Episode 33 - Induction
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD.
Mel:
[0:08] And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey. Welcome to another episode of the Great Birth Rebellion. And today we welcome Hannah Darland, She's a professor of midwifery at Western Sydney University and has had a very, very long career in midwifery internationally and locally here in Australia. So welcome, Hannah, to The Great Birth Rebellion.
Hannah:
[0:42] It's lovely to be with you.
Mel:
[0:43] We're going to talk about induction today. And I've invited Hannah because recently, 2021, she, along with some other massive, heavy-hitting authors, Hannah, like, look at this lineup. Charlene Thornton and Sue Down and Ang DeJong and Sally Tracy and Mark Tracy and Andrew Bissertz, Lillian Peters, and there's another person whose name I can't pronounce, so I'm guessing that's, like, the statistician. But is it?
Hannah:
[1:10] Tell me. Well, Lillian was the main statistician involved in it. And Anna is another statistician, yes. She's definitely got a statistician. They're both Dutch. Very good at statistics.
Mel:
[1:22] Right. So massive, like real famous research behind this paper. So you know it's going to be good. So we're going to talk about that later in the episode as well. And Hannah's been also doing some recent research in the best study about women's experience of induction. So we're going to bring all that data in as well. So we wanted to start by just talking you through the steps and process of an induction because this term, oh yeah, we're just going to induce you or women are like, yeah, I got induced. It kind of sounds a bit benign and like you walk in and you just get induced and then your baby comes out and everybody's happy and it's all fine. But an induction is kind of quite an involved process. So I thought before we start speaking with Hannah about all the research that I'd just step you through what to expect if you're going to be induced. So you've already agreed to be induced. Here's what's likely to happen to you. And the process might change depending on which hospital you're at. So the day before your induction, you will attend some kind of day clinic at the hospital where they'll do an internal exam to assess your cervix. And then they give it a score. So it's called the Bishop score and they allocate a score to kind of how ready your cervix is to go into labour or to be open enough so that they can break your waters.
Mel:
[2:48] So if your cervix is what we would call favourable, then you may not need this first step. They may just say, yep, your cervix is ready. Come back in the morning to get your induction started.
Mel:
[3:03] Or they'll say your cervix is closed and long and hard and we can't actually get through your cervix to break the waters. So they can do a number of things at that point and it will depend on the hospital's policy and on the clinician and sometimes on the doctor of the day as to what they'll recommend to get your cervix ready for the next day's induction process. So already, it's likely to be a two-day process and may involve an overnight stay at hospital. So when you arrive, they'll do that. So firstly, be prepared for an internal vaginal exam where they will put two fingers into your vagina to find and assess your cervix.
Mel:
[3:44] Then they'll offer you some kind of prostaglandin gel or tape or something that will cause your cervix to soften and open. Sometimes they also use what's called a Foley's Cassata, which looks like a little tube with a balloon on the end that gets to the size of a walnut, maybe, when you inflate it.
Mel:
[4:09] So they would put that in your cervix, which literally kind of mechanically starts to open your cervix. So basically they inflate this balloon in your cervix which mechanically makes a change and tries to mechanically dilate it and release prostaglandins in the hope that this either triggers off labour or makes your cervix favourable and open enough that they can break your waters. And that's the same idea with this gel or the tape that they put in and it depends on the brand and again the hospital as to what technique they use to do this. So any of these first steps could actually send you into labour as well. So at each step here of induction, your body might respond and actually start labouring on its own, which is great. And it reduces the number of steps you need afterwards. Likely on this day, they'll also do what's called a CTG. So again, we had an episode on this way back when, I can't remember what number it was, with Kirsten Small, but a CTG is put on to make sure that your baby has not been compromised by these initial few steps. And some hospitals will happily send you home to come back in the morning. Others will require you to stay in hospital overnight for monitoring. So it's up to you to find out from your hospital what their usual process is.
Mel:
[5:32] So assuming everything goes beautifully overnight, there's no complications from this and also ask them what the complications are because every single one of these steps has risks as well as benefits. So it's not risk-free. You may go into labor overnight. Fantastic. If not, you'll be sent down to birth unit in the morning or sometime in the following day to start your induction. Sometimes if you request it, they may offer you a second dose of whatever they originally put on your cervix to see if they can create any more change in your cervix. If it's discovered that that initial step has not ripened your cervix, that's when they might offer you a second dose. Or, and again, depending on your clinician, they may suggest a cesarean section instead of attempting more steps to start an induction. but it's quite individual so that's not always going to happen. So you'll be head down to the birth unit if your cervix is favourable.
Mel:
[6:35] If it is fabulous, again, you'll have a CTG put on that monitoring, which will likely be continuous if you're having an induction because an induction is an intervention that we know could stress your baby and create additional complications. So the CTG is put on to monitoring. You'll receive another vaginal examination, which will check where your cervix is up to, if it's favorable for your waters to be broken. And if it is, they will break your waters with a little, looks like a crochet hook, what we call an amnihook. And that's the next step in your induction. Again, you could go into labor after having your waters broken if they don't start the next step, which is the drip. So for people who are keen maybe not to have a full induction process, you could take each step one at a time. So have the gel, see what happens with that, maybe a second dose of gel or the Foley's catheter, whatever it is your hospital uses.
