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Rigging the Election: When it comes to elective induction, are women asking for it?

September 24th, 2010 by avatar

There is a growing movement, backed up by evidence, practice guidelines, and efforts by agencies including the March of Dimes, the Institute for Healthcare Improvement and the Joint Commission, to reduce elective inductions, especially those occurring before 39 completed weeks of gestation.

Media coverage of these efforts tends to frame the problem as too many women asking for early delivery with no medical reason and the solution as hospitals “saying no” to these women.  But this woman-blaming paradigm is simplistic and flawed. New research shows that, not only have maternity care providers failed to convey the risks of early delivery to women, they may be offering or recommending elective deliveries despite the risks, and telling women they have a medical reason for induction but documenting the inductions as “elective”.

First, the evidence that educating women does help.

As reported in the July/August issue of the American Journal of Maternal/Child Nursing, researchers at St. John’s Mercy Medical Center in St. Louis, MO, studied the effect of a 40-minute educational intervention given in the context of hospital-based Lamaze classes. The intervention was an educational module about elective induction incorporating evidence and professional practice guidelines, taught along with the otherwise-unchanged Lamaze class curriculum. Researchers compared the elective induction rates between attendees and nonattendees in the 7-month period following the introduction of the new module. The content of the educational model was straightforward:

Specific risks of elective induction presented during the class included cesarean birth with longer postpartum recovery, pain, and potential complications as well as other associated risks such as longer labor, use of pharmacologic agents and their effects on the mother and fetus, and neonatal morbidity. Benefits included advance planning and timing with personal schedules. (p. 190)

Women were also given “talking points” to discuss with their provider if induction was recommended.

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The intervention appeared to be very effective. The elective induction rate was about 37% in both attendees and nonattendees before the intervention and in nonattendees after the intervention. But 28% of women who attended the classes that included the educational content had elective inductions, a significant reduction indicating that the hospital would only need to educate about 11 first-time mothers to prevent one elective induction.

But, you might say, that still leaves more than 1 in 4 first-time mothers having elective inductions. What else might be driving this besides lack of education? Well, it might be this: the researchers also discovered that nearly 70% of women were offered elective induction by their doctors. And, not surprisingly, women whose doctors offered them elective induction were far more likely to choose elective induction, whether or not they were exposed to the educational intervention. In fact, the magnitude of the difference was much greater than with educational content. Roughly speaking, doctors would have to refrain from offering elective induction to just three first-time mothers to prevent one elective induction.

Prior to the educational intervention, when the hospital leadership were considering how to decrease the use of elective induction, most doctors believed that the problem was that uninformed women were asking for it, an assumption turned on its head by the research findings.  In postpartum surveys, three-quarters of women who had “elective” inductions indicated that the physician suggested the option compared with only 25% of women who indicated that they initiated the request themselves.  Class attendance had an influence on whether women chose to act on the option of elective induction, but the difference wasn’t huge. About 38% of women who attended the class and whose doctors offered elective induction chose the option, compared with 50% of those who were offered elective induction but didn’t attend the class.

The researchers conclude:

Although education provided in prepared childbirth classes can be helpful for women in making the choice of whether or not to have their labor electively induced, the physician is a powerful influence…It is possible that patients perceive the offer of the option for elective induction as a recommendation that they actually have the procedure, particularly if they are told they are due now, overdue, or their baby is getting too big. (p. 193)

And therein lies the problem: it turns out many women having “elective” inductions think they’re having medically indicated inductions. In a follow-up study by the same research team, published in the current issue of the Journal of Perinatal Education (full-text available to Lamaze members), the researchers report more of their findings from postpartum surveys as well as data gleaned from reviewing the medical records of each woman after delivery.  They write:

The most significant discrepancy between the medical record and patient perception was related to macrosomia as an indication. For example, based on the medical record, macrosomia was the indication for 26.7% of inductions; however, 39.9 of patients noted that their physician told them they needed to be induced because “my baby was too big.” The next most common reason women believed they had an induction was that they were “due now or overdue” (20.3%), yet only 35 women (6.4%) who had an elective induction were 41 completed weeks of gestation and none were more than 41 3/7 weeks. The majority of women who indicated they were induced for being “overdue” were only 1 to 4 days past their estimated due date. (p. 28)

