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This is an archive newsletter musings. If you missed the email, you can find the content here. You can also find lots of information on my blog.

Reduced fetal movements and double standards

(August 2025)

This musing is a bit of a whinge, so if you aren't up for that, stop reading now. For those who are happy to accommodate my gumping, read on. 

As part of my simplification strategy, I will focus on one topic per month, based on my research for Collective lessons. Blog posts and this newsletter will reflect my research and musings on that topic. This month's topic is reduced fetal movements. In the Collective, I covered the pathophysiology and research related to fetal movement, monitoring, and interventions. But for this musing, I want to share my reflections on concerns raised by care providers: that some women pretend to have reduced fetal movements to access early induction. Of course, this may or may not happen. Only the woman knows her baby's movements. But let's assume, for the sake of this musing, that a small number of women do use this strategy, knowing that reporting reduced fetal movements will likely lead to an induction.

Firstly, it is no surprise that women are keen to have their baby born sooner rather than wait for spontaneous labour. Antenatal care is all about assessing risk and identifying potential problems. The underlying message is that pregnancy is dangerous and women's bodies must be constantly monitored, and intervention is often necessary to ensure safety. Many women find this anxiety-provoking. They want their baby out and safe so they can stop worrying.

Induction is also framed as safe, effective and evidence-based (reinforced by media narratives). Today, in Australia and other similar countries, only a minority of women experience spontaneous labour after 40 weeks of gestation. Early term, induced labour is the social norm, and women see this reflected in their peers' experiences. In a culture that values scheduling, control and instant solutions, waiting for a bodily process to unfold naturally can feel stressful. Add to this the fear-based messaging about 'big babies' (with the implication that a smaller baby is safer), the discomfort of late pregnancy, and the lack of understanding about the benefits of spontaneous labour and the risks of induction. So, I don't think we can blame individual women for wanting an early induction.

But what about manipulating care providers to get an induction? You could argue that manipulating the maternity system to get what you want is unethical. I'm not going to make that argument, because before we point the finger at women, we need to look at care providers. It is interesting how much outrage exists around a minority of women allegedly manipulating the truth to get an induction. Yet, there is far less concern about the routine manipulation of women by care providers to coerce them into induction. It is widely accepted that care providers mislead, pressure, or use fear to coerce women into birthing on a timeline that suits the system. But it is considered unacceptable for women to mislead care providers so that they can give birth when they want to.

This double standard reflects a maternity system that is set up to meet the needs of the institutions and care providers, rather than individual women. So, how about we focus on supporting women in cultivating self-trust during their pregnancy and being fully informed about the benefits of spontaneous labour? And demand that care providers provide adequate information about induction to obtain informed consent for the procedure.

Practice-based evidence

(June 2025)

This musing is a bit of a whinge, so if you aren't up for that, stop reading now. For those who are happy to accommodate my gumping, read on.

I'm sure many of you are aware that the long-awaited findings of the Big Baby trial were published last month. Well, this musing is not about those findings specifically (although I have been asked several times for my take). I haven't reviewed the paper yet and won't until I do a lesson about it for the Collective. I haven't even read any reviews of the study yet. However, if you are looking for a critique, Sara Wickham has one on her blog, and I trust her review will be comprehensive as always. (Also, consider buying her a coffee as a thank you; it takes a lot of time and effort to write a review.)

Instead, I want to share with you why I am irritated and weary of these 'high profile' studies that are snapped up by the waiting medicalised maternity system to justify the practices they are already doing. I have been involved in research and creating and disseminating evidence-based information for over a decade, and I am fed up with the pattern and the ongoing spiral of more and more routine medical intervention over the years.

We are in an era of practice-based evidence rather than evidence-based practice. If practices were based on scientific understandings of physiology, research comparing interventions with physiology and research about what women want, the maternity system would be very different. However, the introduction of 'evidence-based practice' into maternity care didn't happen until the 90s, after birth was medicalised and interventions were the norm. We are now in a situation where research evidence is required to demonstrate that it is safe to discontinue interventions introduced without any evidence to support their introduction (e.g., premature cord clamping). Even with good evidence, it is extremely difficult to change a practice that supports an institution's functional and cultural needs. Research is ignored or dismissed for various reasons: e.g. 'our population is different', 'the study does not apply to our facility', etc.

In contrast, when a new study appears to support an already established practice (e.g., early induction), it is welcomed, reported in news articles, and cited by care providers and guidelines. Suddenly, it doesn't matter if the study population and context differ from the practice setting. Midwives, doulas and educators spend time and energy trying to interpret the study so they can inform women about it. People with academic backgrounds scrutinise the study design and the interpretation of findings to find flaws and determine why the findings do not align with previous research. However, all of this is in vain. The intervention rates are likely to increase significantly, for example, the rise of early induction after the ARRIVE Trial (without improved outcomes). The ARRIVE Trial simply gave a tick of approval for what was already happening.

We also need to consider that research studies are conducted on populations of women giving birth in medical settings with routine medical interventions. In these settings, physiological birth is rare, and care providers often have a lack of knowledge and experience (and comfort) in facilitating spontaneous, undisturbed birth. In contrast, care providers are very good at administering and managing interventions effectively and safely. Often, study findings are influenced by the decisions and practices of care providers. Whether a woman has a c-section during labour will be determined mainly by her care providers' assessment of the situation, thresholds of comfort and recommendations. For example, a care provider who is dealing with a situation they are an expert in and feel 'in control' of (eg, induction) with a woman they feel is 'low risk' (eg, 39 weeks) is likely to have a high threshold for recommending a c-section. In comparison, a care provider caring for a woman in spontaneous labour who they believe is 'high risk' (eg, 42 weeks) and is feeling a lack of control and does not have experience in normal variations is likely to have a lower threshold for recommending a c-section. This reality is reflected in research findings.

As more research is carried out in the current maternity context, we will see more and more studies supporting current practices, ie, more intervention, because we now have practice-based evidence. The truth is that a woman birthing in a medicalised maternity system with care providers who are experts in intervention will likely have better short-term outcomes if she follows the norm (ie, agrees to recommended intervention). Whereas a woman trying to have a physiological birth in a setting that is unable to support that will likely have worse short-term outcomes.

Like many of you, I am frustrated and weary of constantly trying to push back against what feels inevitable. And I know I keep banging on about this, but we cannot reclaim childbirth from within the paradigm that holds it hostage.

Midwives and intervention

(May 2025)

The word 'intervention' refers to actions (and words) aimed at changing a situation, with the intention of improving it or preventing a problem. Humans are masters at intervening in nature to meet their own needs. We invented clothes and shelter for protection, tools and technology, and developed ways to intervene in natural processes such as disease and injury to improve outcomes.

