Sara Wickham (midwife, author, speaker, researcher) reflects on the questions which arose while she updated her newest book, “Inducing Labour: making informed decisions”.
The process of updating a book is a great opportunity for reflection. What has happened or changed since the last time I sat and crafted these words? How have they worked for those for whom I wrote them? Are there gaps? What do women need and want; what are they being told when they enter the maternity care system; what are they hearing from other birth workers; how has the evidence and the zeitgeist changed?
This spring, while I was sitting with my book on inducing labour (which, I am delighted to tell you, is now available – https://amzn.to/2IatbPe), some key things struck me about how the situation has changed for women in just a few years. I invited comments and questions from women, midwives, doulas, birth educators, obstetricians and anyone who might be interested. I then used these to help me work out how I could best develop the new edition, and I thought it might be interesting to share a couple of the most common themes, as they offer some interesting food for thought.
The first theme that arose in the responses that I received could be called, “post-term isn’t the main issue anymore”. Women, doulas and midwives expressed concern that a significant number of women are now less likely to reach 41 weeks of pregnancy. This particularly struck me. Some ten years ago now, I wrote my PhD thesis on holistic midwives’ knowledge of ‘post-term’ pregnancy, and one of the reasons I chose that as a research topic was that I was already involved in writing information leaflets and booklets for the many women who were affected by the offer of induction of labour for post-term pregnancy.
Merely a decade later, the situation has changed. Nowadays, an increasing number of women are offered induction before this point. The offer (and I will continue to use the word ‘offer’ because although I realise this may not an accurate summary of some people’s experiences, I believe in modelling positive language) is made for one of a number of reasons. It might be that the woman is thought to have a large baby (even though we don’t have accurate ways of measuring this, and are frequently wrong, and there is no evidence that induction makes a significant difference), or she has been diagnosed with gestational diabetes mellitus. Perhaps the woman is older; maybe she conceived via IVF or another assisted fertility treatment. Whatever the specific reason given for offering induction, fewer women are reaching the point in time where induction is offered because they are ‘post-term’.
This links with the second theme that I noticed in the responses: “show me the evidence, please!” I received many comments from people who were frustrated that the offer of induction was not always accompanied by evidence which could help the woman to decide whether this would be the right course of action for her, even when this was specifically requested. This is a huge problem. Sometimes induction of labour can be lifesaving, but sometimes it is a routine offer which might not be right for a particular woman. Without an honest discussion of the evidence and the woman’s circumstances, it can be hard for a woman to get the information she needs to make the decision that’s right for her.
We could spend hours unpacking the question of why this is the case. We could chat about our risk-focused culture, the dominance of the technocratic approach towards birth, the patriarchal approach to health care which still exists in many settings or the implications of vested interests in the maternity services. In some situations, the evidence isn’t always available because the research hasn’t been done. In a number of situations, we know that the stillbirth rate is higher for particular groups of women, and this is the reason usually given to justify an offer of induction. But we often don’t have good research evidence which can tell us whether induction actually lessens the chance of stillbirth for women in that particular situation. And induction of labour is associated with possible risks as well as possible benefits, so the decision is not always clear cut.
There were other themes as well, of course. Many women didn’t feel they had enough information about the process of induction and what it entailed. Some wanted to know whether and how the induction process could be tailored to fit their wants and needs. I have addressed those questions in the book as well, but it is the evidence-related questions that have stayed with me. The pressure to have labour induced seems to be increasing, despite a lack of good evidence in many cases to support this. I am left feeling surer than ever that some of the most useful things that we can do for the women, babies and families we serve are to make sure that we understand the evidence, stay on top of what’s new and develop the confidence to converse with others about it.
Sara Wickham is a midwife, author, speaker and researcher who divides her working time between creating live and online courses, writing books and providing consultancy services for birth-related organisations around the world. She writes a twice weekly blog at www.sarawickham.com and can also be found on Facebook and Instagram (@DrSaraWickham)