Why are some women dissatisfied after induction of labour?

Why are some women dissatisfied after induction of labour?

What it is that they dislike so much?

And why are women’s views being misrepresented by some of those who purport to care for them?

I have been hearing recently from a number of people who are concerned about the misrepresentation of women’s views about induction of labour. Specifically, they are concerned that a small number of obstetricians who are speaking about induction on a national level are claiming that “women really like induction of labour.”

Now let’s be clear and spell out the reality here. Some women really do like induction of labour.

But many don’t.

Some regret the decision to be induced and are traumatised by their experience.

In this blog post, I share some studies that have looked at this topic.

How do women feel about induction?

One key study found a big gap between what women need and want and the reality of what they experience (Coates et al 2018).

This was a systematic review and thematic synthesis which brought together eleven papers (covering ten studies) containing peer-reviewed qualitative evidence. In other words, this is good quality data.

The studies involved healthy women as well as women who were perceived to have a higher chance of problems.

This is important because an increasing number of healthy women are finding that they are offered induction of labour on a routine basis. This is in contrast to the situation where a woman is offered induction of her labour because she is experiencing a specific problem.

What did the women say?

As the authors show, “The review indicates that induction of labour is a challenging experience for women, which can be understood in terms of the gap between women’s needs and the reality of their experience concerning information and decision-making, support, and environment.” (Coates et al 2018).

I can relate to that. When I updated my book on Inducing labour, one of the key things I heard over and over again was that women hadn’t realised what the reality of induction would be like.

And they didn’t just mean in relation to the pain or the increased intervention; they wished they had known about the social aspects.

They wished they had known that they might end up on the antenatal ward for three days before their labour really kicked in.

They wished they had known that their partner might only be allowed to visit during certain times.

More evidence of dissatisfaction

But this isn’t the only study to find that women are dissatisfied after induction of labour.

Another study on this topic was carried out by Adler et al (2020).

Their findings showed that, “The women who underwent labor induction were less satisfied with their birth experience compared to women with spontaneous onset of labor.” (Adler et al 2020).

Dupont et al (2020) also looked at the experiences of some of the 1453 women who answered a questionnaire two months after their birth in France.

More findings

They found that:

“Overall, 30% of the nulliparous women were dissatisfied (n=231/770) and 19.7% (n=130/659) of the parous women.”

“The specific independent determinants of dissatisfaction for nulliparous women were antenatal birth classes that failed to include discussion of IoL and lack of involvement in the decision-making process.

For the parous women, a specific determinant was a delivery that lasted more than 24 hours.

Determinants of maternal dissatisfaction common to both groups were unbearable vaginal discomfort, inadequate pain relief, lack of attention to requests, caesarean delivery and severe maternal complications.” Dupont et al (2020).

Another systematic review

A year or two before, researchers had brought together the results of a number of qualitative studies and published another systematic review looking at how women feel about having their labour induced when their pregnancy has passed a certain date.

“Whereas there is substantial and ongoing scientific research on the potential medical advantages and limitations of postterm induction, less is known about the perspectives of the pregnant women. Furthermore, the results of the few existing studies are ambiguous.

In a randomized, controlled trial of IOL [induction of labour] versus expectant care, [it was] found that at 41 gestational weeks, 74% of the pregnant women preferred to be induced. In the IOL group, the majority (85%) of induced women reported a positive labor induction experience and 74% would prefer the same management in future pregnancies.

However, other studies have found that IOL was associated with less satisfaction, a less‐positive birthing experience, and a higher concern for the baby’s safety. In an online survey among women with induced labor (all indications), the majority (57%) would not choose IOL in a future pregnancy and requested more information on alternatives and more participation in decision making. These results are important because a negative birth experience is associated with postpartum mental health problems.” (Lou et al 2018).

What don’t women like?

Eight relevant studies were analysed in that systematic review, and the findings were grouped into three main themes.

The first dealt with the way in which the offer of induction of labour led to a shift in expectations. 

“For these women, their original hopes and expectations of spontaneous labor were disrupted by the induction guidelines or induction offer/recommendations. Thus, realizing that time had run out for spontaneous labor to happen was experienced as requiring a shift of perspectives.” (Lou et al 2018).

The feelings were conflicting. Some women felt relieved that they knew when their labour would begin, but others “described how IOL caused feelings of disappointment, resignation, and passivity.” (Lou et al 2018).

A ‘nondecision’

The second finding was that “many women experienced IOL to be a “nondecision.” For example, one woman described how she felt unable to intervene in the IOL protocol or request anything other than what the medical staff suggested.

