Induction rates on the rise: why we are concerned

 

A third of births in England are induced. The rate of induction is up by 10% in the last decade. At Make Birth Better, we have several concerns about the increase in the number of people being induced. Here’s four reasons why and some recommendations to help you make a decision around induction.

In the last few months, we’ve taken a deep-dive into induction and upskilled our team on the latest research. We attended the AIMS workshop Focusing On The Induction Of Labour which we highly recommend for any professional working in maternity care. This blog post sums up our takeaways from the workshop, combined with what we hear from professionals and parents in our network. Our concerns come from:

  • the poor evidence around induction

  • the way NICE Guidelines are presented and how this impacts hospital policy

  • how induction themes relate to birth trauma themes

  • the worries we hear from midwives and other healthcare professionals

1. The issue with evidence

As an organisation, we are all about evidence. One of our five core values is ‘evidence-based’, which represents the fact that we are rooted in clinical expertise, lived experience and solid evidence. So, when looking at the rise of induction rates in the UK: what does research tell us? 

Starting with an overview of induction rates in the UK. The reported rate of induction has increased from 23% of all births with known method of onset in 2012/2013 to 33% in 2022/2023. Note that for 27% of births in 2022/2023 the method of onset is unknown. Plus, insights provide the fullest data on England, but there is limited data for Wales and Scotland, and no data for Northern Ireland. In short, what we know from the stats is that the rate of induction is up by 10% in the last decade.

Of course, a rise in rates might not be a problem if induction is beneficial. The issue we find here, though, is that there is no strong evidence on the benefits of induction. Experts, including our organisation partner AIMS, state that the research available, is not robust enough.

“People can get a lot of information around induction, which is not always correct”

But, what do we know from evidence? To answer this question, we’re shining a light on some recent Cochrane reviews that were covered in the AIMS workshop (see also Sources list below).

Membrane sweeping

Membrane sweeping is a method of induction, though it might not always be presented as clear as such. Finucane et al (2020) found that with membrane sweeping it “may be more likely to have spontaneous onset of labour”, though they found “no clear difference in unassisted vaginal births” and “membrane sweeping may reduce formal induction of labour”. It’s important to put emphasis on the word may here: the data are not absolute, so they should not be treated like that. 

Induction at or beyond 37 weeks

Another study from 2020 by Middleton et al (2020) on induction of labour states: “Risks of stillbirth or neonatal death increase as gestation continues beyond term (around 40 weeks' gestation). It is unclear whether a policy of labour induction can reduce these risks.” Following a major systemic review of studies, the data suggested that beyond 37 weeks a policy of labour induction was associated with fewer stillbirths and neonatal deaths, though in would be necessary to induce 544 women and birthing people to avoid one stillbirth or neonatal death.

Home vs inpatient induction

Alfirevic et al (2020) looked at home versus inpatient induction of labour. They found very limited evidence to compare safety, effectiveness or satisfaction. Also no obvious differences in outcomes “although women tended to be more satisfied with going home to wait.” 

Looking at the lack of robust research, this leads us to the concern that people get a lot of information around induction, based on poor evidence and presented as absolute data. Essentially, people often receive information that isn’t always correct.

2. The issue with the NICE Guidelines

Dr Sara Wickham (Author, Speaker & Researcher) published a great article after the latest NICE Guidelines on induction were published in November 2021 and the draft version had caused a lot of controversy when it went out for consultation.

Part of the draft recommendations was to offer induction to Black and brown women at 39 weeks. Following this, the #NotSoNice campaign was launched by our champion Leah Lewin. Mars Lord (Doula, Birth Activist & lead voice in Black Maternal Health) on the campaign: “It's not so nice to decide to combat Black maternal mortality with induction. This does not speak to the problem, it merely creates another.”

In addition to this, Sara’s main issues with the induction guidelines are a change of tone (reflecting a further shift towards normalising induction), an earlier offer of membrane sweeping, an earlier offer of induction, the mention of higher stillbirth rates without explicit recommendations and a lack of clarity on some important points. A key point in Sara’s article is that the NICE Guidelines are not always evidence-based. Read her full reflection here.

“The danger with the NICE Guidelines is that they are not always evidence-based”

On the NICE Guidelines, our friends at AIMS say: “We are still not pleased with the guidelines, but they are getting better around bodily autonomy and informed decision making.” AIMS have done a lot of lobbying to make amends in the NICE Guidelines happen and were also big supporters of the #NotSoNice campaign. 

AIMS advocate for people to be more aware of their rights which supports informed decision making: “It’s important to realise that in the end it’s up to the birthing woman or person to decide whether they want to be induced or not. They should be given the right information to make an informed decision. It’s always your right as a birthing woman or person to decline induction.”

A quote from the NICE Guidelines on induction that supports bodily autonomy: “Recognise that women can decide to proceed with, delay, decline or stop an induction. Respect the woman’s decision, even if healthcare professionals disagree with it, and do not allow personal views to influence the care they are given.” 

Another important thing to flag around the NICE Guidelines is the way hospital policy uses the guidelines and its data. AIMS shared: “Anecdotally we hear about hospital policy stating that inducing at 41+ weeks is standard and that they are following the NICE Guidelines. That is actually not true.” This is what the NICE Guidelines say on induction at 41+ weeks: “Explain to women that some risks associated with a pregnancy continuing beyond 41+0 weeks may increase over time. Discuss with women that induction of labour from 41+0 weeks may reduce these risks but that they will also need to consider the impact of induction on their birth experience when making their decision.” Again, may is a crucial word here - the data used in the NICE Guidelines should, as with wider research on induction, not be presented as absolute.

