Podcast: Induction of Labour with Dr Sara Wickham
Induction of Labour with Dr Sara Wickham
Season 3, Episode 1
In this episode, Dr Sara Wickham shares her insight and wisdom into all things 'Induction of Labour'.
Sara is a World Leading Midwifery expert in the area of induction and has dedicated her life's work to disseminating, unpicking and making accessible the evidence around induction of labour.
Sara and I explore the landscape of the maternity system, the rising rates of induction and give you some really practical tips and advice on how to navigate decisions around induction of labour (a decision which the majority of us will inevitably face!).
TRANSCRIPT
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Let's go.
Hi, everybody.
Welcome back to The birth-ed podcast.
I am delighted today to be joined by Dr.
Sara Wickham.
Sara is a renowned midwife, best-selling author, educator and researcher.
She is the director for the Birth Information Project, a free service that provides independent, midwife-led sources of birth-related research and information.
Basically, just keeping on top of breaking down and critiquing everything we know or are learning about birth in a way that makes it understandable and accessible to the people that are actually giving birth and those who care for them.
Sara has authored 17 books, edited three journals, and lectured in more than 30 countries worldwide.
Essentially, her CV in the birth world is somewhat endless.
I personally have learned and still take so much from her incredible work.
And when I actually started the podcast a few years ago now, I had thought to myself, imagine if we could get Sara Wickham on, and now we have.
So if you weren't familiar with Sara's work before now, I guarantee you are going to be very grateful to have stumbled across it today.
So Sara, welcome.
Thank you so much for joining me.
Thank you for inviting me.
So in today's episode, we're gonna be looking a little deeper into a topic that Sara focuses much of her work on, induction of labour, but particularly considering how do you know if you actually need or want one?
So to kick us off, Sara, can you tell us why so much of your work focuses on induction of labour?
Well, from my very early days as a midwife, even a student midwife, I kept meeting women who had a poor experience of induction of labour, or who were experiencing problems either for themselves or their babies afterwards because of induction.
And some of them regretted it afterwards.
And some didn't regret it, and some thought it was the right decision for them.
But quite a few of them said that they hadn't been fully informed and that they might not have agreed to induction if they'd actually been told more about it.
Some of the women had wanted to question induction, but they hadn't known how to.
Sometimes the problem was that they didn't know where to go to get information or perhaps a more balanced perspective.
And I became really passionate about helping women and families to get that balanced picture before they made decisions.
So that they could make decisions that were truly informed.
And that's really the core of what I do.
And if I may just say at the outset that although much of my work questions induction, and I'm sure that's what we're gonna talk about a lot today, that's not because I think induction is always or inherently a bad thing.
Induction can be brilliant in situations when it's truly warranted.
And I know many people, many women have been really happy that they had an induction.
And that's great.
It's all about informed decision-making.
It's about you making the decision that's right for you and your family, not the decision that I think is right or your neighbor, obstetrician, doula, midwife, friend.
It's what's right for you.
And that might be different from the next person because we're all different and one size doesn't fit all.
But at that time, when I kind of set out on this journey, the kind of information that women and families needed wasn't available.
Or when it was, it was hidden deep in these dusty old obstetric journals in libraries.
We're going back 30 years, I'm quite old, and it wasn't much use to families there because first of all, you needed to know where to look and you needed to be confident in understanding the numbers, willing to spend hours digging it out, analyzing it, evaluating it, because not all research is good research.
And then it needed to be put together in a coherent format.
So that's where my whole kind of career started before we had the internet or social media or any of these tools.
It really was based on the fact that women and families wanted this information and somebody needed to go and get dusty in the libraries, crunching the numbers and putting it into a form that people could make sense of.
And induction was one of the biggest topics then.
Induction and anti-D or ROGAM, if you have listeners in the US, they were two of the earliest topics that I looked at.
And I actually went on to look at several other things.
As you know, we've talked about this, about topics like vitamin K group B strep, screening in pregnancy.
But the bottom line is that induction of labour has remained the biggest issue throughout the 30 years of my whole career.
I wrote my PhD on induction back in 2008.
And actually people haven't stopped asking me to talk about it.
I laugh because sometimes I say, I'd quite like to talk about something else.
But the reality is it has never gone away as the issue of our time.
And in recent years, it's being offered more and more.
So it's something that more women and families than ever need to think about.
Yeah, I mean, even in the past 30 years, you must have just seen that rate just go, not even creep up, just fly exponentially bigger and bigger.
And so the kind of most recent official statistics that we've got in the UK that come from the National Maternity Statistics from the most recent years that we've got are 2020 to 2021.
So we're recording this in summer of 2022.
So they're a little bit old now.
And in that year, we know that only 47% of women went into spontaneous labour.
So this is under half of women actually going into labour kind of on their own.
So if you're interested in the kind of specific statistics, that's 18% planned cesarean and 34% induction rate.
10 years prior to this, it was 67% of women going into spontaneous labour.
And I imagine 10 years before that, it was kind of lower again.
So what is going on?
How did we get here?
Well, to be honest, and I know you know this, Megan, but your listeners might not, the number of women going into spontaneous labour is actually even lower than that in some areas.
Also, when we look at how many women are now having membrane sweeping, and membrane sweeping is itself a mechanical method of trying to induce labour.
