Birthillogics #1 – induction for advanced maternal age

sara_wickham_birthillogicsIs the recommendation of induction for advanced maternal age truly based on sound evidence? Or is it illogical when you break down and really think about the issues?

For anyone who hasn’t heard the term ‘birthillogic’ before, I created this word to refer to a birth-related claim or recommendation which, when analysed, lacks logic, sense or clear, sound reasoning. I have discovered quite a few of these over the years, and have read about many more through the work of other people, so they are numbered on my website for anyone who would like to find them more easily.

I actually have two examples of ‘birthillogics’ to offer on this topic. I have long been interested in the literature and research on the routine offer of induction of labour for advanced maternal age. It’s something I wrote about in Inducing labour: making informed decisions. This literature is, if I may be so rude, a morass of unhelpfulness. Not, I hasten to add, that I am seeking to apportion blame for this, and it isn’t the real reason for my post, but it might help to put the birthillogics into context if I briefly explain what I see as the problem.

icon_dancingIf you are a woman who is pregnant at an older-than-average age (and good for you: we don’t celebrate this nearly enough, perhaps because people are too busy being negative and fear-based, so let’s just briefly stop and say yay!), you may well face a difficult decision somewhere around or just after your pregnancy reaches ‘term’. You may be offered induction of labour and will need to think about whether or not to have your labour medically induced. Induction of labour involves a series of procedures that are not the most pleasant and that may also bring unwanted side effects. You can also decide to await spontaneous labour. This is easier in that it is the default position, but, if we are honest, waiting is challenging for some. Both options come with pros and cons. One of the most fundamental questions you would want to know the answer to is whether there is really an increased risk of losing a baby if you are older and wait and, if so, whether this outweighs the risks of induction?

You will likely (and rightly) be told that there are studies out there whose findings suggest that waiting carries an increased risk. But unfortunately that is not the whole story, and there are good reasons to be concerned about the extent to which the findings of the studies are accurate and relevant to the women making this decision today. Many of the studies do not take into account the fact that women who are older are more likely to have existing problems (such as high blood pressure) and more likely to have conceived through the use of assisted reproductive technologies (ARTs). Both the use of ARTs and the existence of other problems (sometimes called co-morbidity) can lead to problems in themselves, and so a good research study needs to take that into account and (in simple terms) try to separate out the risk caused by these known problems from any risk caused simply by age. Most of the studies don’t do that, and so their findings aren’t that helpful to the majority of women making this decision.

The scientific opinion paper that the RCOG (2013) published on this topic acknowledged this, and cited two papers that controlled for these factors.  Fretts et al (1995) used data gathered in Canada from 1961 to 1993, while Pasupathy et al (2011) analysed data gathered from the experiences of Scottish women who gave birth between 1985 and 2004. Unfortunately, as Rosemary Mander (2013) recently pointed out, both of these studies included women who gave birth so long ago that it is questionable whether their experiences can be compared to those of women giving birth today.

It was also Rosemary who, while she was analysing this RCOG paper (2013), spotted the first birthillogic that I would like to share on this topic:

‘There are also a number of unexplained slightly paradoxical points which reduce the reader’s confidence in the paper, such as the statement ‘that ageing impairs myometrial [uterus muscle] function’ (2013). This leads the reader to question why, if this is so, are such ‘older mothers’ being recommended to labour at all?’ (Mander 2013: 48)

Quite. But, to be clear, and before anyone wonders whether ‘the better answer’ is cesarean section, I think that before we focus on the potential implications of the original statement. The claim that aging impairs myometrial muscle to a problematic degree. We actually need to ask whether the original statement is even true. I would think that it would be prudent to conduct a rather thorough investigation of any such claim, especially given its potential impact, but (to my knowledge) this research has not been done. Assumptions have been made. And the problem with assumptions is that they can affect the beliefs of care providers and others, and that can sometimes mean that beliefs turn into self-fulfilling prophecies.

Our second birthillogic on this topic runs along similar lines. Pasupathy et al (2011) concluded that the increase that they found in stillbirths in women over 40 was the result of hypoxia. But, if this is the case, how is induction of labour an appropriate response? Induction of labour generally involves the use of synthetic oxytocin, and one of the many downsides of using synthetic oxytocin is that it can cause hypoxia…

These two birthillogics are based on slightly different claims. We may or may not accept either or both of those claims. But even if we did accept them then induction of labour isn’t the most logical solution to either. Again, we need to do lots more work before we can be clear about whether there really are risks, and what those risks are.

And there’s one more important point. Even if there is an increased risk, we cannot know if induction of labour reduces that risk until sufficiently robust randomised controlled trials have been carried out. To date, I know of no such trial.