The NICE Guidelines are often used by Trusts as a foundation for their policy, but it’s important to note that a lot of hospitals follow their own guidelines. This means different options are being offered to people in different areas, which is referred to as ‘the postcode lottery of induction’.

3. Induction themes are birth trauma themes

There are as many birth stories as there are people who give birth. Each story is unique. However, when we listen to the traumatic experiences people share with us, we can certainly point out common themes. For example: not being listened to, feeling pressured or out of control. We see a strong overlap between the common birth trauma themes, and the themes that come up in people’s stories around induction. Stories of induction often reflect poor communication, scaremongering and being pressured. “If we don’t induce, your baby might die”, for example, is a phrase commonly shared with us.

Some common themes from induction stories:

  • Poor communication

  • Feeling pressured /coercion

  • Feeling scared / scaremongering

  • Lack of bodily autonomy

  • Feelings of failure / disappointment

  • A cascade of interventions

  • No sense of control

  • Lack of informed consent

Looking at the commonalities in these themes, we would even hypothesise that people who have inductions are more likely to be affected by birth trauma - though we can only base this on anecdotal evidence.

“We hypothesise that there’s a link between induction and birth trauma”

The NICE Guidelines and hospital policy often direct healthcare professionals towards induction. There’s a huge issue with that, knowing the evidence around induction is poor and the information people are getting isn’t always correct. In addition to that, people aren’t being prepared for what induction involves. Not knowing what to expect can lead to disappointment, feeling out of control and feeling overwhelmed - again, common themes around birth trauma.

Last, but by no means least, there is an issue with midwives being forced into an inductions-for-all position by their leadership. There is no one-size-fits-all approach to birth options and an induction may not (always) beneficial to the circumstances of the individual. 

Like we said, each birth story is unique, because each person is unique. Person-centred care is trauma-informed care, and essential in preventing birth trauma. For healthcare professionals it is vital to get the facts on induction right, and communicate them properly. The right language is key. 

A helpful tool for professionals and parents to use around induction is BRAIN: discuss Benefits, Risks, Alternatives, Intuition (how does this make someone feel?) and doing Nothing (what happens if we wait?).

4. The worries we hear from midwives

Midwife Sheena Byrom asked on her Instagram page: “Why the huge increase in induction of labour?”, and it sparked an interesting conversation amongst her followers which reflects the conversations we have with midwives. Some main themes from the comments:

  • Over-medicalisation

  • Distrust in physiological birth / knowledge of midwives

  • Fear of litigation / death / adverse outcome reports

  • Not putting birthing women / people / parents / families at the centre of care

  • Lack of continuity of care

  • The NICE guidance

Keeping in mind Middleton at al’s study (2022) on induction at or beyond 37 weeks: 544 inductions were required to avoid one perinatal death. Let’s not shy away from the conversation about the implications of that. 

To Sheena’s question on the rise of induction rates Amity Reed (Midwife, Writer & Campaigner ) replies: “The drive to reduce stillbirths at any cost: the cost being physical, psychological, and emotional harm to mothers, and loss of their autonomy.”

“We must expose the issue around unnecessary inductions and coercion around them.”

At our Summit one of the attendees shared in the chat box: “We must expose the issue around unnecessary inductions and coercion around them.”

The conversation we had with attendees at our Summit, also showed worries on the quality of care, similar to what we find in the comment section of Sheena’s post:

“Could the trauma be related to the poor quality of care around inductions, rather than the induction itself? The more we fill wards with women having induction of labour, the more the quality of care reduces.”

“Induction of labour is all too often an assembly-line procedure carried out in an industrialised environment. It would be so different in a calm, individualised, respectful environment.”

What it all boils down to in the end: midwives worry about the quality of care birthing women and people are getting. They feel it’s not the care that people want (and need), plus it’s not the care that they want to provide.

Making a decision: our recommendations

Clearly, we are concerned. But we’re not here to leave you worried. We feel it’s our responsibility to share our worries openly with you, but also to provide you with tools that help you make an informed decision.

Reading recommendations

Tommy’s (advocates for safer pregnancies and birth) have a helpful page on talking to your midwife or doctor about induction and speaking up for your partner during labour. It covers making an informed decision, consent and your rights, see here. 

AIMS have a detailed page on induction, which covers what it is, how you can decline/request an induction, when you should be offered one, what is involved in an induction, how it might affect your choices for the birth and what can help you make a decision, see here.

The AIMS Guide to Induction of Labour by Dr Nadia Higson, see here.

In Your Own Time. How Western Medicine controls the start of labour and why this needs to stop by Dr Sara Wickham, see here. 


Use BRAIN

This wonderful tool is not exclusive to making a decision around induction, it’s useful in making any decision around pregnancy or birth. We highly recommend parents and professionals use it as a conversation starter. When making a decision, discuss Benefits, Risks, Alternatives, Intuition (how does this make someone feel?) and doing Nothing (what happens if we wait?).

Your body, your choice

What’s the balance? How does a small increase in chances of a serious outcome relate to higher chances of medical interventions, limited birth options and possible longer-term outcomes including emotional well-being? In the end, only the birthing woman or person has the right to decide what risks are acceptable. And this is always a personal decision - different and unique for each individual.

We’ve mentioned AIMS as a great support organisation, but also our organisation partner Birthrights are here to help you protect your rights in birth and labour.

Sources

 
Evelien Docherty