I agree with all you have said Sheila in principle – though of course the same reasons could be put forward for not having any healthy women and babies in labour in a hospital setting! - but one of the reasons that women who do need to be induced (or, indeed, who do need to be in hospital in spontaneous labour, if they do indeed have real risk factors for actual pathology) are not getting the attention they need and deserve is that so many women are now being induced who are in fact healthy (and whose babies are healthy).

For me, the issue is, as I said earlier, one of category error, and of technocratic slide. In increasingly reifying induction of labour as a simple, no-risk process that we can use to reduce other interventions that we know are not low risk (CS without real indication for example) we permit it to become trivial as an intervention, meaning that we do it more often, meaning that we cant properly support and care for all those experiencing it, meaning that we find ways to get them out of the hospital (which does in fact coincide with women’s preferences under these circumstances) but also meaning that we run the risk of both making induction the expected norm (indeed, rending women ‘bad mothers’ if they decline the offer of induction, and staff as negligent if they don’t offer/push it) and, importantly, meaning that we fail to see and attend to the women /babies who really do need induction and close support/care because they really are at risk.

So we potentially end up with this paradox, where staff who wouldn’t dream of suggesting to healthy women and babies that they labour spontaneously at a birth centre /home (even though the evidence supports this in the vast majority of cases) quite happily suggest (even encourage, to reduce bed blocking?) that women who have undergone pharmacological induction go home (even though there is no evidence either way on the risks and benefits of this) and, due to the routine nature of induction in general, we may become less alert to the potential dangers of induction, especially in  women/babies who really do need it.

I’m not opposed to induction of labour and/or to women being supported properly to go home or to a birth centre (and not just sent there because so many women are being induced that the staff in the hospital cant support them)  if they are induced for good reason(and if they are  not then abandoned because there are no community staff to support them, an d the labour ward phone is always busy when they try to check I). However, I really feel that we should go into this whole arena of ever-widening criteria for labour induction with our eyes wide open, and make sure that we are not falling (again) into the trap of trying to ameliorate a technocratic extension of routine intervention for the vast majority of women that only in fact benefits very few  (the 2012 Cochrane review of routine labour induction at or beyond term found that between about 320 and 1500 women/babies need to have their labour induced to reduce perinatal mortality by 1, for instance).

Surely the solution here is to argue that less is more: that midwife-led continuity of care and/or women’s groups might have the same or even better impacts on reducing prematurity/mortality/instrumental birth, and that we can then reserve IOL for those women and babies who really are at risk of pathology when they go overdue, and who therefore need and deserve an offer of labour induction with proper staff care and attention and support, wherever this may be given?

We have been here with twilight sleep, routine episiotomy, near-routine CS in some countries. I think we just have  to be very careful that we don’t fall into the same trap again – it is so hard to undo it once it is done…

all the best

Soo

From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Sheila Brown
Sent: 13 June 2015 00:03
To: [log in to unmask]
Subject: Re: Isnt the concept of low risk induction a category error?

An interesting debate and a topic that I am particularly interested in, but I wonder if important points are being missed by focusing on whether labour induction for prolonged pregnancy should be categorised as low risk or not? What do women think? Do they realise that when they are "offered" labour induction for prolonged pregnancy that they will be admitted onto an antenatal ward and that the process of cervical ripening may take a few days? Do they consent to this? Are they making a fully informed choice? Allison previously raised some of these points.

I asked women about their experiences of cervical ripening on  an antenatal ward through undertaking a small qualitative study in the UK. There is a perception that an antenatal ward is a safe environment for cervical ripening however, women stated that they felt alone, separated from significant others and that they had not been adequately informed about the process of cervical ripening. I wonder where the ring fence of safety ends when women are admitted to hospital for cervical ripening? Women I spoke to were permitted to leave the ward for periods of time, which a few said they did in order to spend time with their partners. One woman and her partner sat in their car in the car park of the hospital. So, is sitting in the hospital café or in a car in the car park safer than going home? What care do we offer women when they are admitted to an antenatal ward? Intermittent assessment of the fetal heart rate or intermittent monitoring tells us very little. Women I spoke to stated that they felt that their complaints of pain were ignored. I wonder if they had been allowed to go home for a period of time and advised to return to hospital when they were feeling uncomfortable, if their complaint of pain would have been more readily addressed? I agree that the procedure of cervical ripening should not be considered a "low risk" intervention, but I am not convinced that inpatient cervical ripening reduces risk significantly.

