First do no harm: how there is a serious danger that interventions in childbirth are becoming 'n
There is a hugely important discussion happening about induction of labour at the moment. It's happening on many levels, and much of the conversation is taking place on the internet. Parts of this blog post have already been shared, but we felt that it was an important enough issue to keep it out there for discussion, and add some other important questions as well.
Last Sunday, one of us (Sara) shared the above picture and the following explanation on social media:
"The latest induction-related discussion is the result of the publication of a debate in the British Journal of Obstetrics and Gynecology. The debate is about whether induction should be offered to all women at term with a "for" and an "against" article. You can read the "for" article here. You may already have seen it. It was made freely available and was shared all over social media. But the "against" article wasn't being shared much at all. While the "for" paper had been made freely available, you could only see the "against" argument by either paying or having academic access to the journal." Sara Wickham
Here is an excerpt from the against article:
"Although induction at term could prevent rare cases of fetal death," write Seijmonsbergen‐Schermers et al (2019), "all induced women will be exposed to potential disadvantages. Women whose labours are induced have a higher risk of postpartum haemorrhage, uterine rupture, hyperstimulation resulting in fetal distress, and perineal injuries (Miller et al. Lancet 2016;388:2176–92). Furthermore, more women need pain medication and have limited freedom of movement, a longer labour, and a negative birth experience. There is increasing evidence that suggests negative consequences of synthetic oxytocin administration. This may influence maternal–fetal bonding, the maternal psyche, and neonatal preparation on being born. A large cohort study found higher rates of jaundice, feeding problems, infections, metabolic disorders, and eczema up to 5 years of age among children born after induced labour (Peters et al. Birth 2018;45:347–57)."
Since this was posted, the 'against' article has now been made freely accessible, and you can read it here.
But, as Sara wrote at the time, "Women deserve better than to only be able to see half the debate. The evidence on which pro-induction arguments are based is not as sound as it could be. We also need to understand that waving a research finding around isn't good enough. These days, "evidence" is cheap. We need analysis and careful thinking, especially when the issues are as complex as they are here. "
And if anybody truly believes that most women 'like or tolerate induction well', you could do one of several things: ask midwives who know how many women approach their second birth after an induction asking for a caesarean birth as they never want to experience an induced labour again; look at comments on Sara Wickham's facebook page, or just ask women.
When the Association of Radical Midwives asked, these are a few of the comments they received:
'Apparently I gave birth. It really doesn’t feel like it.'
'I feel violated.'
'My husband won’t make eye contact with me. I think he feels guilty. I wish I was dead.'
'I wish I’d been better informed. They never mentioned that there would be any risks. I failed my son.'
'Next time it’s a c-section for sure.'
'My 100 hour induction fiasco has left me with a failed marriage and PTSD.'
You will find a few women who were very happy with their induction, but the large majority of comments are sad stories from women who wish they had had more information or had made a different decision.
There is a very real danger that induction of labour which is already performed on nearly a third of pregnant women in the UK (and more in some areas) could become the new normal very soon. Women will accept it because they will have been convinced that their babies will be protected by this intervention without any possibility of informed consent, because the dangers of intervening with the physiological processes of birth have not been made available.
As ARM has said: ‘We owe it to these families to broadcast their stories. They tell them in shame and in secret but we who hear them can shout on their behalf. If even just one family suffers unnecessary harm and consequences then that is one family too many. We cannot continue to justify the use of interventions with such a broad brush with just moderate evidence and not even a nod to biomechanics & birth physiology.’
Middleton P, Shepherd E and Crowther CA (2018). Induction of labour for improving birth outcomes for women at or beyond term, Cochrane Library, 2018
WHO (2018) WHO recommendations for induction of labour, Dept of Reproductive Health and Research. https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/9789241501156/en/