Are women being pushed into childbirth too soon? Doctors say it’s to protect the baby – but the trauma it can cause has left some mothers with lifelong scars
A certain amount of anxiety is to be expected for any first-time mother. But shortly after Lea Teahan’s daughter Ivy was born, those natural worries spiralled into something darker and all-consuming, and she was diagnosed with severe post-partum anxiety.
‘I couldn’t bring myself to leave Ivy with anyone else, even for a couple of hours,’ says Lea, 30, a conveyancer from South Wales.
‘Once, when my partner Rob tried to take me out for lunch, I ended up having a panic attack. I was convinced some awful accident would befall her, or Rob and I would be killed, leaving her an orphan. It was consuming me. My palms would sweat and I’d have a racing heartbeat.’
After Lea Teahan’s daughter Ivy was born (pictured together), she was diagnosed with severe post-partum depression
The trigger for Lea’s anxiety? She believes it was the five days she endured in a painful labour induced at 39 weeks, before Ivy was finally delivered by caesarean last summer.
‘I was in for five nights, unable to sleep properly and only able to see Rob for a few hours a day,’ she recalls. ‘I watched other women come onto the labour ward and go after just a few hours, but nothing happened for me — just immense pain.’
In the UK today, one in three women will, like Lea, be induced. According to NHS figures published in October 2019, 33 per cent of all babies born last year were delivered after an induced labour — yet ten years ago the figure was 20 per cent. At the hospital where Lea gave birth, the induction rate is closer to 40 per cent.
Many experts welcome the medical benefits induction can offer. Professor Alexander Heazell, a consultant obstetrician and director of the Maternal and Fetal Health Research Centre at St Mary’s Hospital, Manchester, says that performing more inductions has been a key part of making birth safer for women and for babies, including reducing the risk of stillbirth.
Indeed, some experts make the case that even more women should be induced for this reason.
But what if you don’t want to be induced?
There are concerns, though, about the over-medicalisation of childbirth, with many women reporting feeling pressured into having an induction they don’t want.
As Lea puts it: ‘I know that during birth there are going to be a lot of things you’re not going to be able to control, but I feel I was rail-roaded into doing something that I didn’t want and that wasn’t in my best interests.’
She believes her anxiety was triggered by the five days she endured in a painful labour
Nor are inductions without their drawbacks. Anecdotally, they can make labour longer and more painful. Evidence also shows they are associated with further interventions, such as the need for forceps or ventouse (a suction device) to aid delivery — which can add to the pain and the risk of further complications, such as vaginal tearing and post-natal incontinence.
Also, such interventions aren’t in keeping with many women’s desire for a ‘natural’ birth.
‘We know that most women would prefer not to be induced,’ says Soo Downe, a midwife and a professor of midwifery studies at the University of Central Lancashire.
Guidance from NICE (the National Institute for Health and Care Excellence) is that in a healthy, low-risk pregnancy, labour should be induced once a woman is one to two weeks overdue (due date being the 40th week of pregnancy).
But many inductions, like Lea’s, are performed earlier than that.
All the doctors Good Health spoke to for this piece said that the main reason for the steady increase in inductions over the past decade is not that more women are going past their due date, but that the women tend to be both older and heavier (50.4 per cent of all pregnant women are now overweight or obese).
This means they are more likely to have other health problems and their pregnancies are likely to be more complicated. The longer pregnancy goes on, the more danger both mother and baby may be in.
Modern mums, riskier labours
Such complications include pre-eclampsia (which causes high blood pressure) and gestational diabetes, explains Dr Brooke Vandermolen, an obstetrician and gynaecologist at an NHS hospital in London. ‘It means you want to deliver babies earlier, before any problems develop.
‘With gestational diabetes, uncontrolled blood sugar levels can mean babies grow very big, which increases the chance of shoulder dystocia, where the baby’s head comes out but the shoulders don’t deliver.’
This results in doctors having to physically manipulate baby and mother, and/or make a cut to free the shoulders. In the worst cases, the baby can be starved of oxygen, risking disability, possible brain injury and even death.
‘There is also an increased risk of stillbirth with gestational diabetes,’ adds Dr Vandermolen.
According to NHS figures published in October 2019, 33 per cent of all babies born last year were delivered after an induced labour
Mothers who are 40 or over have a higher rate of stillbirth after 40 weeks, too, says Professor Heazell. ‘In fact, their risk doubles after this point, which is why the Royal College of Obstetricians and Gynaecologists (RCOG) recommends offering induction around their due date.’
