To induce or not to induce. How to feel confident in YOUR decision.

One in three babies are born due to labour induction (Patient Information Forum, 2021); my blog focuses on informed consent and labour induction. Although my experiences are limited, being only a few months into my degree, I was struck both in the antenatal ward and Delivery suite by the information given to women about being induced and, when women did decline, the attitudes from midwives and doctors alike. Interactions I had witnessed during my placement all revolved around "if you do not have an induction, your baby's risk of being stillborn is significantly increased" There were very few conversations about what induction involves or any risks around it and when a woman did ask very valid questions, the doctors or midwives were dismissive and sometimes manipulative. This manipulation preyed on women's fears, which generally ended with consent, although I argue it is far from informed. This blog, I hope, will give women the information and confidence to advocate for themselves rather than the answer to the problem. I hope it will open conversations between birthing people and their care providers. So, moving forward, women can feel empowered and comfortable about their decisions..

I want to start this article by saying induction can be a lifesaving procedure that allows you to have the vaginal birth you want while minimising the risk of a bad outcome. This blog is for all women regardless of why you have been "offered induction" (more on this later); I am not here to say whether induction is the right or wrong choice for you or to sway you one way or another. I aim to give you enough information to go away and ask the questions to make you confident in your decision.

A survey conducted by Patient Information Forum PIF found that of 2325 women, 930 said the information provided was not enough to make an informed choice; 1511 stated they did not have enough risk to benefit from information, and only 1209 women felt they had the birth that met their and their baby's needs. 1756 responded to the question on the induction method. Collectively, they experienced 3241 induction attempts, further demonstrating the 'cascade of intervention methods' mentioned by respondents when initial induction attempts failed. When asked about informed consent, the word told was one of the most common words to crop up, with more than 70 women using stronger words, including coerced, harassed and bullied. The information, or lack thereof, given around induction must be adequate for women to make a fully informed decision. Informed consent is "permission from a patient for a medical professional to carry out treatment, with a complete understanding of the possible risks and consequences" (Oxford Dictionary, 2020). Doctors often use emotive language and statistics to explain why induction is essential; however, this can be misleading without context. Asking your doctor to convert statistics and percentages into numbers can be an excellent way to understand the level of risk. Everyone's perception of risk is different. Therefore, you can decide what level of risk is acceptable to you. Remember, how numbers are framed has a massive impact. For example, saying "5 out of 100 people had side effects" sounds different to "95 out of 100 people did not have side effects".

One study conducted in Iceland by Haavaldsen et al. (2022) found that many inductions were accompanied by a slight reduction in fetal deaths and no reduction in other adverse perinatal outcomes. They felt that the side effects outweighed the benefits of increased IOL in settings with a low chance of adverse perinatal outcomes. It was essential to put this here: Every woman's circumstances are different; however, asking about the risks of induction is vital. A study by Dahlen et al. (2021) looked at both the short-term and long-term health outcomes of induction between 37 and 41+6 weeks of pregnancy. They found that the long-term child's risk of hospital admission for infections was proportionally higher for children born by induction than those born spontaneously. This study was significant, with over 400,000 participants. Dahlem et al. also found that admission to the NICU for asphyxia (lack of oxygen) increased during induction. Women were also more likely to require an epidural/spinal, instrumental delivery, episiotomy and have a haemorrhage than spontaneous vaginal deliveries; First-time mums were more likely to need a caesarean section. It is essential to know that no decision is risk-free; you must weigh the benefits and risks. For example, induction used when a woman has a preterm rupture of membranes can reduce the risk of infection in both mum and baby (NICE, 2021). NICE states that women should be given time to discuss the information before deciding. Ask for more time; in most cases, there is no imminent risk to life; therefore, asking to go away and think about it can give you time to discuss all your options and research. Start making a list of questions – write them down so you do not forget.

Offering induction is a topic that is important to consider. My experience in the day assessment unit has shown me that women come in needing clarification as to why they have been sent a text telling them their induction is today when they have not had any discussions. Wickam (2020) talks about this in detail in a blog post; she states it is common practice in some health areas, and the problem is that it is convenient for the healthcare system. It is more efficient and straightforward; however, it leaves the recipient feeling like just another number rather than a person; it can also make women feel like they have no choice. One study by Coates et al. (2019) found that women want to be a part of the decision-making process about their maternity care but need more information. This study highlights the correlation between women's relationships with their babies, their sense of self and future reproduction, and their perception of their labour and birth. In such situations, it is essential to remember that you always have a choice despite how it may feel. Calling your midwife and asking for more information, discussing your options and declining or accepting is okay; remember, it is your body and your baby, and you must do what is best for you.

"It is disappointing but not surprising to see further confirmation that many women undergo induction of labour without having received adequate information about the pros and cons of this. Induction is absolutely the right decision for some women and not right for others. We need to ensure that women and families can get better information about induction. This includes the actual numbers and not just a professional’s assessment of their risk." - Wickahm 2022

In an ideal world, the topics discussed above would be standard practice, there would be no anxiety around induction, and every woman would feel like they are totally in control of their body; sadly, that is not the case right now. From reading above, I hope you feel more prepared and have some ideas on what questions you want to ask, and whatever you decide, you can make a confident decision based on what is best for you. Below I have written some example questions to help you feel more confident in deciding what is best for you.

1) Why are you offering me induction? This question is helpful; you are trying to understand the rationale behind the induction. This will help you to go away and do some research, but also it is essential for your risk assessment.

2) What is the evidence? This can help you understand why healthcare professionals feel this is the safest option. Remember to investigate the statistics and how they are phrased, as this can be very influential. I highly recommend doing your research as well. Much research says induction is the safest option, but not all good studies exist. Look at who sponsored the research and whether they have any conflicts of interest or bias that would affect the accuracy of the research.

3) What are the risks of induction? This is the most important question; you cannot make an informed decision without knowing the consequences of all choices. You must be able to weigh both pros and cons, to make a decision you feel confident with.