So what’s the take-home of all of this?  How do we rein in the overuse of elective induction? Clearly, childbirth education that specifically addresses the risks, benefits, and evidence-based indications for induction helps.  As we have seen, fewer women exposed to this educational content will choose induction. Researchers also found that women who had inductions were more likely to have reported feeling prepared and having the reality match up with their expectations if they had taken the classes. They were also less likely to report not knowing why they were induced compared with women who were induced but didn’t take the class. In other words, the class helped women have more fruitful conversations with their care providers.

But it is clear from this research – the first to explore these issues in depth with a combination of qualitative and quantitative approaches – that we have to change provider beliefs and practices to have a meaningful impact on induction rates. It’s time for more research on what happens behind the closed doors of prenatal visits, and for clear standards that tell doctors it is not okay to offer a major medical (often turned surgical) procedure to women as if it was benign or beneficial.

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  1. September 24th, 2010 at 10:18 | #1

    In my experience, it is absolutely the care providers pushing the inductions. I know a mom whose doctor (first of all) gave her a due date that was actually a full week BEFORE the date the 11 week ultrasound gave her, and then we she was at (what was actually) 39 weeks, told her if she hadn’t dilated by then, she never would and she’d need a cesarean.

    That mom held out, no induction, no cesarean required. But it caused her two full weeks of nonstop stress, anxiety, and a total loss of self confidence that greatly inhibited her ability to cope in labor. Even at 10 cm dilated, she still did not believe that she was going to be able to birth because “the doc said I could never do this!” But she did.

    What these providers do to women is nothing short of abusive.

  2. avatar
    Erin
    September 24th, 2010 at 10:42 | #2

    I’m troubled by the word “suggest” in the report. The physicians “suggest” induction to their patients? Most women I know are in fact TOLD that they will be induced; their views are not considered relevant. They are occasionally bullied into it. And as we know women have to fight pretty hard in this country to birth by evidence-based normal birth standards. While it wouldn’t occur to many women to contradict their doctor who was telling them that they needed a certain medical procedure (to save their baby’s life, of course), others are defeated by the struggle and the overwhelming prospect of trying to find a new care provider at 38-40 weeks. A friend of mine was convinced that she “had” to be induced the day of her “due date” because “the baby’s too big” – luckily she had a successful induction & a vaginal birth, but her “giant” baby? 6 lbs 4 oz.

    In addition to suspected macrosomia, many OBs push inductions by saying (and I’ve heard this over and over again): Aren’t you sick of being pregnant? They make inductions seem like an easy and problem-free alternative to the discomforts of the final weeks of pregnancy – which we all know can be considerable. And then it seems they turn around and blame women for the high rates of elective inductions (and the same pattern holds true for C-section). There needs to be more accountability of OB behavior.

  3. avatar
    MAmomma
    September 24th, 2010 at 10:46 | #3

    First of all, love the title! At my 40 week appointment when checked I had “no signs” of labor. My OB gave me the speech about how at my next appt they would schedule an induction because of the mortality risks of going “late”. Do you think she explained all of the risks of being induced? Big fat no on that. Fortunately I did my own research and knew the risks… but do all pregnant women and families do that? Do they just trust their doctors whole-heartedly? Scary. Also fortunately for me I went into labor 3 hours after my appointment on my own. Shows how much they really know about women’s bodies and what they are capable of.

  4. avatar
    Jessica English
    September 24th, 2010 at 11:10 | #4

    I am worried that the push to curb elective induction before 39 weeks will draw away from the fact that ALL elective inductions come with serious risks. Thank you for addressing the fact that many women having elective inductions believe that they are “medically necessary.” I like the Lamaze Healthy Birth Practice Paper #1 for many reasons, but especially for its list of research-based reasons for inductions. And even those can be grey areas (how HIGH should your blood pressure be to justify induction?), there are providers who can find a “medically necessary” reason for any woman to be induced.

