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By Gemma McKenzie
Coates, R. Cupples, G. Scamell, A. McCourt, C. (2019) Women’s experiences of induction of labour: Qualitative systematic review and thematic analysis. Midwifery, 69: 17-28
What was the study about?
The researchers wanted to understand whether there had been any studies undertaken which explored women’s experiences of induction of labour (IOL). The goal was to find all of those relevant studies and to see whether there were any common themes that ran through women’s accounts of their experiences.
Why did they want to do this?
Statistics show that the number of IOLs carried out in this country and abroad is rising. In the financial year 2016 and 2017, 29% of labours in English NHS hospitals were induced.1 However, the vast majority of studies concerning IOL relate to the safety and efficacy of various methods, and very little refers to women’s experiences. More recently, questions are being asked about where IOL should take place, with some UK trusts offering outpatient induction. The researchers felt it was important to understand women’s views on IOL as their birthing experiences may impact on their relationship with their baby, their sense of self and their future reproductive decisions.
How did the researchers carry out the study?
The researchers created a set of inclusion criteria as to the type of studies they were interested in. This included, for example, studies that had been peer reviewed and those that relied on qualitative data, i.e. interviews with women. After setting these criteria, they then systematically searched a number of databases. They read the abstracts of potentially relevant studies, before deciding which ones satisfied their criteria and reading these in more detail. Only 10 studies were deemed relevant enough to be included in their review, and these dated from between 2010 and 2018. Five were from the UK, two from Australia, and one from Brazil, USA and Ireland respectively. The researchers then compared and contrasted the results of these studies and explored the recurring themes that appeared throughout.
What were the results of the study?
The researchers discovered four overarching themes:
All of the studies reported that women did not feel involved in the IOL decision-making process. Worryingly, some felt that information was withheld, while others stated that there was only minimal discussion with a health care provider (HCP). Nevertheless, women generally appeared to trust HCPs, with some women going as far as stating that they would never question a doctor.
In all of the studies, it was noted that women were concerned about the likelihood of further intervention once the induction had begun. Of interest is that in one UK study, women questioned why they were booked for an IOL based on an urgency to reduce the risk to their babies, only to find that once they arrived at hospital, they experienced delays in actually starting the process.
In six of the studies women had no clear understanding of why they were booked for induction. There also appeared to be a lack of understanding surrounding the risks associated with the procedure. In only one study did women report feeling prepared, with reference to an information leaflet and an opportunity to discuss IOL with their midwife being cited as important factors.
Ownership of IOL
In five of the studies women felt under-prepared for the IOL process. Some participants were unclear on how long the procedure would last, whether pessaries were given orally or vaginally, and whether their partners could stay with them. In four of the studies, women complained of feeling as if they were simply part of a checklist, and were moved around the hospital depending on what stage of the process they were in. Conversely, when women were induced as outpatients, they felt a greater sense of control.
Some women felt forgotten and alone yet recognised that midwives were rushed and so they did not want to pester them. Others complained of staff not believing they were in pain. However, in a few cases, these negative feelings were compensated for by compassionate care from HCPs during the process. Support from family and friends also fostered a sense of security, but the lack of privacy in hospital often meant that women did not feel that support as strongly. Women also expressed discomfort regarding the noises they made during labour while on a busy ward, and also complained of being disturbed by other women in the same situation.
Importance of Place
The hospital was seen by participants as noisy, busy and lacking privacy, yet also a place of security and safety due to access to HCPs and technology. Ward rules were not seen as favourable to women, with some reporting that their partners and family were forced to leave at various times, which left women distressed.
At AIMS we are unsurprised at the results of this study. Medicalised induction in the hospital setting has been around for many decades, yet the amount of research conducted on women’s experiences of the procedure is tiny. Notably, none of the studies in this review explored the long-term impact of IOL. Indeed, we believe such a study has never been carried out. This gap in the research demonstrates how our maternity system has lost sight of what should be central to the service it offers, i.e. pregnant women and their babies.
While this review only found ten recent studies on women’s IOL experiences, there have been two much larger studies carried out in the 1970s that the researchers missed. Shelia Kitzinger carried out a study in 1975, and Ann Cartwright in 1979. There are some awful examples of mistreatment in these studies, including a practice whereby during vaginal exams, midwives pulled out tufts of the baby’s hair to show the labouring mother.2 A second example included only putting women on a syntocinon drip during office hours. This meant that when the drip was removed overnight, the woman’s labour would slow, and she would be left exhausted and in pain.3
While these practices have now ended, many of those reported in the present study existed in the 1970s and still remain. This is especially true around the areas of decision making and consent. This evidence raises serious questions about informed consent and suggests that in these instances not much has improved over the last 50 years. Given that the process of IOL is now much more frequently carried out, it could be argued that the problems are getting worse.
One positive that comes from this study, and which appeared in the earlier two, was that compassionate care from HCPs makes a big difference to women’s IOL experiences. At AIMS we believe that Continuity of Carer is the best way to foster a supportive relationship between a woman and her midwife, and in turn this may enable women undergoing IOL to have a more positive experience.
1 NHS Digital (2017) Maternity Statistics [online] Available at: digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2016-2017
2 Kitzinger, S. (1975) Some Mothers' Experiences of Induced Labour. London: The National Childbirth Trust, at p. 29
3. Ibid at p.25
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