Intervention has always been the core business of midwifery. Midwives were invited to births throughout history because of their expert knowledge of physiology and pathology, as well as their ability to intervene when necessary. How they intervened reflected the society and culture in which they were working. For example, before the emergence of modern medicine, midwives in Europe practised folk medicine, using herbal remedies as interventions. It was midwives who discovered that ergot, a type of fungus, is effective in stopping postpartum haemorrhage (ergometrine is still used today). Midwives also developed interventions to manage stuck babies and complicated births.

The role of the midwife changed with the development of medicine and the infiltration of childbirth by physicians in the 1700s. Midwives were predominantly female and working-class; they lacked access to the new medical technologies that were being developed. For example, only male physicians were allowed to use forceps (and that is a whole other story!). This gatekeeping of innovation resulted in midwives calling physicians to complicated births when midwifery intervention was not enough to save the mother and/or baby. Later in the 1900s, when birth moved into hospital, midwives became the physician's assistant, rather than the primary care provider who called in the physician when needed. Midwives had become nurses, no longer able to initiate interventions without the direction of doctors.

I sometimes wonder what midwifery would have become if midwives had remained community-based, autonomous and able to develop their own body of knowledge. Here is my little fantasy of a parallel universe (indulge me). Midwives would have continued to learn, develop new skills, technologies, and practices, just as they had throughout history. Their scope of practice would have continued to include interventions for pathologies and complications. However, unlike physicians, intervention would be underpinned by a deep knowledge and experience of physiology and normal variations. However, all of that is speculative. Midwifery and obstetrics are now split and hierarchical. Obstetrics defines the parameters of 'normal', and the scope of midwives is diminishing alongside those parameters.

Midwifery knowledge of physiology has also been lost (see my previous newsletter), and midwifery interventions have undergone significant shifts. The focus of midwifery intervention is now on the assessment of medically defined parameters of 'normal' (eg. vaginal examinations), and interventions to keep women within those parameters. It's not just midwives. Doulas and birthworkers also enact interventions aimed at keeping women within 'normal' parameters. Some of these interventions are invasive and not evidence-based, and they reinforce the external expert rather than the woman. There is even a resurgence of interventions aimed at assessing the adequacy of a woman's pelvis by carrying out vaginal examinations in pregnancy! Obstetrics stopped doing this decades ago, and it was never part of traditional midwifery practice.

So, what can we do? Interventions are not 'bad'. Appropriate interventions can improve outcomes and experiences. Midwifery came about because women wanted birth attendants who could carry out interventions when necessary. Traditionally, the emotional, social and physical support of a birthing woman was the job of her female family and friends (gossips). The midwife's role was to distinguish between physiology and pathology and intervene if necessary. Most births did not require the midwife to intervene at all.

We need to take a step back and consider individual interventions, asking:

  • What is the underlying purpose of this intervention? What is it trying to assess or alter, and why?
  • Is it effective? Does evidence support the idea that it can assess or alter the situation?
  • What are the risks of carrying out the intervention?
  • And most importantly, does the mother want the intervention? Does she have adequate information to give consent to it?

No intervention should be routine. It may be routine to discuss and offer particular interventions (eg, testing in standard antenatal care, listening to the fetal heart in labour, etc.), but whether they are carried out or not is based on the individual woman's decision.

Have we lost the plot with physiological birth?

(April 2025)

Physiological birth is becoming extinct. The extinction process has been relatively quick, with a rapid loss of knowledge and skills since the wholesale move of birth from the home/community into medical settings in the 1900s. I probably need to clarify what I mean by physiology, so here is an excerpt from my book, Reclaiming Childbirth:

"The word 'physiological' describes the 'normal function of an organism'... I use the term 'physiological' to describe a birth that involves a woman labouring and birthing her baby in a healthy and uncomplicated way without interventions that alter the functioning of her body. Physiology also encompasses all the individual variations that are not the 'norm' but are also not pathological."

We now have generations of women and care providers who have no experience of physiological birth. Women, in general, are blamed for this due to being too [insert preferred risk factor] or because they demand intervention. Neither is true (as I write about in my book). In contrast, there is a growing movement to reclaim physiology supported by knowledge of birth hormones, long-term health outcomes and women's experiences and preferences. Unfortunately, we have lost the plot and are attempting to reclaim physiology from within the paradigm that brought it to the brink of extinction.

Indicators and Objectives

We are not measuring what we want to increase and grow, so we have no clear data points for progress. Many countries collect maternity statistics and report key indicators to measure improvements in the quality of maternity services. However, indicators and objectives are about reducing the rates of intervention rather than increasing the rates of spontaneous vaginal births resulting in a healthy (physically and emotionally) mother and baby. If we want to reclaim physiology, we need to know how often (or not) it is happening. In my opinion, if we want to assess how well a service or institution supports physiology, there are two key questions:

  1. What % of first-time mothers go into spontaneous labour, labour without augmentation, and have an uncomplicated non-instrumental vaginal birth?
  2. What % of women report having respectful care and adequate information to support their decision-making?

Whilst data for question two is usually not collected, it is very likely that the data for question one has been collected, just not reported in a way that answers the question. You can sometimes read between the lines of the reports, but it is very frustrating trying to isolate statistics about non-intervention. For example, here is what I managed to extract from the Australian government maternity report: Overall, 30% of women went into spontaneous labour and laboured without augmentation, which leaves me with more questions than answers. What proportion of that 30% had a non-instrumental vaginal birth without an episiotomy? What were the stats for first-time mothers, because they are usually much less likely to avoid intervention? I also acknowledge that if we are to include birthing the placenta without intervention as part of physiological birth (which it is), then we are probably talking about less than 1% of women in hospital settings.

Research

We don't have research into physiological undisturbed birth. Maternity research emerged after birth had moved into hospitals, and medical management was the norm. So, we've ended up with studies comparing interventions with other interventions. For example, comparing labour induction at 39 weeks with induction after 40 weeks and/or medicalised spontaneous labour. Or, how one birth position compares to another rather than what positions women instinctively get into if they are undisturbed (because directions and disturbance are the norm). We don't have an evidence-base for physiological birth and are unlikely to get one via research in settings where physiology is rare. Also, scientific research, by its very nature, is 'problem-based' and starts with a problem to solve, such as reducing complications by introducing an intervention. For physiology, we need a different approach. We need to study physiological birth and find out what supports it. Learning from the settings and care providers with high physiological birth rates. What are they doing or not doing that supports physiology?

Education and Practice

Midwifery education and practice have been severed from their foundation of physiology. Midwives in hospital settings seldom see physiology; they may get glimpses of it, but an entirely undisturbed physiological birth is a rarity. Instead, they get to see lots of interventions and complications caused by those interventions. Physiology is also slipping through the fingers of community-based midwives as increasing regulations and medical oversight require them to bring hospital practices into the home. Some midwives also disrupt physiology with 'natural' interventions to get women's bodies to fit medically prescribed labour patterns and 'norms'. Student midwives are caught up in a Catch-22 because they are supposed to become the experts in physiological birth, yet they cannot observe undisturbed physiology on their placements. They are also assessed on their intervention skills rather than their ability to support physiology. Some are even bullied for questioning interventions and/or trying to apply evidence to support physiology.

