The RCM response to the NICE induction of labour draft guideline
By Lia Brigante, RCM Quality & Standards Advisor and Birte Harlev-Lam RCM Executive Director for Professional Midwifery on 07 July 2021 Maternity Services Safety Induction NICE - The National Institute for Health and Care Excellence Labour
Several new recommendations from the updated draft 2021 NICE guideline on induction on labour have caused concerns in the midwifery community. In particular, the implication of those recommendations on service provision, midwifery workforce, safety, long term clinical and psychological outcomes for women and babies, and experience of care for women and their families did not seem fully considered by this NICE guideline.
The RCM is a registered stakeholder for all NICE consultations related to maternity care. When this consultation opened in May, we set up a working group to inform our response by consulting members, via the RCM Consultant Midwives Forum, RCM Heads and Directors of Midwifery Forum and the RCM Professorial Group. We also advertised on social media that we were preparing a response and welcoming our members’ views. Our final response addresses several issues emerging from this guideline focusing on three important aspects: interpretation and transferability of the evidence; methodology and service implication. We are confident that NICE will take those comments on board before finalising the guideline.
The care midwives provide needs to be informed by the very best evidence available and should not be limited to randomised controlled trials as seems the case with this guideline. There are some good observational studies, as well as qualitative reviews that can offer data on the long-term outcomes for women and babies, including the impact on mental health and their experience of care. Offering earlier induction of labour to all healthy women, will affect their experience of labour and birth and limit the options available to them in terms of place of birth and midwifery-led care at home or in midwifery units. Women should be informed that the body of evidence on the gestational age beyond which continuing the pregnancy may pose any additional risks to mother and/or baby is contradictory. That said, there is some evidence that although small, the risk of stillbirth or perinatal death in the first week of life may increase with expectant management between 41 and 42 weeks, roughly from less than one per 1000 pregnancies to four per 1000.
We should provide this information to women in clear absolute risk terms, developing infographics from the body of research evidence and enable women to decide what’s best for them in their individual circumstances. We should not just refer to ‘increased risk’ and make decision for them as this guideline suggests, we should provide women with the information and evidence based on their personal circumstances including risk, so that they can make an informed decision. There is a recommendation to offer women declining induction the opportunity to ‘revise their options weekly’. We need to be careful we don’t stray into coercive behaviour but rather remain focused on personalised evidence based and informed care. According to the NMC midwifery standards, all midwives ‘In partnership with the woman, use evidence-based, best practice approaches to plan and carry out ongoing integrated assessment, individualised care planning and evaluation for both the women and the newborn infant, based on sound knowledge of normal processes and recognition of deviations from these”.
To provide safer care, we need to provide truly personalised care and refrain from blanket approach recommendations. Offering induction of labour at 39 weeks to all women falling in the so called ‘high risk’ bracket is not evidence based, particularly when women fall in this category just because they have an increased BMI, are aged over 35 or from an ethnic minority group. Black, Asian, mixed, and ethnic minority women face a constellation of biases when accessing maternity services, often experiencing poorer quality of care and lower satisfaction. Introducing an intervention that is singling out women on ethnicity alone, when there are likely to be large differences in health status and values within the group could itself be considered discriminatory. There are a number of initiatives, including training and support to reduce racial inequality and promote culturally sensitive care in maternity services that would be more effective.
There is already evidence suggesting that women can feel pressurised into accepting an induction and therefore detailed, evidence-based discussion is essential to support women to make the choices that are right for them. And that they can change these decisions at any point if they change their minds and will be supported in doing so by their midwives and the wider maternity team.