Another factor is that doctors are also now confident that while an induction can increase interventions such as ventouse and forceps, it won’t increase the risk of a caesarean — as was once thought.
In fact, a 2018 review of 30 studies by the respected Cochrane group concluded that induced births resulted in fewer caesareans and fewer babies admitted to neonatal intensive care after birth.
This means that doctors may also be more likely to agree to so-called ‘social inductions’ for reasons that aren’t strictly medical, suggests Dr Patrick O’Brien, a consultant obstetrician at University College Hospital in London and spokesperson for the RCOG.
‘So now, if someone is 39 weeks pregnant and they request to be induced, we would try to accede to those wishes.’
Move to cut chance of stillbirth
Some doctors now argue that the 41 to 42 weeks the NHS advises for inductions should be brought back to before 41 weeks to save lives.
They point to evidence such as the small but significant increase in the risk of stillbirth in pregnancies that continue to 41 weeks compared to babies born at 40 weeks, reported by a British study last year using data from 15 million pregnancies.
Writing in the journal PLoS Medicine, researchers calculated that the risk of stillbirth rose incrementally from 0.11 in 1,000 pregnancies at 37 weeks to more than three in 1,000 by 42 weeks.
And results were published in November 2019 from a Swedish trial that was halted early after six babies died in the group of women selected to be induced at 42 weeks as opposed to 41 weeks. It is not known exactly why very overdue babies are more likely to be stillborn, but one possible explanation is that the placenta may become less efficient late in pregnancy.
Based on their findings, the Swedish researchers suggested all women be induced before 41 weeks.
Professor Heazell believes women who go beyond their due date aren’t always adequately informed by their doctors about the risks. ‘I do see a number of women who have lost babies after 41 and 42 weeks — and they always say nobody told them this could happen,’ he says.
He believes the social taboo around stillbirth plays a part in this.
‘If doctors are unwilling to use the ‘S-word’, how on earth can women make an informed decision?’
Based on the latest UK birth data, he estimates that 2 per cent of stillbirths could ‘be relatively easily prevented’ by inducing labour by 41 weeks.
Yet such figures need to be handled with care, suggests Amy Gibbs, CEO of Birthrights, a charity that promotes human rights in maternity care.
‘Women are often told that without an induction their risk of stillbirth doubles; but that figure needs to be put into context,’ she says. ‘For example, the actual chance of stillbirth may rise from one in 1,000 to two in 1,000.’ Other experts go further, suggesting women should be routinely induced at 39 weeks. A 2018 U.S. suggested this could reduce the chance of women needing a caesarean.
While such evidence may mean some women would choose to be induced, others worry it could be used to over-rule women’s personal choice. Women already report feeling pressured into inductions — sometimes when the medical justifications are far from clear-cut, according to Amy Gibbs.
‘We do have concerns that women feel under pressure to be induced,’ she says. ‘For example, we hear from women who decline an induction, yet they get daily calls from the hospital continuing to ask them about it.
‘Or women who are booked in for an induction before they’ve had any discussion with their healthcare providers about their options.’
Women denied facts to reach a decision
This ‘pressure’ rings true for Lea, who was induced early after being told her baby was ‘large for her dates’, although she did not have gestational diabetes or any other complications.
‘The consultant kept saying it was a risk not to do anything,’ says Lea. ‘She didn’t explicitly say what the risk was, but I was left thinking she was referring to stillbirth.
How to kickstart labour
Consultant obstetrician Dr Patrick O’Brien explains that there can be three steps to an induction.
First, the cervix — the neck of the womb — is ‘softened’ using a pessary or gel containing hormone-like substances called prostaglandins. Alternatively, this can be done using a balloon to stretch the cervix mechanically.
Sometimes, this first step alone is enough to trigger labour.
Then, once the cervix has dilated enough, if a woman’s waters haven’t broken, they’ll be broken manually. Again, this can prompt labour. Finally, if labour hasn’t been triggered by the first two steps, a drip of the hormone oxytocin is given to stimulate contractions.
Dr O’Brien says inducing labour this way, in three stages, mimics natural labour much more closely than inductions used to.
‘Twenty years ago, induction got a really bad name,’ he says. ‘They’d start the oxytocin drip straight away, and while that was really good at making contractions come, it would mean they were being forced against a cervix that was rigidly closed, so back then labour did tend to be much longer and more painful.’