I'm not sure what the answer is. But I know it is unlikely to come from within the current paradigm. We've had 30 years of trying to reclaim birth and improve the maternity system using research and education. Yet, we are drifting further away from physiological birth as the norm. Is it time for a radical restructuring of birth knowledge and practice for those who want to reclaim physiology?

Surprising Research about Epidurals and Pushing Positions

(March 2025)

 

Physiological birth is uncommon in our maternity systems. Most women don't experience physiological births, and most hospital-based care providers care primarily for women having medical interventions in labour. We have a situation where medical intervention is routinely applied to physiological labour, creating risk. In contrast, principles of supporting physiological birth are applied to medical births, creating risk. A medical birth, in particular an induction and/or an epidural, requires a different approach to care to improve outcomes, and in my Medical Birth Learning Package, I explore this in more depth. However, here, I'd like to share a research article with you that got me rethinking my previous approach to supporting women with epidurals in the pushing phase. It is also an example of how we need to be cautious in applying research about physiology to medical birth.

Research (and experience) has established that epidurals increase the chance of an instrumental vaginal birth. In an attempt to increase the chance of a spontaneous vaginal birth, care providers often encourage women with epidurals to get into upright positions and assit them to move about while pushing. With low-dose epidurals, women can often kneel or squat with assistance. This approach is based on research that demonstrates upright positions improve outcomes for women without epidurals, and we have assumed it will be the same with an epidural. However, the BUMPES RCT only included women in labour with an epidural, and the primary outcome was spontaneous vaginal birth. The participants were 3093 nulliparous (first baby) women who were randomised in the 'second stage' to either upright or lying down positions. The upright group spent the 'second stage' with their pelvis in 'as vertical a plane' as possible, which included walking, standing, sitting out of bed, supported kneeling, sitting bolt upright in bed (not semi-supine), or any other upright position. The lying down group spent the 'second stage' with their pelvis in 'as horizontal a plane as possible' in a left and/or right lateral position (on their side). The study found that the upright group had significantly fewer spontaneous vaginal births (35.2%) compared to the lying down group (41.1%). Lying down increased the spontaneous vaginal birth rate by 5.9% with no 'apparent disadvantages for short or longer term outcomes for mother or baby'. The reason for this surprising finding is unknown. It could be something to do with how an epidural effects the pelvic muscles, or how the physical and mental activity required to get upright whilst anesthetised influences oxytocin release. But, for now that is all speculation.

These findings support a different approach to pushing for women with epidurals. Rather than busying about helping a woman with an epidural to get up and move (while still trying to monitor her baby), potentially stimulating her neocortex and inhibiting her oxytocin release. Maybe, instead, we could help her to relax and create a quiet, calm, oxytocin-facilitating environment for the baby to arrive into, low lighting, comforting massage, limited pushing (a whole other topic) etc. This would also support the woman to release oxytocin in her brain (even if she has Syntocinon/ Pictocin), ready for bonding and breastfeeding. 

Reflections on my Experiences with OP Positions

(February 2025)

 While I was digging about in research for the lesson on epidurals, I re-found this article: When does fetal head rotation occur in spontaneous labor at term, and it got me reflecting (again) on our cultural beliefs and practices regarding occiput posterior (OP) positions. The women in the study were in spontaneous labour with their first baby in a medical setting. They had regular vaginal examinations and ultrasound assessments of their baby's positions (not the ideal environment for physiology). The findings are very interesting. More than 50% of the babies were in an OP position throughout the 'first stage' of labour. The study concluded that the occiput posterior position was the most common fetal position throughout the active phase of the first stage of labor. Occiput anterior only became the most frequent position at full dilatation and after the head had descended below the midpelvic plane. I have written and spoken a lot about how an OP position has become pathologised in modern maternity culture. Historically, OP was understood to be a normal position, but if the baby was unable to rotate during labour, it could be a symptom of a problem. Not the cause. This has shifted, and now an OP position itself is considered to be a problem. See my blog post for more on the physiology of OP. In this musing, I thought I'd share my own experiences with OP positions during my time as a midwife and how culture influenced my beliefs and practice. I use the term 'we' in referring to midwives in general, including myself.

Problem bodies

When I trained as a midwife in the 1990s, research was only just beginning to make it into education and textbooks. The identity of 'midwife' was still heavily influenced by the medicalisation of maternity, and our value was in our ability to 'do' and 'manage'. There was kudos in skills and clinical expertise. OP was considered to be a common 'malposition' caused by an 'android pelvis'. If a woman was in labour with an OP baby, we assumed it would be a long and difficult labour, likely to result in an instrumental birth, particularly with a first baby. An upright and forward-leaning position was encouraged initially. However, if labour progress (ie. the cervix) failed to fit partogram timeframes, an epidural was recommended along with a syntocinon infusion. We thought we were doing the best thing for women; we never considered that it might be the timeframes that were wrong rather than the woman's body.

Problem behaviours

Towards the end of the 1990s, midwives were trying to reclaim their autonomy and distinct professional knowledge and practice. However, we were building upon the foundations of medicine rather than research or challenging incorrect assumptions about physiology. OP was still considered to be a malposition that could be caused by an abnormal pelvis. However, we also believed women's behaviours and lifestyles contributed to this malposition. Optimal fetal positioning (OFP) was all the rage. I attended workshops and read books about OFP. I shared information with pregnant women about how to avoid an OP baby by not relaxing on their sofa and spending time on their hands and knees. In labour, I encouraged women to get into 'optimal' positions to get their babies to rotate. I cringe now. However, at the time, my midwifery identity was still based on myself as the expert. I wanted to save women with information. I failed to realise that it wasn't women's bodies or behaviours that were the problem.

Problem care providers

My paradigm shift didn't happen until the early 2000s when I was attending homebirths as an independent midwife without timeframes or policies. Observing women birthing on their own terms taught me more about physiology than the hundreds of births I'd attended in the NHS (hospital and home). An OP position in labour was normal, and I stopped assessing or documenting the position of the baby (other than head down) because it had no bearing on what I would do. I wasn't doing VEs routinely. Women moved instinctively without instruction. I simply waited for the baby to arrive. And they did. Occasionally, the woman would have backache and request support with that (massage, hotpack, sterile water injections). I realised that the problem with OP was not women's bodies or behaviours. It was a lack of understanding of physiology and the application of non-evidence-based timeframes. At the same time, I was researching midwifery actions and interactions during birth for my PhD, and what I found transformed my philosophy and approach to midwifery practice. I began to see how my words and actions influenced women's experiences and how reinforcing my own expertise could erode their self-trust. By applying the framework of childbirth as a rite of passage, I could see that the 'problem' with OP was me/us.