  5. avatar
    jj
    September 24th, 2010 at 11:17 | #5

    I think one of the key issues here is that the rate of induction is not being driven by mothers, NOR is it being driven by hospital policies, but rather it’s being driven by doctors (who are not hospital employees in most cases). The key place for an intervention to reduce induction is doctor education, not putting the onus back on moms.

    My OB won’t induce for “overdue” until 41 weeks, simply because he was concerned that date of conception wasn’t totally clear unless a mom had assisted fertility treatments. What if mom thinks she’s at 39 weeks (by the wheel) but she’s really only 37? Baby may need more time to cook.

  6. September 24th, 2010 at 14:21 | #6

    Some wonderful points were made. I think combining educating moms with OBs not offering is the best solution! It is true that if an OB suggests an induction, many moms feel that it is a medical suggestion.
    I see many of my doula clients being “offered” inductions without being told the risks.

  7. September 24th, 2010 at 17:32 | #7

    I’d like to see late term ultrasounds tossed out of the regular practice. One hospital I am thinking of does these routinely. Women are routinely spooked about the size of their baby. Simply tossing aside this unnecessary procedure would cut down on how many conversations pregnant women must have about their “big baby.”

  8. avatar
    shelly
    September 24th, 2010 at 17:49 | #8

    Shelly Schadeck-Wilcox And its not just the hospitals IV in the arm just in case that starts making you think something might go wrong, its the attitudes from the begining as if every baby is a clock work, text book delivery.. It is known fact by any mother swapping birthing stories that every delivery invoves different days of gestation, dialation, stalling, and readiness for each individual story given. Yet the doctors are pushing such worries as: if the baby should be c-section, if the baby is already big enough, if the head is too big, if the time of gestation is too long if you start having complications. All of these statements from trained professionals puts womens confidence in themselves comprimised from the begining. We need more, women can have babies, women do it all the time and dont have complications, coming from the doctors. These worries all bring one thing to a head with birthing and birth, and that is that it has to follow text book timelines. This is somewhere that does not work. When that happens doctors start using, inductions that are too soon for the body to kick in the appropriate hormones and stalling that is too long for doctors to wait for and broken water sacks and scrapped membranes that do nothing for the progression many times and is seen as a reason for bacterial worry after a certain time line. All unatural proceedures can easily lead to c-section let alone the feeling of the lack of confidence that it can be done with patience this ALL ultimately leads to, c-section.

  9. avatar
    Laura
    September 24th, 2010 at 20:33 | #9

    During my 1st pregnancy my OB did a cervix check at 38 weeks 5 days and found my cervix to be not dilated, not effaced. He then informed me that my next “appointment” would be an induction (two days before my EDD). He did not ask me if I wanted to be induced nor did he discuss the risks with me.

  10. avatar
    Katherine Hunt
    September 25th, 2010 at 07:02 | #10

    I firmly believe that providers push it on women who are both inexperienced, and nervous enough as it is. A relative of mine was even induced against her will, her doctor just pulled her mucous plug with out any prior warning and told her after she felt it.

  11. September 25th, 2010 at 10:07 | #11

    Education, education, education: the key to empowered decision making, right? I really appreciate the messages put forth in these studies, and Amy’s review thereof. Whether the result of these studies becomes increased education of maternity care providers re: dangers/risks vs. benefits of induction, or the increased education of maternity care consumers…education (the dissemination of the lessons provided by these studies) still remains the key.

    In my childbirth preparation classes, I often remind my students that in so many other scenarios in life, we spend plentiful amounts of time educating ourselves before buying into something and, therefore, empowering ourselves with the skill of informed decision making. How many of us purchase a car without spending ample time researching the make, model, gas mileage, aesthetic features, safety profile, etc., etc.? And when we buy a new computer? We don’t likely just walk into a store and tell the person behind the counter, “whatever you think is best.”

