When Emma, a 30-year-old lawyer from Perth, was 30 weeks pregnant with her first child, her doctor told her the baby had a large head.
This, the obstetrician told her, exposed her to complications during childbirth, with the risk of the baby getting stuck in the birth canal if the pregnancy progressed to 40 weeks.
Although Emma, who would prefer not to disclose her full name, wanted to start labor spontaneously, she felt compelled to accept that her birth was medically induced. Her doctor booked her for induction just after she hit 38 weeks.
“It wasn’t even a discussion, it was, ‘this is what’s going on,’” she says. “It’s really, really hard to disagree with doctors or people in positions of authority – and especially when you’re in such a vulnerable position.”
Inductions are more painful than natural labor, and childbirth has been a traumatic experience for her. After labor did not progress for several hours, her baby appeared to be in medical distress and she was taken to the ward for an emergency cesarean.
Her son was born at 3.8 kg – a slightly above average weight.
Induction of labor occurs either surgically or with prescribed drugs, as opposed to spontaneously. Inductions are often medically necessary, most often when the baby is late – beyond 41 weeks – but also for women with underlying medical conditions such as diabetes.
But a new study of births in New South Wales between 2001 and 2016 found a significant increase in the number of women induced to low-risk births, when there is no apparent medical reason.
The study, published in the journal BMJ Open, included 474,652 women aged 20 to 35 who had delivered without complications and whose gestational age of the baby was between 37 and 41 weeks.
He revealed that 15% of these healthy young women had had induced labor without a recorded medical indication.
The study also found much higher rates of medical intervention for new mothers who were induced, which is listed as a risk of induction by the Royal Australian and New Zealand College of Obstetricians and Gynecologists. 71% had epidurals, compared to 41% who were not induced. Cesarean section rates were more than twice as high – 29% vs. 14% – and episiotomies occurred in 41% of births vs. 31%.
Over the 16-year period of data, induction rates doubled for first-time mothers at 38 and 40 weeks gestation.
Lead author Professor Hannah Dahlen of Western Sydney University said the most disturbing result was that the rate of inductions in first-time mothers at 37 weeks had tripled.
“This worries us because these babies could potentially have another three weeks in the mother’s womb,” says Dahlen, an expert midwife. “Those three weeks they miss in their mother’s womb are actually very critical for brain development.”
Infants born to births induced in the study were also more likely to be admitted to hospitals later with respiratory and ear, nose and throat infections.
According to World Health Organization guidelines: “Induction of labor is not recommended in women with an uncomplicated pregnancy below 41 weeks gestational age.”
Although the full term is considered to be 39 to 40 weeks, the length of a woman’s pregnancy naturally varies, says Timothy Moss, an associate professor at Monash University who was not involved in the study. “37 weeks will be fine for one person and 41 weeks might be suitable for another,” he says.
Research found that black and South Asian women, for example, have an average duration of pregnancy before spontaneous labor shorter than white European women, giving birth on average at 39 weeks compared to 40.
“There is no doubt that medical intervention during labor and the involvement of physicians in care during pregnancy in some cases are necessary,” said Moss. “Throughout history he has certainly saved thousands, millions of lives.
But, he says, the evidence also shows that healthy women with low-risk pregnancies can give birth safely without unnecessary medical intervention.
“They are able to do this with great results for their babies, for their bodies, but also for their mental well-being.”
Australian researchers conducted a 2018 review studies on low-risk births and found no statistically significant difference in infant mortality rates, whether the baby was born in a hospital, home, or birthing center.
Dr Alex Polyakov, obstetrician and clinical lecturer at the University of Melbourne, disputes the methods used in the NSW study.
Because the study examines historical data, it believes the results cannot be compared between a woman who is induced at a given length of pregnancy and a woman who spontaneously gives birth within the same week.
He mentions a 2018 study, known as ARRIVE study, in which 3,000 women were randomly assigned to be induced, and another 3,000 had spontaneous births.