Today, the 'problem' of OP continues to prevail in the medical birth culture and in the natural birth culture. Both cultures are underpinned by the same belief that women's bodies (categories of pelvises) and behaviours/lifestyles are the problem and that external expert knowledge and intervention are the answer. It is also about care providers' need to be seen and validated in a birth culture that values skills, techniques, doing, instructions, accreditations, etc. The research about these interventions (techniques and instructions about positions) does not demonstrate that they are effective at rotating a baby. However, they do improve the care provider's perceived self-efficacy in providing support and reduce the chance they will recommend a provider c-section.

I feel that I need to add a disclaimer because this topic always results in a barrage of backlash. Some individual women experience difficult OP labours. Very occasionally, a truly obstructed labour occurs, and an OP baby is unable to rotate (symptom not cause) and requires intervention. However, I am unconvinced that the most common position in labour (OP) is a 'malposition' requiring intervention.

Standardisation and Lost Knowledge – Normal Pregnancy Duration

(January 2025)

I've been researching pregnancy duration for a Collective lesson and ran into the usual difficulties with finding information about normal variations. So, I thought I'd use the topic as an illustration of how we are losing knowledge about normal physiology in general. Our modern maternity system is set up to standardise women's bodily processes and control for variations. This works well for a generalised system but poorly for individual women and pregnancy/birth knowledge.

In countries with well-resourced, medicalised maternity services, endemic induction skews data about normal pregnancy duration. For example, in Australia, most babies are born at 39 weeks (31.6%). In fact, more babies are born at 38 weeks (23%) than at 40 weeks (19.2), and only 0.6% of pregnancies get to 42 weeks or beyond. The majority of babies are born before their due date, and most inductions are not carried out for 'prolonged pregnancy'. Instead, increasing groups of women are being induced at 39 weeks for all kinds of reasons (maternal age, 'gestational diabetes', high BMI, etc.). Therefore, current research into pregnancy duration and outcomes is carried out on populations of women having inductions before 42 weeks. Even the research into induction compares induction at a particular gestation (e.g. 39 weeks) with expectant management, which includes induction at 41 weeks. So, we don't have any recent research about how long normal pregnancies can last if you wait until the baby initiates labour or the outcomes of those pregnancies.

However, we can get some information about the length of gestations pre-mass induction by looking at historical evidence. For example, a 1955 journal article by Dr James Reid discusses the duration of pregnancy and includes data from 500 of his 'patients' with accurate information about their last monthly period. Note that the table in the article counts gestational weeks from the last day of the last monthly period rather than from the first day of the last monthly period, as we do today. So, for the lesson, I adjusted his gestations backwards 4 days (estimating an average menstrual bleed) to approximate how the gestational lengths would align with today's measurements. Most of the babies were born between 39+5 weeks and 41+5 weeks, with 8% of pregnancies lasting 42 weeks and beyond. Six babies were born after 44+5 weeks!

A Swedish study looked at birth registry data from 1976 to 1980 to determine gestational length. The findings included induced labours; however, the researchers maintained that although induction data might alter the findings at the end of the distribution, i.e. post-term, it would not change the median and mode values. They found that the mode (most frequently occurring length of gestation at birth) was 283 days or 40+3 weeks, and 10% of pregnancies were post-term.

So, in summary, if the birth date is left up to the baby, most healthy pregnancies last longer than 40 weeks. Our birth culture's inability to tolerate normal variations has resulted in us being unable to research or experience healthy 'outliers'. We currently know very little about physiological pregnancy duration or the long-term impact of interrupting a baby's natural gestation.

Gestational Diabetes and Clinical Guidelines

(October 2024)

For weeks, I have been knee-deep in gestational diabetes (GDM) and blood glucose evidence and literature, creating two lessons for the Collective. The Q&A sessions always include questions about diabetes, so I thought I'd cover the topic in depth because there is clearly a need for information. However, I was not prepared for the level of nonsense around this topic. My husband has been subjected to a number of exasperated rants. So, I thought I'd pick one to share with you!

The truth is there are risks associated with having abnormal blood glucose levels during pregnancy. By abnormal, I mean actually abnormal. Not the new lower thresholds based on non-diabetic blood glucose levels (see my blog post for more information on thresholds). The more significant risks (miscarriage, stillbirth, congenital abnormalities) are related to pre-existing diabetes and abnormal blood glucose levels in early pregnancy. Gestational diabetes, i.e. diabetes caused by pregnancy, occurs after 20 weeks, and the risks of abnormal blood glucose levels relate to birth and the postnatal period (eg. shoulder dystocia, hypoglycaemia, jaundice, polycythaemia). Not pregnancy loss.

However, women diagnosed with GDM continue to be told they have a higher risk of stillbirth if they do not control their blood glucose levels. The Queensland Health Guideline on Gestational Diabetes (with the cover by-line of 'translating evidence into best clinical practice') includes the following risk for GDM: 'Stillbirth (late) if GDM is uncontrolled or not treated resulting in raised fasting plasma glucose'. This statement directly contradicts research findings, including Cochrane reviews, and the guideline cites a UK study (Stacey et al. 2019) that does not apply to Australia. The UK uses risk-based screening, whereas Australia uses universal screening, and the study defined 'raised fasting plasma glucose' as ≥5.6 mmol/l, which is much higher than the Australian definition of ≥5.1 mmol/l. The study explored stillbirth risks associated with screening for women 'at risk' of GDM.

The study findings were the opposite of the statement made in the clinical guideline. Women diagnosed with GDM did not have an increased risk of stillbirth even if they had raised fasting plasma glucose. The increased rates of stillbirth occurred in the group of women 'at risk' of GDM who did not get tested i.e. a group of women who were more likely to have undetected pre-existing diabetes and other health risk factors. The study conclusion and recommendations support testing and diagnosis of women 'at risk' of GDM.

It is disappointing that clinical guidelines purporting to 'translate evidence into clincial practice', fail to cite appropriate research to support statements and recommendations. However, guidelines are created by working parties primarily made up of clinicians (not researchers) and often reinforce cultural norms and preferred practices rather than research evidence. So, I guess the moral of the story is don't rely on culture-based guidelines for evidence-based information. There are risks of having high blood glucose levels with uncontrolled GDM. Stillbirth is not one of those risks.

