Updated NICE guidance for induction of labour

Senior NHS Midwife, Hannah O’Sullivan shares her thoughts on the new NICE (National Institute for Health and Care Excellence) guidelines; a reminder that guidance is only guidance…

This year NICE have published draft guidance around Induction of Labour. You may have seen lots of posts about this, from lots of birth workers and those with an interest in birth.

Current guidance from NICE published in 2008 states that;

“Women with uncomplicated pregnancies should be given every opportunity to go into spontaneous labour.

Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy. The exact timing should take into account the woman's preferences and local circumstances.”

Proposed new guidance has changed this advice to;

“In uncomplicated singleton pregnancies, offer induction of labour at 41+0 weeks, to take place then or as soon as possible afterwards. 

Consider induction of labour from 39+0 weeks in women with otherwise uncomplicated singleton pregnancies who are at a higher risk of complications associated with continued pregnancy (for example, BMI 30 kg/m2 23 or above, age 35 years or above, with a black, Asian or minority ethnic family background, or after assisted conception).”

There is concern that prolonged pregnancy is associated with an increase in stillbirth rates, but the evidence for this is not entirely clear-cut. NICE guidelines are evidenced based, but there is not robust evidence behind many of these recommendations.  Where research evidence is not available, professional opinion will be used.  There is a small increase in the chance of stillbirth, but it is very small and comes later than many people think (Sara Wickham’s book Inducing Labour; Making Informed Decisions is a must read for more in depth information).

The ARRIVE trial is the piece of evidence which underpins much of this guidance, but many experts have criticised the ways that this research was carried out. To start with, about 73% of the pregnant women and birthing people who were asked to be involved in the trial declined.  Around 16,000 people declined an early induction of labour to take part in this study.  This tells me that women and birthing people do feel positive about this level of intervention.

In the UK care in pregnancy and labour is heavily midwife-led, with support from our medical colleagues for those with complexities. Care from a midwife is evidenced to improve outcomes.  The ARRIVE trial was carried out in countries where highly medicalised care is given to everyone. That does not happen here in the UK so calls into question how valid those outcomes are in relation to the UK.

The complexities of induction of labour, the cascade of intervention associated with induction of labour, women and birthing people’s experiences of induction of labour, do not appear to have been considered.

In recent years systemic racism has been shown to have a significantly negative impact on Black women and birthing people. Black women and birthing people have been shown to be five times more likely to die than white women and birthing people, while women and birthing people from Asian heritage are known to be twice as likely to die in pregnancy or birth than white women and birthing people.  

Pathologising the bodies of Black and Asian women/birthing people, and suggesting that the risks to their health and safety are down to their own physiology, as opposed to systemic racism, is an appalling response to the ongoing work done by many birth workers to raise the profile of this issue and demand improvements in perinatal care.  Trying to paper over the cracks by offering an intervention which comes with its own risks and negatives is not the answer to improving outcomes for Black and Asian families, and in fact could lead to more avoidable harm.

This is a hugely complex topic, and this blog post is more of a train of thought from a practicing midwife than anything else.  But I do feel concerned about the avoidable harm caused if the guideline is implemented.  Long-term outcomes for women and birthing people and babies do not appear to be considered, impacts on an already understaffed NHS do not seem to have been considered…

Remember that guidance is only guidance.  Use your BRAIN and make good, informed decisions about your body, your baby and your birth.

We urge you to join us in preventing the implementation of these guidelines:

For a deeper understanding of these guidelines and the conversation, we recommend you check out the following accounts: @notson.i.c.e @abueladoula @fivexmore @_aliciaburnett @drsarawickham @_midwifelife_ and @mixing.up.motherhood.

Written by Senior NHS Midwife, Hannah O’Sullivan