November 2021 saw the publication of the 2021 NICE guideline on inducing labour.
The guideline “…concerns the circumstances, methods and monitoring for inducing labour in pregnant women.” (NICE 2021). The draft version of the guideline caused a lot of controversy when it went out for consultation. That led to many people responding to NICE and sharing their concerns.
Thankfully, the final 2021 guidance does not include all of the changes that were proposed in the draft guideline. However, some things are still of concern. In this blog post, I’m going to outline five of the key changes in the recommendations.
* 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.
1. A change in tone
The 2021 NICE guideline on inducing labour encompasses a further shift towards normalising induction of labour. This is on top of concerns about shifts in practice that occurred during the coronavirus pandemic.
When the draft version of the guideline came out, we noticed that a key line from the 2008 guideline had been removed. That line was:
“Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour.” (NICE 2008).
The NICE panel have now reinstated this line in the 2021 guidance and removed some of the proposed interventions (which were not evidence based).
However, the new guideline suggests that clinicians should:
“Discuss preferences about mode of birth with women early on in their pregnancy. Take into account their individual circumstances, and discuss that options for birth can include:
- expectant management, or
- induction of labour, or
- planned caesarean birth.” (NICE 2021).
Previously, there was no recommendation to discuss induction until 38 weeks of pregnancy, and the suggestion that planned caesarean should be discussed early in pregnancy is also new. Some clinicians and birth workers are concerned that this introduces doubt and undermines women’s confidence in their bodies from the beginning of pregnancy. As I have previously written:
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.
2. An earlier offer of membrane sweeping
The 2008 guidance in this area recommended that, “Prior to formal induction of labour, women should be offered a vaginal
examination for membrane sweeping.” (NICE 2008).
The timing of this depended on whether or not the woman had given birth before.
“At the 40 and 41 week antenatal visits, nulliparous women should be offered a vaginal examination for membrane sweeping.
At the 41 week antenatal visit, parous women should be offered a vaginal examination for membrane sweeping.” (NICE 2008).
But this has changed in the 2021 guideline, which recommends that membrane sweeping should be offered routinely from 39 weeks. This is regardless of whether or not someone has had a baby before. It is also despite the fact that, elsewhere in the guideline, the panel state that, “Research into when and how frequently membrane sweeping should be carried out
to maximise its effectiveness and acceptability would be of value.” (NICE 2021).
The guidance suggests that clinicians should discuss, “…that pain, discomfort and vaginal bleeding are possible from the procedure.” (NICE 2021). It does not tell clinicians to inform women that, occasionally, the waters may accidentally be broken, which can lead to the woman having to consider her options, as this can increase the chance of infection.
3. Earlier offer of induction at/around 41 weeks of pregnancy
The 2008 guidance stated that, “Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks…” (NICE 2008).
In the 2021 guideline, the “between” has changed to “from,” and the conversation is about offering induction and discussing risks that occur “from 41 weeks…” (NICE 2021).
This is a subtle but significant change, not least because this is a time when many women go into labour spontaneously.
As I wrote in my book on this topic, 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 people and documents suggest. In addition, there are risks to induction and significant advantages to going into labour spontaneously. So it’s important to weigh up the pros and cons.
I have written extensively on the research in this area, and you can find more resources here.
4. Mentioning higher stillbirth rates but without explicit recommendations
One of the most controversial aspects of the draft guideline was the proposed recommendation that earlier induction be offered to certain groups of women, including older women, larger women and women who conceived via IVF or ARTs. It is clear that some groups of women/babies have a slightly higher chance of stillbirth compared to other groups. But data on this are often crude, 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.
The draft also proposed recommending that induction of labour should be considered at 39 weeks for women “with a black, Asian or minority ethnic family background.” Many people and organisations (including myself) pointed out that is no evidence that this is beneficial. We argued that, while it is vital that we look at how we can improve inequity, increased intervention is not the answer. There is, again, no evidence of benefit, and there are concerns that this reflects a belief that some bodies are less capable than others, rather than addressing systemic racism and other inequalities.
These recommendations were not included in the final version of the 2021 guidance, but there is a caveat.
The section on “Pregnancy lasting longer than 41 weeks,” contains the following statement:
“Be aware that, according to the 2020 MBRRACE-UK report on perinatal mortality, women from some minority ethnic backgrounds or who live in deprived areas have an increased risk of stillbirth and may need closer monitoring and additional support.” (NICE 2021).
The guidance does not specify what the guideline writers mean by, “…closer monitoring and additional support…” and there are concerns that this may still be interpreted as a recommendation for increased and earlier recommendations of intervention by clinicians, Trusts and Health Boards. There is no evidence that this would be beneficial.
For more on this, please see “Racial profiling for induction of labour: improving safety or perpetuating racism?”
“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).
5. A lack of clarity
Some people think that the new guideline is unclear on some important points. I have already mentioned some: for instance the paragraph concerning Black and Brown women and those living in deprived areas. It’s also the case that, while the proposed recommendation to offer induction to older and/or larger women (among other groups) has been removed, the guideline writers have not clarified that there is a lack of evidence to underpin this. We all know that early induction is being offered to these women in some areas and not others. Clear statements about the lack of evidence for offering intervention in some situations would be helpful. This is especially the case where NICE are critical of the fact that there is variation in practice. There are also discrepancies between this guideline and others, which have been published by NICE themselves and by other organisations such as the RCOG. As this guideline has literally just been published, it is possible that this may change in the near future. But a lack of clarity is unhelpful and will perpetuate the existing induction postcode lottery.
These are not the only concerns that people have about the new guidelines, and there are more changes that will affect other aspects of care. I am sure that other people will be writing about their concerns and the issues that relate to their own areas of expertise in the days to come, and I look forward to reading and highlighting their work.
Many of my hospital-based colleagues remain concerned that pressure on women and families to accept earlier induction may further undermine trust in care providers and systems of care.
As I noted in my previous post on this topic, many units are understaffed, some are at breaking point and further increases in induction rates will make care less safe for everyone.
We also know about a significant problem wherein some women are given induction dates but then unit capacity and staffing issues mean that these need to be postponed. It’s not the fault of the midwives. But it’s 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 because there’s no bed for you.
We can and should do better than this.
And if you’d like to read more about my work on this area, here’s my induction information hub.
NICE (2008a). Induction of Labour. London, RCOG.
NICE (2021b). National Institute for Health and Care Excellence Guideline: Inducing Labour. November 2021. London: NICE.
How to find out more
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.
I also 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.
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