Doesn't necessarily work very well.
It has downsides.
I actually have a blog post or two on that, if anyone would like to look at it further.
But it's now being offered so early that almost everyone is being offered a membrane sweep.
So if that was taken into account, even fewer women would be going into spontaneous labour.
And as I said, the statistic you're quoting is the national average from a couple of years ago.
I know now from doctors and midwives who are friends, colleagues in practice, that in many areas, it was higher than that then, because that's an average, but now it's even higher.
So how did we get here?
It's actually the answer to that.
It's a really deep answer.
In a nutshell though, because we live in a society that doesn't value and respect the female body and the physiology of birth.
Our culture prioritizes speed and efficiency over having good experiences, over good mental health.
We measure, not you and I, but our culture measures success in terms of crude short-term outcomes.
And we don't look enough at long-term health and wellbeing.
We prioritize immediate physical health over mental health.
And actually we have power structures.
This is becoming apparent to so many people in recent years.
We have power structures at every level in countries generally and in healthcare systems, many industries that are unfair and that prioritize the needs of the few people at the top rather than those that they claim to serve.
So our culture is increasingly focused on risk and intervention.
And all of that means that the priority becomes to do things, to act, even when there's evidence that it might be better to not do things.
And when we kind of take that and apply it to birth and the onset of labour, we've basically been led to believe that it's better to hurry babies out and intervene with the process of birth, even when the evidence clearly shows that this isn't better for the vast majority of moms and babies and families.
And I mean, on another level, we now have guidelines that are bringing the date on which women are offered induction in relation to their estimated due date.
This date is coming further and further forward.
And even when there isn't a specific guideline, many women are now told, well, we're going to offer you induction because you're older or you're a bit larger than average, or you're conceived your baby by IVF.
And in many cases, there's no evidence to support the idea that induction improves outcomes, or perhaps there's a marginal difference if we look at thousands of women and babies, but an individual woman or family may not find that evidence compelling.
But that's really, those changes have, is really, I think, what's affected it.
Can I just point out one thing about guidelines in case I forget to say this later?
Because I just want to point out that when we talk about guidelines, the guidelines on induction have changed recently.
There were new guidelines in the UK in 2021.
More and more women are being offered induction as a result of this.
But it's really important to know that guidelines in any area of healthcare, they're written for professionals and healthcare systems.
And they are about managing large populations of people.
And you, as an individual, may or may not want the population recommendation.
You may feel it's right for you in your situation or you may not.
And the important thing is that you don't have to follow any guidelines that aren't right for you.
They are written as a guide to what professionals should offer you, but you can take it or leave it.
You can say no to anything you want.
And I'm sure you've said this before, no is a complete sentence.
Yeah, I think something that's also really interesting on that that people sometimes don't realise is that, yes, there are these nice guidelines, which are a kind of standardised one for the kind of whole country, but each individual hospital will also have their own guidance.
And you might be offered things in.
So we had I had a like an in-person course recently.
Two women both giving birth at different hospitals, both had conceived their pregnancy by IVF, but otherwise had healthy pregnancies.
They were both in their early thirties.
One of them was being quite strongly recommended an induction.
The other had never had it mentioned to her at all.
And this was because the like hospital level guidelines were very different from this hospital to that hospital, which meant that the care that they were receiving and the advice that they were being given was completely different, literally just based on the fact that they lived about a town apart from each other.
Obviously, the town that you live in doesn't actually affect your physical experience of pregnancy or birth.
And so in terms of kind of like actually unpicking those guidelines and really thinking, actually, I can ask more questions, going like, you know, is this something that absolutely everybody is going to be offered, or is it kind of specific to me?
Absolutely.
And the same thing happens when you look around the world.
I mean, I work in kind of a global way.
I teach midwives, doctors, you know, people from all around the world.
And the differences are even more marked when you look at the differences between countries.
And for me, what this tells us is, this is evidence that the evidence is really uncertain.
Because if there was one clear answer and a really clear difference, then everybody would be recommending the same thing.
For instance, if you are going to jump out of a plane, no matter where you are in the world, we all agree that it would be a good idea to be attached to a parachute, you know.
Now, actually, interestingly, there's no evidence that parachutes work, because we haven't done the trial to find that out.
But we agree on that because it's, you know, it's clear that it's clearly going to make a difference to the outcome.
The reason things differ so much is because the evidence is really unclear.
The differences are often marginal.
They're really tiny, and there are huge variations between women and babies.
So I just want to play like devil's advocate a little bit here, because this is a question that I am often asked, and I imagine some people listening now will probably be thinking.
But why wouldn't you have an induction?
Doesn't it just make birth happen quicker?
Sometimes that's what it feels like it's presented to do.
Say, what do you reckon?
Absolutely.
No, absolutely.
I absolutely get it.
It's tiring being pregnant, particularly this time of year.
As you said, we're recording this in the summer.
You get hot and heavy, and it's hard to move, and you're exhausted.
So it often feels like induction would be a massive relief.
And the thing is that if it was genuinely a relief to the majority of women, I wouldn't be here today, because as I said right at the beginning, I've spent decades looking at this, because so many women regret it or had a poor experience.
But I think there's a couple of important things to mention here.
The first is that there are many, many benefits to going into labour spontaneously, to allowing labour to begin on its own.