The current juxtaposition of the enormity of the choice that these women have to make alongside the lack of good data to which they can refer is appalling. In the meantime, rather than routinely offering justifications for induction which sometimes seem to be based more on fear than evidence, how about if we routinely offered a bit of clear thinking, a bit more honesty about what we can and can not tell from the research and, frankly, an enormous dollop of support and TLC for those women who have to make such decisions? And (with many thanks to Rosemary for highlighting this too) a few more ‘yay’s in celebration of their good news might not go amiss either…

If you’d like to read more about induction of labour, for older women and in other circumstances, you might enjoy my book, Inducing labour: making informed decisions.


Fretts RC, Schmittdiel J, McLean FH et al (1995). Increased maternal age and the risk of fetal death.  NEJM 333:953–57.
Mander R (2013). Induction of labour for advancing maternal age. EM 4(8): 46-49.
Pasupathy D, Wood AM, Pell JP et al (2011).  Advanced maternal age and the risk of perinatal death due to intrapartum anoxia at term. JECH 65:241–45.
Royal College of Obstetricians and Gynaecologists (2013).  Induction of labour at term in older mothers (Scientific Impact Paper No. 34).  London: RCOG.

12 comments for “Birthillogics #1 – induction for advanced maternal age

  1. Helen Shallow
    May 16, 2014 at 1:26 pm

    Hello Sara. I went to see an ex girl friend of my son, who is now 40 and having her 1st baby. She was telling me how helpful you birth illogic article is. And it is! What we do without thinkers and writers like you to put some balance and challenge out there. All the best. Helen

    • May 16, 2014 at 5:06 pm

      Oh that’s so good to hear, thank you Helen 🙂

  2. dan
    November 17, 2014 at 2:59 pm

    Hey there,

    This is a great resource. You mention ART as a co-morbidity, I wondered in what way this is a co-morbidity and what kind of ART? I ask as my wife is being pushed to be induced as an older mother, but she’s used an egg donor who is 23 (me).


    • November 18, 2014 at 8:06 am

      Hi Danielle 🙂 I’m not referring to specific data saying that older women + ART = even more problems here; I’m lamenting the fact that studies on older women don’t separate out those who have other things going on, like the use of ARTs, which makes is harder to see what is what. And, as you note, ARTs come in many different varieties. I think the take-home message here is that women frequently get told they are at risk and “need” induction (or augmentation or whatever) when there is sometimes very little or no data to support that, and when the intervention (which might be induction, augmentation or caesarean section) carries risks of its own. I can’t offer advice on your particular situation, of course, but if anybody feels they are being pushed into accepting intervention which they are not sure they want/need, it can help to ask the person doing the ‘pushing’ to talk you through their rationale and provide evidence – if available – to support their viewpoint. Ask to see the studies, and observe their response. It’s usually pretty clear whether you’re dealing with a situation where you have a good clinician who is genuinely and rightfully concerned because there are good data that show a high likelihood of problems or because something about your partner’s situation genuinely warrants it, or whether you are hearing hospital policy that is not supported by good evidence.

  3. Elaine
    February 13, 2015 at 6:48 am

    Thank you for another great article. I have wondered for some time why our default response to situations where baby and/or mum may be compromised, is to perform interventions that are known to compromise baby and/or mum! Surely if we assume one part of the dyad is at risk, it becomes *even more* important to limit interference to only what is absolutely necessary, so that the natural birth process has the best chance of unfolding normally, in a positive and healthy experience for both?

  4. Catherine
    April 23, 2015 at 10:18 am

    Thank you for your article I am a 42 year old first time pregnant mum to be, conceived using my own eggs and husbands sperm. The hospital have told me that they would look to induce at 39 weeks although I have not confirmed that I will do this only to say that I’m open to discussion about it. I don’t see any reason why this should be the case without evidence that there is a problem or that my baby is distressed. Do you know if it’s possible to determine healthiness of the placenta as a cause for trying to induce labour?
    Some helpful comments on your post.

  5. Amy
    July 2, 2015 at 10:41 pm

    Thank you for all your informed articles on induction. I am 39 years old, pregnant with my 5th child. I have carried all my babies from 39 to 41 weeks gestation (according to the numbers) and now this time because of my age they ‘more than recommended’ induction at 39 weeks. I said I ‘probably wouldn’t’ unless I noticed huge changes with my body and the baby’s movement. My midwife, within a fairly commercialized system, tried to pass on the fear factor of stillbirth and how some babies just don’t want to come out. Blah Blah. That is definitely when I hit the internet to figure out true data of complications of inductions vs. complications of older mothers at 40 plus weeks (especially healthy ones). I really don’t trust the healthcare industry and their statistics, especially when you find out how much they can charge your insurance for every added thing. (Including induction type drugs, added nurses to monitor, use of monitors etc) I just hope more women stand up for their rights and say “No” to unnecessary interventions. Thanks again!

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