Advanced Maternal Age and Risk

(September 2024)

Advanced Maternal Age (AMA) refers to pregnant women 35 years and older. In Australia, this represents a significant portion of pregnant women. In 2021 (the latest available stats), the percentage of women classified as AMA was:

  • First baby: 17.4%
  • Second baby: 30%
  • Third baby: 35.6%
  • Fourth+ baby: 49%

So, if you provide care or education to childbearing women, a significant proportion of your clients will be categorised as AMA. Increasingly, induction of labour is being recommended to women simply because of their age. Therefore, we need to be able to discuss outcomes associated with AMA and provide clear and honest information to support women in making decisions that are right for them.

Perinatal mortality

The main risk cited as the rationale for induction of labour for AMA is an increased chance of stillbirth. Women of AMA are often told their chance of stillbirth doubles after 39 weeks gestation. This is true; at least the general chance, rather than the individual's chance, doubles from 39 weeks to 40 weeks. However, women need to know what this actually means to put 'doubling' into context. A US study found that women aged between 35 and 39 years had a 4.6 in 10,000 rate of stillbirth at 36 weeks compared to a 9.1 in 10,000 rate at 40 weeks. Women aged 40 years and over had an increased rate of stillbirth, from 6.7 in 10,000 at 39 weeks to 14.2 in 10,000 at 40 weeks. A study in the Netherlands stratified the general stillbirth rate according to maternal age and found the rates were 0.1% for 18-34 years, 0.2% for 35-39 years and 0.3% for 40+ years. So, whilst the general change of stillbirth does increase with AMA, the relative risk remains very low, i.e. under 1%. It is up to the individual woman whether these numbers are significant enough for her to agree to an induction.

Induction outcomes

A woman being offered an induction for AMA also needs to know whether the intervention reduces her risk of stillbirth, the general risks of induction, and the risks specific to women in her age range. Unfortunately, most research showing a small (less than 1%) reduction of perinatal death with induction compares induction with expectant management rather than with spontaneous labour. Expectant management includes women who develop complications and who have their labour induced later on for a variety of reasons. However, the study cited above (Netherlands) did report that women who had a spontaneous labour were at lower risk of adverse perinatal and maternal outcomes (including stillbirth) in comparison to induction or c-section (excluding women over 40 years having an elective c-section). They concluded 'induction of labour in comparison with spontaneous onset of labor was more strongly associated with adverse outcomes than AMA was.'  Women also need to consider that if they are over 35 years old, induction increases their chance of a c-section, particularly for first babies. For example, a UK study compared induction with expectant management for women 35+ years having their first baby. They found that induction increased the rate of c-sections by 20-30% and instrumental birth by 10%.

In Australia, only 36.1% of pregnant women aged between 35-39 experience spontaneous labour, and 23.4% of women aged 40 and over. I wonder what proportion of women are given adequate information about AMA to gain valid consent for induction.

Nuchal Cords and Research Issues

(August 2024)

While updating my blog post on nuchal cords, I revisited a frustrating issue that impacts much of childbirth research. Research into childbirth practices only started after birth had moved into hospital settings and after routine interventions became the norm. This means that it is often difficult or impossible to distinguish outcomes caused by variations from outcomes caused by the management of variations.

For example, most of the research examining outcomes related to a nuchal cord during birth report an association with fetal heart rate abnormalities, operative delivery, lower cord pH, lower Apgar scores, and admission to special care nursery. So, if we just looked at this research or a systematic review of this research we might come to the conclusion that a nuchal cord causes complications. However, association is not causation, and there are a number of problems with interpreting the results of these studies:

Reporting bias

If a baby is born in a compromised state requiring resuscitation, the presence of a nuchal cord is more likely to be documented. A study by Greenwood and Impey compared outcomes associated with a tight nuchal cord between one hospital that routinely recorded the presence of a nuchal cord at every birth and hospitals where recording was at the discretion of the birth attendant. When recording was discretionary, the presence of a nuchal cord was associated with lower Apgar scores and cerebral palsy. However, this association was absent when nuchal cords were routinely documented.

Combining results

Most studies do not distinguish between a loose nuchal cord and a tight nuchal cord. Studies that do differentiate report that the association with complications is only related to tight nuchal cords. The strategy of combining results for two different scenarios is commonly used when misinforming women about induction. Induction does not increase the chance of a c-section for women who have previously given birth. However, does for first-time mothers. By combining the results for these two groups, you can report the generalised outcome that induction does not increase the chance of c-section.

Ignoring the risk of interventions

The research demonstrates that only tight nuchal cords (not loose) are associated with complications. However, the reason may have nothing to do with the tight nuchal cord but rather with what the care provider does. It is common practice to clamp and cut a tight nuchal cord. In some studies, the definition of a 'tight' cord is the 'need' to clamp and cut it. So, what studies are actually reporting are the outcomes for babies who have their umbilical cord prematurely cut, and there is plenty of research demonstrating that premature cutting of the umbilical cord after birth compromises the baby.

Critiquing research

This is why it is important not to take research at face value. We need to take a more critical and nuanced look at research findings. Most of you are busy supporting women and their families and don't have the time to pick over journal articles or develop the research skills necessary for assessing and critiquing findings. Luckily, you don't need to because there are people like myself and others (e.g. Dr Sara Wickham) who do that for you and create resources you can share with your clients.

Small for Gestational Age vs Fetal Growth Restriction

(July 2024)

There appears to be an increase in inductions for 'small babies'. Indeed, most women appear to be growing babies that are either too big or too small! I have already written about big babies in a previous newsletter and blog post, so it's time to give small babies some attention. The term 'small for gestational age' (SGA) simply refers to a baby who is measuring smaller than the 10th centile for gestational age. It doesn't distinguish between a healthy, small baby and a baby who is small due to a complication. This is an important distinction to make when considering interventions.

Healthy SGA vs FGR

Between 50% and 70% of SGA babies are healthy, meaning they have developed normally, are well-oxygenated, and just happen to be smaller than the average baby. The reason for their smaller size is usually genetic. For example, smaller women tend to grow smaller babies. However, up to half of SGA babies are small because their placenta is not functioning well, and the reduced oxygenation and nutrients result in restricted growth. These babies are at increased risk of poor outcomes. For example, the stillbirth rate for undiagnosed FGR is 19.8 per 1000 compared to 2.4 per 1000 for non-FGR babies (Unterscheider et al. 2014). This rate is reduced to 9.7 per 1000 if FGR is identified and the baby is born before the placental function declines further. So, it is important to identify FGR babies and manage them differently from healthy SGA babies.

Identifying FGR

In order to make an informed decision about a recommendation for early birth (induction or planned c-section), women need to know whether their baby is simply SGA (variation) or experiencing FGR (complication). Ultrasound size and growth estimations are inaccurate and will not tell you why a baby is small. Yet, often, the recommendation to induce is based on size estimation only, resulting in unnecessary inductions. To identify FGR, you need to know how well the placenta is functioning because FGR is a complication of the placenta. This requires an ultrasound Doppler assessment of umbilical artery blood flow, the baby's cerebral artery blood flow, the ratio between the baby's abdominal circumference and head circumference and femur length (Marchand et al. 2022; Lees et al. 2022). These findings, along with the individualised benefits and risks of interventions should be discussed with the woman to support her decision-making about options. This should be standard practice, but unfortunately, it is not.

