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 some don’t. Some regret the decision to be induced and are traumatised by their experience. We can see this from what women say, what they write and also from studies like that 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).
A one-sided perspective
But, studies like Adler et al‘s apart, the women dissatisfied after induction aren’t always being heard. And we need to find a way to honour both of those groups – and everyone in between – while ensuring that everybody gets the information they need to help them make the decision that is right for them.
It’s because of the one-sided perspective that is being shared in some circles that I was really pleased to see another paper on women’s experiences of induction of labour (IoL) by Dupont et al (2020). It details the experiences of some of the 1453 women who answered a questionnaire two months after their birth in France. (So yes, one limitation of this kind of research is that it may have led to more responses from those who had particularly good or particularly bad experiences and who were keen to share them. But even if these were the only women in the bigger group who were dissatisfied, that’s still way too many and a significant number).
So what did they find?
Here are some of the key findings:
“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).
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.
The authors conclude 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).
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.
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Adler K, Rahkonen L, Kruit H (2020). Maternal childbirth experience in induced and spontaneous labour measured in a visual analog scale and the factors influencing it; a two-year cohort study. BMC Pregnancy and Childbirth 20(1):415. doi: 10.1186/s12884-020-03106-4.
Dupont C, Blanc-Petitjean P, Cortet M et al (2020). Dissatisfaction of women with induction of labour according to parity: Results of a population-based cohort study. Midwifery 84: 102663.