A recent Irish study which reported that it is safe for first-time mothers to spend the first 24 hours of induced low-risk labour at home has been criticised by researchers seeking improvements in maternity services in Ireland.
Published in the Lancet and led by Prof Fergal Malone – professor of obstetrics and gynaecology at the Royal College of Surgeons of Ireland (RCSI) and obstetrician at the Rotunda Hospital in Dublin – the study found that three-quarters of the mothers delivered their babies vaginally following induction of labour at 39 weeks using either a prostaglandin gel or a device that dilates the cervix.
“Given that more and more patients are now choosing induction of labour, which is causing challenges for busy maternity hospitals, outpatient induction of labour is an emerging system that might enable larger numbers of patients to choose induction if that is their preference while remaining in the comfort of their own home,” said Prof Malone upon publication of the study at the end of July.
However, researchers at the Association for the Improvement in Maternity Services (AIMS) Ireland have criticised the study. “The trial was conducted on first-time mothers who were entirely healthy. There were absolutely no clinical issues or problems with either the mothers or their babies. But, by enrolling them in the trial, there were instantly transformed ... with their labours extensively medically managed and both them and their babies exposed to the risks of medical induction,” says Lisa Lamboloz from AIMS Ireland, a voluntary organisation aimed at supporting women in the maternity system.
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The risks of induction, according to various guidelines from organisations including the American College of Obstetrician and Gynaecologists, include uterine overstimulation causing frequent contractions that can lead to changes in the foetal heart rate, more painful labour and increased likelihood of instrumental delivery (ie with forceps or ventouse).
The World Health Organisation has repeatedly warned against the medicalisation of birth and the routine use of interventions on otherwise healthy women and babies due to the risks associated with them.
The National Clinical Practice Guidelines on Induction of Labour recommends that women with uncomplicated pregnancies should be offered induction of labour at 41 weeks, but adds that it is reasonable to offer induction of labour at 39 or 40 weeks’ gestation for women aged 40 and over. The women in the above mentioned study were aged between 18 and 39. “Inducing otherwise-healthy mothers at 39 weeks is in conflict with our newly issued National Clinical Practice Guidelines on Induction of Labour,” says Claire Kerin, research officer at AIMS Ireland.
However, Prof Malone says the guidelines do not prevent clinicians offering induction at 39 weeks. “We are not contradicting the guidelines. There is nothing to stop us discussing the option of induction at 39 weeks. It’s about providing women with choice. I’m not recommending that every woman is induced. It’s about giving them the information and letting them decide for themselves.”
Women report being coerced, frightened and even bullied into induction
The backdrop to these disagreements come at a time when induction rates for first-time mothers are between 40 and 50 per cent of all first-time pregnancies in Irish maternity hospitals. The rate of induction for first-time mothers was 74 per cent one month this year in one maternity unit. “These rates are not this high because women are rocking up to maternity units begging for an induction,” says Dr Krysia Lynch, chairperson of AIMS Ireland. “These rates are high because women are being told they are going to be induced, that they have no choice in the matter.”
Dr Lynch says one of the most consistent queries and complaints researchers at AIMS Ireland receive is the lack of informed consent surrounding induction of labour. “Women report being coerced, frightened and even bullied into induction. They also report information being given in a very biased way and [clinicians] rarely discussing the risks.”
The National Clinical Practice Guidelines on Induction of Labour does recommend that request for induction of labour from 39 weeks (but not before 39 weeks) should be considered after discussing the benefits and risks with the woman, and taking into account the woman’s circumstances and preferences as well as the maternity hospital/unit’s resources and established care pathways.
The Lancet study reported no increased risk of Caesarean delivery in the first-time mothers induced at 39 weeks compared with women who choose to continue their pregnancy until full term. A previous study of induced labour in low-risk first-time mothers at 39 weeks found a 4 per cent reduction in Caesarean delivery compared with the “wait and see” management of labour.
Dr Lynch suggests that there are many other ways of reducing the risk of a Caesarean delivery by between 20 and 25 per cent. “These include hiring a doula [a woman who provides support and guidance to a pregnant woman during labour], engaging in midwifery-led care and planning a home birth.”
Researchers at AIMS Ireland suggest that if maternity units find they are stretched beyond capacity with high induction rates, rather than moving mothers into the home, they should instead “invest their time, energy, resources and private funding into meeting the objectives of the National Maternity Strategy.
“Such measures include expansion of our home birth services, birthing centres, continuity of care by a known midwife and wider access to non pharmacological pain relief options such as water during labour.”
We know that inducing labour early is safe for babies. But is it better for the mum?
They also refer to research which has found it is the infant who signals it is ready for birth by releasing chemicals through the placenta to the mother’s brain triggering the natural release of oxytocins. “Knowing this, why are we continuing to expel infants at such as high rates from their mothers before they have completed their natural gestation and clearly are not ready to be born,” asks Dr Lynch.
However, not all researchers agree with the AIMS researchers. A 2023 study from the University of Melbourne Department of Obstetrics and Gynaecology found that elective induction of labour at 39 weeks gestation is associated with 37 per cent decreased risk of perineal injury (tears) for labouring mothers. The study, published in the Journal of the American Medical Association Network Open, pooled data from 14 studies of women.
Dr Roxanne Hastie, co-author of the study said the findings were reassuring given the rising number of women birthing via induction of labour. “Over 40 per cent of labours are now induced at 39 weeks in Australia. We know that inducing labour early is safe for babies. But is it better for the mum? This study is the first to confirm that inducing labour seems to protect mums,” she said. Her co-author Dr James Hong added that “we also found that inducing labour reduced the likelihood of having an operative birth (with forceps or vacuum extraction)”.
Prof Malone adds that while spontaneous labour is better than an induced labour, studies have found that the “wait and see” group have higher rates of Caesarean than those who opt to have induced labour at 39 weeks. “When a woman goes into spontaneous labour, she is less likely to have a Caesarean section and induction is a slower, harder labour with a higher chance of Caesarean section. But, when you compare the “wait and see” group – some of which will go into labour spontaneously themselves but lots will need induction anyway – to those induced at 39 weeks, the latter have a lower C section rate.”
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