Dear Alison and colleagues,
Thanks, that is really helpful - I am kind of heartened by the knowledge that the IOL epidemic once subsided, and maybe our current upward trends will also subside over time. We do clearly have a multi-factorial increase in IOL, associated with over-intervention that has uncertain benefit for babies (in the sense that we don't really know yet which babies, if any, benefit and whether any identified benefits might come from one or from a combination of the SCB interventions, or from any of a number of other changes) and additional health burdens for women, as well as for resourcing intrapartum care.
I am always interested that the press reports that discuss increased IOL rates very quickly refer to increased complexity and women who are older at first pregnancy as the underlying justification, but I have never seen anything which shows the induction rate and broken this down into the reason(s) for IOL and trends for these, to substantiate this. I am not even sure whether primary reason for IOL is recorded, or recorded consistently enough, that this question could be answered. Perhaps we need something like a Robson categorisation for IOL, or a quality indicator for IOL decision-making, to help unpick what's happening here, or maybe there are already detailed reports available, that I'm not aware of? I'd love to know, if there are.
It's interesting to compare with the Scandinavian countries, many of which have high OU birth rates, but yet lower interventions, much like the early 90s here (I am so glad I gave birth then, even though I wasn't 'allowed' a home birth, I was much safer from over-intervention in OU than I would be now!)
Best wishes
Kirstie
From: Macfarlane, Alison <[log in to unmask]>
Sent: 26 October 2018 16:14
To: Coxon, Kirstie <[log in to unmask]>; A forum for discussion on midwifery and reproductive health research. <[log in to unmask]>
Subject: Re: New maternity statistics for England published today
Dear Kirstie,
A point I forgot to mention that the research in Cardiff in the 1970s was the MSc project of a young obstetrician just back from two years working in Gaza who went on to do an MSc in Public Health at London School of Hygiene. He criticised the unrandomised analysis of the 1958 perinatal mortality survey and said we needed randomised trials. If you haven't guessed, that was Iain Chalmers.
Alison
________________________________
From: Macfarlane, Alison
Sent: 26 October 2018 15:07
To: Coxon, Kirstie; A forum for discussion on midwifery and reproductive health research.
Subject: Re: New maternity statistics for England published today
What happened to induction in the 1970s was that an analysis of the 1958 perinatal mortality survey had been published showing that perinatal mortality was higher among post term than term babies. This was assumed to be causal rather than selection. So without looking for further evidence in an era when RCTs were few and far between and systematic reviewing hadn't yet been invented the powers that be decided that post term babies should all be induced. Then the definition of 'post term' widened so that the induction rate shot up to 44 per cent. This was challenged by the campaigning groups which were also campaigning for home births in reaction to the Peel Report, which had also decided, in the absence of evidence that all births should take place in hospital. There was some evidence to oppose the induction epidemic. An analysis of a 'natural experiment' comparing trends over time in two maternity units in Cardiff with very contrasting styles of practice failed to support the conclusion that rocketing rates of induction would reduce perinatal mortality. A key campaigner in this was Jean Robinson, who was very active in AIMS until the recent coup. Amazingly, the epidemic subsided. The gap in the data was because of change in data collection. It was difficult to collect data about induction in the previous system as it recorded ARM and oxytocics but didn't distinguish between their use for induction or augmentation, so the 44 per cent may be an overestimate, but the rate was certainly high. So a combination or research and strong minded campaigners seems to have been a key factor.
Today's epidemic, I gather, is in response to the late Secretary of State's 'ambition' to reduce our stillbirth rates to the same level as in Norway, where intervention rates are low and the midwifery profession is strong. Those of you who sit on committees can correct me, but I understand that two components of the 'Saving Babies Lives' care bundle are fetal movement counting, which the AFFIRM trial has shown didn't reduce stillbirth rates but did increase induction and caesarean rates and electronic fetal monitoring which also has been shown to increase intervention rates but not to decrease mortality.
It looks to me as if 'Saving Babies Lives' is much more powerful than any 'Maternity Transformation plans'. Are there any campaigners left out there, apart from those campaigning for caesarean section on demand and for privatisation of midwifery care?
Perhaps Norwegian midwives are the people to ask for advice?
Best wishes, Alison
________________________________
From: Coxon, Kirstie <[log in to unmask]<mailto:[log in to unmask]>>
Sent: 26 October 2018 12:19
To: A forum for discussion on midwifery and reproductive health research.; Macfarlane, Alison
Subject: RE: New maternity statistics for England published today
Dear Alison
Thanks for circulating these statistics and for sharing the attached graphs. Out of interest, do you, or other list members, know what on earth was happening with induction in the 1970s? (Graph 2) Or how it managed to rise and fall so dramatically? Perhaps there are lessons there for us now?
Best wishes
Kirstie
From: A forum for discussion on midwifery and reproductive health research.
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