The National institute for clinical excellence (NICE) has published new draft guidelines for induction of labour. They are open for consultation until the 6th of July 2021.

The part that is most concerning is this:

Consider induction of labour from 39+0 weeks in women with otherwise uncomplicated singleton pregnancies who are at a higher risk of complications associated with continued pregnancy (for example, BMI 30 kg/m2 23 or above, age 35 years or above, with a black, Asian or minority ethnic family background, or after assisted conception).

You read that right. The new guidelines propose that everyone whose body mass index is over 30, above 35 years old, who is black, brown or any non white background, who have conceived through IVF, should all be induced at 39 weeks of pregnancy. I couldn’t help but wonder: how many people does this leave, who do not fall in these categories?

I had a look at the office of national statistics, to check what percentage of the population these groups represent together. I haven’t been able to find detailed enough data to remove overlaps between the groups. However, I have found the following:

• About 50% of pregnant women are classified as overweight or obese in the UK
• Black, brown and ethnic minorities represent about 10% of the UK population
• About 25% of babies born in the UK were conceived by IVF
• About 25% of babies born in the UK are from mothers over 35

I know that some of these categories overlap, but I’m guessing that not many people will still fall within the “low-risk” people being “allowed” to go into labour naturally if this guideline passes at it is. Especially as, in my experience, few people question the “guidelines” and apply them as if they were the law.

Worryingly the rate of induction has already just gone through a major rise. Since March 2020 many trusts have seen steep rise in induction (and cesarean) rates. (this is easy to find in the infographics shared from various trust pages on social media). In my local trust, the induction rate has gone from being between 25 and 30% prior to March 2020 to 39% in May 2021. Doesn’t it feel extremely odd to you that nearly 40% of the population already needs to have their labour artificially started? Isn’t it possible that this rise wasn’t justified by evidence, but rather by a knee jerk reaction to the covid crisis?

If the above guideline goes ahead as it is, what rates of induction are we going to see? Are we headed towards in a situation where everyone has their labour induced? How is this logical? How is this balanced? Have we taken leave of our senses?

The draft guidelines  are open for consultation until the 6th of July 2021. If you wish to comment, you are welcome to copy and paste some of my comments to issue your own reply to the NICE consultation. Just email InducingLabourUpdate@nice.org.uk

Dr Sara Wickham has published an extensive blog about it too.

Dear Nice labour induction team

My name is Dr Sophie Messager. I am an ex biology research scientist turned doula and perinatal educator.

Over the last ten years in this role I have seen the rate of induction of labour in my local trust rise from 24% to 39% without an improvement in maternal or fetal outcomes.

What I have witnessed however, is that induction of labour often causes trauma for mothers and their partners. I have also witnessed time and time again that true informed decision rarely takes place because the majority of parents rarely get told what induction of labour entails (in primips often a 3 to 5 days process which ends up in a caesarean). They rarely get told that it is a choice (most get told “we’ll book you in for an induction”), and they also rarely get told of the risks that are involved in inducing labour (increased risk of caesarean birth and fetal distress amongst other things). I also see a lot of coercion in making sure people consent to having their labour induced, and in particular implying that the baby might die if they do not agree. I wrote in more details about it in this blog post.

Since March 2020, most hospitals trusts banned the access of partners to antenatal wards, only allowing them during established labour, I have witnessed women being induced for 5 days, alone in antenatal wards with no support from myself or their partners. This is dehumanising and traumatising for women and their partners.

Since March 2020, I have also seen rates of induction and caesarean rise by about 10% in many hospital trusts, with no evidence behind the change. In my local trust, the induction rates was 40% in May 2021, when it was between 25% and 30% prior to March 2020. Carrying out a survey of the rise of induction rates since 2020 across UK hospital trusts since March 2020, and the reasons behind them, and whether this rise improved outcomes or not would probably prove very informative. Surely the percentage of women who go into labour spontaneously has not decreased by 10% in less than a year?

I am worried that the people who are making the recommendation in the guidelines have no experience of supporting women and their partners in labour, and in particular, induced labour, or that if they do, they have no experience of what happens in the aftermath. Most health professionals only get to see people for a few days after birth, until they leave the hospital. Doulas and other private perinatal practitioners often support new families for weeks after birth, and they may be the only ones who truly understand how traumatising induction of labour can be, especially when the process hasn’t been communicated adequately ahead of time.

The draft guidelines state the following:

Consider induction of labour from 39+0 weeks in women with otherwise uncomplicated singleton pregnancies who are at a higher risk of complications associated with continued pregnancy (for example, BMI 30 kg/m2 23 or above, age 35 years or above, with a black, Asian or minority ethnic family background, or after assisted conception).

Yet the guidelines also state that “As there was no evidence to identify the optimal timing of induction in these groups, the committee made a research recommendation”.

I had a look at the office of national statistics, to check what percentage of the population these groups represent together. I haven’t been able to find detailed enough data to remove overlaps between the groups. However, I have found the following:

• About 50% of pregnant women are classified as overweight or obese in the UK
• Black, brown and ethnic minorities represent about 10% of the UK population
• About 25% of babies born in the UK were conceived by IVF
• About a quarter of all babies born in the UK are from mothers over 35

Which percentage of the population does this leaves that still falls within a low risk group? Has this been assessed as part of the drafting of the guideline?

If the draft guideline gets published as it is we are very likely to see a further rise in an already alarmingly high induction rate, and a concomitant rise in caesarean rate, as despite some flawed research claiming that induction of labour doesn’t increase caesarean rates, in practise (and according to some recent research), induction of labour usually leads to doubling of the rate of caesarean. See https://www.sciencedirect.com/science/article/abs/pii/S0301211521002463.

I am worried that we are headed for the same rates of caesarean as countries like Brazil or China (which are around 50%), without improvement in birth outcomes.

Experience and history (for example in the case of the Hannah breech birth trial) shows that when new guidelines like this one get published, they tend to get adopted widely without question within maternity care, and that, even when new evidence disproves the original results, it is very hard to get the system to change, because the belief about what is “normal” has become entrenched within maternity care.

The long term impact of a rise induction of labour on the health of the general population is this happens is greatly concerning. As concluded by the author of this study explains:

“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.“

More worryingly, there appears to have been no consultation of the interested party, i.e people having to undergo the actual induction of labour (women and their partners) in the drafting of this guideline.

I urge you to reconsider these guidelines, and in particular, ensure that a consultation of the experience of induction of labour for mothers and their partners takes place prior to any new recommendations being made. I would also like to see the long term physical and mental health implications for families and babies taken into account to balance the recommendation.

Regards

Dr Sophie Messager