Despite being assertive generally, I felt that medical decisions and decisions being made by medical professionals are somehow outside my control.” (Lou et al 2018)

Finally, women described their experiences of the induction process itself. Many women “experienced delays and long waits between admission and the actual induction” and “other examples of the lack of information included cases where women were expected to stay at the hospital, but had not been informed in advance and/or cases where the partner was not allowed to stay overnight at the prenatal ward.” (Lou et al 2018).

Women also reported feeling neglected during the process and did not have continuity of carer.

Lou et al (2018) conclude that,

“This review identified several negative experiences of women undergoing postterm IOL. However, the experiences of women with induced labor can likely be improved by a communicative and patient‐centered approach. To support their informed choice and shared decision making, women need high‐quality, unbiased information about IOL, alternative options, and potential outcomes, as well as time to reflect on their personal values and preferences. Women may also need supported opportunities to re‐evaluate their hopes and expectations before receiving IOL.”

The delay problem

The results echoed the contents of my own inbox when I asked for input into my updated book on inducing labour. 

Many women emailed to tell me of their dissatisfaction, with the information they were given, with the induction process itself, with the care they experienced, and also by the social elements of the experience, which included long delays and separation from their partner and family.

In the USA

A study in the USA highlighted other factors that are associated with women feeling dissatisfied by their experience of labour induction. Hamm et al (2018) found that:

“There was no significant difference in birth satisfaction by maternal age, BMI, starting Bishop score, or the drug that was used to induce labour” (Hamm et al 2018). It is particularly important to bear in mind here, however, that the study was fairly small. These factors would be worth looking at again in a larger study. In my part of the world, for instance, women do sometimes report different experiences depending on the drug used, although perhaps there may not be as much variation in the substances and methods used where this study was carried out.

“Self-identified Black women were more likely to be unsatisfied than White women (54.0% vs. 37.2%, p=0.037)” (Hamm et al 2018). Given the massive and unacceptable discrepancies in the maternity care and outcomes experiened by Black women (and this is not to exclude women from other groups who receive less than optimal care as well) this is something that needs to be addressed urgently.

“Women having their first baby were more likely to be unsatisfied compared to women who had already had one or more babies (54.2% vs. 40.9%, p=0.019), and women whose labor resulted in a cesarean delivery were more likely to be unsatisfied than women with a vaginal delivery (67.4 vs. 42.3%, p<0.001). Additionally, increased labor length quartile was associated with decreased satisfaction (p=0.003). This trend held true even for women that had a vaginal delivery.” (Hamm et al 2018).

What can we take from this?

The response to such studies (sometimes from the authors themselves, and sometimes from those who read them) is often to declare that we need to make induction better. But, as Lou et al’s (2018) systematic review showed, it is the very act of interfering with the normal progress and rhythm of pregnancy that makes induction of labour so upsetting and difficult for some women.

And there is another way, at least for some women. It’s a controversial way, given that we live in a technocratic world that is so strongly influenced by market values and the emphasis of doing over being. The other way is to cease using population-based standards and reconsider whether each individual woman truly needs to have her labour induced.

What do we do?

Once we know that there are women dissatisfied after induction, the question becomes what we can and should do about this.

One group of researchers concluded that,

“To reduce dissatisfaction in nulliparous women, IoL should be discussed during antenatal birth classes and women should be made to feel that they shared in the medical decision to perform IoL. For parous women, care providers should inform them that the duration of delivery may exceed 24 hours. Continuous support for all women during IoL should pay closer attention to vaginal discomfort, pain and women’s requests. Postpartum discussions with mothers should be arranged to enable conversation about the experience of unexpected events.” Dupont et al (2020).

That’s not enough

I would personally go further than this.

For me, the goal is not to ‘make the woman feel included in the decision’ and ‘prepare her for the reality’, but to ensure that the decision IS actually the woman’s.

We need to make sure that the reality is something that she truly wants and that the offer of induction is just that – an offer.

This is particularly important in situations where, while some groups of women may face a small increase in the chance of stillbirth compared to other groups of women, there is a bigger picture to be considered.

To wit: the increase is often marginal, induction of labour also carries risks and negative consequences for women and babies (as the findings of the above study attest) and in some situations there is no evidence that induction will actually reduce the chance of stillbirth.

As my own research has shown, the evidence for many indications for induction is marginal at best and often there is no evidence that induction of labour improves outcomes. So every woman needs to weigh up what is best for her individual circumstances.

And that’s why midwives, doulas, birth educators and other birth folk like me get passionate.

When it comes to intervention in labour, it’s not that we want all women to say no; we want all women to have full information so they know what they are signing up for and don’t have regrets later on.

You can also learn more on this topic in our information hub:

Post-term pregnancy and induction of labour resources

---

---

---

Books to help you become informed and make the decisions that are right for you…

---

---