In 2022, Spanish public hospitals received 203,251 vaginal deliveries. Of these, 27.5%, or more than one in four, were induced deliveries, that is, not spontaneous but medically induced. Since 2016, this number has continued to grow and shows a tendency to induce more and more births, although the World Health Organization emphasizes that this is a practice that should only be used in cases where it is highly justified.
New data on pregnancy duration and fetal risk have something to do with this growth, but also with the medicalization of births and the lack of complete information allowing mothers to give informed consent. Some voices warn that inductions are also not without risks – more risks of instrumental delivery and serious tears, for example – and advise that mothers should be well informed and that the resources and time necessary to carry out these procedures when necessary.
The annual report of the National Health System published by the Ministry of Health shows that 27.5% of births were induced in 2022 and also the huge increase that has occurred in recent years: since 2016, the percentage has increased by 61.8%. “The induction of labor is not without risks, so its use must be justified under obstetric indication,” the report states. Currently, the vast majority of public hospitals generally indicate the induction of labor around the 41st week of gestation: while some centers prescribe it as soon as this week is reached, others leave a few extra days of margin.
Induction is a procedure that aims to trigger contractions so that labor can occur by administering hormones and/or vaginal examinations or breaking the sac. Why induce labor and why is it a procedure that continues to grow? Obstetrician Charo Quintana explains that it is a trend that is also occurring in other countries and is linked to “the medicalization and technicalization” of births, as well as the results of different surveys that, in recent years, are changing “the practices of voluntary termination of pregnancy.” ” of a pregnancy.
“Previously, for those who were prolonged, it was recommended to terminate the pregnancy by induction at week 42. The new studies speak of an increase in mortality from week 41, and that is why the termination at this week is recommended, it can already increase the rate by several points,” he says. However, Quintana emphasizes that “much larger” studies are needed with large groups of women to detect clearer and more solid trends, “and we do not have them, what matters to women is of little interest.”
From week 41 onwards, there may be a greater risk that the birth will end in caesarean section, that the baby will end up in a neonatal unit and that there is a greater risk of neonatal death. This leads to an increase in incentives, but this increase is primarily due to the lack of information that women have.
Helen Eyimi
— United Nations Advisor on Maternal Health
“There is a lot of uncertainty because we do not have sufficiently powerful reports on perinatal deaths, which are fortunately a very rare event, nor all the evidence that we would like. In addition, it is common for there to be errors in the dating of pregnancies and for a pregnancy in the process of being prolonged to have a different due date,” continues the obstetrician, who provides some data on the average number of inductions that are done to avoid a perinatal death. Some studies, he points out, show that 410 inductions are carried out to avoid one case of perinatal death, others speak of 230 inductions.
Nurse and midwife Helena Eyimi, a UN maternal health advisor, calls for individualization of cases to avoid generalizing a practice that “poses risks to the mother and baby.” “From week 41 onwards, there may be a greater likelihood of delivery ending in cesarean section, of the baby ending up in a neonatal unit, and a greater likelihood of neonatal death, leading to an increase in inductions. But in my opinion, this increase is primarily due to the lack of information among women about the possible risks and benefits,” she says.
In women without pre-existing medical complications, “the vast majority,” the risks of induction include increased pain and therefore the delivery of epidural anesthesia, uterine rupture, fetal bradycardia or a greater likelihood of instrumental delivery and, therefore, serious tears and injuries that affect the perineum and sphincters. Uterine hyperstimulation caused by the intake of synthetic hormones “can cause an alteration of contractions and this can affect the circulation of the placenta, the blood supply that reaches the baby.” duck.
More information
The Spanish Society of Gynecology and Obstetrics (SEGO) explained some time ago what it attributed the increase in inductions to: “There are many factors that can justify this increase, such as greater accessibility to diagnostic tests and more exhaustive monitoring of pregnancy, with the consequent increase in the detection of pathologies that require termination for medical reasons. It can also be influenced by “the increase in pregnancies obtained through medically assisted reproduction techniques, which are sometimes associated with a greater probability of gestational complications or because in this group of the population, maternal age is higher and, in addition, mothers have a higher incidence of diseases that already existed before pregnancy”, said obstetrician Tatiana Figueras Falcón, head of the Tocogynecological Emergency Unit and the Delivery Room at the Maternal and Child Hospital of Las Palmas de Gran Canaria.
Midwife Helena Eyimi defends inductions when they are necessary “because they can benefit the mother and the baby”, but denounces that, on many occasions, they are done without women having complete information to be able to decide what they prefer and without examining each case on a case-by-case basis. “You have to inform correctly and honestly, and give your informed consent, not to believe that you have to incite and that’s it. Let them know where, why, how it works… Also, if they say no, what are the options available to women if they want to wait for something longer?
They should be reserved for situations with a clear medical indication in which the expected benefits outweigh the potential harms, such as preeclampsia, uncontrolled cholestasis, pathologies with the presence of antibodies or diseases that cannot be treated before delivery.
Eyimi explains that there must be an alternative that involves frequent monitoring, performing ultrasound scans to assess the amount of amniotic fluid, documenting that an informed decision has been made, and considering other options for analgesia if induction is chosen. Regarding the age of the mothers, he insists that cases must be seen individually, “so as not to induce because you are over 40 without any other indication, because now there may be 43-year-old women who are better off than a 25-year-old woman.”
Some professional associations are calling for a review of the integration protocols. For example, the Catalan midwives association ALPACC, which last year published an information guide that lists the reasons for initiation, offers women questions they can ask health personnel, reviews their rights and provides information on the risks.
The guide warns that inductions should not be applied systematically to terminate multiple pregnancies, with breech babies, mothers with gestational diabetes, rupture of the amniotic sac or pregnancies over 40 weeks, among other situations. On the contrary: “They should be reserved for situations with a clear medical indication in which the expected benefits outweigh the potential harms, such as preeclampsia, uncontrolled cholestasis, pathologies with the presence of antibodies or diseases that cannot be treated before delivery,” it specifies.
Less waiting
Another reason why labor is induced is the rupture of the membranes when the pregnancy is already at term (from week 37), but the woman does not have contractions. “Before, we waited 24 hours because during this period a large majority of women spontaneously began labor, but now there is data that speaks of a possible increased risk of infections or complications, such as meconium aspiration by the baby, so the indication is now not to wait more than 12 hours after the rupture of the sac,” explains obstetrician Charo Quintana. This does not mean immediate integration, he emphasizes, but rather respecting those 12 hours of waiting. Those that should be “avoided” are, he says, those that are done “for the convenience” of either party, and without maternal or fetal cause.
Training is required, hospital facilities sufficient for prolonged admissions, technical application adapted to new obstetric knowledge and impeccable support for women.
Charo Quintana
— obstetrician
The expert points out that the way they are performed also influences the experience of childbirth and the possibilities of avoiding risks and complications, from the use of instruments to sphincter tears, perineal trauma, the reduction in the frequency of skin lesions or postpartum hemorrhages.
“For this, we must have training, sufficient hospital facilities to have prolonged admissions, a technical application adapted to the new obstetric knowledge and impeccable support for women, which includes explaining the indication, the risks, what is going to happen… “If they say they are going to induce you and after a few hours they tell you that it has failed, it is not an induction, which can easily take 36 hours,” he says. Quintana urges to always evaluate all the risks related to induction or not to do it and to give women a “margin of decision” and indications on the symptoms to which they must be attentive.