‘I discussed it with Rob and we were both terrified. We went ahead, because we thought there’s no way they’d say that if it wasn’t absolutely necessary. It was never framed as a choice.
‘At no point did anyone talk me through the procedure. I was handed a leaflet and effectively shoo-ed out of the room. What’s more, no one told me that sometimes an induction just doesn’t work.’
Lea spent a week in hospital waiting for active labour to kick in, before the procedure was deemed to have ‘failed’ and her baby delivered by caesarean.
Milli Hill, founder of the Positive Birth Movement and author of the book Give Birth Like A Feminist, says: ‘Even if research one day found unequivocally that induction was guaranteed to save babies lives, women still have the fundamental right to choose what happens to their bodies.’
After her health visitor spotted that Lea’s anxiety went far beyond normal new mother worries, Lea was referred for group counselling sessions at her local hospital. ‘I was very lucky that I got help quickly,’ she says.
Even so, she says: ‘We always wanted two or three children, but now I can’t see myself going through it again.’
Professor Heazell acknowledges: ‘There is a lot of concern about women’s experiences with induced labour. It’s longer and it’s more associated with mental trauma and a lack of mental well-being afterwards — and we can’t overlook that.’
A study published in 2019 in the journal Midwifery, which looked at women’s experiences of induced labour, reported they felt under-prepared for the process as well as unsupported during it. Pain was often mentioned, and ‘anxiety, fear and isolation’.
‘It’s a widespread concern,’ says Professor Downe. ‘A lot of women report finding the experience very traumatic, even some years after the event. The difficulty is knowing whether that would have been the case if they’d had a spontaneous labour.’
Some hospitals now give women the option to start the induction process (see box) as an outpatient, says Dr Vandermolen. This involves a pessary containing a hormone-like substance to ‘soften’ the cervix, after which women can go home for 24 hours.
What everyone agrees on is that proper communication between women and their doctors is key.
Professor Heazell says: ‘We need to be using the data to have open conversations with women. There isn’t a right or wrong answer, but individual women can only make that decision if we’re prepared to have a proper conversation with them —- and that conversation has to include all outcomes.’
Five of the best
We’re meant to floss our teeth daily, but surveys show that more than a third of us never bother — despite the fact it’s vital to clean between your teeth to remove plaque. We asked Uchenna Okoye, a dentist at London Smile Group and a spokesperson for the British Dental Association, to select some of the best alternatives to floss.
DENTEK COMPLETE CLEAN FLOSS PICKS
Pack of 75, £5, boots.com
WHAT IT IS: A 3cm piece of floss strung between two prongs. Insert floss between your teeth and slide it back and forth. There’s a pick at the other end.
EXPERT VERDICT: Great if you aren’t comfortable using normal floss. The pick at the end of the handle is good for removing bigger pieces of food. Choose a thick floss, ideally one that’s waxed to help it slide between teeth without pain or breaking.
PHILIPS SONICARE AIR FLOSS
WHAT IT IS: This uses a combination of high-pressure air and water to blast away food and plaque. Fill the reservoir in the handle with warm water or mouthwash.
EXPERT VERDICT: These are useful — the combination of air and water makes them a powerful tool, but it may also be gentler on teeth and gums than normal floss. Plus, it’s much faster than manual flossing.
HUMBLE BAMBOO INTERDENTAL BRUSHES
Pack of six, £3.99, hollandandbarrett.com
WHAT IT IS: About the size of a match, this has a tiny brush on the end of a bamboo stick.
EXPERT VERDICT: My favourite method for cleaning between teeth and I recommend these to most of my patients. I find them easier to use than floss and the tiny brush head can get in and clean the whole area. They also come in varying widths to fit different size gaps in the teeth.
WATERPIK CORDLESS FREEDOM WATER FLOSSER
WHAT IT IS: This battery-operated gadget shoots a jet of pressurised water between the teeth.
EXPERT VERDICT: This type of flosser has been shown to clean deeply between the teeth and below the gumline — removing up to 99.9 per cent of plaque. The downside is that they create a lot of spray.
WISDOM INTERSPACE BRUSH
WHAT IT IS: A narrow toothbrush head with a pointed shape and firm bristles designed to splay to reach between the teeth and around the gum line.
EXPERT VERDICT: Particularly good around crowns, implants and bridges. This manual brush has a long handle to help reach difficult areas at the back.
By Caroline Jones
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