Mel:
[7:38] Then you could have your waters broken and ask for some time to see if that's a thing that might put you into labor. And that's entirely possible, particularly if you're getting closer to your due date or you've had babies before. I've seen that work quite well without the need for any more induction processes. But typically your waters will be broken and then they'll start an IV drip so it's in your vein and you'll be attached to that for the rest of your labor so already we've got the CTG monitor on which depending on the hospital might be attached to a CTG machine so have cords and leads to that so you kind of tethered to that then yeah so you've got the CTG on then you they will start an IV drip with what's called syntocin on if you're in Australia, pitocin if you're in America. And I guess in the UK they use something, but it's artificial oxytocin.
Mel:
[8:34] And they start at a low dose and then there's a protocol for how they will increase that every half hour or hour to respond to how your body's responding. So they give oxytocin because if you were to go into labor spontaneously without this induction process, that's part of what your body will do. It'll release oxytocin from your brain. Your uterus then receives that oxytocin and it'll elicit contractions. That's a very simplistic idea of how labor starts, but they're trying to mimic all the possible things that they know about labor to see if they can get you into labor artificially. So they're inducing labor.
Mel:
[9:17] So by the time your induction is completely underway, you will have your waters broken. So you'll have fluid leaking. So probably have to wear a pad or something because that'll keep leaking through your labour. You'll have the IV drip going, which will start to induce contractions. And you'll have the CTG monitor attached. So with all of this, they'll often tell you you can't use a bath. You may be able to use a shower if the CTG monitor has what we call telemetry, so it doesn't have cords. You can actually take your drip pole off to the toilet, off to the shower. And sometimes, depending on the hospital, you might be able to submerge yourself in the bath for labour. But that's kind of if your hospital's got top quality equipment and access to that and train staff to do that. So you'll start to get contractions which are mostly controlled by how much oxytocin or syntosin or pitocin is coming through your drip. So once they establish a contraction pattern with this medication, they'll decide at what point they're going to stop increasing the dosage of the medicine that's coming through your drip. And sometimes they'll go up and down trying to find a balance for what's the right level to get the right amount of contractions to hopefully create a change in your cervix and start the labour process off.
Mel:
[10:41] That's a bit of a nutshell of what an induction will involve. And before we start going into the other nitty gritties of this, just a disclaimer that some inductions are absolutely completely necessary and will create better outcomes than waiting. Obviously, that's all very individual. But I think we're talking about induction today because it's so overused and plugged as a necessary part of something like 40% of women's births. Now if we look at the mothers and babies report. And so we kind of want to take out the inductions that are actually medically necessary where the woman and baby would most likely be much better off being induced than staying pregnant. We're going to put those into the medically necessary inductions.
Mel:
[11:27] And what we do want to really highlight is the possible benefits and risks to
Mel:
[11:33] being induced and sometimes those risks are outweighed by the benefit of being induced. So these are the decisions you always make. So here we want to just really try and flesh out what are the risks and outcomes and possibilities of being induced so that if you're presented with the option of being induced, you can decide do these risks outweigh the or benefits outweigh the risks of what is being offered to me so we're not saying decline all inductions because some of them are really life-saving and helpful but we are challenging the idea that so many women need inducing and we'd like to know what the impact of that is going to be like on women and their babies so q hannah so if hannah can you give us a rundown.
Mel:
[12:24] On so this particular paper that I really wanted to flesh out with you today it's open access so if anybody wants to read it you can actually just google it but also it'll be in the resource folder for this podcast if you're on the mailing list you'll have the link to that it's called intrapartum interventions and outcomes for women and children following induction of labor at term in uncomplicated pregnancies. And it's a 16-year population-based linked data study. We're going to tell you what all that means in a minute, of course. But basically, you're looking at full-term pregnancies that were uncomplicated. That's where the data came from, right?
Hannah:
[13:07] Yeah. And it's in the BMJ Open, which means it's an open access journal, which means that anyone can basically click on the link and get the full article. But the other thing that we did alongside this is a conversation article. I think that would be really useful to upload because even for a hardened academic like myself, these can be very boring papers to read and fairly heavy once you get into all the statistics. Whereas in the conversation article, we step it out in everyday language with lots of links for women to read further if they want to.
Mel:
[13:43] Yeah, so we'll make sure to put the link to the conversation article in the show notes of this podcast as well. So you can just click on through and get to the conversation article that Hannah's talking about as well. So Hannah, can you talk us through what was this study? And we'll talk about the findings as well. But what did you do?