    Why, then, do so many short change the due diligence required in making decisions about the ‘how’ and ‘when’ of birth?

    The reason for offering or, occasionally, seeking an induction are extensive: fear of macrosomia (usually unfounded), apprehension about being attended by the doctor on call, vs. one’s own maternity care provider, concerns about the potential for a post-date pregnancy, desire to have baby born on particular day in coordination with a visiting relative, observation of a slowly creeping blood pressure…in a moment of fatigue and vulnerability, any one of these “justifications” might initially seem relevant. We do, after all, live in a world in which uncertainty and lack of control are generally abhorred and avoided. And, perhaps, for the maternity care provider who frequently offers inductions, these “justifications” are overpowering enough to prompt the aforementioned offer. No on likes to see another person in discomfort and, quite frankly, many OBs (and family docs and midwives) listen to repeated late-pregnancy patient complaints of poor sleep, indigestion, overwhelming fatigue, oppressive impatience… does the human (read: empathetic) side of these care providers cave into these complaints? Also, I certainly know plenty of maternity care providers who WANT so much to be present at their patient’s births (rather than one of their partners, according to the call schedule) that an offered induction is the best way he/she can orchestrate that. And yes, I know there are some cases in which an offered elective induction harbors a less altruistic intent.

    The reasons for elective induction are numerous–but many of them, I believe, are based on benevolent or preventative intentions (even if these intentions are misguided and/or unfounded) but the truth remains the same: reason does not necessarily equate to scientifically founded justification and when our heart strings, impatience, ulterior motive or misinformed motivations lead us toward considering an elective induction, we must return to the basic tenants of education: what is TRULY in the best interest of the mom and baby? And not just in the short term, but in the long term–extending into the postpartum period where both immediate and long-term breastfeeding success depends on an alert, calm baby and a rested, alert, calm mother.

    I’ve been there. I’ve seen it, experienced it and also avoided it: elective induction is not the simple solution it is often thought or presented to be–even when it seems like a tantalizing option at the time. To demonize any one entire party ( doctors, mothers, nurses, insurance companies, hospital administrators) is far too simple a response to this complicated issue. But effectively delivered and well-founded education can make decision making abundantly clear and more easily exacted, for both pregnant woman and maternity care provider, alike.

  12. avatar
    Val
    September 26th, 2010 at 20:51 | #12

    Are there any attempt to educate OB’s on the power of their words and suggestions? Maybe, just maybe, they don’t realize that their suggestions are so powerful.

    Just a thought. Thanks for the great read. Loved it.

  13. avatar
    Connie B, (CD)DONA
    September 27th, 2010 at 18:13 | #13

    @Kimmelin Hull, PA, LCCE
    Amen! I could not agree more. I have been in this business for 25+ years. I have watched the pendulum swing back and forth and back again as far as a woman’s (and care providers) attitudes, and they both bare responsibility for many aspects of care, including inductions. Time after time I see women who are so uncomfortable towards the end of their pregnancy that they are either willing to overlook (or not find out)the risks of induction. Especially if the doctor even mentions a “big baby”, which can start coming up early in pregnancy- “your a small woman,let’s hope this baby doesn’t get too big”. I see husbands/partners who would never dream of questioning the doctors “authority”, and when coupled with the moms end-of-pregnancy discomforts see induction as necessary. I think we must see this problem as multi-faceted, and try to address it from many angles. Doctors need to be held accountable for perpetuating bad info and disguising convenience as medical need. Women need to stop telling other women their “horror” stories- the length of their labor, how “overdue” they were, how “easy” their induction went, and even that their c-sec was a relief and recovery from it went smoothly. While all those things may be true for that particular woman, it certainly does not give a realistic picture of the risks. I have had women tell others how “great” an epidural is and they would never consider going through all that pain. We need to give women the bigger picture of normal birth. We need to share with them the unscientific origin of EDC,and EDD. We need to tell them that they are strong and capable, and designed to give birth without medical intervention MOST OF THE TIME!!! These facts are rarely known by the average person, and certainly are not represented in the media. Those of us that have had positive, physiological birth experiences need to share that at every opportunity. We need to do this without fear that we may offend those women who have not had a positive birth. I encourage all educators to offer classes for women even before pregnancy or early in pregnancy so they can educate themselves on evidenced base care, & how to pick a care provider that will support their choices. I read somewhere that before those EDC/EDD’s started being the standard, women used to be given “seasons” regarding when the baby would come-expectations would be so much different if women were told- “Your baby is due in early Spring” or “late Fall”. While I realize this is not likely to happen, and is not advisable for some reasons, it seems it would relieve lots of the unrealistic expectations women have when pregnant. We need to help them understand that the process works best without unnessary intervention.