And those benefits are for both women and babies.
And we don't know exactly how labour begins, but we are fairly sure from the science that it's our babies who decide when labour should start.
And on the whole, especially once a woman has reached the point that we call term, babies are fairly good at determining when they should be born.
We are the product of millions of years of evolution, and the medical management of birth is about 200 years old.
I'm not saying that women's and babies' bodies always get it right.
And medical management is brilliant for those who genuinely have a problem, but all the evidence suggests that we're doing far too much, far too soon to interfere.
And we're not allowing the benefits of physiology, of spontaneous labour.
In some cases, we're not doing enough quickly enough.
We haven't got that balance right.
And this notion in maternity care of, we're doing too much too soon, and sometimes too little too late, that's actually recognised at the highest level by organisations like UNICEF and the World Health Organisation.
So bringing on labour before the baby's ready, whether that's by induction or elective cesarean, you mentioned that elective cesarean is also about interfering with spontaneous labour.
Well, that overrides the baby's say in the matter.
And it means that you lose all of the advantages of spontaneous labour.
There's a hormonal cocktail that goes along with spontaneous labour and labour that has beneficial effects that can last years, perhaps decades into the baby's life.
This is often underestimated and overlooked.
We're told about the benefits of induction, but not about the benefits of spontaneous labour.
In fact, when I looked into this, I found so many that I managed to write a whole book chapter on the benefits of spontaneous labour, but we're not told.
And secondly, there are risks to induction, just like with any other medical intervention.
Induction and elective caesarean, they both carry the chance of making a baby be born too early, and that can have negative consequences.
We talk about estimated due dates, and that's exactly what they are, estimates.
Sometimes they're wrong, sometimes they're quite way out.
An ultrasound isn't perfect, it isn't always that accurate at measuring the size of a baby.
There's a margin of error.
So that's a key issue when we're considering induction.
It seems like a great idea, I'm really hot, but it can make a baby be born too early.
And we know that being born too early can mean the baby is more likely to be ill or to not make it.
And then induction as a process involves having a series of interventions that happen over several days.
And each of those has downsides and knock-on effects, just like any medical intervention.
And interventions are fabulous.
If you truly need antibiotics, for example, you'll cope with the possible thrush and the gut, tummy issues, because the infection needed to be tackled.
It's about weighing up the pros and cons.
And if you and your baby, you or your baby are in danger, and the benefits of hurrying things up with an induction or elective caesarean, they could well outweigh the risks.
That's for you to decide.
But those drugs and interventions can cause problems.
And that's why there are concerns about rising rates of intervention and induction.
Because we know that many healthy women are being offered induction when it may not be warranted.
And there was a really important study published in 2021 by Professor Hannah Darlin and colleagues.
And this was in Australia, but it's really applicable to many Western, high-income countries.
And they looked at the outcomes of babies born after induction compared to babies born after spontaneous labour.
And what they found is that induction leads to more intervention and more adverse maternal, neonatal and child outcomes.
And in fact, another group of researchers called this avoidable harm.
And what we mean by that is there are issues like, babies are more likely after induction in these studies to have respiratory problems, to be hospitalised for infection, birth trauma rates are higher, babies needing resuscitation after birth.
There's more likely to be separation of mum and baby.
And these are the things that I mean, when I say we measure the physical effects, but not the wider effects, because that can lead to issues with bonding, with breastfeeding, and some of these things that are harder to measure.
Induction sometimes can often actually, can take three days to work.
And it doesn't matter whether you're in hospital or having what's called an outpatient induction, where you go in and you have a cervical ripening agent, or you might have a balloon catheter to use, and then you go home.
You're still dealing with the niggling pain of the drugs, that are being given, or the methods that are being used to ripen your cervix.
So maybe you're not sleeping as well as you might have done, and then you go into labour tired.
And then that may mean you're less able to cope, and you then need more interventions, and there's a cascade of intervention.
And then when the baby finally arrives, you're exhausted, and it can take weeks or months to recover.
And of course, that can have a massive impact.
I feel like I'm being really negative.
It's not about that.
It's about getting both sides of the picture and helping people understand that actually, it's not just like, yeah, let's speed up the delivery, and it's an equal, you know, a level playing field.
It's not.
We sort of sold the idea of induction, because as you say, why wouldn't you want the baby out?
You know, well, everyone wants to meet them, and you won't have to wee every 30 seconds, you know?
It's just not that straightforward.
So, you know, I always think it's worth weighing up the pros and cons in relation to your individual situation and weigh up and decide whether it's genuinely the right thing for you.
Yeah, absolutely.
And I think one of sort of what you're touching on there, but one of the things that kind of really gets my goat, if that's a phrase, about that we do as women who are pregnant and we see within the healthcare system as well, is we consider pregnancy, birth, and the postnatal period or parenting as three completely separate events.
Like you're pregnant, that's one bit, and then you give birth, that's another bit, and then you are postnatal and that's another bit.
And everybody seems to ignore the thread that actually runs through the whole thing.
And actually, the decisions that we're making in pregnancy, the things that we're doing, whether that's having scans or extra scans, what kind of education we're doing, what kind of preparation we're doing, where we're choosing to give birth, whether we're having care from a midwife or an obstetrician, all of these things that happen in pregnancy actually go on to influence labour and birth.