My interest in this area does stem from previously working as an obstetric nurse in BC, Canada, where women were (and still are) routinely discharged home during cervical ripening. I am not saying that all women should be discharged home, but I do think that women need to be adequately informed about the process, risks and offered a choice of environment. There is more to this than determining whether the process of cervical ripening should be considered low risk or not. There are risk to women sitting on an antenatal ward for hours, being separated from their families and feeling like they are not being listened to.

Perhaps we need to involve the views of service users in this debate.

Sheila

On 12 June 2015 at 09:45, Allison Farnworth <[log in to unmask]> wrote:

We’ve been doing some work with practitioners and pregnant women around this issue in Newcastle as part of an NIHR Knowledge Mobilisation fellowship, with the aim of increasing the use of high quality evidence in discussions about induction; we have chosen to focus on the issue of postdates induction as an issue of concern raised by service users and staff.  Note that we are trying to increase the use of this evidence, not suggest that it is the only form of knowledge used in individual decisions about IOL – we just want to make sure it’s somewhere in the discussion.

The qualitative work we did suggested that a major barrier to evidence use is the way in which postdates IOL is offered; not as a choice but as something that ‘happens’ (the phrase ‘what we allow’ and ‘what I’m allowed to do’  came up again and again, as it sadly does in many aspects of maternity, and indeed health care).  The set-up of services created an additional layer of influence in terms of what is viewed as a ‘good’ choice (i.e. go along with local guidelines, midwife will arrange the induction) and what is viewed as problematic (i.e. you want something different?  You need to see a consultant).  Where a choice is not presented as a choice (i.e. the alternatives are not described) then this decreases a woman’s motivations to seek information about her options, and where women don’t ask questions health care professionals assume that they’re happy and don’t want any more information (added to that the difficulties of accessing, interpreting and discussing the evidence base, particularly when it involves discussion of risks around difficult topics like stillbirth).  Additionally, the issue of who holds the power to decide was relevant, with midwives shying away from discussion of risks and benefits when they felt that they ultimately couldn’t sanction decisions (e.g. not wishing to provide information which could support the idea of going for care which is ‘off guidelines’ when that would mean involving a consultant).  So in terms of implementation it is far more complex that just providing the information, to either staff or women, there are cultural and institutional forces at play – the fact that induction is viewed as routine is a major barrier to increasing choices.

The issue was just as difficult for women who requested IOL without indication (similar issues to the elective CS debate which has been occurring on the mailing list recently) – it seemed as if evidence was given to them selectively, to support the position set out in the guidelines (or the position of the individual clinician).   Incidentally, many women I spoke to were more than happy to complete their pregnancy as soon as was possible and it’s important to note that many were engaging in all kinds of activities to try and induce labour ‘naturally’ – some of these activities were potentially dangerous (i.e. performing multiple cervical sweeps on themselves or getting their partner to do it, castor oil etc.).  I think in our wish to give good information about the benefits of physiological labour, we need to be very careful not to alienate women who don’t place a lot of value on that (for some women, labour is just a means to an end, and one they would happily accelerate or omit if they were able to). 

We’re currently working on a service development initiative, working with service users and frontline practitioners to see whether making choice explicit, providing good quality information, and then supporting choice makes a difference (in terms of knowledge, confidence and perceived involvement in decision making).  We’re also doing some work with a health economist to look at the way in which women prioritise different factors when making choices about induction at term.

Sorry, I have rambled on a little there!  To address the low risk/high risk issue of the original post – risk is on a continuum and informed by individual risks and population level risks.  Low risk postdates induction involves women with no pathology who just happen to fall into a category where we know that risks of stillbirth are raised at the population level (although this is rarely communicated well to women).  It’s a very blunt screening tool but, as we are not good at identifying which are the women most likely to experience an adverse outcome, we offer IOL to all. Induction itself is clearly an intervention, so not low risk, but if evidence supports it being an intervention which can be safely managed in an environment designed for low risk situations for women who are having the procedure in the absence of an additional individual pathology, then I think we should consider that – if that matches a woman’s preferences.   It’s worth remembering that we perform cervical sweeps at home/in clinics and consider it a  spontaneous onset if the woman subsequently labours – but it is an intervention and one which appears to be administered to ‘low risk’ women quite liberally and haphazardly in my experience, food for thought!

Thanks, Allison

From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Yvonne McGrath
Sent: 12 June 2015 12:47 AM
To: [log in to unmask]
Subject: Re: Isnt the concept of low risk induction a category error?