Hannah:
[14:03] Yeah, so a little kind of context to why we did this study is probably really important. And I don't know how much you want to go into the existing evidence on induction of labour. Yeah, go into it all. Yeah, because really we were driven to do this by the ARRIVE trial. And that was a large, very well run. And, you know, it's really important we don't badmouth good research, but all research has got its limits. So the ARRIVE trial was a big trial undertaken in the U.S. In 2018, and it is a huge trial. It had over 3,000 women in an induction group, 3,000 women in an expectant management group, which means that basically women were randomly allocated to being induced or waiting for their labor to start. So being induced routinely at 39 weeks or waiting for their labor to start until 40 plus 5 is the kind of, you know, maximum. And they were first-time mothers and they randomly allocated them and they induced half and they waited for half until the maximum of 40 plus 5. And when they...
Hannah:
[15:19] Looked at the data, they found that the primary outcome, which is really important for people to understand if you go back to the non-evidence that I talked about, the primary outcome is the one you power your trial for. So the primary outcome was a composite, which is a grouping together of all the bad things that can happen to a baby. Death, damage to the breakup plexus, which can happen in labour, which is on the neck, damage to the clavicle, low apocos, a whole bunch of bad stuff put together is called the composite. And they found that when they looked at the primary outcome, there was no statistical difference. So being induced didn't protect your baby. But suddenly they were fascinated and this became the thing that led the headlines. Unfortunately, everybody forgot about this. One of the secondary outcomes was reducing caesarean section, which may seem really counterintuitive when we know so much now about the cascade of intervention. So they found 18.6% caesarean section in the group that had an induction and 22.2% in the group that waited. And so what went around the world was routinely inducing women at 39 weeks is going to reduce caesarean section.
Hannah:
[16:38] So intention to treat means that you stay in your group from the randomization onwards for analysis. But that's not the point. The biggest point is these women were so low risk. They literally were, in order to get into this trial, there was nothing whatsoever that they had in their medical history. And they still ended up with one in five of them having a cesarean. Now, if you look at the same trials that were run in countries like the Netherlands and in Sweden and in the UK, you've got vastly different numbers of cesarean sections. In fact, you've got 11% of women who are no risk having a cesarean in that group compared to the US. So what were some of the problems with the US study? This is why we did the trial.
Hannah:
[17:29] Only 27% of women who were eligible agreed to be randomized. So that tells you something straight away. You're not looking at the general population. If women didn't want to be induced or women didn't want to wait, they're not being involved in this trial. So you have a population that is not your typical. We're talking about 73% of women approach said, no, I'm not being involved. 6% of these women in the American trial were cared for by midwives. 94% were cared for by private obstetricians who were not blinded to the intervention. So these obstetricians knew if the woman that they were caring for was being induced.
Hannah:
[18:13] So this is a big hazard with randomized trials is the blinding. And private obstetricians do more inductions and are much more likely to be favorable to them. So you've got a whole lot of these problems that don't exist in a general population. So basically, they concluded that one cesarean was avoided for every 28 planned inductions. But this has always been my challenge back. One cesarean is avoided for every 14 women who have continuous labour support. Why is that not more important? So what this reveals to you is this deep medical agenda, dominance, discourse, understanding, which is doing more must be good, and the lack of questioning on the way that we could potentially end up with similar outcomes. Remember, the babies weren't any better off in this trial, but we could end up with less cesareans by having continuous support in labor. Than we could doing this, but why do we always have to do more?
Hannah:
[19:16] And so we then set out and said, okay, what about we look at this kind of a population and we look at women who have inductions for no medical reason from 37 weeks onwards up until 41 completed. And that led us then to look at the 16 years of data from New South Wales. And we looked at every woman who has given birth in New South Wales between 2001 and 2016.
Hannah:
[19:47] We looked at women who are between 37 and 41 weeks and we looked at all the characteristics about the child, the mother, the type of birth, the interventions used, the outcomes for the child and the mother as well. And then we did what is called multivariable logistic aggression. Now, what that basically means is we know women are induced tend to have a few more things sometimes going on with them than women who start labour spontaneously. So in order to try and make the population quite similar, we said we're going to adjust for your age, we're going to adjust for all sort of factors to try and make the population as similar as possible. But we removed anyone who smoked, anyone who drunk, anyone who drunk alcohol, anyone who had medical complications, anyone who had a mental health history, you name it, we removed it. We actually ended up reducing that population, starting with a million. We reduced it to 474,000, so nearly 500,000 women were involved. And 15% of those women had an induction with no medical indication given, and that was the population that we looked at. So 15% had an induction with no medical indication given. And then we had the women who started spontaneously. Half were primates, half were. So half were having the first baby and half were having a subsequent baby.
Hannah:
[21:12] Then we looked at every week and we matched them. So, if you had an induction at 37, what did women who didn't have an induction look like? At 38, 39, 40, we looked at all of those weeks and we looked at each outcome for each gestational week and then we looked at the children for 16 years onwards. The most shocking part of this was the dramatic rise, and you'll see the graph in the paper, which shows the dramatic rise in babies being induced for no medical reason at 37 weeks and 38 weeks in the years between 2001 to 2016. So it went from about 11%, 12% in 2001 all the way up to 23% in 2016, inducing 37-week babies. So we're inducing women for no medical reason earlier and earlier and earlier.
