Induction of labour: the infl uences on decision making - New Zealand College of Midwives
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JOURNAL
New Zealand Research
Induction of labour:
the influences on
decision making
Diana Austin and Cheryl Benn
From autonomy and
back again: educating
midwives across a century
Sally Pairman
Promoting normal birth:
a case for birth centres
Joan Skinner and Sue Lennox
Keeping birth normal:
midwives experiences in a
tertiary obstetric setting
Deborah Earl and Marion Hunter
Commentary
The sunshine vitamin -
is there really a need
for dietary vitamin D?
Sandra Elias
To p i c a l D i s c u s s i o n
Midwives as mentors
Elaine Gray
journal 34
New Zealand College of Midwives • Journal 34 • April 2006 1
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J O U R N A L 3 4 April 2006 contents
Editorial Board
Induction of labour:
Alison Stewart
Rhondda Davies
New Zealand
Research the influences on decision making 6
Deborah Davis Diana Austin and Cheryl Benn
Jean Patterson
Sally Pairman
Reviewers
Maggie Banks
Anne Barlow
Cheryl Benn
Sue Bree
New Zealand
Research
From autonomy
and back again: educating 11
Rea Daellenbach midwives across a century
Kathleen Fahy (Australia)
Sally Pairman
Maralyn Foureur
Karen Guilliland
Jackie Gunn
Debbie MacGregor
Marion McLauchlan
Suzanne Miller Promoting normal birth:
Lesley Page (United Kingdom)
Elizabeth Smythe
New Zealand
Research a case for birth centres 15
Mina Timu Timu Joan Skinner and Sue Lennox
Sally Tracy (Australia)
Nimisha Waller
Gillian White
The sunshine vitamin -
Philosophy of the Journal
Promote women’s health issues
Commentary
is there really a need 19
as they relate to childbearing women
and their families.
for dietary vitamin D?
Promote the view of childbirth Sandra Elias
as a normal life event for the majority
of women, and the midwifery profession’s
role in effecting this.
Provoke discussion of midwifery issues.
Submissions
Submit articles and letters to the Editor:
Alison Stewart, School of Midwifery,
New Zealand
Research
Keeping birth normal:
midwives experiences in a 21
Private Bag 1910, Dunedin. tertiary obstetric setting
Phone 03 479 6107
Email alisons@tekotago.ac.nz Deborah Earl and Marion Hunter
Subscriptions and enquires
Subscriptions, NZCOM,
PO Box 21106, Edgeware, Christchurch.
Advertising
Please contact Angela Tainui
Channel Publishing
Topical
Discussion
Midwives as mentors
Elaine Gray
24
Phone 03 365 5575
Email angela@channelpublishing.co.nz
575 Colombo Street, Christchurch
The New Zealand College of Midwives Journal
is the official publication of the
New Zealand College of Midwives.
Book Reviews Mary-Clare Reilly, Julie Richards
and Barbara Churcher 28
Single copies are $6.00
ISSN.00114-7870
Koru photograph by Ted Scott.
Views and opinions expressed in this Journal
are not necessarily those of the
New Zealand College of Midwives.
New Zealand College of Midwives • Journal 34 • April 2006 5
N E W Z E A L A N D R E S E A R C H
Induction of labour: the influences on decision making
the methods women use to initiate labour prior The rate of elective or non-medical inductions
Diana Austin RCpN RM BA(SocSc) MA(Hons) to admission to the maternity facility. ranged from 2% to 59.2% in the studies located
Part-time Midwife: currently Quality Co-ordina- (Dublin et al., 2000; National Women’s Hospi-
tor at Auckland Distrist Health Board. Induction of labour refers to the “initiation of tal, 2004). All the studies showed a significant
labour by artificial means” and is indicated when increase in the rate of caesarean section following
Cheryl Benn RCpN, RM, B Soc Sc (Hons) the health of the mother and/or fetus would “be an induction of labour with no apparent medi-
Magister Curationis Doctor Curationis compromised by the continuation of pregnancy” cal indication, especially for nulliparous women
(Stables, 1999, p. 501). The onset of labour is a (Dublin et al., 2000; Maslow & Sweeny, 2000;
Associate Professor and Director of Midwifery
normal progression in the process of giving birth Seyb, Berka, Socol & Dooley, 1999). Despite
Programmes, Massey University but the aetiology of labour is complex and not well this link it is not possible to talk about cause and
understood (Stables, 1999). Enkin et al. (2000, effect as there may be other factors that may lead
Contact for correspondence:
p. 374) state “the decision to bring pregnancy to an to the increase in caesarean sections, for example
lp.dm.austin@clear.net.nz end before the spontaneous onset of labour is one of the initial reason for an induction, women’s at-
the most drastic ways of intervening in the natural titudes to intervention or the influence of the
process of pregnancy and childbirth.” It is essential health practitioner.
therefore that the benefits of and need for the ac-
Abstract tion of induction of labour The common means of
The study was undertaken to gain an understand- are clear and women are induction used in hospi-
ing of why nulliparous women were having an fully informed of both the Decision making can be influenced by tals are amniotomy, pros-
induction of labour (IOL) and what influenced risks and advantages. taglandins and oxytocin
factors other than clinical indications.
