
As I wrote in Inducing Labour: making informed decisions, there is a slightly increased risk if pregnancy is prolonged, but “the increased risk comes later than most people think, is less than most people think and cannot necessarily be prevented by induction of labour.” (Wickham 2018: 71).
A key concern with the draft NICE guidance is that induction will be offered earlier, without there being good evidence to support this change, as I expand upon below.
3. The ARRIVE Trial controversy
The controversial ARRIVE trial is used as a key reference to underpin many of the changes in the draft guideline. Yet this trial has been criticised by many experts. It is described by NICE as “high quality evidence” and yet experts agree that there are numerous methodological issues with this study. More than 16,000 women declined to be in this study, which was about 73% of those asked. As a result, the women who were in the study may not be representative. The care that participants received was highly medicalised. The vast majority were cared for by a doctor, which does not happen in countries like the UK. The caesarean section rate was extraordinarily high given that the women in the study were “low risk.” And the study showed no difference in mortality for babies.
To read what a number of highly qualified people have written on this, see this perspective from a Professor of Obstetrics, and read the comments of stillbirth researcher Jane Warland. GP Dr Sarah Buckley has written this analysis. Henci Goer, an experienced medical writer and expert on evidence based maternity care has written two pieces on this: Preventive induction of labor: does mother nature know best? – Henci Goer Examines the ARRIVE Study and Parsing the ARRIVE Trial: Should first-time parents be routinely induced at 39 weeks?
4. The frame of reference is too narrow
One of the concerns about this guidance is that the included evidence is very restricted. There is no discussion about long-term outcomes, negative consequences of induction or women’s views. Instead, the questions considered by NICE are mainly limited to the immediate intrapartum period. This isn’t helpful or ethical, because induction has long-term implications for women, babies and families, as I explore below.
5. Long-term outcomes are poorer after induction of labour
There is concern that long-term outcomes are poorer after induction of labour. Both the drugs and mechanical methods used in induction and the interventions that may result can have unwanted and potentially harmful consequences. These may be justified where induction will benefit an individual. But when induction is a routine recommendation and information on long-term outcomes is not being offered or considered, we are denying women and families the right to make informed decisions. A paper by Seijmonsbergen‐Schermers et al (2019) offers a good summary of how induction leads to avoidable harm.
A number of studies provide more evidence that we should not be offering induction earlier than truly warranted. The TIGAR study, for instance, showed that childhood hospital admission rates were higher among children born at early gestational ages. In this study, even children born at 38 weeks had higher admission rates than those born at 40 weeks.
In another example, a paper from The Millenium Cohort Study showed that “children born at earlier gestational ages are more likely to experience SEN [special educational needs], have more complex SEN and require support in multiple facets of learning.”
And recent research by Dahlen et al (2021) showed that induction of labour leads to more intervention and more adverse maternal, neonatal and child outcomes. This study also showed that, although the induction rate has tripled in some groups of women in the past 16 years, there has been no reduction in stillbirth.
This information is needed by those making decisions about induction of labour. Yet the draft NICE guidance on inducing labour has not included it.
6. Women’s views are not taken into account
Many women are dissatisfied with induction and for some women induction of labour can lead to trauma and mental health problems.
Others have questions that remain unanswered or did not feel that they were given appropriate information upon which they could make the decision that was right for them.
A German study found that most women who experienced induction of labour would try to avoid it in a future pregnancy, and many would like to have information on alternative and complementary methods of induction of labour.
A number of other studies have also shown this. For example, a systematic review reports that women felt unable to request anything other than what the medical staff suggested.
Research on what women want has been carried out. But none of this work has been taken into account by those developing the draft NICE guideline on inducing labour.
7. Undermining trust
Early discussions about induction can undermine women’s trust in their bodies and this can impacts long-term confidence and parenting.
Several studies highlight how undermining induction can be for women. One example is a Welsh study which looked at this in depth. Among many other findings, women reported negative experiences of inpatient cervical ripening, and these negative experiences appeared to relate to their senses of being undermined.
8. Debatable claims about caesarean reduction
The claim that induction reduces the chance of caesarean section is supported by some evidence, but this is debatable.
The main paper cited in support of this is one of the most controversial studies on this topic.
In fact, studies have shown for years that, in the real world, induction increases the chance of caesarean.
The blog posts that I cited in point 3 also discuss this issue.
9. We do not have enough robust evidence on stillbirth reduction
It is clear that some groups of women/babies have a slightly higher chance of stillbirth compared to other groups. Data on this are often crude, however. The absolute risk may not be that high and we often have no trial evidence to show whether or not induction of labour would make a difference.
This has not stopped the development of population-level recommendations.