Hannah:
[22:10] And what's the problem with that? Well, we now know that actually for every week that you have inside your mother, it adds to your neurodevelopment. developments. So we know that your brain develops differently when babies are born younger. We know educational schools are affected. We know behavioral disorders are affected. So we're basically taking babies out of their mother's uterus, this amazingly still highly not understood environment that is so finely tuned, and we're bringing them out into the harshness of the world. And then we are often traumatizing their mums. We are disrupting feeding, so they're not often getting breast milk as well. There's all those issues that happen. And so we're basically priming an awful lot of children without a good medical reason for doing it at a time when they're incredibly vulnerable. When we looked at the baby outcomes, we found there was more major resuscitation in all weeks for babies induced for no medical reason. There was more respiratory disorders. there was more birth trauma, there was more asphyxia, more NICU, neonatal intensive care, and more infections up until the age of 15 in children being admitted back into hospital.
Hannah:
[23:25] When we looked at the mum, we found more episiotomy. We found more hemorrhage at all the weeks in women who were induced compared to women who weren't. We found more vaginal repair. And the only thing we found that had a slight advantage towards induction was severe perineal trauma at 39 and 40 weeks. There was a reduction in that for women induced compared to women who were expectantly management. And it was a very small reduction, but because of our big sample, it was statistically significant. So the conclusion that we made in this paper, and may I say this paper was not popular with my obstetric colleagues. The conclusion was that, you know, induction without a medical reason in a total population. So remember when I talked about the ARRIVE trial in the US, that you had about 73% of women who were approached saying no. So in our paper, you have 100%, but you don't have the advantage of randomization. So because the population may not be the same, that's why we had to use some complicated statistics to try and do that. But what we're saying is that in all of the studies where they've done a randomized trial into induction, up to 86% in some studies, women have refused to be included.
Hannah:
[24:45] When you include all women like we did, there are harms that are not being identified in randomized controlled trials that we need to seriously look at and we need to chase the ripples that result from birth intervention down the track, not just is the baby out and is the up gargled.
Hannah:
[25:05] Down the track? What else are we interfering with by bringing these babies into the world earlier? So that's kind of a summary of that paper, but you can have a look at the graphs and the conversation article for more detail. So we took the philosophy that 42 weeks beyond was post-dates overdue.
Hannah:
[25:24] So it was 41 up until 41 minus one day to 42 weeks. So I think it's important to actually look at what are the current recommendations so if you look at the world health organization recommendation around induction of labor which came out in 2018 they say it's inductions recommended and can i just put these words in place because i want to go through where we're going wrong i believe it's recommended for women who are known with certainty to overreached 41 weeks. So this is WHO.
Hannah:
[26:01] It is not recommended for women with uncomplicated pregnancies at gestational ages less than 41 weeks. So what we found in our study is the lion's share of these women having inductions going up are in 37 and 38 and 39 weeks. They're not in the later weeks. That's all coming down because we're sliding the induction to earlier and earlier. But if you then look, and I think it'd be really good for the people listening to this podcast to look at the nice induction of labour guidelines from 2021, because they are what is missing in all of this. They have a whole section on information and decision making. And they talk about, confirm the woman's preferences, explain to the woman that induction of labour is a medical intervention that will affect their birth options and their experience of the birth process.
Hannah:
[26:59] Make sure that they understand they may have more vaginal examinations. Their choice of place of birth will be limited. There will be limitations using the birthing pool. They may need more assisted vaginal birth. They may have more increased risk of obstetric anal sphincter injury. They may end up with hyperstimulation, which can lead to changes in the baby's heart rate and fetal compromise. They may find labor is more painful. Their hospital stay might be longer. So they have all of this listed that you
Hannah:
[27:34] have to go through with women. And I can tell you, having read the data from women when we've asked them about their induction, they're not being told this. They're not being discussed. They're not being given alternative options. They're not being given risks and benefits. They're just being told, you really need to get induced. And here's a gap in the diary. And we're going to slot you in. And the biggest thing women are coming back and saying to us is, no body.
Hannah:
[28:01] Told me everything that was going to happen. I had no idea it was going to be like it once. I had no idea that my normal birth was basically going out of the room. I got no time to discuss it. I got no alternative information given to me. I was not encouraged to ask questions. And at no point did I feel that I had a voice in it. And that is what I think is really problematic. So NICE, which is the National Institute of Clinical Excellence in the UK that sets the kind of temperature for a lot of how we then laid around the world perform, NICE says very clearly, you need to tell women this is going to affect their labours.
Hannah:
[28:44] And when we asked in the BEST survey, and the BEST survey is a large survey, Hazel Kiedel and myself are leading, where we have looked at over 8,000 women responding to a national survey in Australia about their birth experience. And we asked women, if you knew what you know now, do you think you would make the same decision about having a labour induction? What we found is that 21% said they definitely would not have made the same decision. We found 19% said they probably would not have and so if you add that together you've got 40% of women saying I wouldn't make that same decision most likely or definitely you've got 24% who said probably would have and you've got 35% saying definitely would have and when we ask them then who made that final decision to have that induction. And look, bottom line is a woman has to make that final decision to have an induction. It is a medical intervention that usually involves a surgical intervention because you're breaking waters, you are doing something artificially. We asked women who made that final decision and 14% of women said it was their decision mainly.