And then that experience of labour and birth, as you mentioned, like feeling tired, that can affect how much you bleed after birth, and then if you bleed after birth, that might affect establishing breastfeeding.
And it's always talked about in such isolation.
I was reading an article today, it was in the National Geographic magazine, and it was about why breastfeeding rates are so low.
And they were doing some digging into women's diet or something.
And at no point had they mentioned what the birth experience might have been like, what the system that they were trying to feed their babies in looks like in terms of the other demands that are put on mothers and the expectation to care for other children or go back to work and separate mothers and infants all the time.
And you're like, nobody's thought about this as an ongoing experience.
It's all so separate.
It's all so separated.
And when exactly as you were saying, when we're talking about induction as just a way to get a baby out, we're forgetting that actually, well, what does that potentially lead to?
What's the follow on to that?
What does the actual early part of that labor and birth potentially look like?
And we're just thinking of it as a kind of exit method, and it's not there.
It's an experience, isn't it?
Absolutely.
And the wider context as you're talking about is also really important.
And as I was saying, a lot of the research that's done and our culture, it just focuses on the short term physical outcomes of like, is the baby okay at the end of labor?
And it doesn't take into account the wider context.
Sometimes midwives and doctors are so under so much pressure and they have five minutes to see somebody.
And it's really hard to take somebody's wider context into account.
For instance, I know when I was working in hospitals, I would see women and they looked really frazzled and their blood pressure was raised.
And you need to go, well, is your blood pressure raised because that's actually a problem?
Or have you just had to get three buses here and are all your kids really driving you nuts and you haven't had to rest for ages and your partner's got a mental health problem and is off work and you're really struggling to keep it all together.
But these recommendations that are made about populations, they don't take into account the wider context and the individual aspects of our own lives.
So that's why we have to do that.
We have to look at things in relation to our own lives.
How important is sleep to you?
You know, do you know what I mean?
That the big issues in our own lives.
So I think we both agree that in some sort of specific circumstances for some women, induction can be a really beneficial intervention in birth.
But there is absolutely no way that less than half of women can safely go into spontaneous labour, because if that was true, the human race would have been wiped out a very long time ago.
It's literally just maths.
But a dilemma that so many women face, probably because of the way these conversations about induction are often presented, is how do they know if they are one of the small number of women for whom induction is going to potentially be a safe and beneficial way to give birth, or if they're facing kind of potentially completely unnecessary intervention.
So let's say 34% plus of women are having an induction at the moment, probably kind of higher.
And the other thing we didn't mention kind of with that statistic is that we know that for first time mums, it is higher, specifically higher.
And so alongside that figure, there will also be many more women that are either offered an induction and then go into spontaneous labour before it happens, or offered an induction and decline it, or offered an induction and opt to have a planned cesarean birth instead.
So the chances then of somebody having to make a decision around do I want to have an induction or not, are at the bare minimum one in three, probably at least one in two, maybe even higher.
So now what?
What considerations would you recommend somebody makes when facing this decision?
This is such a good question.
And I actually published a blog post on this specific question.
So I can tell you what I wrote, and maybe we can add a link to that into the blog post as well.
And the blog post was called something like five questions to ask if you're offered an induction.
And the first one of those is to ask why, why am I being offered an induction?
And that's a really important question because is this something that is offered to everybody at this point in pregnancy?
Are you being offered induction because it is a population recommendation?
Is induction offered to everyone who's a bit older or larger than average, as I mentioned to you, conceived by IVF?
Are you being offered induction because you fit into a group and it's therefore a population recommendation?
Now, if that's the case, I would suggest you go away, have a look at the evidence for that specific indication because often there isn't evidence or the difference is very marginal.
But on the other hand, sometimes induction is offered.
For instance, somebody's on an anti-natal ward with pre-eclampsia and the doctors are worried.
They're so worried, they come and visit you every couple of hours.
And, or there's a particular concern about your baby.
Your baby might need a surgery.
Your baby might have a particular problem or disease.
That's a really different situation.
You know, is it that you are perceived to be at slightly high risk and it's a population-based recommendation?
I would say it's because have you ticked a box, basically?
Exactly.
Has a box been ticked on your form?
Is that why?
Yes, exactly.
And sometimes several boxes have been ticked.
But let me just say that just because several boxes have been ticked, that doesn't mean the chances go up.
In many of these cases, we just don't have the evidence.
You know, it's, as I said, we live in a culture that prioritizes doing over not doing.
And medical and midwifery professionals rarely get into trouble for the things they do.
They get into trouble for the things they don't do.
So they are more likely to make a recommendation.
And that applies to healthcare systems.
This isn't about bashing individuals at all.
It's, you know, we live in a culture where the idea is that it's better to do something than not at all.
So that's the first thing is, are you being offered it because it's offered to everybody who has a BMI of 36 or, you know, who's 37 years old or whatever, or is there a specific reason in your situation that induction or elective cesarean is being recommended?
I think it's really important to address the stillbirth question.
It's a difficult thing to hear and talk about.
It's not someone that anyone wants to think about, but the reality is that the, the kind of the phrases like your baby is at higher risk of stillbirth if you don't have an induction, are used to persuade many women and families to go for induction.