the decision to induce. Using an interpretive ap- while the methods used
proach, 79 nulliparous women and 74 of the Lead Consumerism is now part of health care
Literature review in the community include
Maternity Carers (LMC –Midwife, Obstetrician In preparation for this with an expectation that in some situ- homeopathy, herbal reme-
and General Practitioner) who cared for these study a broad review of dies, evening primrose oil,
ations services provide for the prefer-
women, were interviewed prior to induction, us- the literature covering a 10 exercise, sex and nipple
ing a structured questionnaire with open ended ences of the individual (Fox, 2003). This
year period of 1993-2005 stimulation and sweeping
questions, between December 2002 and April was undertaken. Most of can sometimes lead to a gap between of the membranes. The
2003. This paper focuses on the reasons identi- the studies related to in- literature is limited or
what a woman may prefer and what
fied for induction of labour by women and their duction of labour were does not support the use
LMCs, their understanding of the positive and may appear to be best clinical practice
based on retrospective data of many of the methods
negative effects of induction of labour, as well obtained from health da- (Savage, 2002). of induction used in the
as some of the key themes identified from the tabases. There seems to be community. However,
interviews using a modified Boyatzis’ method little evidence to support there is a small amount
of analysis. the use of induction of labour for some of the com- of research evidence, from smaller rather than
mon reasons identified in the literature, namely larger studies, that supports the use of sweeping
Introduction post-dates, large for gestational age and maternal the membranes, especially in multiparous women
Birth by caesarean section is an increasing occur- choice (Dublin, Lydon-Rochelle, Kaplan, Watts, (Boulvain, Stan & Irion, 2005). The use of cas-
rence for women in New Zealand (Ministry of & Critchlow, 2000; Irion & Boulvain, 2000; tor oil was found to be effective in one study
Health, 2003). The rising caesarean rate for nul- Menticoglou & Hall, 2002). Common reasons for of 103 women at term with intact membranes,
liparous women has been of concern at the unit induction of labour given in the literature include in which 57.7% of women began active labour
where the primary author worked as a Research post-dates, post-term or post maturity (Moldin after receiving 60ml of castor oil diluted in fruit
and Quality midwife. The unit’s induction rate, & Sundell, 1996; Parry, Parry, & Pattison, 1998; juice, compared to 4.2% of women in the control
during the 2-month retrospective review of nul- Yeast, Jones, & Poskin, 1999). These terms are group who received no treatment (Garry, Figueroa,
liparous women, was 28% (Austin & Belgrave, often used interchangeably to describe a prolonged Guillaume & Cucco, 2000) but as only one study
2002). The mode of birth was ascertained for pregnancy but the period of prolongation may dif- was found the authors of the systematic review
induction and spontaneous labour. Twenty two fer from study to study thus making comparison (Kelly, Kavanaugh, & Thomas, 2001) indicate the
percent of women who had a spontaneous onset of findings difficult. Menticoglou and Hall (2002, need for more studies on this topic to provide the
of labour delivered by caesarean compared to required level of evidence.
p.240) make the following strong statement about
54% who had their labour induced. Although induction of labour:
the audit was small it raised the question, does Kavanaugh, Kelly and Thomas (2005) undertook
the ‘evidence’ on which current practice and
having labour induced increase a woman’s risk of a Cochrane Review to investigate the effect of
popularity of routine or as we prefer to think of
having a caesarean section? It also showed the need nipple stimulation on initiating labour. Six ran-
it, ritual induction at 41 weeks, is based is
for a prospective study looking at the reasons for domised trials with a combined sample of 719
seriously flawed and an abuse of biological norms.
induction, the influences on that decision and the women were included in the review. The nipple
Such interference has the potential to do more harm
information women receive about the risks and stimulation required of the women ranged from
than good, and its resource implications are stag-
benefits of an induction. This study also explored one hour per day for 3 days to 3 hours per day, al-
gering. It is time for this nonsensus to be withdrawn.
ternating breasts every 10 minutes. The percentage
6 New Zealand College of Midwives • Journal 34 • April 2006
of women not in labour after 72 hours was reduced Study design and method LMCs were interviewed. The remaining six LMCs
to 62.7% in the treatment group compared with Following approval of the General Manager of the did not decline but were either too busy or the
93.7% in the control group. Kavanaugh et al. do maternity facility, ethics approval was obtained woman had been handed over to secondary care.
warn however that due to concerns about safety from the Massey University Human Ethics Com- The LMCs that were too busy were still able to
issues related to perinatal deaths in two of the mittee and the Auckland Ethics Committee to tell the researcher the main reason for induction.
three arms of one of the trials reviewed, nipple undertake a study primarily using an interpretive When a woman declined to participate, her LMC
stimulation should not be considered for use in a approach. A structured questionnaire with open was not interviewed.
high risk population. ended questions was used to explore the reasons
for induction of labour for nulliparous women The women and their LMCs who consented to be
Decision making can be influenced by factors and the influences on women and Lead Maternity part of the study were interviewed in the birthing
other than clinical indications. Consumerism is Carers (LMCs –Midwives, Obstetricians and suite prior to the induction commencing. This
now part of health care with an expectation that in General Practitioners) in coming to that decision usually occurred during the preliminary cardioto-
some situations services provide for the preferences at a secondary care1 maternity facility in Auckland. cography (CTG) as both women and LMCs did
of the individual (Fox, 2003). This can sometimes The interviews were part of a larger study that not want the interviews to delay induction com-
lead to a gap between what a woman may prefer compared the outcomes for 157 women who had mencing. Most interviews took about 10 minutes
and what may appear to be best clinical practice their labour induced and 347 whose labour began although some participants wanted to talk further
(Savage, 2002). spontaneously. on the topic and this was encouraged.
Information sharing is an essential part of informed This study aimed to identify: The process of thematic analysis and code de-
choice. However, ensuring the information is ef- • the outcomes for nulliparous women and velopment, as described by (Boyatzis, 1998),
fectively passed on to women is not always easy. A their babies when labour is induced compared was used to ‘make sense’ of the qualitative data
randomised trial in the United Kingdom involved to labour that begins spontaneously obtained during the interviews. Boyatzis (1998,
more than 6000 women in 13 maternity units • the reasons for and methods of induction of p. 11) identifies
and compared the effect on informed consent of labour and what aspects relating to these may four stages in developing the ability to use
women, reading 10 evidence based information be contributing to the high induction rate thematic analysis
leaflets produced by the Midwives Information • the risk of caesarean delivery following 1. Sensing themes - that is, recognizing the
and Resource Services (MIDIRS), with women induction for nulliparous women. codable moment
who did not receive the leaflets (O’Cathain, 2. Doing it reliably - that is, recognizing the
Walters, Nicholl, Thomas & Kirkham, 2002). Al- codable moment and encoding it consistently.
