Induction: Are women really free to choose?

When is induction an informed choice?

If girls were brought up surrounded by women who gave birth undisturbed and breastfed openly, would they ever doubt their body’s ability to give birth? If a woman was taught to trust her intuition, to listen to her body and trust in the birth process, would she ever feel that medically forcing her body into labour before it’s ready is a better option than staying pregnant? If women were told that birth is a bodily function and works perfectly well when undisturbed, would they ever be turning to medical staff to tell them whether they are okay or not, and asking them to interfere unnecessarily?

I believe the answer to all of these questions is no, so maybe the answer to the big question of this blog post is also no. The coercion into induction (and medicalisation of birth in general) starts long before pregnancy begins, and is reinforced with every interaction with maternity services.

Ultimately opting for an induction is down to the woman believing that her body is incapable of going into labour by itself. So what does lead women to believe this?

In a study done about induction vs waiting, women said the reasons for “choosing” induction were “feeling safe”, “pregnancy taking too long” and “knowing what to expect”. So women are being told that induced labour is safer, that going “overdue” means that the pregnancy is going on too long, and that induction is more predictable than natural labour. One can only assume then that these reasons come from scaremongering, time pressures based on a bullshit due date and the idea that natural birth is super unpredictable. All of which come from the medical system and the media.

Is it ‘informed’ if the risks of staying pregnant are overstated and the baseline is medicalised birth?

According to the NHS, 1 in 5 pregnancies are artificially cut short by induction. This does not include sweeps which are most definitely part of the induction process. According to the 2013 Listening to Mothers survey, 41% of mothers in the US said that their care provider tried to induce their labour.

The reasons they give for induction are:

“If your pregnancy is uncomplicated, having your labour induced after 41 weeks of pregnancy reduces your chance of having a stillbirth. The risk of stillbirth is:

1 – 2 babies in 3000 at 39 weeks (0.06% risk)

3 babies in 3000 at 40 weeks (0.1% risk)

4 babies in 3000 at 41 weeks (0.13% risk)

5 babies in 3000 at 42 weeks (0.16% risk)

6 babies in 3000 at 43 weeks (0.2% risk)

It also reduces the risk of your baby opening their bowels and passing their first poo (meconium) whilst in the womb, as this is more likely to occur the longer a pregnancy continues.

If your pregnancy continues after your due date, inducing your labour so that you can give birth to your baby will end the discomfort of being heavily pregnant.

If there is a risk to you or your baby’s health, your doctor/ midwife may advise you to have your labour induced early as this is safer for you/your baby.

If your waters have broken and after 48 hours your labour still hasn’t started, inducing your labour so that your baby can be born reduces the risk of you and your baby developing an infection.”

Let’s explore these “reasons”:

