The rate of induction of labour is increasing at an alarming rate. We are facing an induction of labour epidemic.
More and more women are being coerced into having their labour induced early based on very debatable evidence, and threatened with dire consequences for their baby if they do not consent. They are being told that they are “overdue”, that their placenta is failing, and a whole host of other reasons such as being too old, too big, being from an ethnic minority etc.
Over the last 2 years, rates of induction have shot up even further (in my local area, from around 25% to 35%). Surely the medical needs of the population cannot have changed that much in such a short time to justify such a large increase? I suspect this is more likely to be a knee-jerk response to the current pandemic and maternity staffing crisis. And if it is such a life saving intervention, shouldn’t we observe a drop in stillbirth rates in parallel?
Before I go any further I want to make something clear: I am not anti induction when the balance of risk clearly shows that continuing the pregnancy would be endangering the mother or baby, for example in the case of pre-eclampsia. As a doula I have supported many such births and I also feel as fiercely supportive people who want a medicalised births, as I do of low intervention ones. This is because the underpinning principle of my work is supporting body autonomy and informed choice. I am concerned by the rising rates of induction and the lack of clear evidence behind it.
But we are running into crazy territory with induction of labour. Earlier this year, the National Institute for Clinical Excellence produced a new draft induction guideline, which suggested induction at 39 weeks pregnancy for everyone who was over 35, had conceived through IVF, had a BMI over 30, or was from an ethnic minority group. I blogged about this here. The draft guideline received a lot of backlash and the final guideline which was published in November has slightly less extreme suggestions, but it still has moved the postdate induction forward, from between 41 and 42 weeks, to closer to 41 weeks. This means that yet more women are going to be pushed to be induced for the sole reason that they have reached a certain date.
I have blogged before about induction of labour for postdates, and also about the myth of the aging placenta, which is something that it usually quoted like a mantra (“Your placenta is failing right now”) to instil fear and coerce expectant parents.
I am also concerned about the fact that the reality of labour induction and risks associated with it aren’t usually discussed with parents, and I have talked about it in this blog before. What I’ve witnessed time and time again is parents only being told about the risks of not inducing, and the reality of induction not mentioned at all, and downplayed by parroting research that claims that induction do not increase the rate of cesarean.
Since March 2020, there has also been added trauma, because covid rules means that some hospitals restricted partner’s access until labour had progressed enough to warrant transfer to the labour ward. I supported such births remotely, were women were alone, having contractions, for several days in antenatal wards, without access to pain relief or any direct support from myself or their partner.
Recent published research has come to light which refutes the fact that induction does not increase the rate of cesarean. In their 2021 paper title Reducing the cesarean delivery rate, Levine et al demonstrate a clear increase (on average doubling) of cesarean rate following induction (which is something I have personally observed in hospital data since 2012). They also found no differences in neonatal morbidity. Dr Sara Wickham wrote an in depth analysis of this paper.
The authors conclused that:
Awaiting the natural onset of labor, if there are no maternal or fetal reasons to intervene, may yield no worse a perinatal outcome than an earlier induction of labor. The consequences of a cesarean delivery are known to be associated with immediate and longer-term maternal morbidity, and this may be potentially avoided, if elective inductions of labor can be minimized.
More concerning is also the fact that, in this long term study by Hannah Dahlen , induction of labour was shown to increase the rate of intervention:
Women with uncomplicated pregnancies who had their labour induced had higher rates of epidural/spinal analgesia, CS (except for multiparous women induced at between 37 and 40 weeks gestation), instrumental birth, episiotomy and PPH than women with a similar risk profile who went into labour spontaneously.
And this study also shows for the first time that induction has long term impact on the health of children, namely that:
Between birth and 16 years of age, and controlled for year of birth, their children had higher odds of birth asphyxia, birth trauma, respiratory disorders, major resuscitation at birth and hospitalisation for infection.
The authors concluded that
IOL for non-medical reasons was associated with higher birth interventions, particularly in primiparous women, and more adverse maternal, neonatal and child outcomes for most variables assessed.
In the paper by Dahlen, inductions rates in Australia were found to have tripled, with no concomitant reduction in stillbirth rates.
UK maternity statistics show that 21% of women had their labour induced in 2009, versus 34% in 2020-21. Data also shows that stillbirth rates were 3.5 per 1000 in 2009, and 3.9 per 1000 in 2020. So during this period of time that the rate of induction has gone up by 62%, without a reduction in stillbirth rate. In the Levine paper above, the authors also found that there were no differences in neonatal morbidity between the induced and non induced groups.
If induction of labour does reduces stillbirth, it puzzles me that the rate of induction steadily going up, yet the stillbirth rate is staying pretty much the same. Something just doesn’t add up. It doesn’t feel right that medical professionals mention stillbirth to coerce women in consenting to induction.
Where are we headed with this? Towards induction rates of 50% or more as it already is the case in some UK hospitals? Towards caesarean becoming the norm as opposed to the life saving operation is normally is? Towards 100% of babies being born by caesarean like it already is the case in some Brazilian hospitals?
Levine et al share this concern:
The rate at which cesarean deliveries are performed has continued to rise in these past couple of decades, for which many have expressed concern. The reason for this concern lies in the associated maternal morbidity that has been seen with cesarean delivery.
Why is it that even in the face of solid data proving otherwise, we seem to always move towards more intervention, rather than reflecting on the fact that the intervention itself is not solving the problem, and causing harm? We leave in a technocentric culture, one that always sees interventions as more desirable as waiting. One that is motivated by the fear of litigation. And one, which, as Dr Rachel Reed says so eloquently in her book ,Reclaiming birth as a rite of passage, treats the mother as potentially dangerous to her unborn baby.
In her latest book, book In Your Own Time: how western medicine controls the start of labour and why this needs to stop, Dr Sara Wickham explains that:
The female body is really capable of growing, birthing and feeding a baby and, when we support ourselves and each other to do that, intervention is only occasionally needed.
I believe that change cannot come from within the system which has created the problem, but from grassroots movements, from birthworkers who understand that birth is a healthy physiological process that mostly goes well rather than a catastrophe waiting to happen, and from women who take back ownership of their birth and demand balanced, respectful care.