Eighty-seven women were invited to be part of
though women reported they were more satisfied 3. Developing codes
the study. Of these 79 women met the eligibil-
with the information they received there was no 4. Interpreting the information and themes
ity criteria (nulliparous, gestation >=37 weeks,
difference in the proportion that reported exercis- in the context of a theory or conceptual frame
singleton pregnancy and planning a vaginal
work - that is, contributing to the development
ing informed choice. In a qualitative aspect to the birth) and agreed to be interviewed. Seventy-four
of knowledge.
study they also found the leaflets were seldom used
to their maximum effect due to staff disagreeing
Table 1. Main reasons for induction Table 2. Second reason that contributed
with the content, the options suggested were not
to decision to induce labour
available locally, staff making inaccurate assump-
tions about the ability and willingness of women Main reasons for induction LMC Women Second Reason LMC Women
to participate in decision making and the leaflets
Post-datest 45 47 Post-dates 2 2
being given out wrapped up in advertising mate-
GPH/Hypertension 12 12 GPH/Hypertension 4 5
rial. Time pressure was another constraint to their
Social 5 1 Social 5 6
use “within a culture that supported existing norma-
Reduced liquor 4 4 Reduced liquor 0 0
tive patterns of care rather than informed choice”
Large baby 3 3 Large baby 1 4
(Stapleton, Kirkham & Thomas, 2002, p. 641).
IUGR 2 2 IUGR 1 3
Women-held maternity records and decision mak-
Diabetes 3 3 Diabetes 0 0
ing tools however have been found to increase the
Age 1 1 Age 1 2
likelihood of women feeling they have been well
Increased liquor 1 0 Increased liquor 0 1
informed (O’Connor et al., 2003; Rowe, Garcia,
IVF/precious baby 1 1 IVF/precious baby 0 1
Macfarlane & Davidson, 2002).
Booking system 0 1 Booking system 12 5
Lichen sclerosis 1 1 Specialist advice 11 4
The fear of litigation can sometimes influence
Previous myocardial infarction 1 1 LMC on call 2 2
practitioners to use technology rather than evi-
History of previous miscarriages 0 1 Christmas 2 2
dence based care (Stapleton et al., 2002). A study
Contractions but not dilating 0 1
by Symon (2000) found that 3.8% of midwives
and 2.4% of obstetricians used induction as part Total 79 79
of defensive practice.
continued over...
New Zealand College of Midwives • Journal 34 • April 2006 7
continued...
Induction of labour: the influences on decision making
Some adaptations were made to Boyatzis’ method The main reason for induction of labour identified last woman who was being induced under her care
to accommodate the style of research and the in the study was post-dates which is consistent she had told everything to and nothing worked “so
sample groups. A final code was developed that with other facilities in New Zealand and overseas this time I didn’t bother”. Relatives had suggested
describes the influences on decision making for (National Women‘s Hospital, 2004; Yeast et al., castor oil but when women asked their LMC they
induction in the study sample. This code was made 1999). Only 2 women had a prolonged pregnancy were told not to use it.
up of ten themes, four of which are presented in that was consistent with the World Health Organi-
this paper. zation definition of 42 completed weeks gestation The wide range of methods used by women in
or more (Chua & Arulkumaran, 2002). In the the community in an attempt to initiate labour
It is important to identify that the sample of research by Duff and Sinclair (2000) 33.2% of indicates a desire by some women and their LMCs
women interviewed represents a subset of the women whose labour was induced for post-dates to avoid induction of labour in the hospital. The
community, namely nulliparous women who had had a gestation of less than 41 weeks and 3 days information about methods appeared to have
accepted the option of induction at the hospital. compared with 49% of the women interviewed been given in an ad hoc manner with the research
This is also true of the LMCs as only those who in the current study. Nine (20%) of the women literature being sparse to support many of these.
cared for women who were having an induction of in the study were induced at 41 weeks or less. If Further research is required in relation to some of
labour were interviewed. It is also recognised that the advice from the Cochrane review was being the alternative methods of induction being tried.
the set up of other hospital facilities for induction closely adhered to this is still earlier than the re- Health professionals need to inform women of
of labour may be different and therefore limit the viewers recommend: “…routine induction of labour the research evidence to support ‘sweeping of the
generalisability of the findings to other maternity after 41 weeks gestation appears to reduce perinatal membranes’ and the use of castor oil as methods
settings in New Zealand. mortality” (Crowley, 1997, p.3). of induction of labour. The NZCOM consensus
statement on complementary therapies advises
Findings and discussion Other methods used to induce labour midwives to either undertake “a recognised edu-
Reasons for induction Women were asked if they or their LMC had cation programme or refer clients to appropriately
The main reasons given for induction are listed tried any other methods to bring on labour. The qualified practitioners” (New Zealand College of
in Table 1. For most women there was a second responses are shown in Figure 1. Twenty-seven Midwives, 2000, p.1).
reason that contributed to the decision to induce women (34%) said they had not tried any other
(Table 2). The main reason for induction as stated methods before coming into hospital for an in- Source of information regarding effects
by the woman was different from that stated by duction. For those who tried other methods, sex of induction
the LMC in 8 situations. Five LMCs stated the was the most common method used. Two women Women were asked what they understood to be
main reason to be maternal choice or for social the positive and negative
Figure 1 Methods for induction used prior to admission
reasons but 4 of these women said it was for other effects of induction and
for formal induction
reasons; post-dates (n=2 women)2, raised blood how they had heard about
pressure (n= 1 woman), and previous miscarriages these (Table 3). Of the 30
(n=1 woman). women (38%) who said
they had heard about in-
In some situations the reason for induction was duction during childbirth
not clear as the LMC, consultant obstetrician and education classes, 13 said
woman considered the induction to be indicated it was only covered briefly,
for differing reasons. For example in one situation methods only were talked
the reason for induction appeared to have become about or they couldn’t re-
lost in the realm of it being a routine practice member much about it.
and merely an extension of a normal pregnancy. Another woman said she
The LMC presumed the indication for induction received a booklet from
stating “oh I thought it was just a routine post- the antenatal class but had
dates.” Another reason for the lack of clarity was not read the information
the circular communication process between the in-depth. “Skimmed over
woman, LMC (midwife or general practitioner) it as the negative list always
and consultant obstetrician i.e. each person passed outweighed the positive”.
on information to the next person rather than * 5W is a herbal preparation containing Black Cohosh root, Squaw Vine herb, Dong Ouai root, Butcher‘s
Others said they had read
there being a three way discussion. One LMC was Broom and Red Raspberry leaf information received from
* Prebirth is a homeopathic preparation containing Caulophyllum Cimicifuga, Arnica, Pulsatilla
explaining the reason to be high blood pressure. and Gelsenium antenatal classes either for
The registrar on call later said it was not blood the first time or reread it
pressure but post-dates and a large baby. The prior to induction.