Childbirth Trauma

(June 2024)

I tend to avoid this topic. I spent a number of years researching and presenting about childbirth trauma, which was challenging and ultimately disappointing (you can find an article here). From a purely selfish perspective, I decided to move away from it and focus elsewhere. However, the issue of childbirth trauma is once again in the news, and I keep getting asked about it. So, here are my thoughts and reflections.

Trauma as a symptom

Historically, a minority of women experienced complications, had interventions without analgesia, and/or lost their babies during birth. It is very likely that these women were traumatised by their birth experience. However, the picture of trauma in modern birth is different. Today, around a third of women experience childbirth trauma, and the majority report that their trauma was caused by care provider actions and interactions rather than particular complications. In my study and others, women report being disregarded, coerced, threatened and violated. They felt that the needs of the institution and their care providers were prioritised over their individual needs. In research and in the recent Australian and UK government inquiries into childbirth trauma, women have bravely shared their experiences. There is a common underlying theme – women are not listened to. They are not listened to when they say they don't want or need intervention. They are not listened to when they say that they are concerned about their baby and want intervention. Their knowledge and wishes are ignored. For some women, this has resulted in them losing their babies because no one listened, and their embodied knowledge was not valued. For others, it resulted in them being violated and abused by their care providers. Women are not valued, and this is the root of the problem. Childbirth trauma is just one of the symptoms (domestic violence is another). The maternity system was not set up to meet the needs of women or care providers. It was set up to meet the needs of institutions and those who hold power within the institutions (medicine).

The response as a symptom

The response to this latest attempt to 'be heard' in relation to childbirth trauma has been disappointing but unsurprising. It mirrors the response/backlash I experienced seven years ago to my research findings. Once again, women are not being listened to. They are being silenced and gaslit. We have obstetricians demanding that the term 'obstetric violence' is not used to describe women's experiences of obstetric violence. We have the 'problem' being reframed to blame the women and their unrealistic expectations of birth rather than what is said and done to them. Solutions include 'improving' childbirth education to better prepare women for the 'reality' of medical intervention and getting women to meet the medical team during pregnancy to groom them for interventions. Women have consistently asked for continuity of midwifery care based in the community for decades, in multiple government reports, in multiple research studies, over and over. Yet, recommendations (heavily influenced by medicine) drop the 'midwifery' component of women's requests. Instead, they recommend 'continuity of carer' in general and refer to GPs and obstetricians. 

It is frustrating. In 2017, the solutions were already known. A decade ago, the WHO published recommendations for 'the prevention and elimination of disrespect and abuse during facility-based childbirth'. I was in the working group developing the 2020 Queensland guideline 'partnering with women who decline recommended maternity care'. The guideline provides very clear information about women's rights and health professionals' responsibilities. There has been no noticeable implementation of the recommendations, and I can't find any evaluation of service improvement since the guideline was released. There has been ongoing global consumer activism, supported by countless research studies, fighting for relationship-based, community-based models of maternity care led by midwives. We know that women experience less trauma (even if there is a bad outcome) when they have respectful care that centres them and care providers who listen to them. We have known this for a long time. There is guidance available about how to implement respectful maternity care. Yet, the maternity services continue to move in the opposite direction. Nothing will change until the underlying issue is addressed. We need a social and cultural shift. We need to value women, listen to them and centre them in all matters that concern their lives and their bodies. In the meantime, we need to keep shouting about it to expose what is happening and demand better. However, we may also need to find other radical ways of creating change outside of the systems.

Vaginal Examinations: beliefs and practice

(May 2024)

In this musing, we are going on a bit of time travel to see how beliefs about vaginal examinations (VEs) in labour have shifted over time.

1600s-1700s: VEs to assess complications at homebirth

I'm starting with the 1600s (Europe) because before the rise of the publishing industry, birth knowledge and practice were shared from woman to woman. Midwives were working-class women who were not formally educated, and they learned their craft through many years of apprenticeships. The first midwifery textbooks were based on observations of practice, so likely reflect what was happening at that time. These early textbooks (for example, by Nicholas Culpeper, 1651 and Jane Sharp, 1671) do not mention assessing cervical dilation. VEs were only carried out in response to concerns about a baby being stuck, and there were no specific timeframes for labour length. 

In the 1700s, there was a rise of male midwives and physicians who could use new technologies (e.g. forceps) to manage complicated births in women's homes, and female midwives were excluded from using these interventions. It is also important to note that at this time, the term 'midwifery' referred to providing care during birth, so physicians were practising 'midwifery'. We now had texts written by physicians for physicians about how to manage complicated births. VEs were used to assess the baby's position before an instrumental birth. Again, the length of labour was not assessed against specific timeframes, although William Smellie (1790) did refer to 'lingering or tedious labours'.

1800s: VEs to assess fetal descent in institutions

The emergence of institutionalised birth and education in the 1800s was the first major shift in the practice of VEs during labour. Lying in hospitals meant that some women were now birthing in institutions, and physicians were taught how to manage their births in keeping with the principles of industrialisation (efficient and effective). Language had shifted, and we had 'stages of labour', 'mechanisms of parturition', angles and measurements of the pelvis and fetal skull. VEs were now considered to be a means of assessing labour progress. However, there were no specific timeframes for labour progress, and Griffiths Swayne (1884) warned that 'any attempt to foretell the exact duration, especially of a first labour, would be very likely to end in the exposure of the false prophet, and in the disappointment of the patient.' The assessment of labour progress centred on the descent of the baby in the 'second stage' rather than cervical dilation during the 'first stage'. Women were cared for by nurses during the 'first stage' who were not permitted to do VEs. The physician attended during the 'second stage', and VEs were frequent; for example, Fleetwood Churchill (1843) recommended a VE every 'four, six, eight or ten pains' during pushing.

1900s: Concerns about sepsis and rectal examination

At the end of the 1800s and into the 1900s, there was significant concern about sepsis and warnings about the infection risks of repeated VEs. Examinations were limited because 'repeated vaginal examinations can do no good and only increase the risk of sepsis' (Berkely 1941). However, by the 1970s, labour progress timeframes were becoming increasingly established alongside 'active management' of labour (speeding it up to fit the timeframes), and this approach required regular monitoring of cervical dilation. Rather than risk infection by increasing VEs, frequent rectal examinations became the norm (the cervix can be felt through the rectum). For example, O'Driscoll and Meagher (1986), the founding fathers of active management, advocated hourly rectal examinations to assess cervical dilation rather than VEs. However, in their discussion of rectal vs vaginal examination, they write, 'a recent controlled study in this hospital revealed to our surprise that women, in general, prefer vaginal examination.' I'm fairly sure that the women were not asked if they preferred vaginal, rectal or no examinations at all! O'Driscoll and Meagher conclude that 'the choice of method is therefore likely to remain a matter of local custom' (not of women's choice).

