Steep rise in first-time mothers being induced

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A huge jump in first-time mothers having their labour induced is a worrying trend that is putting women at unnecessary risk ...

The proportion of labour induction among women who carried their babies to term rose from 18.6 per cent of all births in 1990, to 26.2 per cent in 2008.

... and the majority of those [inductions] were carried out before the 41st week of pregnancy.

... at the same time, the rate of stillbirth remained steady.

"Induction seems to be increasing and that doesn't seem to be improving the outcomes for babies,'' ...

More older mothers and increases in instances of medical conditions, such as gestational diabetes, explained only some of the rise ... Women who were more likely to undergo induction ... tended ... to have private health insurance.

... the study was worrying because it showed inductions were often not done for conventional reasons such as high blood pressure or prolonged pregnancy.

''Unspecified'' reasons were given for between a third and half of all inductions ...

... as the rates of induction had gone up, so had the rate of caesareans. Between 2001 and 2007, fewer than half of the women who had their labour induced went on to have a natural birth, with a third of inductions resulting in caesareans.

... women were often put under subtle pressure by doctors to undergo inductions and did not have the risks of further interventions explained to them.

"If you knew your chances of having a normal birth were less than half, you would think more carefully about what is being advised," she said. "They trust us and they trust the advice that they are getting is correct and that is very concerning."

... Women who had a caesarean for their first birth were more likely to have the procedure for subsequent births, leading to increased risks of complications such as the placenta growing through the uterus wall ...

Perhaps a policy needs to be developed whereby all inductions need to be cleared by a committee of at least 2 senior doctors and 2 senior midwives, prior to authorisation by the induction committee. Sometimes a meeting with senior clinicians can help to generate other options instead of resorting to induction. This would, however not be applicable in the private sector, where most of the inductions are performed.

In NSW in 2008, one private hospital had a 38% induction rate, while another private hospital had a 41% induction rate. At those hospitals, only 1 in 5 women went into labour spontaneously. Interestingly - and perhaps in conflict with this article - at those same hospitals, while around 50% first-time Mums were induced, only 1 on 5 first-time Mums had a caesarean - so it doesn't necessarily follow that a high induction rate leads to high caesarean rates. Both of those hospitals have caesarean rates that are in-line with the NSW State average.

I am not suggesting that inductions are wonderful and all women ought to be lining up for them - and the increase in non-indicated inductions is indeed worrying because there should always be a valid reason to bring a pregnancy to an end sooner than nature (and the baby) had intended. There's no doubt that induction rates and caesarean rates are very high - too high - in private hospitals. But I'm not sure that one is leading to another because the bulk of the caesareans are performed electively, ie, prior to labour starting. The most common reason for an elective caesarean is a previous caesarean (I've never accepted that this is even an indication because VBAC is safe ... but I'll have to concede to the majority view that "previous caesarean" is somehow a justifiable reason for another caesarean). Also, as my stats have shown above, despite the huge rate of inductions in first-time Mums, there's not a corresponding increase in the caesarean rate amongst first-time Mums.

So, I wonder if there's something else at play here. I wonder if it has something to do with continuity of care and trust being protective. So that women may be augmented and induced without it impacting the caesarean rate, provided that those women receive continuity of care from someone they trust. In private hospitals where induction rates are higher than in the public sector (along with all types if intervention), women receive continuity of obstetric care and although we might assert that, "women were often put under subtle pressure by doctors to undergo inductions and did not have the risks of further interventions explained to them", it is also true that, "They trust us and they trust the advice that they are getting".

On the other hand, in the public system, continuity of care is not generally a feature of the care provided. Women are often seen by a different midwife or doctor at every visit, they receive impersonal care from a stranger, and by-and-large, they are terrified. Add "induction" to the mix, and viola! You have a caesarean. I wonder if the cause of the caesarean was the lack of continuity of care and trust, rather than the intervention itself. More on that later!