LMC had been told by the obstetrician not to let knew of methods that could be tried but said they
the woman go 1 week past 40 weeks gestation, couldn’t be bothered. One woman had been told The most common positive effects identified by
as he did not want her to have an abruption. As by her LMC not to worry about it and 2 women the women were “the pregnancy coming to an
there was no documentation of the visit to the said they had no time to try other methods prior end” (n = 31, 39%), “more control about when hav-
obstetrician and the LMC had not been present, to knowing they needed to be induced. One LMC ing baby” (n=30, 38%) and “less risk/stress for baby,
the actual initial reason was not known. However, made the comment to me that she had not told safe” (n=21, 27%). The 3 most common negative
the indication was coded according to that given the woman about any other methods to try as the effects mentioned by the women were “contractions
by the registrar at the time of induction.
8 New Zealand College of Midwives • Journal 34 • April 2006
were aware of was contractions following induc- for induction.” On other occasions the LMC said
Table 3: Source of information for
women prior to induction of labour tion were more painful and difficult. A LMC they would have been happy to let the pregnancy
acknowledged the lack of information sharing by go longer if the woman had been the type who
Source Percentage stating “ooops I didn’t prepare her very well”. When was happy to push boundaries. It was not appar-
Verbal discussion with LMC 74 the primary author asked a woman the question ent from the interviews with the corresponding
Written material 64 “what are the negative effects of being induced?” women that the women were aware they had been
Friend/family 50 she said she asked her LMC the same question given a range of options relating to their own
Childbirth education 38 and was told, “she would be in hospital for longer perceived philosophy.
Specialist 9 rather than the first bit at home” and that “there
Internet 3 were no distractions walking up and down the hos- Women appeared to be limited in their participa-
Hospital registrar 1 pital corridor.” Some women may have forgotten, tion in decision making with evidence of pater-
misunderstood or chosen not to hear the negative nalism by LMCs to either support or discourage
more painful, stressful” (n= 32, 41%), “artificial, not effects conveyed by their LMCs. Although women induction for the woman they were caring for.
natural” (n= 25, 32%) and “more likely to need more appeared to have minimal knowledge of the risks This was illustrated by the occasions when women
intervention” (n=16, 20%). of induction prior to coming to the maternity were given limited information and the event
facility in which the study occurred, the decision minimized as illustrated in previous quotes, such
Themes for induction and actual initiating of the induction as being told there would be no distractions in
In the development of a code for ‘influences on is the responsibility of the obstetrician on call for the maternity suite. The reply by the LMC, “no,
decision making for induction of labour’ 10 that day. It is therefore expected that information she does what I say”, when asked if the woman’s
themes were identified as listed in table 4. Only sharing by the obstetrician (or registrar), prior attitude had influenced the decision to induce, was
four of these themes are discussed in this article to induction commencing, is a requirement of a more obvious example of paternalism.
and are indicated in italics in the table. informed choice.
A multidimensional balancing of risk for the
Table 4: Code with themes There is also no legal consensus on the right LMCs was apparent with some expressing a con-
Code Influences on decision making amount of information required for making cern about litigation or a fear of judgement from
for induction of labour. informed decisions (Draper, 2004). However, colleagues, factors that may have contributed to
Themes • Giving over and taking over neglecting the values of individual women in iden- LMCs influencing women for or against induc-
of responsibility. tifying relevant information required for consent tion of labour.
• Participation of women in decision “fails to grant patient values their proper role in the
making is limited. decision-making process” (May, 2002, p. 18). Effect of hospital booking system
• Minimal evidence of women as The booking system influenced the timing of an
informed decision makers. Influences for or against induction induction and was manipulated as practitioners
• Women are influenced for or A woman may be influenced during pregnancy tried to overcome the control thereof. To begin
against induction. about induction by the LMC’s approach. Prior an induction a space needed to be available
• Multidimensional balancing of risk to induction being necessary many LMCs had within the daily allocation in the booking book.
for the LMC. already expressed their opinions to the women. Two inductions could be started each day with
• Focused risk for women. Some had said, “[I] tell them at booking not to ask one more space reserved for an urgent situation.
• Hospital booking system. for [an] induction.” Other LMCs said they “tell The idea that the booking system was possibly
• Induction of labour integrated into them [the women] at 40 weeks about induction then an iatrogenic influence on early inductions was
care as a routine practice. book them in so [they] don’t miss out on a space.” suggested by an LMC early in the study: “People
• Induction perceived as both taking The early booking for induction was identified as are induced two days earlier than needed, [booking
from and giving to the birth a problem: “if [women are] booked in advance, it system is an] iatrogenic effect.”
experience by women. clogs [the booking] book up, women think induction
• Incongruence between LMC’s – are programmed for induction.” The facility’s Eleven LMCs and five women made further
stated belief about induction and
protocol, at the time of the study, did not detail complaints about the booking system confirming
their current situation of induction.
when a woman should be booked for induction the notion.
for specific indications. However, a limit was put
on the number of women who could have an Inductions for post-dates were being done a couple
Minimal evidence of women as informed deci-
induction on any one-day to ensure resources to of days earlier than the LMC considered necessary,
sion makers
care for women were adequate. as “apart from today there were no spaces available till
The women interviewed for the study seemed to
next week when [the pregnancy] would have been 42
have limited knowledge of the negative effects of
Participation of women in decision-making weeks.” For 19 women (24%) the booking system
induction. Most women stated in some way that
All the LMCs were asked how the woman’s at- had influenced the day of induction. When there
induction would reduce potential risk to them-
titude influenced the decision to carry out an was a lack of space LMCs tended to go for the
selves or their baby. Sixteen percent considered
induction of labour. Some commented that the earlier date available rather than later. “Waiting for
there to be no negative effects, another 3% said
woman had not asked for it but then later said someone to ring with an available space is stressful
they did not know and 1% said they did not
they told them at the beginning of pregnancy “I for women and me, especially going to term plus 14
want to know. Sixty six percent of women were
will not think of induction till [your pregnancy is] and waiting.” “I would have let her go a week, but
aware of less than 3 risks of being induced. The
over 41 weeks” or “I tell them at booking not to ask continued over...
most common negative effect women said they
New Zealand College of Midwives • Journal 34 • April 2006 9
continued...