Hannah:
[30:02] 43% said it was mainly my maternity carer's decision. And 42% said we made that decision together.
Hannah:
[30:12] And, you know, it's really interesting when you look at the models of care on this data and you look at, you know, the providers. So we broke it down by providers and we looked at standard care and GP shared care and private OB care and midwifery group practice. And then we also looked at private practicing midwives of which the majority of those women our babies at home and then we look at you know how does that mainly my decision or mainly the care provider's decision or we made the decision to how does that vary and it's starkly evident if you look at standard care 55 percent say or nearly nearly 56 percent say it was mainly their care provider's decision if you look at gp share care it's about 54 percent if you then look at private midwives is 21%. So you've got this dramatic difference in women feeling like it was mainly the provider's decision. And if you look at, you know, we made this decision together, quite clearly in the continuity of care model, particularly private midwifery, you've got two thirds of women in the private midwifery saying, we made this decision together. So the stat, the typically shared decision-making kind of approach. And if you look at standard care and GP share care, we're talking about one third. So we go from one third feeling they made it together, but in all the others it's lower. So the more continuity you have,
Hannah:
[31:34] The more you feel part of the informed conversation that you feel you made a decision together with your provider. So relationship-based care is absolutely critical when it comes to how this is shaped in women. We also asked them about induction and trauma, birth trauma, and this is critical because in the whole of the BEST survey, we found 29% of women considered their last birth traumatic but that's really horrendous when you think about it and when we asked when we then looked at well what happens if you're induced or spontaneous labor or you have no labor at all which means you have an elective cesarean section what is the levels of birth trauma and in the level of birth trauma in women induced was 40.5 percent compared to spontaneous onset of labor which was 23.4%.
Mel:
[32:25] So you double the obstetric trauma rates by just having an induction.
Hannah:
[32:34] And if you have no labor, which is an elective cesarean section, it's 27%, which is lower than induced, but higher than spontaneous. But you think about it. What this is essentially giving us great evidence of is an induction is a very long process. It involves many providers, usually over a couple of days. It involves lots of painful procedures. So there's much more opportunity for birth trauma to occur. If you have a cesarean plan, you book in, you come in, you're half an hour, you go in, you have your spinal in, half an hour later, you've got your baby in your arms. There's so much less opportunity in that for the interaction with all these different providers that could essentially create that increased risk of birth trauma. If you then look at obstetric violence, we found 11.6% in the best survey had obstetric violence. We've just published a paper late last year which really shows what's going on. But obstetric violence is also higher in those induced. It's 14.8% compared to 10.5% in those who spontaneously labour. And it's 8.7% in those who don't labour at all, in other words, have elective cesarean sections because the less time you have interacting with providers,
Hannah:
[33:53] The less chance there is that people are going to start to override your decisions or do things that you may not want to happen. So it gives us some really valuable insight that induction of labour needs to be looked at in a much, much broader context. And some women, you know, we're all different personalities and some women do like the idea of having an old plan, the date in the diary.
Hannah:
[34:17] When you have that and you have a continuity of care provider, I think birth trauma and we've got some other research coming very shortly continuity of care ameliorates so much of birth trauma anyway you can do an awful lot of things to a woman in a trusting relationship and they're very forgiving about it it's when trust is violated it's when strangers say things to women and there isn't that connection and there isn't that ability of feeling respected, heard and participating so continuity of care is is really vital. But just to pick up on what you said, Bernie, the reviews of the qualitative studies where women have been interviewed about induction, there's a wonderful systematic review of 10 studies that found the biggest thing was women did not feel involved in decision-making regarding induction and they were unprepared for many of the aspects of the process. So these are where we know where we're failing women. So we need to actually be much clearer about that.
Hannah:
[35:20] We asked some great questions, and one of them in the best survey was, and I kind of put this in at the last moment, I went, I really want to know this answer to this question. How important is having a normal birth to you? Best question ever to ask women. How important is knowing your care provider and how important is your birth environment? Those three questions have just produced the most amazing data because exactly what you just said, Bernie, is in there, in that women who choose private obstetricians
Hannah:
[35:48] That's less important, but may I say it's still most important. So if you look at, you know, a woman choosing private OB asked about, you know, how important is a normal birth? The highest importance is women who see private midwives, which totally makes sense. You know, they're choosing a philosophy, they're choosing a whole model of care based on supporting that. And the lowest is with private OBs. But even the lowest, it's still more than 50% who think it's important. So, there are still women who go to private OBs and let me say, there are some extremely good private OBs who are very, in fact, there are some private OBs that are more philosophically aligned to supporting normal birth and there are some midwives, that's a reality.
Hannah:
[36:37] When Mel and I undertook, remember the ethnographic study we undertook where we looked at, we sat in the corner and particularly Mel did a lot of sitting in the corner in home births and in birth centres and in standard delivery wards.
