Induction: How to explain choices to parents when the choices aren’t clear
One question childbirth educators are very likely to be asked relates to the pros and cons of induction, especially in the context of pregnancy continuing after 40 weeks.
Mary Nolan, Professor of Perinatal Education, University of Worcester, UK; Editor of International Journal of Birth and Parent Education
One question childbirth educators are very likely to be asked relates to the pros and cons of induction, especially in the context of pregnancy continuing after 40 weeks.Anecdotal evidence from the UK strongly suggests that parents come under intense pressure, increasing with every day post-term, to start on the induction journey. Many parents therefore are seeking unbiased, authoritative information – and the opportunity to discuss it - on the risks as perceived by health professionals of a post-dates pregnancy and to explore their induction options.
Keywords: induction, evidence, antenatal sessions, decision-making, information-sharing, discussion, question-asking, pandemic
In a recent study of use of childbirth interventions in high income countries, Seijmonsbergen-Schermers et al. (2020) compared induction rates (for all indications, not just post-dates pregnancy) across twelve affluent Western countries. They found that for nulliparous women, Ireland had the highest rate, inducing 36 women in every hundred, and Sweden the lowest rate with 14 inductions per 100 women. Germany induced 24 nulliparous women per 100 and the US and England were similar with 28 and 27 inductions per 100 women respectively. For multiparous women, Sweden again had the lowest rate with eight inductions per 100 women and again, Ireland had the highest rate with 23 inductions per 100 women. However, there is no clear correlation between a high induction rate and better neonatal mortality figures (i.e. deaths within 7 days of birth). For example, the UK has a relatively high rate of neonatal mortality compared to Sweden (in 2019, 2.9 neonatal deaths per 1,000 live births in the UK compared with 2.4 per 1000 in Sweden), yet induces more women, and the United States has one of the highest neonatal mortality rates in the developed world (5.8 neonatal deaths per 1,000 live births), yet does not have one of the highest induction rates (Nuffield Trust: Infant and Neonatal Mortality, 2020).
The figures quoted by Seijmonsbergen-Schermers et al. (2020) are population figures i.e. the actual number of inductions in a given population. Population figures are not the same as the figures generated by research which provides data only for the women and babies who participated in the particular study or studies. So, the findings from the most recent Cochrane Review (2018) of randomised controlled trials (RCTs) of induction of labour for women with normal pregnancies cannot be compared directly with population figures. The Cochrane review was based on 34 randomised controlled trials based in 16 different countries and involving > 21,500 women (mostly with low risk of complications). The trials compared a policy of inducing labour usually after 41 completed weeks of gestation (> 287 days) with a policy of waiting for labour to begin spontaneously (expectant management). The Review concludes:
A policy of labour induction was associated with fewer perinatal deaths. Four perinatal deaths occurred in the labour induction policy group compared with 25 perinatal deaths in the expectant management group. Fewer stillbirths occurred in the induction group (22 trials, 18,795 infants), with two in the induction policy group and 16 in the expectant management group. (https://www.cochrane.org/CD004945/PREG_induction-labour-women-normal-pregnancies-or-beyond-37-weeks)
The researchers also conclude that, ‘Women in the induction arms of the trials were probably less likely to have a caesarean section compared with expectant management’, but use of the word ‘probably’ suggests a degree of uncertainty. Indeed, the Review summary uses the word ‘probably’ on six occasions, and ‘may’ on three (‘may increase’; ‘may also have risks’; ‘may make little or no difference’), all implying at least a degree of uncertainty about the evidence.
The risk of letting pregnancies continue after 40 weeks, and especially after 41 weeks, remains a matter for controversy as it has been for several decades. Also controversial is the question of whether the risks of induction itself may or may not outweigh any benefits of its use. Overall, researchers have concluded:
The optimal management of pregnancies at 41 weeks and beyond is thus unknown. (Wennerholme et al., 2010)
The research evidence about the impact of induction on caesarean rates is contradictory and has been much debated by experts. (Higson, 2020)
Although induction of labor can be crucial for preventing morbidity and mortality, more and more women (and their offspring) are being exposed to the disadvantages of this intervention while the benefit is at best small or even uncertain (Seijmonsbergen-Schermers et al., 2020a).
In 2018, the same year as the most recent update of the Cochrane Review (2018), the World Health Organisation also updated its recommendations for post-dates pregnancies:
1. Induction of labour is recommended for women who are known with certainty to have reached 41 weeks (>40 weeks + 7 days) of gestation. (conditional recommendation, low-certainty evidence)
2. Induction of labour is not recommended for women with an uncomplicated pregnancy at gestational age less than 41 weeks. (conditional recommendation, low-certainty evidence)
‘Low-certainty evidence’ is defined by WHO as ‘Confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect’ (p13).