Induction of labour: the influences on decision making
this is when there was a vacancy, rather than wait The use of information leaflets and childbirth References
a lot longer.” education classes may help improve the quality Austin, D., & Belgrave, S. (2002). Retrospective review of
primips and LSCS. Paper presented at a New Zealand
of the information provided to women about Hospital - name not included for confidentiality reasons.
Accepting a space in the booking book earlier than induction of labour. Information should include Boulvain, M., Stan, C., & Irion, O. (2005). Membrane
was indicated frequently appeared unnecessary in positive and negative effects of induction as well sweeping for induction of labour. Cochrane Database of
Systematic Reviews, Issue 1. Art. No.: CD000451.
hindsight. When the primary author interviewed as methods, including the evidence supporting pub000452. DOI: 000410.001002/14651858.
the LMC they would explain that the woman suggested methods. CD14000451.pub14651852. http://www.mrw.inter-
was being induced earlier than they thought science.wiley.com/cochrane/clsysrev/articles/
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Midwives can use the findings from the study Fox, J. (2003). Consumerism: the different perspectives
to review their own practice by developing an within health care. British Journal of Nursing, 12(5),
Postscript 321-326.
increased tolerance for pregnancy closer to 42
Following the presentation of the study the hos- Garry, D., Figueroa, R., Guillaume, J., & Cucco, V. (2000).
weeks for well women and babies. This has the Use of castor oil in pregnancies at term. Alternative
pital booking system has been changed to ensure
potential to decrease the induction rate through Therapies in Health and Medicine, 6(1), 77-79.
that women who require a post-dates induction Irion, O., & Boulvain, M. (2000). Induction of labour for
a reduction in the number of inductions at 41
at a gestation of at least 41 weeks and 3 days are suspected fetal macrosomia. Cochrane Database of
weeks or less for post-dates pregnancy. There is Systematic Reviews(1), Retrieved March 4, 2003 from
able to be booked on the day requested. Numerous
also a need to appreciate the risks of prolonged http://www.ucl.ac.uk/kmc/kmc2002/cochrane.
practitioners have commented on the ease with
pregnancy for growth restricted babies rather than Kavanagh, J., Kelly, A. J., & Thomas, J. (2005). Breast
using the label of growth restriction as a means of which they can now book an induction on the day stimulation for cervical ripening and induction of labour.
most beneficial to the woman. The information Cochrane Database of Systematic Reviews, Issue 3.
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a risk is not actually present. leaflet has been updated to include ‘sweeping of CD14003392.pub14651852. http://www.mrw.inter
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frame.html.
Decision-making around induction of labour risks of induction. A greater awareness, within
Kelly, A., Kavanaugh, A. J., & Thomas, J. (2001). Castor
should be a shared process whereby the woman, the facility, of induction of labour and the need oil, bath and/or enema for cervical priming and
the LMC and the consulting obstetrician have to inform women of the risks as well as benefits induction of labour. Cochrane Database of Systematic
Reviews, Issue 2. Art. No.: CD003099.DOI:
input. Further research into this decision-making has occurred through the ongoing presentation
003010. 001002/14651858.CD14003099. http://www.
process is warranted. When the maternity facility of the results, and the inclusion of cases, in the cochrane.org/reviews/en/ab14003099.html.
guideline on induction is next reviewed, factors regular case review meetings where women have Maslow, A. S., & Sweeny, A. L. (2000). Elective induction
had an induction of labour. An audit following the of labor as risk factor for cesarean delivery among low-risk
that could assist health professionals understand women at term. Obstetrics and Gynecology, 95 (6 (part 1))
and clarify their responsibilities in regard to induc- implementation of the recommendations from the 917-922.
tion of labour could be included. The development study showed a 7-10% decrease in the induction May, T. (2002). Bioethics in a liberal society: the political
of labour rate for nulliparous women. framework of bioethics decision making. Maryland: The
and use of a decision making tool that coordi-
Johns Hopkins University Press.
nates the information sharing between women, Menticoglou, S., & Hall, P. (2002). Routine induction of
Accepted for publication: January 2006
LMCs, obstetricians and staff working in the labour at 41 weeks gestation: nonsensus consensus. British
maternity facility may be helpful to facilitate Journal of Obstetrics & Gynaecology, 109, 485-491.
Austin, D., & Benn, C. (2006). Induction of labour: Ministry of Health. (2003). Report on Maternity 2000 &
information sharing. The women should keep
the influences on decision making. New Zealand 2001. Wellington: Ministry of Health.
their own copy of this tool to enable open and on-
College of Midwives Journal, 34, 6-10. Moldin, P., & Sundell, G. (1996). Induction of labour: A
going communication.
10 New Zealand College of Midwives • Journal 34 • April 2006N E W Z E A L A N D R E S E A R C H
randomised clinical trial of amniotomy versus amniotomy
with oxytocin infusion. British Journal of Obstetrics & From autonomy and back again:
Gynaecology, 103 (4), 306-312.
National Women’s Hospital. (2004). National Women’s Annual educating midwives across a century Part 2
Clinical Report 2004. Auckland: Auckland District Health
Board. of the smaller group of midwives and the decision
New Zealand College of Midwives. (2000). Complementary Sally Pairman RM BA MA D.Mid to form the New Zealand College of Midwives was
therapies [NZCOM consensus statement]. Retrieved
December 31, 2005 from www.midwife. Head of School of Midwifery, taken. The impetus for this was largely the result
org.nz/content/documents/2070/complementary%2020
Otago Polytechnic, Dunedin of two main areas of disagreement; how should
therapies.2204.doc.
a midwife be educationally prepared and was a
O’Cathain, A., Walters, S. J., Nicholl, J. P., Thomas, K. J., Contact for correspondence:
& Kirkham, M. (2002). Use of evidence based leaflets
midwife also a nurse?
to promote informed choice in maternity care: randomised sallyp@tekotago.ac.nz
controlled trial in everyday practice. British Medical Advanced Diploma of Midwifery
Journal, 324 (7338), 643-646. This article is based on keynote address
given at NZCOM Biennial Conference, Midwifery education was swept along with
O’Connor, A., Stacey, D., Entwistle, V., Llewellyn-Thomas,
H., Rovner, D., Holmes-Rovner, M., Tait, V., Tetroe, Wellington, 16 – 18 September 2004. It is changes made to nursing education in the 1970s.
