Today, Tanya Cawthorne reviews a recently released book; “In Your Own Time - How Western Medicine Contrils the Start of Labour and Why this Needs to Stop” by Sara Wickham, MD examining labour inductions from an interesting perspective. - Sharon Muza, Connecting the Dots Community Manager.

If you have been working as a childbirth educator, doula, nurse or midwife over the last few years, the significant increase in the numbers of people who have had their labours induced would not have gone unnoticed.

In the United States, the Centers for Disease Control (CDC) reported that 27% of pregnant people were induced in 2018 (Martin, et al. 2019). But that number is probably low. It’s likely that induction of labour is underreported in federal vital statistics (Declercq et al. 2013).

Here in Australia, where I live, our national induction of labour rate is at an all-time high. According to the Australian Institute of Health & Welfare (AIHW) who publish the National Core Maternity Indicators, in 2019, 46.8 percent of women giving birth for the first time had an induced labour. That statistic is equal parts mind-blowing as it is horrifying. Bear in mind too, that these statistics pre-date COVID. We can only assume that these rates have increased further in the last couple of years.

In 2011, the World Health Organization (WHO) published 17 recommendations on induction of labour, including two recommendations on the induction of labour at or beyond term. They included;

• Induction of labour should be performed only when there is a clear medical indication for it and the expected benefits outweigh its potential harms;

• In applying the recommendations on induction of labour, consideration must be given to the actual condition, wishes and preferences of each woman, with emphasis being placed on cervical status, the specific method of induction of labour and associated conditions such as parity and rupture of membranes.

 WHO states that there is insufficient evidence to recommend induction of labour for women with uncomplicated pregnancies before 41 weeks of pregnancy and while this recommendation pre-dates the ARRIVE Trial, it should be noted that WHO has not changed their recommendations since ARRIVE was published.

As childbirth educators, it is incumbent upon us to provide current, evidence-based information for our clients. It can be challenging to access data at times, and even when we can, it can be difficult to analyse and appraise its quality. This becomes even more challenging when we have clients tell us that their care provider has quoted research and evidence that supports early induction of labour – be that at 37, 38 or 39 weeks gestation.

Given how hot a topic this is right now, Dr Sara Wickham’s new book, In Your Own Time: How Western Medicine Controls the Start of Labour and Why this Needs to Stop (Birthmoon Creations, 2021) could not have come at a better time.

For those readers unfamiliar with Dr Wickham’s work, she is a U.K.-based professor of Midwifery, a prolific author, researcher, educator and in-demand public speaker. Dr Wickham possesses that rare gift of not only making research accessible, she makes it interesting too!

In this book, Dr Wickham explores the myriad reasons why we are seeing a global increase in inductions of labour (IOL) and most importantly, examines the evidence behind it.

Specifically, she looks at some of the most common reasons pregnant people are being told that they need to have an induction; being post-dates, fetal macrosomia and maternal age and weight. Personally, I would have also loved to have seen more information on induction for people who have used IVF or other assisted reproduction techniques, but as Dr Wickham points out, there is very limited research currently in this area.

Very importantly, Dr Wickham has also included information on race, racism and induction. There is no doubt that Black, Brown, Asian and mixed-race birthing people are at risk of adverse outcomes when they give birth in systems of care designed by and for white people (Giscombe & Lobel 2005, Muglu et al 2019, Douglass, C., & Lokugamage, A. 2021). Wickham goes on to cite an abundance of research that clearly demonstrates that health inequities and disparities are rooted in systemic racism, placing people of colour at significantly greater risk of poor perinatal and neonatal health outcomes than white people.

In each chapter, Dr Wickham provides important historical context, examines the current research and evidence and very importantly, explains the difference between relative risk and absolute risk. We are all familiar with coercive tactics some people encounter in an effort to get them to consent to an IOL. No doubt we have all encountered variations of “your baby has a high chance of stillbirth” or “your baby will almost certainly die if you don’t come in for an induction right away.” Sheila Kitzinger (2006) described this as “emotional blackmail” although many of us refer to this more crudely as “playing the dead baby card”.