Hannah:
[36:49] And we looked at, you know, how did women move and what happened? And we found that there were different philosophies. So we found the physiological paradigm was very much seen amongst women who gave birth at home. The midwives also have a strong physiological paradigm so they were very aligned in the birth center we found a mixed paradigm we had some women who went there just have shorter waiting lists and just shorter wait times and they're like the environment but they were always intending to go and have an epidural their midwives though were physiologically aligned which meant when they wanted to go over the road sometimes the midwives were really trying to get a normal birth and then we went to the delivery ward where it was a go with the flow kind of if it works it works doesn't it doesn't and of course you can understand then that normal birth is going to happen most in the environments where women and midwives are on the same page trauma is going to happen most in the environments where midwives and women are not on the same page and acceptance and high intervention but acceptance of it is going to happen high most high in environments where everybody goes well we just see what happens it's important that women know what they want And it's important they have a care provider who is on the same page because trauma, if you really look at the source of trauma,
Hannah:
[38:07] it's this mismet expectations and often feeling let down and failed by your care provider.
Mel:
[38:17] Hannah, in that research that we did with the home birth birth center and, you know, we did see the most dissatisfaction really in those birth center clients who there was a mix. You know, the midwives were.
Hannah:
[38:29] You know, really- Paradigms were not aligned. Yes.
Mel:
[38:33] That's right.
Hannah:
[38:34] Which made me, and I'm sure you, rethink that blanket sort of assumption that home birth's best, birth center's next best and delivery ward's the problem. No, it's completely far too simplistic to say that. Yes, your outcomes as far as your intervention will be higher in the delivery ward, but you actually might be quite happy and satisfied with your birth.
Mel:
[38:58] Yeah, and so more importantly, well, less importantly is the location. More importantly is that your philosophy is aligned with that of your care provider.
Hannah:
[39:07] And you have a relationship with that care provider that's respectful, trusting, and honoring. That's the key. Working as a private practicing midwife along with Mel, one of the first questions I'd ask every couple that sat down with me is, tell me your hopes and your dreams. What are you, what, when you think about this birth, tell me what you're seeing. And then from that you can go into discussing those aspects to find out what exactly is behind that. And we don't do enough of this, you know.
Mel:
[39:42] Anna, I'm looking at this study that you did, the induction study, and, you know, kind of when you were talking about it earlier, it made me think, okay, well, why would we get induced if there was no medical reason? Because you concluded that induction for non-medical reasons was associated with higher birth interventions, particularly with primips, so women who haven't had babies before, more adverse maternal, neonatal, and childhood outcomes for most of the variables except for severe perineal trauma in those 37, 38, 39-week periods. And I'm looking at the stats. Like, it's significantly different. So I'm looking here, if you had an induction, and, Your chances of spontaneous vaginal birth were 42.7% versus 62.3% if you didn't have an induction. Instrumental birth, so where it was vacuum or forceps, was 28% if you did have an induction and 24% if you didn't have an induction. Intrapartum caesarean section, so caesarean during labor, 29.3% if you had an induction and only 13.8% if you went into spontaneous labor.
Mel:
[40:57] Epidurals, if you had an induction, and this makes sense because inductions are way more painful than spontaneous labor, 71% of women had an epidural versus 41% who went into spontaneous labor. Episiotomies were higher by 11.2%. So 41.2% of women who had an induction had an episiotomy versus around 30.5% if you didn't. Postpartum hemorrhage increased in the induction group, which we again spoke about in our postpartum hemorrhage episode. 2.4% of women who had an induction had a PPH versus 1.5%.
Hannah:
[41:36] And that's dramatically understated because we know PPH is much higher. We know that data is really problematic, so it's going to be much higher. Yeah.
Mel:
[41:46] And, but there were similar outcomes.
Hannah:
[41:50] Multiples were very, so this is a really important point. The biggest problem with inductions is really, the biggest amount of difference you see in outcomes is the first time mother. And yet 47% of first time mothers in Australia are being induced. It's the highest number of inductions occurring in the group which have the biggest differences in their birth outcomes. Once you've had a baby, I always say babies lay the breadcrumbs. The first lays the breadcrumbs for the others and the body just works better. It kind of knows what to do for multiple reasons which I won't go into. So you can, when you induce a woman who has had a baby before. They go less wrong. It doesn't mean that there isn't differences. But the biggest issue is first-time mothers where the majority of inductions are okay.
Mel:
[42:43] Yeah, they go less wrong if you had a baby before, but they still don't go as well as if you go into spontaneous labor.