J., Barry, M., & Jones, J. (2003). Decision aids for people Canadian nurse-educator, Dr Helen Carpenter,
facing health treatment or screening decisions. The presented in two parts. The first part was
Cochrane Database of Systematic Reviews(2003), Issue 1. included in the October 2005 Journal. was invited to New Zealand to advise on nursing
Art. No.: CD001431. DOI: 001410.001002/14651858. education. Her report provided a catalyst for major
CD14001431. http://www.mrw.interscience.wiley.com/
cochrane/clsysrev/articles/CD14001431/frame.html.
change in the way that nursing education was
Parry, E., Parry, D., & Pattison, N. (1998). Induction of Midwifery education as the focus of understood and delivered. It culminated in a shift
labour for post term pregnancy: an observational study. disagreement with nursing from hospital based apprentice-style training to a
Australian & New Zealand Journal of Obstetrics &
By the time these women’s groups were advocating polytechnic-based student focused education sys-
Gynaecology, 38(3), 275-280.
Rowe, R. E., Garcia, J., Macfarlane, A. J., & Davidson, L. L.
for an autonomous midwife, midwifery itself was tem (Papps, 1997). It also shifted the prescriptive
(2002). Improving communication between health at its lowest point. By 1971 the word ‘midwife’ had curricula to more liberal and theoretical nursing
professionals and women in maternity care: a structured been removed from the title of the legislation alto- education that prepared the ‘comprehensive nurse’
review. Health Expectations, 5(1), 63-83.
gether. Although the separate register for midwives who would be able to provide care in a variety
Savage, W. (2002). Caesarean section: who chooses - the
woman or her doctor? In D. Dickenson (Ed.). Ethical was retained, midwifery was seen as a specialist of health care settings. Carpenter saw midwifery
issues in maternal-fetal medicine (pp. 263-283). Cambridge: postgraduate area of nurs- as post-basic nursing and
Cambridge University Press.
ing practice rather than a argued that this course
Seyb, S., Berka, R., Socol, M., & Dooley, S. (1999). Risk of
caesarean delivery with elective induction of labour at term separate profession in its By the time these women’s groups should be improved by
in nulliparous women. Obstetrics and Gynaecology, 94(4), own right. Midwives had shifting it into the tertiary
600-607. were advocating for an autonomous
lost their relative auton- system (Donley, 1986).
Stables, D. (1999). Physiology in childbearing with anatomy
omy and worked instead midwife, midwifery itself was at its
and related biosciences. London: Bailliere Tindall.
Stapleton, H., Kirkham, M., & Thomas, G. (2002). with delegated authority lowest point. By 1971 the word ‘mid- The Midwives Section
Qualitative study of evidence based leaflets in maternity under the supervision of immediately sprang into
care. British Medical Journal, 324(7338), 639-643. wife’ had been removed from the title
doctors. The maternity action presenting remits
Symon, A. (2000). Litigation and changes in professional
service no longer needed of the legislation altogether. at NZNA conferences in
behaviour: a qualitative appraisal. Midwifery, 16(1), 15-21.
Yeast, J., Jones, A., & Poskin, M. (1999). Induction of labor autonomous midwives 1971 and 1973 calling
and the relationship to cesarean delivery: a review of 7001 because the majority of for the St Helens hospital
consecutive inductions. American Journal of Obstetrics &
Gynecology, 180(3), 628-633.
women gave birth in hospitals under medical midwifery programme
care. Childbirth was seen as a pathological event to be strengthened by extending it from six to
requiring hospitalisation and medical intervention twelve months. The Section forwarded a draft
This paper is adapted from the unpublished thesis in order to achieve a safe outcome. In 1979 the curriculum for a one-year programme to the
presented in partial fulfilment of the requirements for six-month midwifery courses were closed and Nursing Council and received support for their
the degree of Master of Arts in Midwifery at Massey instead midwifery became an ‘option’ module arguments from a Department of Health report
University, Palmerston North, New Zealand. within the polytechnic-based Advanced Diploma on Maternity Services (Hill 1982). However, these
Acknowledgements: of Nursing (ADN). moves for a one-year hospital-based midwifery
programme were unsuccessful. In 1979 the St
The women, midwives and obstetricians who
Interestingly it was this downgrading of midwifery Helens midwifery programmes were closed and
participated in the study.
education that provided the catalyst for midwives midwifery training was only available through the
Associate Professor Jenny Westgate and Dr Sue to become politically active in an effort to claim a ADN programmes offered in four polytechnics in
Belgrave for their supervision and support of the separate identity to nursing. For many midwives Auckland, Hamilton, Wellington and Christch-
larger project. midwifery education highlighted their differences urch. Nurses with two years post-registration
The Health Research Council for the award of a with nursing and through the 1970s and 80s the experience could undertake a one (academic) year
Summer Studentship. Midwives Special Interest Section of the New full-time programme at a Polytechnic to advance
Zealand Nurses Association (NZNA) was largely their nursing knowledge and practice. Within
1
Secondary care refers to the availability and provision of at odds with their parent body over the issue the ADN programmes there were various options
specialist care in addition to primary care when required. such as maternal and child health, community
of midwifery education. Eventually midwives
2
Post-dates refers to the reason stated by the LMCs or women
realised that NZNA was always going to put the health nursing, medical / surgical nursing and
rather than according to a clinical definition of post-dates.
needs of the larger group of nurses ahead of those continued over...
New Zealand College of Midwives • Journal 34 • April 2006 11continued...