As we have established, stillbirth rates are incredibly low and based on gestation (which is based on due dates that are coincidentally correct 4% of the time) is only 0.2% at its peak. There is some evidence to say that induction reduces stillbirth rates, but not a lot of information about the complications babies face from being born too soon. The majority of babies admitted to NICU are “full-term”, but labour doesn’t start spontaneously until the baby’s lungs have fully developed (in healthy babies), so induction at any point is starting labour prematurely. 25% of all NICU admissions are due to breathing difficulties.
Meconium is passed in 12% – 20% of all births (this statistic doesn’t take into account how many women are induced before full-term. If women were left to their own devices this number would be much higher because it’s a normal part of pregnancy). Only 2-10% of those babies will develop MAS (meconium aspiration syndrome). Of that 2-10% of babies who develop MAS, only very few of them will have any complications from it. I couldn’t find any data on whether those who had complications following meconium in the waters were also separated from the placenta immediately and taken from the mother for extended periods of time – both of which would negatively impact the health of a newborn. According to the BMC, induction of labour also increases the risk of there being meconium in the waters, so using the potential risk factor of meconium as a justification for induction doesn’t make sense.
They are suggesting that the discomfort of the end of pregnancy (which for sure is real for lots of women, but is also made worse by the fearmongering and societal expectations) is best dealt with by replacing it with the discomfort of an induction which is known to cause longer, more painful labours, and can often involve being in hospital for 2-5+ days, and more often than not results in instrumental birth or a caesarean, birth trauma and a much longer recovery period.
Induction of labour at 41 weeks in “low risk” pregnancies resulted in an increase in NICU admissions and low APGAR scores at 5 minutes post-birth. This shows that induction has a negative impact on babies who are considered to be well prior to labour. How could it possibly be justified to put a baby who is unwell through the intense and stressful process of being born before they are ready? We also know that induced labours are often longer and more painful, so if the mother is unwell, how does it make sense to do this?
The main concern medical staff have with a pause after the waters have broken is the risk of infection. That risk is only increased by leaving home, being examined or having anything inserted into the vagina. It doesn’t make a whole lot of sense to induce on the basis of a potential infection being introduced, whilst making that thing more likely to happen. NICE guidelines state that for an induction to be started, a vaginal examination must be carried out before and during the induction – this is already two opportunities to introduce infection.

NICE guidelines say to advise women that an induction will impact their birth experience in these ways:

“vaginal examinations to assess the cervix are needed before and during induction, to determine the best method of induction and to monitor progress
their choice of place of birth will be limited, as they may be recommended interventions (for example, oxytocin infusion, continuous foetal heart rate monitoring and epidurals) that are not available for home birth or in midwife-led birth units
there may be limitations on the use of a birthing pool
there may be a need for an assisted vaginal birth (using forceps or ventouse), with the associated increased risk of obstetric anal sphincter injury (for example, third- or fourth-degree perineal tears)
pharmacological methods of induction can cause hyperstimulation – this is when the uterus contracts too frequently or contractions last too long, which can lead to changes in foetal heart rate and result in foetal compromise
an induced labour may be more painful than a spontaneous labour
their hospital stay may be longer than with spontaneous labour.”

If women are not made aware of the risks of induction, and what comes with it as a package deal, then it is not informed consent. Women are very rarely told this information, and in one recent example we heard from a client, she was told there were “no risks” to having an induction as they coerced her into one.

The maternity service is looking for problems with inaccurate technology and a lack of evidence, inflating the risks of staying pregnant and minimising the risks of inducing labour – this is coercion.

Where does the “cascade” really begin?

Often people talk about the “cascade of intervention” as something that happens once labour has started, such as the label of a “long labour” leading to augmentation, leading to stronger pain relief and more monitoring, leading to instrumental delivery or caesarean section, and that does happen frequently. If we go a step further we can look at where the assessment of “long labour” came from, and that is usually based on timings of contractions or waters breaking and vaginal examinations – information that is given to the midwife. So the first medical intervention in this case could be giving the midwife the information she would use to declare that a labour is “too long”.

Let’s take another step back though and look at why women hand over information about what time their contractions started or their waters broke – they hand it over because they have been told throughout their pregnancy that midwives are the experts and that birth is scary and unpredictable, so they should always tell their midwives important information.

Before entering into the maternity system in the first place, women are socialised to defer to authority, to please other people and they are not encouraged to put boundaries in place or say no to things that don’t feel right. We are essentially groomed way before pregnancy to unquestioningly step into a medical system where birth is and will always be medicalised, to do as we are told and to be grateful for the abuse that we suffer along the way. The patriarchal mistrust in women’s intuition (also known as witchcraft) and the birth process (because men cannot and will never be able to experience it themselves, which therefore makes it untrustworthy in the eyes of patriarchy) has a huge part to play in the medicalised path birth is on.

If women have been groomed to take this path since before they were pregnant, are they ever actually freely choosing to end their pregnancy before their baby is ready? Or have they been incrementally coerced since long before they were pregnant?