Uncertainty, therefore, persists about the optimal management of post-dates pregnancy, making the task of the health care professional and birth educator especially challenging to help women to make their own informed decision about what they would like for their birth.
How do childbirth educators help parents make an informed choice about induction of labour?
In my experience, most parents who come to antenatal sessions would like to deal in certainties. ‘When should I go into hospital after labour begins?’ ‘Is an epidural better or worse for the baby?’ ‘How long is it safe for second stage to last?’ ‘How soon after giving birth do I need to have skin-to-skin with my baby?’
Unfortunately, there are no exact answers to any of the above questions, or to most of the other ones that parents ask. This is difficult for anxious parents and cuts against the grain of the certainties that medicine tends to offer its patients (‘Do this and you will get better’; ‘I know how to treat you’; ‘You can rely on me’).
Antenatal education offers the opportunity of discussing with parents some of the earliest choices they will have to make on behalf of their children, and the chance to understand the nature of medical ‘evidence’ and what their professional carers are and are not certain about. Increasing ‘parental literacy’ around health care benefits parents, babies, health professionals and research.
WHO (2018) is very clear that, ‘The potential need for induction of labour for women with a post-term pregnancy should be discussed with women in advance, so that they have an opportunity to ask questions and understand the benefits and possible risks’. The Cochrane Review (2018) is similarly minded, ‘Discussing the risks of labour induction, including benefits and harms, may help women make an informed choice between induction of labour for pregnancies, particularly those continuing beyond 41 weeks, or waiting for labour to start and/or waiting before inducing labour. Women’s understanding of induction, the procedures, their risks and benefits, is important in influencing their choices and satisfaction’.
Women’s ‘understanding’, however, is a complex space. In the UK, at least since the Peel Report of 1970 (Department of Health and Social Security, 1970), women and those who support them have been indoctrinated by discourses of risk into believing that more technology equals a better chance of having a healthy baby and being a healthy mom. Women have seen on their digital devices, have experienced first-hand, or have been told by their friends that when there are problems with pregnancy, technology can be life-saving; so why not assume that technology is always going to be necessary for a good outcome (Dreger, 2012)? While strides have been made in all areas of healthcare towards achieving greater respect for patients’ capacity for self-determination and right to take part in decisions about their care, the unique vulnerability of pregnancy means that supporting women to assert their autonomy is never going to be easy.
As with almost all the topics you are likely to be discussing in antenatal sessions, it’s likely that, as the educator, you will have a view on induction of labour. You need to see this as potentially dangerous for the health and wellbeing of the parents in your group, as well as for the integrity of the programme you are offering.
Your aim is to share knowledge with parents and develop and support their capacity to participate in decision-making around their care and the care of their baby. As an educator, you respect the desire and need of adult learners to be self-determining. But you also recognise that in modern maternity care, women’s right of self-determination may come into conflict with midwives’ and doctors’ desire to guide patients towards interventions that they deem safest for them. As professionals, they have a duty to advocate for care that is in accordance with what they believe to be in their patients’ best interests.
So where does this leave you as an educator who probably has no responsibility for the actual delivery of clinical care to the parents in your group? It leaves you with the duty of sharing accurate, unbiased information, of enabling discussions that allow parents to develop their thinking on aspects of care, and of helping them, if needed, to acquire question asking and negotiation skills that will lead to outcomes respectful of both their and their carers’ ethics.
Sharing information about induction
What do parents need to know about induction? I would suggest the following:
• The various methods by which it is carried out (when, where, how)
• How effective/ineffective each method may be under what circumstances
• What the research says about induction (and how robust the evidence is)
• Hospital policies
Much of this information will come from the parents themselves who are likely to have either first-hand or vicarious experience of induction as it has been described to them by siblings and friends. As the educator, your role is to reflect back what the group has shared (‘This is what you all know…’) and then to fill in any gaps in their knowledge. Some parents will be interested in non-medical methods of induction such as castor oil, acupuncture, sexual intercourse, homeopathy, breast/nipple stimulation and hypnotic relaxation. They need to know that for all of these methods, the role in IOL [induction of labour] is uncertain, basically because of the lack of studies, if not anecdotal reports (Marconi, 2019).
So, parents should understand that there is no evidence for the effectiveness of these alternatives because there have been no (or at least, very few) studies – as opposed to there being no evidence because studies have failed to show an advantage.
