Why do some women dislike induction of labour?
A few weeks ago, I wrote about a systematic review in which researchers looked at how women feel after induction of labour for post-term pregnancy. The results echoed the contents of my own inbox when I asked for input into my updated book on inducing labour. 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).
Now, a small but interesting study presented at a medical conference in the USA has 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 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).
One thing that strikes me is that 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.
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.
If systems of maternity care are too influenced by market values to be able to offer balanced information to women, then the answer is simple: we need to continue to find more direct ways of sharing that information with women, so that they can make the decision that is right for them.
Objective: Induction of labor (IOL) is one of the most common obstetrical procedures. Prior studies have demonstrated decreased birth satisfaction associated with IOL. Patient satisfaction with the labor process has been directly linked to healthy mother/baby bonding, improved breastfeeding rates, and a decreased risk for postpartum depression. We sought to determine what factors impact birth satisfaction in women undergoing IOL with the ultimate goal of targeting women at highest risk for decreased satisfaction.
Study Design: We performed a prospective cohort study of women with term (≥37 weeks) singleton gestations undergoing IOL with an unfavorable cervix at our institution from Jan 2018 to June 2018. Women completed a modified version of the validated 10 question Birth Satisfaction Scale-Revised (BSS-R) postpartum. Women with a BSS- R score above the mean were classified as “satisfied” and women with a BSS-R below the mean were classified as “unsatisfied.” Risk factors for satisfaction were evaluated by univariate analysis that included Chi-square for categorical and Wilcoxon rank sum for continuous variables. Multivariable analysis was performed using logistic regression.
Results: 330 of 414 (79.7%) of eligible patients completed the BSS-R and were included in the analysis. There was no significant difference in birth satisfaction by maternal age, BMI, starting Bishop score, or induction agent. Self- identified Black women were more likely to be unsatisfied than White women (54.0% vs. 37.2%, p=0.037), nulliparas were more likely to be unsatisfied compared to multiparas (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 (Figure). In multivariable analysis, race, mode of delivery and labor length quartile remained independent risk factors for decreased satisfaction.
Conclusion: Black race, nulliparity, cesarean delivery, and increasing labor length were identified as risk factors for decreased birth satisfaction among induced women. Safe methods to reduce labor length in IOL should be explored as a means to improve birth satisfaction.
Hamm R, Srinivas S, Levine LD (2018).1032: Can we identify risk factors for decreased birth satisfaction among women undergoing induction of labor? American Journal of Obstetrics and Gynecology 220(1): S662-S663
Lou S, Hvidman L, Uldbjerg N et al (2018). Women‘s experiences of postterm induction of labor: A systematic review of qualitative studies. Birth: Issues in Perinatal Care. https://doi.org/10.1111/birt.12412