Rising rates of induced labour need to be reconsidered in light of the UK maternity services staffing crisis, said researchers.
A new study has suggested that already pressured maternity services may underestimate the workload impact of induction of labour (IOL) services. Published in PLOS ONE, the research suggested that increasing rates of induction of labour of pregnant women in the UK, without considering the accompanying real-world impact on staffing workloads and patient care, may have "unintended consequences".
The authors of the study explained that IOL was offered when the risks of the pregnancy continuing were believed to outweigh the risks of artificially starting labour. "For those deemed at lower risk, maternity services are offering this as an 'outpatient' service, where the woman returns home in the first stage of induction – despite limited evidence on its acceptability to pregnant women, birth partners, and maternity staff, and how different approaches work in practice," they cautioned.
Around one-third of pregnant women underwent IOL in the UK in 2021, the authors highlighted. Rates had "surged" in recent years due to new evidence on safety and efficacy, but varied considerably between maternity services, with some rates as high as 50%, the authors explained.
Complex With Significant Workload
For the study, the researchers, from City, University of London, and the University of Edinburgh, explored IOL from the perspectives of 73 clinicians – including 49 midwives, 22 obstetricians, and two other maternity staff from five maternity services across the UK (three in England and two in Scotland) that served urban, suburban, and rural populations . Between November 2020 and December 2021, 49 semi-structured interviews and four focus groups were conducted with the clinicians.
The research was undertaken as part of the CHOICE study, a prospective cohort study and process evaluation investigating cervical ripening at home or in-hospital.
Specifically, the researchers investigated the recommended 'cervical ripening' (CR) and the option of the pregnant person to return home from hospital during that process.
The findings formed part of a thematic analysis to reveal common themes in the clinicians' responses – 'Implementing home cervical ripening', 'Putting local policy into practice', 'Giving information about induction', and 'Providing cervical ripening'.
During the interviews and focus groups a wide range of practices and views regarding induction were identified, which suggested that the integration of home CR into care was far from straightforward, emphasised the authors. Moreover, it demonstrated that whether provided at hospital or home, IOL care is complex and represents a significant workload to maternity services staff, remarked the authors.
The study highlighted the limited evidence around the delivery of home-based IOL services, which were seen as an important step to reducing maternity staff workload. In addition, it identified large gaps in knowledge on how to deliver home-based care, with workload perceived to be increased in some cases, relative to hospital-based services.
Professor Christine McCourt, from the Centre for Maternal and Child Health Research at University of London and study co-author, said: "This study shows that well-intentioned interventions may have unintended consequences for quality of care and staff workload."
Deviation From Guidelines
Most clinicians who took part were positive about home CR. They perceived it to be better for themselves in terms of managing maternity workload, and also better for women and their families, especially those who were deemed low-risk and healthy, said the authors.
Home CR was believed to reduce unnecessary time in hospital for women, which was linked to the perception that women would prefer to be at home and that their experience would be improved by the offer of home CR.
However, researchers identified deviations from guidelines for providing IOL, particularly when new guidelines were implemented. "Not everybody interprets that guideline the same way," one clinician commented. "The policy's changed and not everybody’s on the same page. Things filter down and not everybody is privy to the information."
A midwife raised concerns about clarity around what was expected. "I just don’t think it’s clear. Like it's hearsay whether you find something out, and you’re learning from someone else that’s telling you something and you don’t necessarily know if what they’re telling you is correct. You just kind of hope it is."
The authors highlighted that policy dissemination beyond hospital into the community was "uneven, ever changing, difficult to access and lost in a sea of communication".
Tensions Created Between Healthcare Professionals
Different professional perspectives on IOL were unhelpful, stressed the authors, with one non-clinical manager expressing that " there’s a very much a split in terms of views about induction between the obstetricians and the midwives".
IOL was typically offered and booked by midwives for those deemed low-risk, whilst obstetricians offered and booked IOL for those deemed high-risk, the researchers learned.
This created tensions amongst the different roles in the process of IOL, which included gaps between an ideal of how home CR might work and the everyday reality in their service.
The authors stressed that the decision-making process around IOL was complex, because the "IOL pathway and its associated risks are themselves complex".
Delays throughout the IOL process affected women having home and hospital CR, and frequently occurred between the CR procedure and admittance to the labour ward for artificial rupture of membranes. In turn, this incurred further delays in admitting women for CR and administering a second CR agent, if needed. Study participants most frequently attributed delays to inadequate staffing, the authors pointed out.
Shifting Workload
The authors concluded that:
- Providing IOL care was complex
- Home CR was being implemented with varying success across the NHS
- The integration of home CR was not always straightforward
- Deviations from local guidelines might occur when put into practice
- IOL had a large impact on midwives' workload, and required additional planning and communication with women
"Superficially, home CR appears to be about improving women's experiences, but it is also strongly linked to managing workload," said the authors. However, this perspective was based on under-developed and inconclusive evidence about the safety and efficacy of home CR or the impact on workloads and resources, they warned.
Home CR did not necessarily lessen workload but rather shifted it from one space, or person, to another and, in some cases, increased it, they said.
Professor McCourt urged that efforts were needed to target induction of labour effectively and ensure "genuine informed choice".
The authors pointed out that the study highlighted services' limited preparation for increased IOL rates, in terms of workload changes and additional staff time.
In light of this, making IOL more routine, whether at home or in-hospital, should be reconsidered, and its potential risks, including unintended effects and those beyond the usually recognised clinical scope, required further scrutiny, declared the authors.
Funding for the study was provided by National Institute for Health and Care Research Health Technology Assessment Programme. The authors declared no conflicts of interest.