And so the second thing I would suggest is if that is used to kind of explain to you, well, we're recommending it because, you know, your baby has a higher chance of stillbirth, always ask for the numbers and go away.
My recommendation is always go away and look for information yourself before you make that decision.
This is exactly the kind of thing I write about.
And not just about whether there is an increased risk in your situation, but about whether induction can actually do anything to reduce the risk, whether we even have evidence of that.
With women who conceived by IVF, for instance, we just don't have research.
We do know that the stillbirth chance is slightly higher, but we don't have studies to tell us whether or not induction makes any difference.
I don't think it's ideal that women have to go away and get informed about this stuff in pregnancy.
I'd rather they could just sit in the garden, you know, chill out, but this is the reality of the culture that we live in.
The notion of risk gets thrown around a lot in an attempt to persuade people to comply with things, but we really need to take a step back and, you know, and so one thing I think is to, if you find risk-focused language being kind of thrown at you, take a step back and think about that.
You know, we all take risks every day.
It's a bit more risky to drive to the shops in the rain than to go when it's fine, but that doesn't stop us doing it.
It's important to try not to feel really anxious when you are told this is risky.
Take a step back.
A really important thing to know is that if you are truly in an emergency situation, you won't be offered induction.
You know, all health professionals know that induction can take three or more days.
It's not something that's offered in an emergency.
If someone was truly desperately worried about you or your baby being in imminent danger, they would be offering you an emergency cesarean, not an induction.
So I think that's important to know, because I think, sad, but it's true, that I think sometimes the risks are overplayed.
I don't know whether that's something you find as well.
Yeah, certainly.
And then I think sometimes that, if you then accept an induction, that can certainly affect the experience of induction, because often you have this, I've had an induction, I've had one induction and one home birth was, again, fortunately, I had read your book before, so I felt very informed, felt like I was able to ask everything that I needed to ask.
But it's the conversation where you're sort of led to believe that you are kind of in imminent danger, that your baby needs to be born right now, like as soon as physically possible.
But then the reality of giving birth in the modern maternity system is, by the time we then got there, they go, oh, we haven't got a room now.
Yes.
So you're just gonna have to wait.
Then you're sitting there going, but you told me that it was really urgent that my baby was born and that I couldn't wait until tomorrow.
But now, because you don't have space, it's fine for me to wait until tomorrow.
And so that's why just understanding the kind of the expectations of what the induction experience looks like, which is explained really well in your book, Inducing Labour, which I think that's a really important thing to understand if you do either accept or decline an induction, really get into grips with, what does it actually look, what is that experience actually going to look like?
Because it might not, still might not be kind of as you completely expect, that doesn't necessarily mean your baby is going to be born today or even tomorrow, either because the process takes a long time or because you're now trying to fit into like a busy maternity unit and things are prioritized.
So I think definitely like a really difficult thing for people to navigate is sort of as you've already mentioned, but is understanding the evidence around a recommendation.
Say that as we've sort of talked about, there is this assumption or a trust in the people that are looking after us that when they're making recommendations, they must be doing so on good evidence or at least with the kind of best interests of you and your baby at heart.
But as we've already mentioned, this is not always the case.
Sometimes evidence is very flawed, and we still hear healthcare professionals citing evidence that is quite obviously very flawed or completely irrelevant to the system in which you're birthing in.
It might suit, say, an obstetric-led system like something in America, but if you're giving birth in a midwifery-led system like in the UK, the two things are not necessarily comparable.
Sometimes the evidence is really old and actually not relevant to the rest of the healthcare that we've got at the moment.
Sometimes, as you mentioned, the statistics of something showing an improvement might be much lower than they're made out to be.
Sometimes things are said, the risk of stillbirth will double if you don't do X, Y, or Z.
And then when you look at it in terms of absolute figures, we're talking a 0.15% difference, which when you're hearing it is very, very different.
Hearing double, for most of us in my head, I go 20% to 40%, oh my God.
But actually, when you're told, well, the risk increases by 0.15%, then I'm just pulling figures out of the top of my head here.
But they're two very different things when it comes to decision-making.
Now, it's completely unrealistic for everybody giving birth to suddenly have the skills to find and appraise this research and work out how this research applies to them.
Is it good research?
Is it relevant?
So my first port of call is what you do, absolutely brilliantly, is break this down.
So sharing your books or your free resources, blogs and things on your website, which does literally do this for them.
But do you have any other tips here?
Like how can somebody know what a recommendation is actually being based on and how relevant it actually is to their personal circumstances?
Can I just go back into the first bit of your question and add, I mean, I'm a midwife.
Many, many midwives and doctors absolutely do have your best interests at heart, but they're working in a system that makes it almost impossible for them to practice according to the actual evidence.
They're following guidelines, which are based on this very narrow perspective that I've already talked about that doesn't look at long-term health.
I know that sounds crazy, but that is a product of our culture and how it is right now.
It's something we need to change.
The reason I can do what I do and provide information in this way is because I'm working independently.
I have much more time.
No one's going to punish me for saying something or for not doing something.
I don't have an employer breathing down my neck saying, why aren't you recommending what's in the guidelines?
And so I do think it's really important to get a sense of how the culture affects that.
But I also want to add that many midwives and doctors, some actively want you to question things and would be really happy if you did that.
They have to offer it because they have to offer it.