Hi 

I also totally agree. The concept of a low-risk induction is slightly bonkers and comes back to the interpretation of risk...going beyond 42 weeks versus the risk of induction.  In many cases women who may opt ( as most actually labour spontaneously prior to 42 weeks) to decline induction are treated as though they are playing a game of Russian roulette rather than making an informed decision to wait for spontaneous labour.

As we go 'forward' and things like the RCOG position paper on maternal age and induction inform practice the more I feel like the importance of properly informed consent (as enshrined in recent case law- health care practitioners take note?) increases. To quote the adage- It's not an informed decision unless you have all the information and just as we train women to be 'compliant' midwives are often 'compliant' or even indeed  to 'believe' all of the 'information' that they give to women.  "We offer IOL as the risk of stillbirth increases" but without giving the actual figures...

Yvonne

On Thu, Jun 11, 2015 at 11:41 PM, Lucia Rocca <[log in to unmask]> wrote:

Hi,

I completely agree!

We are getting to the paradox. In many Trusts if women agree to be induced and start labour with 1 Propess they are considered low risk and have access to AMUs....

Why where those women induced in first place?

xx

Lucia

Lucia Rocca-Ihenacho

Consultant Midwife for Public Health

St George's NHS Trust
4^th Floor Lanesborough Wing
St Georges Hospital
Blackshaw Rd
SW17 0QT
London
UK

PhD Student

Centre for Maternal and Child Health Research

School of Health Sciences

City University London

1 Myddelton Street

London EC1R 1UW

07989 230313

Skype contact: luciainsky

On 11 June 2015 at 23:33, Soo Downe <[log in to unmask]> wrote:

This looks like an important initiative that is likely to improve care in many areas, but I have to say,  I just don’t get the concept of a low risk induction. If a woman/baby is low risk, why are they being induced? I was always taught that you never undertake induction of labour unless you are prepared to do an emergency caesarean for the reason that the induction is taking place. So all women who have their labours induced are high risk aren’t they, by definition?

Or am I missing something fundamental here?

All the best

Soo

From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Sandall, Jane
Sent: 11 June 2015 17:05
To: [log in to unmask]
Subject: NHS England London Strategic clinical network for maternity toolkits to improve experience and outcomes across London

Dear all

The NHS England London Strategic clinical network for maternity had a launch event yesterday.

http://www.londonscn.nhs.uk/networks/maternity-childrens/maternity/

The Overarching aim is to reduce variation in outcomes and experience of care for women and their babies in London.

FOCUS AREAS are

§ Maternal mortality

§ Reducing stillbirth

§ Women’s experience

A range of briefings and implementation toolkits are available on the website along with a fantastic film about IMPROVING MATERNITY EXPERIENCE ACROSS NHS SERVICE. The Maternity toolkits cover two work streams on models of care and improving outcomes, and are evidence based and address implementation by providing examples from London.

§ You can see the Full suite of toolkits on the web page above.

§ Continuity of midwife care

§ Outpatient induction of labour in low risk women

§ Midwifery led units

§ Maternity experience workshop

§ Post partum haemmorhage

§ Reducing stillbirth through improved detection of fetal growth restriction

§ Fetal fibronectin testing

Regards

Jane

______________________________________________________________________________

Jane Sandall
Professor of Social Science and Women's Health

NIHR senior Investigator
Division of Women’s Health | Faculty of Life Sciences & Medicine | King’s College London |Women’s Health Academic Centre | St. Thomas' Hospital

London| SE1 7EH

Florence Nightingale Faculty of Nursing and Midwifery

http://www.kcl.ac.uk/lsm/research/divisions/wh/index.aspx

[log in to unmask] | 020 7188 8149 | Skype | jsandall
PA Fiona George | [log in to unmask] | 020 7188 3639
https://kclpure.kcl.ac.uk/portal/jane.sandall

Maternity and Women’s Health and  Capacity Building theme lead
NIHR CLAHRC South London | www.clahrc-southlondon.nihr.ac.uk
King's Improvement Science | www.kingsimprovementscience.org

“Birth in Europe in the 21^st Century" is now published in English and is available  http://www.euro.who.int/en/health-topics/Life-stages/sexual-and-reproductive-health/publications/entre-nous/entre-nous/birth-in-europe-in-the-21st-century.-entre-nous-no.-81,-2015

--

Sheila JS Brown

07840 296 731