A new study suggests that increasing rates of induction of labor (IOL) of pregnant women and people in the UK, without considering the accompanying, real-world impact on staffing workloads and patient care, may have unintended consequences.
The study from City, University of London, the University of Edinburgh and others highlights the limited evidence around the delivery of home-based IOL services, which were seen as an important step to reducing maternity staff workload.
It finds 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.
Around one-third of pregnant women and people underwent IOL in the UK in 2021. Rates have surged in recent years due to new evidence on safety and efficacy, and vary considerably between maternity services, with some rates as high as fifty per-cent.
However, earlier this year, a survey reported by the Royal College of Midwives (RCM) found that UK senior midwives are relying significantly on the goodwill of staff working extra hours to ensure safe services, amidst plummeting staff retention and recruitment rates that they say have reached "boiling point".
The RCM said that midwives are leaving the profession "because they cannot deliver the quality of care they so desperately want to because of their falling pay, and because they are exhausted, fragile and burnt-out."
IOL, or starting labor artificially, is offered when the risks of the pregnancy continuing are believed to outweigh the risks of artificially starting labor. 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.
The current study 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. Specifically, it investigated the recommended first stage of induction known as "cervical ripening" (CR) and the option of the pregnant person to return home from hospital during that process.
CR is either the use of topical medication (prostaglandin) or mechanical means (balloon catheter or osmotic dilator) to help dilate the pregnant person's cervix. Following this first stage, further steps are generally necessary to stimulate the onset of labor.
In the study, clinicians were either interviewed directly by the researchers or took part in focus groups to elicit their views, which then formed part of a thematic analysis to reveal common themes in their responses.
A wide range of practices and views regarding induction were recorded, suggesting that the integration of home CR into care is far from straightforward, and demonstrating that whether provided at hospital or home, IOL care is complex and represents a significant workload to maternity services staff.
The study follows closely on the heels of findings of a sister study which surveyed 309 women who had undergone IOL in the UK, and which was published earlier this month. The women reported receiving little information about IOL and being routinely impacted by delays at every stage of the care pathway, which they widely attributed to staffing shortages.
Professor Christine McCourt leads the Centre for Maternal and Child Health Research at City, University of London, and co-authored the study. She said:
"This study shows that well-intentioned interventions may have unintended consequences for quality of care and staff workload. Efforts are needed to target induction of labor effectively and ensure genuine informed choice; meanwhile, maternity services must be adequately resourced to ensure safe care."
The study is published online in the journal, PLOS ONE.
Yuill, C., et al. (2023) Clinicians’ perspectives and experiences of providing cervical ripening at home or in-hospital in the United Kingdom. PLOS ONE. doi.org/10.1371/journal.pone.0284818.