Hannah:
[42:49] Well, in some of that data in that paper, actually, in a couple of the gestations, they actually did better. Wow. So, you know, overall, no. But I guess it's really important to also have the conversations with women, the difference between induction and induction with your first baby and induction with your second baby and induction if you're 37 weeks compared to if you're 40 weeks. This is what we tried to do in this paper is provide a little bit more of a nuanced ability to have that conversation with women than we have previously gone and lumped everybody into the hole. Well, let's induce. The other important thing is we didn't look at stillbirth. That was not the aim of our paper because we had live babies at the onset of labor. That's how we had a low risk population. The biggest reason that everyone's pushing this induction earlier and earlier and earlier is to reduce stillbirth. Now, when you look at the big trials carried out in Europe in particular, and that's where the big ones come out,
Hannah:
[43:48] What is really evident to me now, the more and more I look at it, so you've got the 35-39 trial in the UK, which was where they induced women who were greater than 35 years at 39 weeks or left them to labor, thinking that maybe that's the group, right? So over 35, because, you know, women's bodies potentially, you know, once you hit 35, I don't know, you seem to obstetrically deteriorate according to obstetrics. But they looked at that and there was no difference. No difference if you induce them at 39 weeks or 11. The Dutch study, which was the index study, looked at low-risk women at 41 weeks in inducing them or expected management to 42 weeks. Okay. So they found no difference in cesarean rate, but they did find a slight reduction
Hannah:
[44:38] in adverse outcomes for the baby. If you look at the SWEPA study, and I'm most fascinated by the SWEPA study. I've been to Sweden, talked to these midwives. They looked at low-risk women induced at 41 weeks, again with expected management up to 42 weeks. And they actually stopped the trial early because of the high rate of stillbirths in the group that were waiting.
Hannah:
[45:02] But when they have looked further at that data, they had several study sites. Stockholm, which you can imagine is a very big center, which was one of the big study sites. Stockholm had no stillbirths and they had a large number of the women in there. But they had a policy of routinely doing an ultrasound of 41 weeks to see whether or not it was safe to keep going. They had no stillbirths. The other centers didn't have it and that's where the stillbirths were. So the conversation we need to have with women is there's no doubt that for every week beyond 37 weeks the risk of stillbirth is increasing by small amounts until you hit about 41 weeks and it increases by bigger amounts so i think it is really reasonable to be having the conversation with women about what do they want to do how are we going to monitor the well-being of their baby and you know thinking about an ultrasound to check is the biophysical profile good is the water good are the baby's movements good I think that we need to now start to look at we know what a woman wants how can we make it safer for that baby to stay in for a longer period rather than just blanketly saying stillbirth increases for all women without these nuanced conversations yeah
Mel:
[46:25] And that's certainly what we would do in private practice if women start to you know creep in between that 41 and 42 week it's like well how can we, supervise this current circumstance knowing what we know about the increase in stillbirth and if you're interested in the actual stats and research on that guys we did a due dates episode which is still our most popular.
Hannah:
[46:46] Episode, but it definitely, it's 41 weeks that you start to see a reasonably big increase to the point that I would say. We should be having that conversation with women. And I would probably say to women, I think if you want to wait to 42 or beyond, why don't we think about an ultrasound and just give ourselves that reassurance that the baby's well. For me, what's really convinced me about that is looking at the SWEPERS trial. And I've talked to my colleagues in Stockholm and they're just like, we're so angry because this has been our policy for so long And we now have got a recommendation for induction that's based on what other people do when in Stockholm we've been doing this very, very safely. We're so black and white with this data. Data is not black and white. Data is there to help us inform and to make good
Hannah:
[47:43] decisions for the individual in front of us. But we never go down to that. We just mass apply data. And that's why it's so important to know how to read research papers because it's all these questions that make you go, aha, one of the biggest problems with the induction trials is 60 to 86% of women in all the randomized trials done have declined to participate. And the biggest reason for decline was to be in the expectant group. So size of the baby are very inaccurate at later ultrasounds.
Hannah:
[48:13] And everyone focuses on the big size of the baby and not the small. The most important one is a baby that is either losing weight or getting smaller, getting smaller or not growing. That's the most important one. And the only way to really know what's going on with that is if you have been having, say, serial ultrasounds. What's the level of water around the baby? Because the water around the baby, the amniotic fluid will tell you how well the placenta is functioning. And then there are the flows through the actual core that can be looked at that can also give you more information. And then there is the baby moving and then there is the baby breathing. So all of that gets put together to give us an idea on well-being. But unfortunately, so much of the focus is on how big the baby is, as in large, but not on the really important things, which are, is this baby no longer doing well in the mom's uterus? And would this baby be better outside than staying in? That's the focus we should have when we do those ultrasounds.
Mel:
[49:12] Yeah, rather than size, which is what we spoke about as well. We've just done episodes on big babies, small babies. And I'm grateful that you pretty much said exactly what we said in terms of size, is that it's less important the size and more important is why is the baby that size. So if you've diagnosed a large baby and this woman has uncontrolled diabetes, okay, the uncontrolled diabetes is the bigger problem. And same with the smaller size babies is are we looking at poorly functioning other things is causing this, So, and something you were saying earlier, Hannah, just made me realize as well is that how women, women's experiences of an induction more so related to not realizing what they were in for, essentially. And so knowing, I suppose, what we know now from your research, that also knowing the process of induction, also realizing that a lot of things like time are not on your side anymore if you're having an induction because it's an intervention that, you know, that will offer you vaginal exams every, depending on the practitioner, every two to four hours, depending on how your labor's going.