As Wickham points out, if a care provider was really that worried about the baby, they wouldn’t be offering induction, which often takes days to get going. Regarding this coercive behaviour, Wickham is quick to point out that sometimes care providers do this in a very friendly, caring tone and with a smile on their face. Some people will believe what they’re saying, and others will be aware that they are being misled. But regardless, when healthcare providers are doing this, it becomes almost impossible for people to make an informed decision, based on accurate current evidence that also takes into account their individual circumstances – what we would commonly refer to as person-centered care.

As Wickham states in her introduction, “I’m not anti-induction. I’m anti using limited and cherry-picked evidence and deceptive claims about risk to try and persuade entire groups of women to hand over control of their bodies and undergo intervention in the name of safety, when the recommendations aren’t based on good science or an understanding of the wider consequences of such actions and may cause harm.”

As a Lamaze Certified Childbirth Educator, I was particularly thrilled to see some of Lamaze International’s most esteemed members cited throughout the book, including Judith Lothian, Debby Amis and Henci Goer.

The Lamaze Six Healthy Birth Practices certainly align strongly with this book, which should bolster our confidence as educators that we are providing our families with current evidence-based information and the critically-important skills to make informed decisions about their care, free of bias and coercion.  Educators have a responsibility to help families feel confident in having conversations with their providers when induction is suggested, and to participate in shared decision where a true understanding of the risks and benefits of induction and staying pregnant are communicated.  In Your Own Time - How Western Medicine Contrils the Start of Labour and Why this Needs to Stop” can help families to understand why induction might be on the table and cut through some of the emotions and examine what the research says on this overused intervention.

References

Australian Institute of Health and Welfare. (2021). National Core Maternity Indicators. Retrieved from https://www.aihw.gov.au/reports/mothers-babies/national-core-maternity-indicators

Douglass, C., & Lokugamage, A. (2021). Racial profiling for induction of labour: improving safety or perpetuating racism?. bmj, 375.

Giscombé, C. L., & Lobel, M. (2005). Explaining disproportionately high rates of adverse birth outcomes among African Americans: the impact of stress, racism, and related factors in pregnancy. Psychological bulletin, 131(5), 662.

Kitzinger, S. (2006). Birth crisis. Routledge

Muglu, J., Rather, H., Arroyo-Manzano, D., Bhattacharya, S., Balchin, I., Khalil, A., ... & Thangaratinam, S. (2019). Risks of stillbirth and neonatal death with advancing gestation at term: A systematic review and meta-analysis of cohort studies of 15 million pregnancies. PLoS medicine, 16(7), e1002838.

WHO recommendations: induction of labour at or beyond term. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO.

About the Author

Dr. Sara Wickham, PhD, RM, MA, PGCert, BA(Hons) is a midwife, author, speaker and researcher who works independently; speaking, writing, teaching online courses and workshops, consulting, and creating resources for health professionals, birth workers, writers and others. Sara has lived and worked in the UK, the USA and New Zealand, edited three professional journals and lectured in more than 25 countries. This is her 18th book. 

You can learn more about Sara’s work by visiting her website: www.sarawickham.com 

About the Reviewer

Tanya Cawthorne LCCE, FACCE is the current President of Lamaze International and the co-founder of Lamaze Australia. She is a Lamaze educator, a program director and birth doula. 

Based in Melbourne, Australia, Tanya is a passionate advocate for equitable and person-centered maternity care and her articles have appeared in The Journal of Perinatal Education, Australian Midwifery News, Connecting the Dots, Interaction – the journal of Childbirth and Parenting Educators Association of Australia (CAPEA) and International Doula (DONA International). Last, but absolutely not least, she is also the mother of two beautiful children, her son Liev and daughter Amalia.

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