  14. October 11th, 2010 at 14:14 | #14

    There is a doctor in our area whose patients come to me for prenatal yoga who has point blank asked them when they want to be induced, citing that she has induced herself for her own pregnancies since the last few weeks are “so uncomfortable”.

  15. October 30th, 2010 at 17:49 | #15

    In my observation, Americans in general are growing too willing to give up their autonomy in a multiplicity of areas because some authority said it was best. This is true in education, government, parenting choices, and, of course, in our medical choices, including in birth. The authority says, “This is best for you,” with a little pat on the head, and we accept it!

    We women (mostly women) on here tend to be more independent and willing to do our own research, and are more willing to go against cultural norms. But, the VAST MAJORITY of women out there will do just about anything their doctors even vaguely suggest, just because he “said so.” It’s frustrating, and outside a huge shift in cultural attitude, I don’t know what’s to be done about it!!

    After having five all natural, no intervention births of my own, whilst keeping a laissez-faire attitude about birthing, not wanting to “push” my beliefs on anyone, I’ve recently turned the corner, and realized that most women haven’t come to their own conclusions and rejected natural birthing — they haven’t come to any conclusions at all, and allow the ship of their entire pregnancy to be steered by Captain Doctor because he’s the authority!!

    I’m now studying to be a doula, and have had the opportunity to be at a number of births recently. Throughout her pregnancy, one young woman was bound and determined to have a natural birth, but when her doctor came in the room (she was in spontaneous labor and contracting regularly, and had only been in labor for about four hours!) and said, “I think we need to speed things up a bit” and put her on pitocin, she didn’t even blink! When he walked out of the room, she said to me, “Well, he must know something we don’t know, or he wouldn’t have recommended it.” I was appalled, but kept my mouth shut… The pitocin led to an epidural which led to drawn out coached pushing (though, thankfully, not a c-section) which led to a drugged baby who would NOT latch on and “needed” formula… Afterward, she reflected on the birth with dissatisfaction, saying, “I wish I had refused the pitocin… But, it’s hard to say no to a doctor!”

    Argh!

    It’s not hard for ME to say no to a doctor. But, I think many, many, many women are in the same boat as my friend: Wanting a natural birth, but finding it impossible to stand up to a doctor’s wishes. They just say, “Yes, sir,” and don’t even realize they have a right to refuse, and even if they know they have that right, they are afraid (or something!) to exercise it.

    I find this perplexing and frustrating, with no clear solution.

  16. avatar
    Danika Surm
    January 25th, 2012 at 12:58 | #16

    In my experience, too, elective inductions are not so much suggested to a woman but rather she is told that on x-date she will be induced. It troubles me that a woman who has felt herself to be in a trusting relationship with her physician throughout her pregnancy is given such one-sided information. How is a woman, if not self-educated on induction risks/benefits, supposed to even know that her physician might be giving her one-sided information if she has, up until this point, had a reasonably open and honest relationship with him/her. I think more pressure needs to be put on health care providers (by the birth community at large) to maintain standards of informed consent (as outlined in their own policies and ethical responsibily guidelines)! It is unacceptable [to me] that women are making “choices” when they really are given no choice, or no indication is given to them that there is even a choice to be made!

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