1990s-today: VEs in the era of culture vs evidence

By the 1990s, rectal examinations had gone out of fashion in favour of VEs. However, active management was here to stay, and cervical assessment is integral to that approach. Evidence-based practice and university-based midwifery education also emerged in the 1990s, creating a conflict between practice and research. Modern research supports the traditional midwives' practice of the 1600s. We now have good evidence that the timeframes for labour are incorrect, VEs don't determine progress, and women find VEs at best uncomfortable and, at worst, traumatic (I've written about this in lots of places - blog posts, books, etc.). Midwives learn about the evidence in university but are then expected to perform the cultural practices of the institutions they work in. I wonder what comes next? It is unlikely that routine VEs will disappear. Particularly as most women birthing in hospitals have medicalised labours (induced, augmented, epidural, etc.) that require monitoring. How can midwives reclaim practice that supports physiology in the current medicalised birth culture?

Books cited:

  • Culpeper (1651) A Directory for Midwives: or a guide for women in their conception, bearing, and suckling their children
  • Sharp (1671) The Midwives Book
  • Smellie (1790) A Treatise on the Theory and Practice of Midwifery
  • Swayne (1884) Swayne's Obstetric Aphorisms
  • Churchill (1890) On the Theory and Practice of Midwifery
  • Berkely (1941) A Handbook of Midwifery for Pupil Midwives, Midwives and Obstetric Dressers
  • O'Driscoll & Meagher (1986) Active Management of Labour 

PAPP-A and Low Dose Asprin

(April 2024)

It seems like every month, a new screening test is added to the ever-growing testing schedule of antenatal 'care'. I often get asked about PAPP-A testing but haven't covered the topic publicly (only in the Collective). So, here you go, a brief overview of PAPP-A and the follow on intervention of low-dose aspirin.  

PAPP-A

The placenta secretes PAPP-A (Pregnancy Associated Protein-A) into the mother's circulation. This protein facilitates the placenta's attachment, development, and growth and prevents the maternal immune system from recognising the fetus. Low levels of PAPP-A in the maternal blood can reflect problems with the placenta's implantation, which underlies pregnancy complications such as pre-eclampsia and fetal growth restriction. The idea of PAPP-A testing is to identify pregnancies where an implantation issue has occurred early in pregnancy before symptoms develop (usually after 24 weeks). Unfortunately, the PAPP-A test alone is not a good predictor of future complications. The positive predictive value is 23-52% i.e. at best, only half of the women who are flagged as 'high risk' via a PAPP-A test will go on to develop FGR, pre-eclampsia, etc. Therefore, it is recommended that the PAPP-A be combined with other tests to predict pregnancy complications rather than be relied upon alone. It is also important that women considering routine screening consider the risk of being labelled 'high risk' and how that might change their experience of pregnancy and options for birth.

Prophylactic low-dose aspirin

If a problem occurs with the implantation of the placenta, it cannot be fixed. Therefore, once a woman has been identified as high risk, interventions are aimed at supporting the placental function to reduce potential complications as the baby's demands for oxygen and nutrients increase. Currently, the standard recommendation is low-dose aspirin LDA to reduce clotting and improve the blood flow to the placenta. A Cochrane review looked at the effectiveness of LDA in preventing complications for women at risk of developing pre-eclampsia. It found that "overall, administering antiplatelet agents to 1000 women led to 20 fewer pregnancies with serious adverse outcomes". The number needed to treat for one woman to benefit (NNTB) was pre-eclampsia 61, preterm birth 61, perinatal death 197, and SGA 146. LDA 'slightly increased' the chance of a PPH >500mls and 'marginally' increased the chance of placental abruption.

Considerations for decision-making

I am not suggesting that women do or don't have PAPP-A testing or LDA, only that they are supported to make informed decisions. The person recommending the test/intervention is responsible for providing adequate information for consent. However, this does not necessarily happen in the real world. So, here are some questions to ask someone if they recommend routine screening such as PAPPA-A:

  • Why is the test being recommended to me?
  • What is being tested, and how does it relate to complications?
  • What is the predictive value of the test?
  • What are the risks of the test, and how will the result alter care pathways and options?

Before consenting to prophylactic interventions such as LDA, ask:

  • What is the intervention, and how does it work?
  • What is the NNTB (number needed to treat for one person to benefit)?
  • What are the risks of the intervention?

Also, remember that a woman has the right to decline a recommendation without giving an explanation.

The Maternity System is Not Broken

(March 2024)

I keep hearing and reading that the maternity system is broken, and all we need to do is fix it, and women will finally have a service that centres their needs. However, I disagree and here is why.

The maternity system is not broken

The mainstream maternity system evolved to sustain medicine and control women's reproduction. It was never set up to promote physiology or to facilitate an empowering experience of childbirth. The origins (herstory) of the system underpins how it operates today. Medicine continues to control childbirth, and the system works very well for medicine and medical institutions. I should probably add (before people get defensive) that medicine does a good job of managing pathology and complications for the minority of women who need interventions. However, it also does a bad job of supporting physiology and meeting women's emotional and psychological needs. Please note that I am not judging individuals within maternity institutions because they are constrained by training, socialisation, workplace culture, and experiences that centre the needs of the institution. My focus is on how the culture (roots) underpin the structure of the system (tree trunk) and the fruits (practice).

We can't fix a system that is not broken

Birth interventions increase year after year. Physical outcomes have not improved, and emotional/psychological harm is endemic. You can't change the maternity system from within the structure of the system. We already have decades worth of research (Cochrane Reviews included) supporting the need to change service structures and refuting common, routine medical interventions. Research only gets implemented into service delivery if it aligns with the culture and supports intervention (e.g. the ARRIVE Trial). Even clinical guidelines are ignored in favour of cultural norms (e.g. induction for 'big' babies). We have midwives in 'high places', yet their voices hold no real power against medicine, and we have consumers on advisory boards who are treated as 'tick boxes' rather than listened to. And we are grateful for crumbs, unable to see how those crumbs further sustain the medical system (e.g. in Australia, our publicly funded homebirth services are led by obstetricians!). You can prune the tree, but you can't change the fruit.

What's the answer?