And actually, it's really good to ask questions in a way that lets them know that you are wanting, actively wanting to take responsibility for your own choices.
You will often be pleasantly surprised when you do that.
That as I said, the guidelines are, this is what the professionals have to recommend.
You can absolutely say no and opt for something else.
But to go back to your question, the first thing to do here is ask for the evidence.
You know, just say something like, I'm one of those people who likes to take a bit of time to weigh things up.
Can you please point me to the evidence behind that recommendation, so I can have a look and discuss it with my family?
Now, people might be thinking about, I don't want to actually look at the study.
Well, to be honest, you don't have to, even if you ask that question, because one of the key things here is that the healthcare provider's response to that question can actually tell you a lot about who they are and how much autonomy they want you to have, even if you don't want to look at the study.
Because if somebody's really interested, yes, here's the study, go and have a look.
I mean, go and pop the study name into the search box on my website.
If it's the arrived trial, use the search box on my website.
I've written a blog post that's really easy to understand.
Other people, I'm not the only person that does this.
Rachel Reed is a fab midwife in Australia, Hensie Goa in the US.
Other people have written about this stuff.
So take the name of the trial and search on it.
And hopefully you will find an easy to understand explanation of it.
But think about how the person responds to that question.
If they are really threatened or if they seem really threatened, or they bristle at that question, well, that's a red flag right there.
Is it that they actually want to be seen as the expert and have you just do as they say?
Or are they up for a conversation?
Do they give you the evidence or tell you where they got their data so that you can go away and have a look at that for yourself and decide whether it's relevant for you?
I think you can tell as much from the interaction, even if you don't want to actually look at the research.
But I also want to go back to something you said, because as you said, it's really important to ask about and get information on the absolute risk of something and not just the relative risk.
Because people do, as you say, often tell you about the relative risk.
They say things like, well, you do know the risk of stillbirth doubles if you do this, or your baby's four times as likely to die.
That sounds awful because it sounds horrifying.
But those comparisons are no good if you don't have the actual numbers.
As you said, if the chance of something doubles, it could be that you go from having a one in four chance of experiencing it to a one in two chance, or it might be that it goes from one in a thousand to one in 2,000.
Those are really different propositions.
And then when you take into account that there are downsides and the sleep loss and all that stuff, yes, I've written lots about this, but I'll give you a spoiler for both my books, if I can say that on the whole, people are really surprised when they read the actual figures that relate to the few situations where induction does reduce the chance of an adverse event.
There are situations in which induction either doesn't make any difference, or we don't know because we haven't done the research.
But even when induction does reduce the chance of a problem, the difference is really quite small.
And the chance of a problem still isn't very high, no matter what you decide.
I think it's also important, while we're talking about information and how to make sense of information, there's so much out there on social media now.
There is, you know, on the internet generally, but so many people are sharing information on social media, and that information is really varied in quality.
So I would suggest that you don't take information from any source at face value.
You know, the decisions you make around birth, I wrote this in one of my books, the decisions that we make around birth can affect us and our families for the rest of our lives.
So it really is worth taking the time to get informed and to go and do a bit of reading.
Yeah, absolutely.
And on the social media front, obviously we share kind of loads on social media, but one of my kind of sort of caveats to everything is just never read just one post and let that be it.
Because, you know, you have such a limit on what you, on like literally the amount of words you're allowed to include, that there is no space for nuance or personalisation or any of that.
And it's little tidbits of information maybe to kind of spark your interest, but then yes, actually reading, doing a course, that there's other ways of kind of hopefully gathering deeper, more, better kind of information actually kind of accessing.
If you read something, think, well, where did this come from?
Can I actually access where it came from rather than this quote that's kind of come from it?
Can I just add something?
Yes, do.
I think it's really important to go and find, it's very boring, it's very old fashioned of me, but to go and look for what we call long form content.
You know, even as somebody who is, you know, has worked in information and research for 30 years, I can't fit everything that's important into a social media post.
And what I always say, often say on mine is, go and look at this blog post or go and look at this.
I think the long form is really important.
Find a blog post, find a book, find a course, whatever it is, but actually go a bit deeper because there's more than can fit into that post.
Yeah, exactly.
That's exactly why I started this podcast because even like your 15-minute antinatal appointment, no midwife is actually able to have the conversation that they want to have with you in 15 minutes.
Generally, if you're talking about, you mentioned Rachel Redial, we've got a podcast episode with her actually, but on the Midwives Cauldron podcast, which is the podcast that she does, they've got these two episodes on gestational diabetes, which I direct people to all the time, but that's like two hours worth of conversation to actually communicate what you would want to know about that topic.
And imagine if every single person who had gestational diabetes was given a two-hour-long appointment.
The NHS would just never ever be able to reach that kind of demand, but that's the level of information that people actually deserve to have if they're making decisions about their kind of care for them, their birth, their baby.
And so I'm hoping that that's what this podcast does as well, is actually just go so much deeper and has the conversations that you want to be having and point to hopefully in the direction of where to kind of go next, where to gather information if you want to go even deeper again.
So once somebody has kind of followed these tips, they've asked the questions, they've maybe done some of that extra digging, extra research, and they've come to a decision that they feel comfortable with.
One of the hardest things, I think, when you are pregnant, particularly in kind of late pregnancy, often feeling quite vulnerable, is communicating this decision back to your midwife or to your doctor.
