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Absolutely Tine! all the best Soo From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Tine Schauer Eri Sent: 12 June 2015 13:08 To: [log in to unmask] Subject: Re: Isnt the concept of low risk induction a category error? Why do we use the term ‘low risk’ if we mean no risk? I think the term ‘low risk’ is in itself a contradiction in terms. Or, is it a silent acknowledgment of the perspective that all birthing women are at risk until we retrospectively can say that they had a normal labour? If so, there is no such thing as no-risk; low-risk women have latent risks not yet identified, and the high-risk women are those with an already identified risk factor. My point is, if we subsume to the biomedical paradigm of worst-case thinking in all births, there is no wonder that concepts of low-risk inductions are evolving. Tine Schauer Eri Associate Professor Oslo and Akershus University College of Applied Sciences, Norway Tlf: +47 67 23 63 73 / 926 65 962 [Image removed by sender. http://www.hioa.no/extension/hioa/design/hioa/images/hioa-sign-en.gif]<http://www.hioa.no/eng> - New knowledge, new practice From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Church, Sarah Sent: Friday, June 12, 2015 12:52 PM To: [log in to unmask] Subject: Re: Isnt the concept of low risk induction a category error? I absolutely agree. There seems to be a risk of blurring the boundaries between what we consider to be within the realm of normality and this perception of ‘low level low risk intervention’. My concern is that midwives will see this as an opportunity to extend choice for women in relation to induction without challenging the need for it and without considering the fact that that there is no such thing as a low-risk induction. Again we come back to the issue of what we mean by low risk and the ways in which this is interpreted and misinterpreted in relation to intervention. Thanks Sarah Dr Sarah Church Reader in Midwifery School of Health and Social Care London South Bank University & Bart’s Health 103 Borough Road London SE1 0AA Tel: +44 (0) 20 7815 8351 e-mail: [log in to unmask]<mailto:[log in to unmask]> From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Soo Downe Sent: 12 June 2015 10:29 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: Isnt the concept of low risk induction a category error? Very interesting observations Allision, and I agree with you we have been guilty of what Annendale calls ‘ironic interventions’ (what midwives do is normal, and we will do it to stop doctors doing all their interventions, which are abnormal) – and your analysis of the choice phenomenon is really insightful in my view. Indeed, the issue of ‘low risk induction’ brings this into sharp focus, as now we are introducing exogenous pharmaceutical agents into the induction process and calling it low risk. Just because we have made the mistake of doing interventions in the name of protecting women from other ‘bad’ interventions before doesn’t make it safe to be extending these ironic interventions into ever more pharmacologically or technologically intensive modes in the name of normalising birth, when the interventions we are trying to protect women from are unnecessary in the first place (acknowledging that the choice debate brings in another dimension here). I have been using a house of cards metaphor to think about/discuss these kinds of issues recently – and I think we are in danger of building up interventions to prevent other interventions (rather than to prevent pathology), when there may be better outcomes for women and babies overall if we backwards-engineer the logic for each layer of the house of cards. I think we also may find that the opportunity costs of the resources we are using to do interventions to prevent other interventions are very large (now induction is being proposed for (? most) women as a general strategy to reduce ceasaren section, for instance). all very interesting food for thought! All the best Soo From: A forum for discussion on midwifery and reproductive health research. [mailto:[log in to unmask]] On Behalf Of Allison Farnworth Sent: 12 June 2015 09:45 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: Isnt the concept of low risk induction a category error? 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]<mailto:[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]<mailto:[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 4th 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]<mailto:[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]<mailto:[log in to unmask]>] On Behalf Of Sandall, Jane Sent: 11 June 2015 17:05 To: [log in to unmask]<mailto:[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<http://www.londonscn.nhs.uk/wp-content/uploads/2015/06/mat-suite-of-toolkits-062015.pdf> on the web page above. • Continuity of midwife care<http://www.londonscn.nhs.uk/wp-content/uploads/2014/11/mat-coc-toolkit-042015.pdf> • Outpatient induction of labour in low risk women<http://www.londonscn.nhs.uk/wp-content/uploads/2015/05/mat-outpatient-iol-toolkit-042015.pdf> • Midwifery led units<http://www.londonscn.nhs.uk/wp-content/uploads/2014/11/mat-mlu-toolkit-042015.pdf> • Maternity experience workshop<http://www.londonscn.nhs.uk/wp-content/uploads/2014/11/mat-user-experience-toolkit-022015.pdf> • Post partum haemmorhage<http://www.londonscn.nhs.uk/wp-content/uploads/2015/01/mat-post-partum-haemorrhage-112014.pdf> • Reducing stillbirth through improved detection of fetal growth restriction<http://www.londonscn.nhs.uk/wp-content/uploads/2015/01/mat-stillbirth-fgr-122014.pdf> • Fetal fibronectin testing<http://www.londonscn.nhs.uk/wp-content/uploads/2015/01/mat-fibronectin-112014.pdf> 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]<mailto:[log in to unmask]> | 020 7188 8149 | Skype | jsandall PA Fiona George | [log in to unmask]<mailto:[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<http://www.clahrc-southlondon.nihr.ac.uk/> King's Improvement Science | www.kingsimprovementscience.org<http://www.kingsimprovementscience.org/> “Birth in Europe in the 21st 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 [logo] [athena swan silver] Copyright in this email and in any attachments belongs to London South Bank University. 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