Hannah:
[50:21] Which will increase your risk of infection and your likelihood of your temperature going up and therefore having antibiotics so this is so the this is the stuff we don't talk enough about which is the cascade it's the cascade of doing this we need to now do this which means we need to do this which means this is more likely so and on and on and on it goes yeah
Mel:
[50:42] Like a slippery slope and you can't bail out once the slippery slope started like if you've gotten an infection because you had an induction and rupture membranes and repeated vaginal examinations, you can't, well, you can, but it's very difficult to sort of suddenly say, do you know what? Nothing else. Not having the antibiotics, I'm bowing out of the induction, like the complications have already occurred. And so they need to keep rescuing you from each complication that's developed as a result of the previous intervention. And so, and realizing this too, that an induction is a lot more painful than spontaneous labour. So you are more likely to need some assistance with pain relief through, you know, something else like an epidural, which immobilises you, which opens up, you know, further steps in that cascade. So I think, yeah, I guess a take-home message for women who either need to be induced or, you know, have been told to be induced, but maybe not a very medically inspired reason is... Is just knowing all this can help you prepare. So if you know that you're more likely to end up with these things, sometimes you might be less traumatized than if you didn't realize that.
Hannah:
[51:56] But also, if somebody's saying you need to be induced because your baby is not doing well and you haven't had an ultrasound, then I would say, look, I'm really grateful for your concern. Could we get an ultrasound just so that we can tell exactly what is going on before I make this important decision. So an ultrasound can give you a lot of information that a clinician may. Look, some clinicians, honestly, it is a procession line. It is a business. It is getting people in, getting people out, and there is a gap in the diary. So it's so convenient for us that you go in on Friday. You know, there is no doubt that we're doing an awful lot around scheduling births in. So you don't want your birth to be one of those scheduled births. And this is a really good reason for that to be scheduled. And, you know, if an ultrasound comes back, ask them to go through every line item with you and say, what does that mean? What's normal? What are you concerned about there? Because it will make them accountable for giving you the total information.
Mel:
[53:02] And I suppose we're not like poo-pooing induction because it's an intervention and we believe in physiological birth. It actually has a number of ongoing risks. And you've already detailed the stats in your paper. And it's not innocuous to the baby either. Like the outcomes for babies are poorer than if you just waited for spontaneous labor.
Hannah:
[53:23] Until a certain point, and I would say that once you get beyond 41 weeks, that's where we're probably seeing increased negative outcomes for babies, which is why I come back to the whole point of I do see some benefit of an ultrasound around 41 weeks to make a decision. It comes back to certainty around dates because I've seen 42-week babies come out with burn-ex all over them, which clearly they were not 42 weeks or their mum cooks them at a slower temperature. I mean, why do we think we all perform like robots? We're individual bodies. We're individual people. We know that some races have longer and shorter gestations. For example, there is rising concern around women from the kind of Indian subcontinents that maybe their babies don't do as well in the later gestations. But then you bring in epigenetics, you bring in diet, you bring in stress, you bring in so many other factors that are going to inform whether or not that uterine environment is a safe place for that baby at that time. Yeah.
Mel:
[54:34] Amazing. I don't think I have any more questions unless there's something you would love to tell everybody about induction.
Hannah:
[54:40] Well, I think just to reiterate how you began, which is so important because we talked a lot about the downsides. Induction is a medical intervention and it should be done because of a medical reason, which means that the mother and baby will be safer by this induction occurring than not.
Hannah:
[54:59] And so that's the point. It shouldn't just be done because. It shouldn't just be done everyone treated the same.
Hannah:
[55:06] That you need to work out what you want. You need to work out what's important for you. And you do have control. And when we looked at was there anything women would do differently if they had another baby, and out of that 6,000 responses that we got in the best survey, 540 were on induction. That tells you how big this is. and the largest amount of responses were that they will resist induction next time to increase the chance of spontaneous labour the largest number they were said i want to get better informed i want to wait for spontaneous labour and i will refuse if there's not a good indication those were the three categories so if you've got any doubts voice them because you're the only one that's going to live with the consequences of that decision in feeling disappointed, feeling let down, feeling traumatized, or that something happens with the baby. So you are the person in the driver's seat that has the full power to ask questions and make sure you're happy. And if induction's needed, it is a life-saving intervention like cesarean section was. If induction is not needed and you want it, then I would fight in the streets for a woman to have that right. But if induction is not needed and you don't want it, then you're the group of women that is largely informing the trauma that we're seeing and that's the group of women we need to really make sure that we reduce that happening.
Mel:
[56:34] Thank you so much for being with us, Hannah. All the resources that Hannah spoke about today will be in the folder. If you're on the mailing list. So if you want to get on that mailing list, melaniethemidwife.com and just click the button, you'll get access to the resource folder, which has resources from all the previous last 33 episodes that we've done as well. And all the links that Hannah spoke about to the conversation article will be in the show notes underneath this episode. So you've been here with me and Hannah Darling at The Great Birth Rebellion. We'll see you again next week. to get access to the resources for each podcast episode join the mailing list at melaniethemidwife.com and to support the work of this podcast wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com follow me mel at melanie the midwife on socials and the show at the great birth rebellion all the details are in the show notes.
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