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Women’s experiences of induction of
labour: a qualitative study
Key findings
Annabel Jay
Senior Midwifery Lecturer and Research Lead for Midwifery
Doctoral student
University of Hertfordshire
November 2014
Sponsored by the Iolanthe Trust
All real names have been replaced with pseudonyms
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Why the choice of subject?
Verbal
evidence
suggests:
Induction is a
major source of
complaints in
some maternity
units.
Large discrepancy
between
expectations of
induction and the
realities
experienced
Very little
qualitative
research into
women’s
experiences of
induction since
the 1970s
NICE (2008)
guideline sets
expectations
for information,
communication
and decisionmaking
BUT are these
being met?
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Research question
Study design
“How do women facing
induction acquire and use
information to make decisions
and what impact does this have
on their experience of childbirth
and early parenthood?”
• Semi-structured, face to face
interviews at 4-6 weeks postbirth
Set within the conceptual
framework of informed choice
• Ethical approval received from
NRES and local R & D office
• Participants identified from a
single NHS Trust in Southern
England, August-December
2012
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Sample
• Opportunistic sample
• 21 first-time mothers: age
range 26-41 years
• Low-risk at booking
• Mostly middle-class, educated
to A’ level or beyond
• 5 induced for medical reasons
• 15 induced for post-dates
pregnancy
• Fluent English speakers
• 1 induced for maternal age
• Induced around term without
anticipation from early
pregnancy
• All attended antenatal classes
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Main findings: Information
• Info about IOL from antenatal classes at best, theoretical; at worst,
patronising
▫ “…we spent half an hour drawing pictures of what we thought
would help induce labour, so pineapple and raspberry leaf tea…
Drawing pictures! We’re all in our 30s, all professionals …and we’re
drawing pictures! (Jasmine: NCT class)
• Information at time of booking IOL was brief and not memorable
• Minimal or no discussion of options or preferences
• Anecdotes from family and friends seen as more meaningful
• Minimal use of literature and electronic media
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However….
• Two women who attended small, specialised antenatal classes (1
private, 1 pre-induction class) providing individually tailored
information were highly satisfied with information received and
felt well prepared for induction.
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Induction seen as a routine: the “right” choice:
“….there is no choice and if that’s what they’re booking, then that’s what you
have to go with” (Sarah: induced at 41+ weeks)
“...it was presented as a choice but they were definitely encouraging me to
strongly consider it rather than waiting” (Clare: induced at 41+ weeks)
Those who wavered were subjected to subtle pressure to
comply:
▫ “…they did say I could push my induction date back, but because I kept going in
every day and all the stress … when it came to it I was like “do you know what?
let’s just do it, I can’t deal with this stress any more” (Nina: induced at 41+
weeks)
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Fear of harm to baby was main driver of
decision to accept induction
• Risks associated with IOL (further intervention, increased pain etc.)
rarely mentioned by health professionals
• At 41+ weeks, women’s perceptions of risk focused on remote risk to
baby of prolonged pregnancy BUT no notion of probability
Number of inductions needed to avoid 1 neonatal death:
410 (Gulmezoglu et al, 2012);
1040 (Stock et al, 2012)
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Outcomes of induction in sample group
Contradicts current evidence that IOL is NOT associated with
increased likelihood of caesarean section (NICE 2012, Gulmezoglu et
al, 2012)
▫
▫
▫
▫
4 x uncomplicated vaginal birth
1 x ventouse
5 x forceps
11 x emergency caesarean section
• Postnatal morbidity:
▫ 2 x postnatal depression
▫ 6 x infection
▫ 1 x third degree tear
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Disparity between expectations and experiences
• Frustrated by delays – seemed to contradict purpose of IOL
• Unprepared for “Invisible rules” of antenatal ward e.g. separation
from partners at night, limited range of analgesia, lack of labour
aids
• Unprepared for lack of privacy
• Lack of acknowledgement of being in labour
“In a way, the scary bit is you’re going to start labour totally on your own,
surrounded by strangers” (Emily: IOL at 41+ weeks)
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Increasing acceptance of medicalisation?
• All women had epidurals, which were highly favoured on reflection
• One third of women would request an elective CS in future
pregnancy rather than undergo IOL again
▫ “I’ve got a scar where all the stitches have fallen out because it
got infected [...] and I’ve had to have 2 lots of antibiotics and I
think, well, maybe a c-section would have been better ... I don’t
really know why they’re so sure that they want you to have this
vaginal birth?” (Emily. IOL at 41+ weeks)
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What this study adds to the body of knowledge:
• Supports earlier studies – lack of informed decision-making,
compliance, induction increasingly seen as “routine”, trust in clinical
opinion
• Supports argument that obstetric-led models of care impede the
implementation of informed choice (Kirkham, 2004)
• Suggests routine IOL has an iatrogenic effect on some women, leading
to loss of trust in their ability to give birth normally and an increased
demand for operative birth in the future (with implications for
maternity services)
• Identifies lack of understanding of risk as a contributing factor to
women’s decisions to accept IOL in uncomplicated, post-dates
pregnancy
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What is needed to improve the IOL experience?
•
A system of care that:
▫
offers opportunities for full and timely discussion of IOL antenatally
▫ provides information tailored to the needs of individual women
▫ fosters realistic expectations of induction antenatally
▫ enables midwives to understand and communicate risks of IOL versus expectant
management to promote informed decision-making
▫ empowers midwives to support women who challenge or decline IOL without fear
of repercussions
▫ treats induction as part of labour and provides a smooth transition from antenatal
to labour care
In short, a change is needed in the organisation and structure of maternity services
towards woman-centred care
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Thank you for listening!
Annabel Jay 2014©
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References
• Gulmezoglu et al (2012). Induction of labour for improving birth outcomes
for women at or beyond term (review). Cochrane Database of
Systematic Reviews 2012 Issue 6. Art. No: CD004945
• Kirkham, M. (2004). Informed choice in maternity care. Hampshire &
New York. Palgrave MacMillan.
• National Institute of Health and Clinical Excellence (2008). Induction of
labour: NICE clinical guideline 70. London. NICE.
• Stock et al. (2012). Outcomes of elective induction of labour compared with
expectant management: population based study. BMJ 2012;
334:e2838 doi: 10.1136/bjm.e2838.