Enabling a discussion
Information is applied by learners in the context of their real lives, both past and present. Information on controversial topics will elicit responses based on:
• Parents’ previous healthcare encounters, including their lived experience of the power-imbalance in the patient-professional relationship;
• Parents’ attitudes towards risk (influenced by whether risks they have taken in their lives have worked out well or badly);
• Parents’ confidence to make their own decisions (this relates to the way in which they were brought up; their temperament and sense of self, and the degree of support they feel they have).
As an educator, part of your remit is to increase health care literacy, that is to develop parents’ capacity to challenge medical hegemony, not with a view to demeaning professionals, or to raising spurious objections/arguments to interventions, but so as to operate a check on healthcare power that, like all power, benefits from being regularly reigned in. Therefore, part of the discussion around parents’ feelings about induction might well be to consider why it’s so hard to be an equal partner in decision-making in the childbirth space. Such a discussion might cover:
• The mental and physical challenges of labour which mean that making decisions which require the involvement of the neocortex when labour is insisting on the supremacy of the brain stem, is especially difficult;
• A sense of powerlessness when making decisions in an unfamiliar environment, surrounded by people wearing uniforms;
• A culture of fear around childbirth;
• Risk-averse attitudes that are prominent in society, especially around childbirth
• Influence of the media, both positive (e.g. ‘Call the Midwife’) and negative (e.g. ‘Grey’s Anatomy’).
In any particular group, it is likely that parents who feel strongly that induction is ‘against nature’ and that the baby should determine when s/he is born will come up against parents who think that health professionals, as a result of their training and skills, know best. When a group is ‘performing’ well, every person in it will find their position shifts, at least a little, in the course of the discussion. This is what adult learning is all about.
In rounding up such a discussion, you might want to remind parents that quality health care ‘calls for individual assessments and personalised, as opposed to standardised recommendations’ (Eide & Bære, 2020). Hospital policies are an aid to decision making, but should not be used to coerce them into courses of action that do not respond to their needs and aspirations.
Childbirth educators are very much aware of the considerable body of evidence (e.g. Brandão et al., 2020; Baas et al., 2017; Green et al., 1990) demonstrating that when women feel in control of decision-making during labour, they enjoy positive mental health after the birth of their babies. Mental health around childbirth is not primarily dependent on what care women receive, but on how it is delivered – a ‘how’ which is ideally characterised by mutual respect, listening, explanation, compromise and support. The recent UK national maternity review (NHS, 2020) talks of the centrality of ‘compassion and kindness’.
Building confidence to ask questions is a primary aim of childbirth education.
There are a number of ways that you can do this:
• By asking parents questions yourself – and listening to their responses, so modelling that having a baby and being a parent are about asking questions and getting answers;
• By inviting the group to follow up topics that have been discussed in antenatal sessions with their midwives/doctors/doulas – thereby encouraging the collection and collation of various points of view from different sources of expertise;
• By suggesting and role-playing calm, respectful questioning using the BRAN mnemonic:
‘What are the Benefits of this intervention for me and my baby?
What are the Risks?
What Alternatives to this course of action are there?
What would happen if we decided to do Nothing?
Reminding parents that very few decisions about their care in labour have to be made immediately and that it’s ok to ask for a little time to think about both the questions they want to ask and to make sense of the answers they receive.
Finally: Will the pandemic affect the induction rate?
The pandemic has provided an opportunity for a major rethink of the way in which maternity services are delivered. It is an opportunity that needs to be grasped. At this point in time, women, birthing people and those who support them are correctly anxious about the possibility of hospital-acquired infections (COVID and other), about institutional control over who can accompany the mother during labour, and about adverse side-effects of medical interventions. Black women and women of colour are – again rightly – alarmed by statistics that show they are more likely to die of COVID, and are more vulnerable in pregnancy and the perinatal period, than white women (Esegbona-Adeigbe, 2020).
From the USA, where the medical/technocratic model of labour has been predominant for many decades, comes the following statement on how the pandemic can help fix maternity care:
Among all the differences that will be part of the new normal after this crisis has passed, a new and less medical approach to pregnancy and childbirth, under the care of a midwife, promises much: fewer unnecessary interventions in birth, less exposure to infection for birthing mothers, more one-to-one care with midwives and doulas…lower costs, and healthier moms and babies (De Vries & Declercq, 2021).
Childbirth educators have their part to play in this brave new world. Grasping the nettle of induction and supporting parents to understand the complexity of medical ‘evidence’ and the determinants of both professionals’ and their own decision-making, will nurture increasingly influential and well-informed consumer involvement in the future patterns of childbirth practices (Enkin et al., 2000:27) to the benefit of everyone.
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