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Rising numbers of first-time mothers with low-risk pregnancies are experiencing a “cascade” of birth interventions, from inductions to caesarean sections, analysis of more than 343,000 births in NSW reveals.
More than one in four women (25.6 per cent) giving birth to their first child in 2018 and deemed to be low-risk experienced a labour induction or augmentation, followed by an epidural, then an instrumental birth or unscheduled caesarean section, with each intervention making the next more likely.
This was more than double the 11.4 per cent of women who underwent this cascade of interventions in 2004, raising questions about whether they are medically necessary and leaving mothers traumatised by unexpected procedures.
The study by University of NSW and University of Technology Sydney researchers published in the journal Health Economics and Policy, said women considered low-risk had no pregnancy complications, a gestation of at least 37 weeks, and a baby in the head-down position.
The study excluded women whose strong birth preferences meant they had either planned caesareans or gave birth in low-intervention birth centres.
These preferences also grew over the time period. In 2004, 2.8 per cent of low-risk women who had never given birth chose to deliver in a birth centre, a cohort which almost doubled to 5.4 per cent by 2018. Elective caesareans also rose in the same cohort, from 5.9 per cent in 2004 to 9.1 per cent in 2018.
Researchers found the rates of cascading interventions among low-risk women almost matched those of high-risk women, and that an increase in the practice was closely related to a decline in natural vaginal births.
“The results were very striking,” said lead author and UNSW Professor of Economics Denzil Fiebig.
“To have so many women across such a long period of time across all hospitals … it’s not well documented and not well understood.”
The report noted vast differences in intervention across the 56 hospitals, leading researchers to conclude that cascading at each institution was a major driver.
“This may be about risk aversion and management,” co-author Serena Yu, an associate professor in health economics at UTS, said.
“It’s not malicious – if you induce a woman and put her down that path, you have more control over the timing and ability to monitor what’s happening to her and the baby, compared to letting her labour, and leaving more question marks over what happens, particularly the possibility of an adverse event.”
For Alicia Woodfield, a cascade of interventions during the birth of her first child left her “traumatised”.
The Lake Illawarra resident had dreamt of a natural birth, but agreed to an induction when she had not gone into labour by just under 41 weeks’ gestation.
Woodfield was considered high risk due to her heart condition, but she was not told that this would limit how long she could be administered the medication that triggers labour. She initially refused an epidural, but later “reluctantly agreed” after just two hours of contractions. The epidural left her bed bound.
When she was then told she would need a caesarean, Woodfield was terrified.
“There was no mention to me about the chances of being induced and using epidural potentially resulting in a caesarean,” Woodfield said. “It was like they tried these things, and if they worked, they worked. If they didn’t, too bad – you go to the next intervention.”
She required a further spinal block during the procedure, and the anaesthesia caused her to slip in and out of consciousness – she missed the first moments of her son’s birth.
“That was important to me,” she said. “You’ve carried this little human for nine months. It’s your time to have that first initial bonding experience.”
UTS School of Nursing and Midwifery Associate Professor and co-author Vanessa Scarf said the study reflected her own experience of clinical work during the study period, and “puts on paper what we’ve known for a long time”.
“When I first became a midwife, induction of labour was not nearly as common as it is now. Epidurals weren’t as common,” Scarf said.
The researchers estimated that if one-third of the hospitals with the highest intervention rates used the same practices as a median-intervention hospital, about 1576 women per year could avoid a cascade of interventions.
The report’s authors accounted forpublic and private hospitals, women giving birth at older ages, and other demographic considerations.
“All those things are factors, but we’ve concentrated on a group that suggests it’s not the big part of the story,” Fiebig said.
“These methods have convinced us that it’s practice styles, it’s not women’s preferences.”
Dr Nisha Khot, president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said the report raised important issues around variations in practice between hospitals, which warranted further investigation.
But Khot said the report’s definition of low-risk was narrow, and did not provide the full context.
She said intervention decisions could also be informed by the risks of IVF pregnancies, high BMI and unexpectedly large babies.
“It looks like these are women who haven’t changed at all, and suddenly intervention rates have gone up,” Khot said.
“But actually, that is not true. The cohort of women who are getting pregnant has changed, and that’s not necessarily captured by a very narrow definition of low-risk.”
The report also examined the reasons for labour induction. In 2004, a little more than half of inductions were due to prolonged pregnancy. By 2018, prolonged pregnancy had dropped to about 20 per cent as the reason for induction, and just over half of inductions were due to “non-medical reasons”.
University of Western Sydney Professor of Midwifery Hannah Dahlen said this lined up with previous studies, which have noted a “dramatic rise in women having inductions for no reason, and the higher rates of intervention that followed”.
Katie Peterson, clinical team manager at the Gidget Foundation, said a cascade of interventions can be distressing for women.
“They can be invasive, painful [and] very unexpected,” she said. “But not every birth intervention will result in birth trauma, and not every birth trauma involves a medical intervention.”
A spokesperson for NSW Health said birth interventions can be important tools to support the safety of women and babies.
“They can also lead to further interventions, which is why it is so important for women to be supported to make informed decisions and be provided with care that is appropriate to their individual circumstances and preferences.
“Rates of labour and birth interventions are monitored by NSW Health, and if required, strategies are discussed with local health districts.”
NSW Health Minister Ryan Park said there have been considerable improvements to the provision of maternity care in NSW, such as the implementation of five fast-track initiatives in response to the Birth Trauma Inquiry, including guidance for clinicians on trauma-informed maternity care and induction.
For perinatal mental health support resources, visit PANDA or the Gidget Foundation.
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