From autonomy and back again: educating midwives across a century Part 2
psychiatric nursing (NZNA, 1984). Midwifery Interestingly this policy statement on nursing edu- continuous prior employment in a maternity hos-
was incorporated into the maternal and child cation was at odds with another statement released pital and an assessment of the midwife’s suitability
health option as a sub-option. Unlike the other by the NZNA Midwives Section in April 1984 and competence to be carried out by the Principal
options nurses in this option were required to meet titled, ‘Report of the Working Party looking into Nurse and an Obstetrician (NZNA, 1981). Ob-
not only academic requirements of the maternal Education for the Role, Scope and Sphere of Practice stetricians influenced Board of Health policy that
and infant health option, but also the midwifery of the Midwife in New Zealand’ (National Mid- suggested ways to make maternity hospitals more
registration requirements of the Nursing Coun- wives Section, 1984). This policy retained nurs- appealing so that women would not choose home
cil of New Zealand, including passing the State ing as a prerequisite to midwifery but supported birth and that established so many ‘risk factors’
Final examination. separation of midwifery requiring referral to an obstetrician that hardly any
education from the ADN. woman fitted the category of ‘normal’ let alone
The Midwives Section was The second, and related, area of Thus by 1984 NZNA had met the criteria required to have a homebirth
active in its opposition contention between midwives and two separate policies on (Board of Health Maternity Services Commit-
to the ADN/Midwifery midwifery education and tee, 1979, 1982). Some influential members of
NZNA was the generally held view that
option. The main issues each was at odds with the Midwives Section also worked against their
identified were the work- midwives must be nurses first and that the other. It was not until domiciliary midwifery colleagues by supporting
load required to complete midwifery education “builds on the 1989 that NZNA pro- these nursing and medical strategies and by writ-
two programmes concur- duced a Midwifery Policy ing their own policy in opposition to home birth
nursing concepts learned in the
rently, the limitations of Statement that properly (Midwives Section in NZNA, 1981).
the theory and practice basic nursing programme” reflected the views of its
components (only 10-12 midwifery members, but These actions caused a major rift amongst midwives
weeks of clinical experi- by then it was too late to and led to domiciliary midwives leaving NZNA
ence), the loss of an apprenticeship model, and stop midwives leaving NZNA to form their own and establishing the Domiciliary Midwives Soci-
the resulting inadequate level of preparation for professional organisation (NZNA, 1989). ety (DMS) to represent their views. Fortunately
midwifery practice of the graduates (Kennedy & for midwifery the DMS was able to successfully
Taylor, 1987; NZNA, 1987). An unfortunate con- Is a midwife also a nurse? oppose moves to transfer domiciliary midwives’
sequence of the transfer of midwifery education The second, and related, area of contention contracts for service from the Health Department
into the ADN programme was that many nurses between midwives and NZNA was the generally to hospital boards and under medical control. This
decided not to pursue midwifery or they left New held view that midwives must be nurses first and meant that when the Nurses Amendment Act was
Zealand to undertake midwifery education over- that midwifery education “builds on the nursing passed in 1990 there was an existing mechanism
seas. From 1981 – 1987 the numbers of midwives concepts learned in the basic nursing programme” to enable midwives to claim payment directly
training and registering in New Zealand dropped (NZNA, 1981, p.9). NZNA policy clearly stated from the Maternity Benefit Schedule managed
from an average of 157 per year to an average of that midwives were nurses but from the early by the Department of Health. This provided the
23 per year (Donley, 1986). The effect of this 1980s the Midwives Section lobbied to adopt the opportunity for midwives to work independently
dramatic decrease in midwives is still being felt in World Health Organisation (WHO) Definition rather than be employed by hospitals, a factor that
New Zealand’s midwifery shortages today. of a Midwife, which stated that a midwife was a has been crucial to the development of midwifery
‘person’ rather than a nurse. The Section was suc- professional practice since 1990.
The Midwives Section succeeded in changing cessful in getting the WHO definition accepted as
NZNA policy from support of the ADN Mid- policy in 1985. However, disagreements remained Separate midwifery programmes
wifery option to support of the proposed separate about the preparation and role of the midwife and The continual lobbying of the Midwives Section
midwifery programme by submitting remits to not just between nurses and midwives, but also for separate one-year midwifery programmes for
the NZNA annual conferences in 1980, 1982 between midwives themselves. A focus for this registered nurses from 1971 onwards finally bore
and 1985, which were passed. Despite changes tension was the small number of domiciliary mid- fruit in 1987. Karen Guilliland and I represented
in policy direction signalled at these conferences, wives in practice. Although the 1971 Nurses Act the Midwives Section at the NZNA conference
NZNA did nothing to give effect to the changes. had removed midwifery autonomy and required in 1987 where it was announced that there was
Indeed, in its 1984 policy on nursing education, a doctor to be present at every birth, the domi- soon to be a meeting to discuss midwifery educa-
NZNA considered that the resolutions seeking ciliary midwives were almost an exception. These tion. Against strong opposition from the NZNA
the separation of midwifery training from the midwives came closest to the WHO definition Executive Director, who had not planned to take
ADN programmes caused “a problem as yet un- of a midwife because they provided continuity of any midwives to the meeting, we insisted on
resolved by NZNA” that posed “professional and care in the community from pregnancy through to the Midwives Section being represented at the
educational difficulties” (NZNA, 1984, p.33). the postpartum period. They were out of step with meeting. At the Annual General Meeting of the
NZNA argued that midwifery knowledge and the majority of doctors, nurses and midwives who Midwives Section soon afterwards, Karen and I
skills were post-basic nursing because they built objected to domiciliary midwifery and homebirth. were nominated to represent the Section at this
on nursing knowledge and skills. Educationally Doctors, nurses and midwifery groups attempted meeting (National Midwives Section 1987).
the ADN was designed to extend basic nursing to control the practice of domiciliary midwives
skills and therefore, because midwifery involved and reduce the number of homebirths through At the meeting we were the only midwives amongst
advanced skills, it should be taught within the the implementation of various policies. a number of nurses including the NZNA Director,
ADN (NZNA, 1984). Gaye Williams and the Chief Nurse, Sally Shaw.
