Response to ‘Induction of labour at 39 weeks should be routinely offered to low‐risk women’

Abstract

Healthcare providers should provide women-centred care, whereby they 'recognise and respect a woman's right to self-determination' and that 'women have the right to make an informed choice'. 1 Although induction of labour (IOL) at 39 weeks gestation for low-risk women should not be routinely recommended, this is not to say that women should not be appropriately counselled as to risks and benefits of IOL at 39 weeks and be supported in their decision-making.We have concerns about a woman's feelings of choice if IOL is routinely offered to low-risk women at 39 weeks. A recent systematic review of qualitative and mixed-method studies on women's experiences of post-term IOL found one of the major themes is that many women experienced IOL to be a 'nondecision', that is, the decision was presented as the next step in the process with little opportunity for discussion. 2 A broader review of both quantitative and qualitative research on experiences of IOL, and more specifically the decision-making around it, concluded that 'women's expectations and preferences are largely unmet in current clinical practice' with the decision-making mainly informed by the clinician's attitude. 3 The included studies that addressed satisfaction with IOL found women who had IOL reported higher dissatisfaction and negative birth experiences. 3 Negative perceptions of the birth experience are generally thought to be associated with higher rates of postnatal depression. 4 The Cochrane review of IOL for women at or beyond term in 2018 noted that no trials reported outcomes such as breastfeeding at discharge and postnatal depression. 5 These crucial outcomes are not routinely measured or reported so it is difficult to know what impact a change in induction policy would have. That said, the ARRIVE trial did measure women's feelings of personal control in childbirth with the Labor Agentry Scale, and found higher levels of control in the induction group (168, interquartile range (IQR) 148-183) compared with the expectant management group (164,. However, these findings do not match those from the systematic reviews. 2,3,6 We respectfully disagree with the assertion that IOL is inexpensive. 1 Recent modelling suggests that offering routine IOL to women at 39 weeks in the United States would lead to a US $2 billion increase in healthcare costs. 7 The women in the IOL group in the ARRIVE trial spent a median of six additional hours in the delivery suite compared with those allocated to expectant management, 6 meaning more resource utilisation around the time of birth was necessary. In addition to the financial cost of providing care to women having an IOL, there is also the quality of life cost associated with the patient experience of IOL. Women report that IOL is a challenging experience. While decision-making might appear overtly to be a maternal choice, women did not seem to be aware of the risks of having or not having the IOL, whether they were able to refuse the IOL, or even why the IOL took place. 3Although the ARRIVE trial showed evidence of b...