And you mentioned kind of going away to make that decision.
That's something that I always tell people as well.
Like, actually, can you go home and make this decision in your own, like your own environment where you feel kind of safe and in your own time, exactly.
But yeah, but not in the kind of, in a hospital, we feel that there's a kind of hierarchy.
There isn't a hierarchy, but it feels like there's a hierarchy, and it feels like somebody else is in charge there.
So can you step away, even if you're going to sit in your car, even if you're going to sit on a bench that's not in the hospital, can you go away to make this decision somewhere else so that it's made kind of on your terms rather than on anybody else's?
And so once you have made this decision, how can we communicate this back to your midwife or your doctor?
How do you say, particularly, I suppose, if you're saying, actually, I don't think I want to do this, any tips on kind of doing that confidently?
Absolutely.
Because if you decide you want induction, you won't have a problem.
The sister is geared up for that.
So don't worry.
If you decide this is what you want, you won't have any problem communicating and getting that.
Although, as you said earlier, it may not happen on the day you think it's going to happen.
So it's still important to be really flexible and to think about what that will entail and what you might want to take in and all of that.
But I think it's really good to know what your rights are so that you can be confident in your interaction and you know what's possible and what's okay.
I always suggest being friendly and calm and assuming positive intent from whoever it is that you're talking to.
I'm not suggesting that people fawn or give up any power or anything like that, but I think that any possibly difficult interaction can go better if we go into it feeling calm, assuming positive intent, especially in situations where you might still need someone's help further down the line and you want to keep that relationship.
So use whatever tools you have to help yourself without breathing or tapping or whatever it is that you do.
Sometimes you might want to email or call or write.
If you are cancelling, often what happens is women are given an induction date without having asked for it.
And this happens increasingly.
So you might want to email, call or write rather than going in person.
There's actually another blog post I've written on this called How to Cancel an Induction, which has some tips on that.
And that can be helpful in other situations as well, because some women, perhaps they do want an induction, or they're open to that, but they want it a week later than it's being offered.
It's not always about a clear yes, no decision, or sometimes it might be that, well, actually, I don't want one right now, but I'd like to reconsider in four days, or I'd like to see how I and the baby do.
If you do go in person, I think it can be worth taking someone with you.
But take someone who is good at communicating and who you know is on your side.
And I know this is a tricky thing to say, but that might not be your life partner.
It might be someone who's a bit more removed from the situation.
Pick someone who you think will be really good at helping you get what you need.
So, I mean, if you do, for instance, want to say, well, I'm open to this, but only if the baby has a problem.
You know, you might want to let the person know that you're not saying an absolute no.
You might want to say something like, look, I'm open to reassessing my decision if something happens that changes things, but I've decided to decline induction for now and see how things go.
I'll let you know if I change my decision.
And I also think it's worth having or practising a line that you can use.
If you do end up talking to somebody who doesn't seem to want to take no for an answer, have something that you can say, and I sometimes even suggest that write it on your phone and have it pinned on your screen, on your phone screen, and keep your phone in your hand.
Something that you can say, like a broken record if you need to, saying something like, thank you for your advice, I've decided to decline induction for now.
And if they bang on again, thank you for your advice, I've decided to decline induction for now.
Whatever works for you, I really hope that you won't have to use these, and most people won't.
But the reason I suggest it is that I know that some people, when they go into any kind of medical decision-making setting, their fear is about how someone might respond, how someone might respond, whether they might be pushed into something that they don't want.
So having something like that written out can help you just to know, this is my bottom line, this is what I'm going to say.
Thank you very much.
Yeah, absolutely.
And I actually say that for literally all of your anti-natal appointments.
If you're trying to communicate anything, write down what the most important things are that you want to have said.
Because I don't know about other people.
I walk in that room and I forget everything.
And I just put my smile on my face and nod along.
And actually, having stuff written down just really means that you can cover everything that you had kind of hoped to communicate, I suppose.
So, amazing tips.
Thank you.
So, finally then, whichever decision somebody ends up making, whether that is to accept an induction or to decline one, it can often kind of leave women in a situation where they're feeling quite anxious now, either because they've stepped away from what they expected or what they wanted from birth, so, like, towards an induction, which might now feel, like, scary or disappointing, or because they've turned down something that has been recommended by a doctor generally.
And so now you sort of get that feeling that, well, it's all on me now.
So do you have any thoughts on how to kind of manage that anxiety that comes right at the very end of pregnancy?
So either in, like, an immediate sense, or things that, if people are listening earlier in pregnancy, things that they could kind of potentially weave into their birth preparation, their pregnancy journey, to build this sense of self-trust and autonomy?
Well, that's a good question.
I'm not entirely sure that this is, like, as much my area of expertise.
It's something I'm looking into at the moment.
I actually want to write about this because I think it's really important to look at it in relation to risk and how we are faced with all this stuff about risk.
I've already mentioned, I mean, there are loads of tools out there.
There is breathing, there's tapping.
Some people use hypnosis.
There are some fabulous courses and people out there.
You know, yoga, you know, there's all sorts of things.
I think that one of my favourite phrases is one size never fits all.
And the thing is that none of these things work for everyone, but I think they're all worth considering.
