Why we disagree with the proposed NICE guidelines to induce labour at 39 weeks

Written by Kate Mackay & Leonna O’Neill

In May 2021, the National Institute for Health and Care Excellence (NICE)—the body which informs NHS policy and practices in England, Wales, and Northern Ireland [1]—published draft guidelines for medical induction of labour.
 
Section 1.2.4. of the guidance states: “Consider induction of labour from 39+0 weeks in women with otherwise uncomplicated singleton pregnancies who are at a higher risk of complications associated with continued pregnancy (for example, BMI 30 kg/m2 23 or above, age 35 years or above, with a black, Asian or minority ethnic family background, or after assisted conception.”
 
At Amma, over 90% of our clients are Black or Asian people within the asylum process. In addition to racism, they face multiple barriers to care including language and poverty. We already see disproportionately high rates of induction among the people we support. Much of our role is focused on advocating to ensure our clients do not experience unnecessary or unwanted medical interventions during pregnancy and birth.
 
If implemented, this guidance would undoubtedly lead to even higher rates of induction among our client group, who already feel disempowered to make decisions within a cruel and inhumane asylum process. For their sake—and the countless other birthing people this will affect—we call upon NICE to stop pathologising race and retract this proposed guidance.
 
Here are some of our concerns in relation to the proposed guidance.
This guidance removes all trust in Black and brown birthing bodies. It implies that they are unable to complete a full term of pregnancy or have a healthy and empowered birth without intervention. It places the responsibility for the higher maternal mortality rate endured by these communities on the bodies of Black or brown birthing people, creating a racial pathology that the medical profession must then intervene to fix.
 
The implication is that people of Black and Asian birthing people are less able to be pregnant and give birth than white people. This is wholly ignorant of material facts and is a form of racial gaslighting that not only avoids acknowledgement of systemic racism but also fails to take any meaningful steps to tackle it.
 
Any attempt at improving birthing outcomes should begin with addressing the systemic racism that exists within the NHS and the asylum and immigration system. There should be a holistic approach to the evident health impacts of the racialised socio-economic and political conditions of those people and communities (of which a higher maternal mortality rate is one indicator).
The guidelines state that they are based on the knowledge and experience of the members of the committee, which does not meet even the most basic definition of evidence. Pages 19-20 of Evidence Review C state:
 
“The committee were aware from their knowledge and experience that women from the Black, Asian and minority ethnic family background…were at a higher risk of adverse events in a pregnancy that was prolonged beyond term. They were also aware that this difference had been reported in wider literature, such as the Mothers and Babies Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK) reports. The committee noted that there was a lack of direct evidence available from this review, therefore they based the recommendation on women with otherwise uncomplicated singleton pregnancies who are at a higher risk of complications associated with continued pregnancy on their knowledge and experience.”
 
We are concerned that these guidelines are not supported by evidence-based research or on qualitative consultation with the experiences of the minority groups and communities that will be affected. The draft itself does not give an open and honest assessment of further interventions and complications that often come as a direct result of medical induction. We believe this is wholly disproportionate, unethical and renders the implementation of these guidelines experimental—an experiment that will have lifelong ramifications on the lived experiences of already oppressed groups of people.
 
As birth workers and allies, we cannot ignore the dark legacy of racism and the many experimental and non-consensual practices that form the roots of modern obstetrics and gynaecology.
We believe there is a general systemic issue around choice vs coercion when it comes to the proposal of interventions during labour. In our experience, the offer of induction is seldom positioned as a neutral offering, or as an intervention that is presented as a choice among other options. Likewise, it is rarely presented with enough time and information to enable genuine consideration of other options.
 
Through our work, we have witnessed:
  • Disproportionately high levels of intervention-based births
  • Pressure to accept proposed interventions without adequately exploring alternative options
  • Failure to explain interventions and their associated risks, benefits, or alternatives in a language the client can understand with the help of an interpreter
We are deeply concerned that these guidelines will exacerbate the above and reduce the ability of the birthing people we support to fully consent to an induction.
 
[1]Although NICE guidelines do not formally apply to Scotland, they are often referred by midwives and obstetricians in the absence of any Scottish equivalent. The Scottish Intercollegiate Guidelines Network (SIGN) issues clinical guidance for Scottish practitioners but offers limited guidance in relation to pregnancy and birth in comparison to NICE.
 
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