A recent study from Ireland suggesting that first-time mothers with low-risk pregnancies could spend the initial 24 hours of induced labour at home has drawn critique from researchers advocating for better maternity services in Ireland. Produced in the Lancet under the leadership of Prof Fergal Malone, a notable gynaecologist and obstetrician at the Royal College of Surgeons of Ireland (RCSI) and Dublin’s Rotunda Hospital, the study discovered that a majority of the mothers gave birth naturally post-induction at 39 weeks using a prostaglandin gel or a cervical dilation device.
Said Prof Malone, “Considering the growing preference for labour induction, which is creating pressures for overrun maternity hospitals, outpatient labour induction could be an emerging method, enabling a greater number of patients to opt for induction while staying in the comfort of their residences.” These comments were released upon the study’s publication in late July.
Yet, the study faced criticism from the Association for the Improvement in Maternity Services (AIMS) Ireland. Lisa Lamboloz from AIMS Ireland, a voluntary group supporting women in the maternity system, said, “This trial focused exclusively on first-time healthy mothers with no clinical complications for either the mother or her baby. However, by enrolling them in the trial, these subjects experienced extensive medical management of their labours, exposing themselves and their babies to potential induction-related risks.”
Guidelines from numerous organisations, including the American College of Obstetrician and Gynaecologists, state that induction risks comprise uterine overstimulation inducing regular contractions potentially altering the foetal heart rate, intensifying labour pain, and increasing the prospects of instrumental delivery such as using forceps or ventouse. The World Health Organisation has regularly cautioned against the medicalisation of birth and customary intervention usage on otherwise healthy women and babies owing to the inherent risks involved.
The latest National Clinical Practice Guidelines on Labour Induction suggest that it may be beneficial to offer labour initiation to women with trouble-free pregnancies at 41 weeks. However, they also propose that for women aged 40 or more, considering labour induction at either 39 or 40 weeks’ gestation is valid. The female participants in the research referenced were between the ages of 18 and 39. Notwithstanding, the proposal to induce obviously healthy mothers at 39 weeks contravenes our recently published National Clinical Practice Guidelines on Labour Induction, argues Claire Kerin, a research officer at AIMS Ireland.
Contrarily, Prof Malone argues that proposing induction at 39 weeks doesn’t undermine the guidelines. He states that the guidelines don’t restrict them from discussing the option of labour induction at 39 weeks. He is adamant that it’s about providing women with choices and enabling them to make informed decisions.
On a related note, the backdrop of these differences of opinions is a time where induction rates in first-time mothers account for 40 to 50 percent of all initial pregnancies in Irish maternity hospitals. Surprisingly, one maternity unit recorded a 74 percent induction rate in first-time mothers during a month this year. This increase is not simply because women are voluntarily opting for induction, confirms Dr Krysia Lynch, the chairperson of AIMS Ireland. She indicates that these rates have grown because women are being instructed about induction, often without sufficient choice.
Dr Lynch also reports that a recurring issue raised and complaint received at AIMS Ireland is the deficiency in informed consent relating to labour induction. She comments that women have reported instances of being intimidated, scared, or even pressured into induction. They also argue that the information provided to them is occasionally partial, and the potential risks are often glossed over.
Importantly, the National Clinical Practice Guidelines on Labour Induction suggest that from 39 weeks onwards (but not before), initiation requests should be reviewed. This should be undertaken after an open dialogue about the advantages and risks of the procedure, taking full account the woman’s situation, inclinations, the hospital or unit’s resources and established care pathways.
The Lancet study revealed no augmented probability of Caesarean birth for first-time expectant mothers who decide to induce at 39 weeks as opposed to those who choose to carry their infants to full term. An earlier study had indicated a marginal 4% decline in Caesarean births in low-risk first-time mothers initiated into labour at 39 weeks, in comparison with mothers who opted for the “observant” approach to labour.
Dr Lynch has proposed a multitude of alternative techniques to decrease the potential for a Caesarean birth by a range of 20 to 25%. Such strategies involve the utilisation of a doula – a female assistant who endows a pregnant woman with guidance and support during labour, endorsement of midwifery-led care and preparation for giving birth at home.
Researchers from AIMS Ireland argue that instead of transferring mothers into the home, maternity departments experiencing overcapacity due to high induction rates could “dedicate their human resources, enthusiasm, facilities and private funds towards the achievement of the National Maternity Strategy’s goals.
“These efforts might encompass broadening our facilities for home births, fostering birthing centres, continuity of care facilitated by a recognised midwife along with wider availability to non-drug pain management options such as water during labour.”
It is known that an early induction of labour does not pose risks to infants. But is it advantageous for the mothers?
The researchers also highlighted the finding of a study which demonstrates that it is the baby who instigates its birth by releasing chemicals via the placenta to the mother’s brain prompting the natural discharge of oxytocins. “Bearing this fact in mind, why are we persistently launching infants – who are obviously not ready for birth – from their mothers prematurely prior to the completion of their natural gestation period,” questions Dr Lynch.
Nevertheless, not all scientists concur with the views held by AIMS researchers. A 2023 research study conducted by the Department of Obstetrics and Gynaecology at the University of Melbourne found that choosing to induce labour at 39 weeks is coupled with a 37% decline in risk of perineal injury (tears) for mothers in labour. The study, which amassed data from 14 investigations of women, was published in the Journal of the American Medical Association Network Open.
In light of the increasing trend of inducing labour at 39 weeks, which currently accounts for over 40% of births in Australia, the recent study conducted by Dr Roxanne Hastie and her co-researcher, Dr James Hong, offers significant insights. The duo attests that this process not only ensures the baby’s safety but also provides protection to the mother. This study is the first to authenticate the benefits for mothers in having their labour induced.
Dr Hong further elaborated that induced labour, in turn, minimised the chances of needing an operative birth, such as through forceps or vacuum extraction.
However, Prof Malone clarifies that despite the benefits, a spontaneous labour still trumps an induced one. Nonetheless, studies indicate that opting to wait for natural labour resulted in an elevated Caesarean rate compared to making a choice for labour induction at 39 weeks.
He explained that while spontaneous labour reduces the likelihood of Caesarean birth, it also suggests a slower and more difficult labour process, thus elevating the risk of a Caesarean. Interestingly, when you juxtapose the group that chooses to ‘wait and see’ – some of whom will eventually resort to induction – against the group that opts for induction at 39 weeks, the latter reflects a diminished C-section rate.