So, you know, keep an open mind to all of the things that are out there.
You know, there are loads of books and tools and resources.
You know, there's actually a fantastic amount just out there nowadays that's really reassuring stuff.
But sometimes I actually think it's about, it's as much about removing the sources of information that trouble us as about putting positive things in place.
So from an information perspective, which is where I'm coming from, my two word recommendation here is unfollow ruthlessly.
Because, you know, when you're pregnant, you've alluded to this, when you're pregnant, you're in a different state.
Your hormones literally make you more open to things because that's what going into labour spontaneously is about.
It's about opening.
So curate your input really carefully, both in person and online.
You know, it might be a really good time to have a digital detox because the pressure often comes from people around us.
They're often the people we love and they're really well-meaning.
But just people going, so it's your due date, when is your due date, you know, and that pressure.
Just take a break from the sources of information that actually might make you question your decision or your trust and, you know, or who might share stories that aren't nourishing.
In fact, I think the word nourishing is a really important touchstone.
You know, ask yourself, what will nourish me on every level and what will deplete me?
And then follow your own instincts on that, you know.
And there's one thing that I've recommended for about 20 years now, and it is to not get attached to your estimated due date.
You know, only 5% of babies are born on their estimated due date.
A few are born before then, but most are born, most babies, if we let things be, would be born in the week or so after their due date.
So don't focus on it.
Don't give it out to people, because people start hassling you at the exact point where you don't have the energy to deal with that kind of rubbish.
So my advice is always, either give them a wider window of time.
So if your due date is November 13th, which, by the way, was my due date, and I was actually born on it, but only one in 20 babies are, then tell them your baby's due in late November, or just say November.
Or some people recommend whatever estimated due date you're given, add two weeks on, and then tell people that date.
The Royals do like a season, don't they?
Winter, the baby's coming in the winter.
We can't change the culture overnight, but we can change the way we respond to it and what we put in place to protect ourselves from its effects.
Surround yourself with people who think you're great and get that your body knows how to do this and who trusts you and get those positive messages, I think.
Thank you very much.
So we are running very short on time.
We've shared so much.
Thank you so much.
Now, the final question that I ask every guest on the podcast is if you could gift a pregnant woman one thing, what would it be and why?
Okay, well, I'm just going to follow on from what I just said about estimated due dates, because so much emphasis is put on the due date, and then a load of related ideas about the length of pregnancy which aren't helpful.
So there's loads to enjoy in the final days of pregnancy, but we don't really focus on that.
And it's actually, it's nature's way of giving us space to adjust to the reality of being parents or of expanding our family.
It's the time when our bodies soften and open to help make birth easier.
And so it's time to rest and nest and ponder this amazing thing that's going to happen.
So what I would like to do is gift every woman a voucher for a spa day and then a lovely meal with someone she loves.
But the key thing here is it's valid only on her estimated due date.
Because like I said, only one in 20 babies are going to come on that day.
So I'm sorry to the one in 20 women.
But actually, you know, there's a really high chance you're going to enjoy it.
If you've had your baby before, there'll be a crush.
So don't worry about that.
I'll just add that into my gift package.
So hopefully you can have a lovely spa day on your estimated due date, just getting some rest and relaxation while you wait for your baby to decide when it would like to be born.
Amazing.
Oh, I would like that, please.
Okay, so I've got three final gifts that I would like to give to people.
I would just like to personally recommend three in particular of Sara's many, many books that are particularly relevant to furthering your knowledge around everything we've talked about today.
So firstly, you might have heard us mention In Your Own Time, which is Sara's second book about induction.
This one is focusing on the landscape in which we are birthing, how we got here, why we need to think carefully about such high levels of induction, really digging deeper into the conversation we've been having today, actually.
Secondly, Inducing Labour, which is probably the more practical of the induction books, talking you through when it might be offered, the evidence around that, what actually happens in an induction.
And thirdly, her book, What's Right for Me, which is just really helpful for making decisions, not just about induction, but actually for the entire pregnancy, birth, postnatal continuum against the backdrop of kind of modern medical maternity care.
So, Sara, thank you so much for that.
I will put links to all of those books and all of the blog posts and everything that we've kind of talked about in the show notes, which you can find wherever you are listening.
But if people are keen to kind of continue following your work, can you let them know where they can find you?
Of course.
So the best place to find me is my own website, which is sarawickham.com.
And there's no H on Sara.
So that's S-A-R-A-W-I-C-K-H-A-M.
I'm on Instagram as Dr.
Sara Wickham.
I'm on Facebook as Sara Midwife.
But the very best way of keeping in touch, I guess, is if you go to my website, sarawickham.com, you can sign up for my newsletter by putting your email address in our blue box, and then you'll get my free monthly birth information update.
And I'll let you know when I've written new books and been on cool podcasts.
Yeah, it's definitely worth a newsletter that is worth being on for sure.
It's not junk mail.
It's full of interesting insights.
So thank you so much for joining me.
It has been so helpful to hear your insight into this dilemma, which so many women will potentially be facing.
I hope that if you're listening, you're feeling a little more confident to go away, ask a few more questions, gather some more information for yourself, and really take back control of your birthing choices.
So thank you so much, Sara, for joining me.
Thank you for inviting me.
Thank you so much for listening to The birth-ed podcast.
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