NZNA proposed a set of minimum standards Sally Shaw presented four options for midwifery
for all domiciliary midwives, including two years education: direct entry, separate one-year course,
12 New Zealand College of Midwives • Journal 34 • April 2006status quo (ADN) or a dual option of ADN and free-market approach. The Ministries of Education opened on 2 April 1989. They were heady days and
separate. Not surprisingly we were the only two and Health were restructured, the evaluation was midwives were buoyed with support from women
in favour of direct entry and the nurses did not never completed and the ADN/Midwifery option and the shared political activity of the time that
consider it a serious option. One person told us ceased without any policy decision to do so being in 1990 would result in legislative change and the
it would happen ‘over her dead body’. The nurses made. The separate midwifery programmes them- reinstatement of midwifery autonomy. NZCOM
were in favour of the status quo or dual option. selves only lasted another few years, as eventually presented an exciting vision of the future of ma-
Gay Williams supported the status quo option registered nurses were able ternity services for women
rather than the (by then) NZNA policy of separate to enter the direct entry and the role that midwives
courses. The Chief Nurse listened to the discussion Bachelor of Midwifery They were heady days and midwives could play in this.
but had the power to make the recommendations programmes. With some were buoyed with support from
to the Minister of Health. credit for prior learning
women and the shared political Direct entry
nurses could complete the midwifery
Eventually on 7 December 1987 the Ministers of degree programme in two activity of the time that in 1990 would In midwifery education
Health and Education and the Acting Minister years instead of three. result in legislative change and the the focus had moved to
of Women’s Affairs issued a joint press release direct entry. The Direct
reinstatement of midwifery autonomy.
announcing that a “dual training option” would Despite their brief time Entry Midwifery Task-
be introduced in 1989 (Ministers of Health, span the separate mid- NZCOM presented an exciting vision of force was established
Education and Women’s Affairs, 1987). Midwifery wifery programmes were the future of maternity services in 1987 as a sub-group
education would be available separately to the Ad- important milestones in of Save the Midwives,
for women and the role that
vanced Diploma in Nursing, although the ADN midwifery education de- a consumer group that
Midwifery Option would continue to be available velopment. The provision midwives could play in this. was itself established in
in a limited number of places. It would also remain of one year of specific 1983 to fight the proposed
available for midwives seeking further qualifica- midwifery education in- 1983 Amendments to the
tions. Midwives met this compromise with some stead of the briefer ‘option’ within a post-basic Nurses Act 1977 (Strid, 1987). The Midwives
excitement. Following the recommendations of nursing programme was the first step to raising Section formally supported the Taskforce but both
the Working Party on Midwifery, Bridging and Re- the profile of midwifery and recognising the groups agreed to focus on achieving the separate
lated Courses separate courses were commenced in potential of midwifery as a major provider within midwifery programmes as a first step and then
on reinstating midwifery autonomy before both
1989 at Auckland Institute of Technology (AIT), maternity services. It also set the direction for
would put their energies into achieving direct en-
Wellington Polytechnic and jointly between Otago further separation from nursing that would follow
try midwifery education (Midwives Section 1987).
and Southland Polytechnics (Pairman, 2002). The the 1990 Nurses Amendment Act. Although the
In the event direct entry and midwifery autonomy
ADN Midwifery option continued at Waikato and separate programmes began before the legislation
were achieved in the same piece of legislation, the
Christchurch Polytechnics. changed they used the WHO Definition of a
1990 Amendment to the Nurses Act.
Midwife to set the boundaries of what a midwife
In the first example of the collaborative approach needed to learn in order to practise. The curricula
The Direct Entry Midwifery Taskforce did a
that has characterised midwifery education over used words such as ‘autonomy’ and ‘continuity of
huge amount of work that cannot be underes-
recent years, representatives of the educational care’ and follow-through clinical experiences were
timated in the eventual achievement of direct
institutions were brought together for a week sought for midwifery students. Indeed when the entry programmes. In 1988, with funding from
in Auckland in 1988 to develop guidelines for Otago/Southland programme drafted a brochure the McKenzie Trust Foundation, it distributed a
these new separate midwifery programmes. to inform pregnant women about the needs of discussion paper and questionnaire about direct
The intention of the Health and Education midwifery students to access ‘follow through’ entry that served to raise awareness amongst many
Departments was to evaluate the separate pro- clinical experiences, the Southland Branch of midwives and others. The 691 replies received
grammes against the ADN programmes over three the New Zealand Medical Association (NZMA) indicated strong support for direct entry (NZ-
years and then decide which type of programme tried to take legal action to stop its development COM, 1990). The Taskforce, in association with
would continue. (Macalister Mazengarb, personal communication Carrington Polytechnic and with support from
10 March 1989). They objected strongly to the NZCOM, distributed a draft curriculum and fur-
However, the evaluation was overtaken by other WHO definition of a midwife that was listed on ther discussion paper in 1990 (Save the Midwives
events. Nurses refused to enrol in the ADN/Mid- the pamphlet and were worried that midwives Direct Entry Midwifery Taskforce, 1990). Again
wifery programme, insisting instead on access to might try to work as autonomous practitioners in there was a huge supportive response. Carrington
the one-year midwifery programme. This demand Southland. The notion of informed decision-mak- Polytechnic submitted their direct entry midwifery
from students led to both Waikato and Christch- ing was another they had difficulty with. curriculum to the Nursing Council for approval in
urch Polytechnics closing their ADN/Midwifery 1990 and this was turned down with the Council
programmes in 1991 and commencing one-year Separating from nursing citing legislative barriers as well as philosophical
separate programmes in 1992. The polytechnics From 1986 midwives discussed the need to disagreement with direct–entry midwifery as their
were able to commence the separate programmes separate from nursing’s professional body (now reasons (Strid, 1991).
without approval from the Health and Education called the New Zealand Nurses Organisation) and
departments because of the Education Act passed during 1988 the 10 regional Midwives Sections of This stance by the Nursing Council concerned
in 1990. Amongst other things this Act removed NZNO all closed down and reopened as regions Minister of Health Helen Clark who sponsored
government control over funded places for health of the New Zealand College of Midwives (NZ- the Nurses Amendment Bill to reinstate midwifery
education programmes and opened up a more COM) (Pairman, 2002). NZCOM was formally continued over...
New Zealand College of Midwives • Journal 34 • April 2006 13You can also read
