Induction: a published article written by Virginia Howes

This article was published in THE PRACTICING MIDWIFE (2004 Jul-Aug;7(7):45-6) 

Thousands of women in this country with normal pregnancies and healthy babies are being put at risk every day in maternity units across the country. Yet like lambs to the slaughter they pack up their bags and head for the hospital in the belief that the doctors, who instigate the barbaric treatment they are about to undergo, are saving their babies lives. 

Many of them then spend the next few days in excruciating pain over and above that what is experienced in normal labour in an effort to drag their unready and unwilling bodies into labour. Their bodies are filled with drugs that may compromise their long-term health so they begin the spiralling cascade of interventions that all too often culminates with entry through the theatre doors. 

The women and their families thank the doctors and hospital guidelines for saving them from the problems they had, problems that are often itrogenic in origin. And so the myth, that their bodies are failing them in the one thing women are best at, procuring a future generation, is perpetuated.

To add insult to injury my colleagues, midwives, who by definition of their title should be the protectors of women and babies, help daily to continue this unnecessary practice. Induction of labour for no medical reason has become a socially acceptable procedure.

The N.I.C.E. (National Institute for Clinical Excellence 2001) Guidelines are the gold seal that have been adopted with open arms and are now governing practice in maternity units throughout the country. The Induction of Labour (IOL) is one such guideline and one that recently instigated a rather heated conversation between a hospital antenatal clinic midwife and myself. Her role as head of the clinic involved speaking to many women who were booked for induction and therefore she was in a very responsible position to give true and unbiased information about IOL to large numbers of woman.

I had telephoned the clinic to arrange an ultrasound scan for a client who was 42 weeks pregnant with her second baby. The pregnancy was normal. The client was very well informed and despite knowing there was no evidence to support fetal surveillance had decided on a scan to check the well being of her baby. Social pressure had made her feel that she needed to "do something" and this course of action, she felt, at least appeased her family, friends and neighbours. What she did emphasise to me was that she did not want to be put under any pressure by anyone to be induced and this I clearly explained to the midwife I conversed with. I asked her to pass that information on to the midwife in charge; an appointment was made for 2 days hence. The following morning I received a letter from the midwife in charge. The letter informed me that a review of the hospital notes made the clients dates "wrong" and stated "in accordance with N.I.C.E Guidelines on post maturity, no woman should go over 42 weeks".

After reading the letter my client, feeling that was this was just the pressure she did not want to subject herself to, lost all faith in the maternity unit. She understandably felt that she would not be given the respect to make her own decisions especially as, without meeting her, judgment had been passed on her by the professions from which she had requested help. Also she must be a stupid woman after all if she knew when she got pregnant! She cancelled the appointment.

The guidelines of course do not say what the midwife had stated. The letter left me in no doubt that this head of antenatal clinic not only had not read the guidelines but also more worryingly had put her own interpretation on them. If this is but one example of how they are being used to manipulate and lie to women what hope do women and society have of knowing the truth and making an informed choice?

Following the publication, in Canada, (Hannah 1992) of the largest Randomised Controlled Trial (RCT) to date concerning induction of labour and further meta-analysis of other RCT The Royal College of Obstetricians and Gynaecologists (RCOG) adopted of the policy of offering induction at 41 weeks. This is now the recommendation of what is regarded as gold standard, The National Institute for Clinical Excellence (N.I.C.E) Guidelines. 

However what is not widely known by obstetricians and midwives alike is that all the studies used to govern today’s practice was and is based on 8 babies! In the case of induction of labour, the number of babies that died following their mothers being induced versus the numbers of babies that died following their mothers left to proceed with pregnancy beyond 41 weeks. There were approximately 3000 women in the IOL group and 3000 in the expectant management group. One baby died in the IOL group and 7 died in the expectant management group.

Hey presto it is obvious then many babies’ lives will be saved if we offer to induce every woman over 41 weeks. 

Does anyone care about looking at the wider picture?

I was taught as a student nurses on diploma courses at the very beginning of my education not to use research that is more than 10 years out of date to underpin my practice. Yet to govern and recommend practice affecting thousands of women and babies, many of the RCT in the Meta analysis used to compile the N.I.C.E Guidelines are more than 20 years out of date, some of the studies even 40 years old. Whilst the way women grow and birth babies has not changed in millions of years, the ways our health as a nation and the ways in which maternity care is delivered and received certainly has. Never more so than in the last 40 years. We now have testing and screening so that abnormalities can be detected earlier fetal surveillance is available for at risk babies and the appropriate care free and accessible to all women.

If we do indeed look at the wider picture we see a whole new one emerging. Of the seven babies that died, two occurred in the 1960’s one of which had a suspected diabetic mother. Hardly a good inclusion criteria in a controlled trial by today’s standards. One baby had pneumonia that is irrelevant to induction of labour. One from a Chinese study that the baby had Meconium aspiration following refusal of induction of labour by its mother after a positive amnioscopy. Another from Meconium aspiration at 43+3 weeks, which would not have any bearing of induction at 41 weeks. One was from a placental abruption, which could occur at anytime. One was a baby of 2.6 grams and clearly growth retarded and the mother had received no antenatal care, (Menticoglou and Hall 2002).

Based on these finding where is the evidence that there is an increased risk of unexplained still birth at 41 weeks? How are the benefits to the 20-25% of women and babies that are being daily induced being demonstrated?

How are we as professionals informing women of the risks of induction of labour versus continuing the pregnancy? Are women given the information in a true and unbiased manner? I doubt it. Just as women are only told the "risks" around birth when they are planning a home birth but conveniently not told the many more risks associated with going into hospital. A woman screened for having a Downs Syndrome baby is informed that if she has a risk factor of less that 1:250 she is a low risk and further action not recommended and yet at 41 weeks gestation she is offered (if indeed it is an offer) IOL because the (very dubious) risk of increased stillbirth is 1:1000.

In a detailed review of the literature Menticoglou (2002) also highlighted details of a women who died in a hospital awaiting treatment for what appeared to be fulminating eclampsia. She was waiting because the wards were full and busy. As many midwives know the wards are often full to capacity and often due to the amount of routine induction of labours that are on going at any one time. Where do women and babies such as these two who died feature in the calculation of risk?

Other than the Hannah trial no further studies were looked at in depth for taking into account when devising the N.I.C.E guidelines. There are other good retrospective studies looking at this subject. Many that shows a substantial increase in the caesarean section rate for routine induction of labour and no significant difference in neonatal outcomes for women and babies that are left alone to continue with healthy pregnancies. The cost to the maternity services must be phenomenal. A cost that could be put to far better use. Money that could spent on improving services so that midwives come back to the profession. Then women and babies who ARE at risk from on going pregnancies may well be highlighted appropriately through good antenatal care instead of a hurried 10 minutes at each antenatal visit and routine induction for all!

We also must not forget the baby in the whole process because it too plays its part in the instigation of labour. The baby is not a passive receiver of the labour process and induced earlier may not have the readiness for labour itself. The biggest reason of all (22%) given in the National Sentinel Caesarean Section Audit (RCOG 2001) was fetal distress. Even given the many wrong diagnosis of fetal distress that exist how many of these babies were induced before they were ready to be born.

Routine induction of labour has become a socially acceptable norm. It is time we professionals, we who are the instigators of what over time becomes "normal" in women and societies eyes, stop this barbaric treatment and give back to women the respect that they and natures deserve.