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

units.

in some maternity Large discrepancy between

expectations realities

experienced of induction and the Very little qualitative research into women’s experiences of induction since the 1970s NICE (2008) guideline sets expectations for information, communication and decision making BUT are these being met?

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Research question

“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?”

Set within the conceptual framework of informed choice

Study design

• Semi-structured, face to face interviews at 4-6 weeks post birth • Participants identified from a single NHS Trust in Southern England, August-December 2012 • Ethical approval received from NRES and local R & D office 3

• Opportunistic sample • 21 first-time mothers: age range 26-41 years

Sample

• Mostly middle-class, educated to A’ level or beyond • 5 induced for medical reasons • Low-risk at booking • Fluent English speakers • Induced around term without anticipation from early pregnancy •

15 induced for post-dates pregnancy

• 1 induced for maternal age • All attended antenatal classes 4

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 5

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 9

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 12

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!

14 Annabel Jay 2014©

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.

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