The only way to change maternity care is to change childbirth culture, and I may surprise you here because I am feeling optimistic about this (after years of watching the landscape). People are waking up, and there is a ground-swell of grassroots knowledge sharing and activism. Physiological childbirth is being reclaimed in a myriad of ways by a myriad of people (including some working within the system). People are realising that whilst they may be unable to change a system, they hold the power when it comes to how they interact with others (their words and actions). This alternative birth culture is growing organically outside of the system, with its roots in the community rather than medicine. The fruits of this new culture are being seen both outside and inside the system. My guess is that if you are reading this email, you are part of this cultural shift!

Supporting Decision-Making

(February 2024)

This musing/rant is in response to a regular question I get asked, and it goes like this: Can you give me some evidence to support my client declining an intervention being recommended by a care provider?

This question reflects the power dynamics of the maternity system and the socialisation of women to be 'good girls' and do as they are told or explain why. So, let's look at how we can reclaim some power in these situations. The following is aimed at anyone who supports women navigating decision-making about recommendations.

The onus is on the person recommending an intervention

The care provider recommending an intervention is obligated by law to provide adequate information to gain consent. That includes explaining the benefits (why they are recommending the intervention) and the risks (the potential consequences of the intervention). They must provide evidence. The onus is entirely on them. So, the first step in supporting decision-making is to encourage and support the woman to ask the person making the recommendation to provide adequate information. Does the woman know about her rights? If not, share that information with her.

Even if evidence is given, there is no obligation for the woman to justify her decision with any explanation or evidence. She can just say 'no', and can say 'no' regardless of the risks, she does not have to make an 'informed' decision. It's her decision to make and hers only. There is no 'shared decision-making' in law. There is also no need to make a decision immediately (excluding an emergency of course). The woman can take time before she provides her answer, and tell the care provider she will get back to them with her answer once she has thought it through.

It's not your job to know-it-all

If the woman wants more information to support her decision-making, then help her to gather it. Notice I didn't write 'give it to her'? This is the woman's rite of passage, and we need to reinforce her as the expert in terms of what she needs to know. What questions does she have? What sources of information does she already have access to?

In your role, you don't have to know everything (phew). You just need to know where to find good quality information and direct the women to those sources. Luckily there are plenty of resources created by people whose entire job is researching, critiquing and communicating evidence-based information. Focus on your role of supporting the woman to gather information and find answers to her questions. Have a list of trusted sources of information and use them like a library, you don't have to keep the answers to every question in your brain. Avoid the misinformation circulating and re-circulating on social media (see my Instagram post about the fetal ejection reflex as an example). 

Support the decision regardless

Release your attachment to what the woman decides. Once she has made her decision, support her to exercise her power and take responsibility for the decision and the outcome of that decision. What does she need from you to do that? How will she communicate her decision to her care provider/s? What support can she gather to advocate for her decision if needed?

In summary, rather than focusing on evaluating and communicating complex information (not your job), focus on supporting the woman to ask questions and gather the information she needs to make a decision. Then support her decision and advocate for her. You need to be a 'listener' and a 'know-where-to-find', rather than a 'know-it-all'.

Induction of Labour and Caesarean Rates

(January 2024)

Women are being told that research shows induction of labour reduces their chance of c-section. However, as usual, blanket statements don't cover nuance. Whether induction reduces an individual woman's chance of a c-section has more to do with the context and setting of the birth than the woman. To support women's decision-making, care providers need to 'share the map' with women. Sharing the map is about discussing the context of the planned birth, including the cultural norms of the setting and practitioners, routine practices and outcomes related to that individual woman's situation. When discussing particular study findings with women, we need to contextualise it so they can decide if it is significant to their situation and decision. I am not suggesting that everyone needs to be proficient in critiquing research methodology or statistics. Rather, that we ask questions to explore beneath the surface of research findings to see if they apply to an individual woman. I am going to focus on one outcome measurement, c-section rate as an example and to keep it simple, but these questions could be used to consider other factors relating to induction. If you want to see the studies I mention, you can find the links in this blog post (if I link them all here, this email will end up in your spam folder).

So, here are some questions that will help you work out if study findings about induction and c-section apply to an individual woman/situation:

Does this study differentiate between women having their first baby and women having second or subsequent babies?

Most of the research showing no increase in c-section rates, or a decrease in c-section rates involves a mixed population. Women who have laboured before respond more effectively to syntocinon (pitocin). Therefore, this group of women alters the outcomes of mixed-population studies. Except for the ARRIVE Trial, studies looking a first labours show an increased rate of c-section during induction.

Does this study compare induced labour with spontaneous labour?

Studies like the ARRIVE trial compare induction at a particular gestation (39 weeks) with 'expectant management'. However, expectant management is 'standard care' and usually includes induction at a later gestation (e.g. 40+5 in the ARRIVE trial). Therefore, the findings of these studies compare a group of women who had their labour induced at an earlier gestation, with a group of women who had a spontaneous labour or induction at a later gestation. These findings do not tell us about spontaneous labour vs induced labour.

Is the study context similar to the planned birth context?

A study carried out in the US on women birthing in a private obstetric setting (e.g. the ARRIVE trial) does not apply to a woman birthing in the UK public system. It is best to cite a study conducted in the same country as the woman or with a similar maternity system. For example, studies from the UK and Australia report an increased c-section rate for first-time mothers having inductions. Yet, here in Australia, the ARRIVE trial is often cited to support inducing first-time mothers to reduce c-section.

Every study I have found compares outcomes for induction vs spontaneous labour in a medical setting (partograms, vaginal examinations, interventions). These findings do not apply to a woman who is planning to birth in a setting that promotes and supports physiology. The golden statistic for determining whether a setting supports physiology is the rates of first-time mothers going into labour without intervention, labouring without augmentation and giving birth vaginally without instruments, cutting or complications. Of course, that statistic is rarely reported and difficult to find. However, you can get an idea about how medicalised a study setting was by looking at the rates of spontaneous labour without augmentation and non-instrumental vaginal birth without episiotomy. Often, the definition of 'spontaneous vaginal birth' includes an augmented labour. I also find looking at episiotomy rates a good indicator. For example, an Australian study reported rates of episiotomy for first-time mothers as 30.5% (spontaneous) and 41.2% (induction). This demonstrates that the women in the study were not well supported to experience physiology regardless of how they began labour. The study stats need to be compared to the planned birth stats to see if they might be relevant.

In summary, whether a woman has a reduced chance of a c-section if she has her labour induced cannot be determined by a generalised study. The context of birth heavily influences the chance of a c-section. Let's take the example of a woman who is planning to birth in a setting with a high c-section rate, where staff are very experienced in managing induction and medicalised births but not so good at supporting physiology. In this setting, induction may help her avoid non-evidence-based timeframes and therefore c-section for 'failure' to meet those timeframes. In contrast, a woman planning to birth in a setting with a low c-section rate that supports physiology and individual labour variations may increase her chance of a c-section if she is induced. Care providers need to share information about the planned birth setting's culture and stats in addition to any research studies.