It found that induction of first-time mothers who had low-risk pregnancies at 39 weeks was associated with a lower rate of cesarean sections – 19% compared to 22% of mothers who had not been induced.
ARRIVE was a randomized controlled trial – considered the most reliable form of scientific evidence because it can show that the treatment has an effect on human health. Observational studies – like the one from NSW – may show that a particular intervention and outcome are related, but not definitely that one causes the other.
For many clinicians, the ARRIVE study is proof that women can be induced at 39 weeks without significant side effects.
“We don’t induce women to 37 weeks for no reason,” Polyakov says. “We wouldn’t provoke women at 38 weeks for no reason.”
One result the NSW study was unable to examine was stillbirths, which occur in Australia at a rate of 7 births in 1,000.
The increase in inductions of first-time mothers around 40 weeks could be the result of doctors being cautious when considering the possibility of preventable stillbirths, Moss says.
“I don’t think there has ever been a sinister intention on the part of midwives or obstetricians who could step in and do something they feel is really necessary, perhaps to save a woman’s life. mother or baby, ”he says.
“Over time, the stillbirth rate actually increases because the placenta has an expiration date. It works up to a point, and usually work sets in before that point, ”Polyakov explains. “The placenta can fail at any time – the chances are low, but it can happen.”
US data estimates that the risk of stillbirth increases from 2.1 per 10,000 births at 37 weeks to 10.8 per 10,000 births at 42 weeks.
“From my perspective, having an epidural is not a negative result, having a cesarean is not a negative result,” Polyakov says. “A negative result is a stillbirth, a negative result is a distressed baby who needs an emergency cesarean.”
The increase in early inductions in first-time mothers, Dahlen believes, may be in part attributable to a growing push for effective health care.
“Childbirth, like so many other aspects of health, has become an industry,” says Dahlen. “You bring people in, you bring people out. Planning inductions, she says, can be one way to make the birth process more efficient and predictable.
Previous search de Dahlen found that low-risk women giving birth in private NSW hospitals were much more likely to have procedures during labor and 20% less likely to deliver their first child regularly vaginally.
But, Polyakov says, in the public hospital system, doctors have no financial incentive to offer inductions because they are more expensive and more resource-intensive than spontaneous births. “Once you instigate someone, you have to keep them in the hospital until they give birth,” he says.
“We don’t do inductions because they are convenient for us,” Polyakov explains. “As an obstetrician, I want a result that is a healthy mother and a healthy baby.”
Moss points out that the results of the NSW study can only be applied to women with low-risk pregnancies.
Of the 1.5 million total births in New South Wales during the study period, two-thirds were excluded from the study because the mothers had risk factors such as underlying medical conditions .
“What this study shows is that the majority of pregnancies in this NSW dataset were not as straightforward and straightforward as they could be,” says Moss.
Obstetric practice has changed over the past decade, Polyakov says. “There are more women who have medical problems, there are more women who are overweight, there are more women who have gestational diabetes and hypertensive disorders.”
As a result, he says, the number of women who have medical indications for induction has likely also increased.
Abbey McCauley, a 33-year-old woman from Melbourne, has had three medically necessary inductions for her pregnancies. Along with her first child, she was suspected of having pregnancy cholestasis, a condition associated with intense itching. Pelvic instability and gestational diabetes were diagnosed for the second and third. “I felt a lot less stressed knowing I was being induced,” she says. “It definitely reassured me.”
Emma gave birth to her second child last year, in a vaginal birth after a cesarean. Compared to her first birth, she felt supported in the process by an experienced obstetrician, as well as a doula and a midwife student. “If it had ended in a cesarean, I would have felt just as good with it,” she says.
There is a lasting frustration that her first obstetrician did not fully inform her of the potential consequences of induction.
“At the end of the day, it should be the patient’s decision, and the patient can’t make that decision correctly if they haven’t been given all the information,” she says.
To other pregnant women, she offers the following advice: “Do your research, determine what your preferences are, and then surround yourself with people who support you and your decisions about your body.