There are significant issues when making recommendations about groups such as older women, larger women and women who conceived via ARTs. The NICE panel members are basing some sweeping statements about these groups of women being at high risk purely on their “knowledge and experience.” No evidence is given to justify offering induction of labour to these women at 39 weeks. NICE has rules as to what constitutes robust evidence but it is sometimes difficult to see how these rules are being applied in this particular draft guideline.
Also of concern is the recommendation that induction of labour should be considered at 39 weeks for women “with a black, Asian or minority ethnic family background”. There is no evidence that this is beneficial and, while it is vital that we look at how we can improve the dire situation which is faced by these women, increased intervention may not be the answer. There is, again, no evidence of benefit, and many people have concerns that this reflects a belief that these women’s bodies are less capable, rather than addressing systemic racism and other inequalities.
A British Medical journal blog post has challenged this suggestion. In “Racial profiling for induction of labour: improving safety or perpetuating racism?” Christine Douglass and Amali Lokugamage discuss the lack of evidence for this suggestion, as well as the wider issues that relate to this question. They state that:
“We are deeply concerned that if these [NICE] recommendations are taken forward uncritically, they could further embed institutional racism in maternity care, strengthen racial biases and stereotypes, legitimise skin tone as clinically meaningful, pathologize healthy pregnancies in women from ethnic minority backgrounds, and undermine choice for black and brown women.” (Douglass & Lokugamage 2021).
The authors also note that, “In a statement from the RCOG about NICE’s draft guidance the college imply that induction has no downsides, but they don’t seem to have taken into account the recent long term adverse outcomes data for inductions of labour in uncomplicated pregnancies from Australia, or the increasing evidence that the risk of stillbirth is reduced by amplifying continuity of midwifery care models.” (Douglass & Lokugamage 2021)
A number of other circumstances that relate to the recommendation to consider offering induction at 39 weeks for some women are also not clear-cut. These include debates on the “aging” placenta, women who have a high BMI, and women who are suspected of having “big” babies. No trials have considered whether or not induction of labour is beneficial for those who conceived via IVF or other ARTs.
10. The offer of routine membrane sweeping is of concern
The recommendation on routinely offering women membrane sweeps from 39 weeks is also of concern to some people.
Again, this undermines women’s trust in their own bodies. It ignores the benefits of going into spontaneous labour. The NICE recommendations do not include discussion of the risk of inadvertently breaking the waters and thus setting off a cascade of intervention. Overall, the evidence shows that membrane sweeping has pros and cons and it doesn’t make much difference. So it’s debatable whether this should be a routine offer.
These are not the only concerns that I have heard expressed about the draft NICE guidance on inducing labour. I have focused on the evidence and write this from the perspective of someone who helps women, families, health professionals and birth workers understand evidence. Some of my colleagues who work in systems of maternity care have other equally valid concerns. Many units are understaffed. Some are at breaking point. Midwives, doctors and managers worry that a further increase in levels of induction will put further pressure on staff and units. This may make care less safe for everyone.
I also have colleagues who can see that an increase in pressure on women and families to accept earlier induction may further undermine trust in care providers and systems of care. It’s also possible that putting pressure on women to have induction will actually lead to more requests for elective caesarean. Colleagues and I are already seeing this in cases where women have been told the baby should be born by a certain point. Some women do not wish to have induction (perhaps because of a previous negative induction of labour experience) and request an elective caesarean section instead. More planned inductions will undoubtedly lead to more postponed or delayed inductions. And it’s really rather scary to one day be told you need an induction because your baby is at risk and needs to be born, and then the next day to be told your induction is delayed.
None of these consequences have been considered in the draft NICE guideline on inducing labour. But they are all too real for women, families, midwives, doctors and birth workers.
How to find out more
If you would like more information and references, you can find this in my book on this topic. Here’s a quick link to the different versions of the ebook.
If you’re looking for information on induction to help you make your own decision, I have some other posts you may find useful One is Ten things I wish every woman knew about induction of labour. And if you have been given an induction date which you do not want, here’s How to cancel a labour induction.
If you’re a midwife or birth worker and you’d like to learn more, I run fabulous (if I do say so myself) online courses. In those, I teach you to understand and get up-to-date with evidence and research on topics like this one. In fact, we’re looking at the research on induction and big babies and also at membrane sweeping in Gathering in the Knowledge 2021!
Please understand that I can’t offer individualised advice or information. We are swamped by requests for this at the moment. I have written this blog post in my own time in the hope of helping those who wish to respond to the draft NICE guideline on inducing labour and do not have the resources to reply to requests for further information.
But if you’d like more from me, I have a newsletter list and we send out a monthly Birth Information Update, in which I share new research and link to my blog posts. That’s also where you can find out about new books, courses and events that I’m involved with. Sign up here.
I’d like to thank Julie Frohlich, Nadine Edwards, Emma Mills and Mavis Kirkham for their help and support which enabled me to plan and write this article in record time.