To think the proposed NICE guidelines on induction are blatant racism?

[NotSoNice75]

A midwife friend of mine has alerted me to this.

There is currently a proposal by NICE to 'recommend' induction of labour for all BAME women at 39 weeks of pregnancy (ie a week before they are due), even if they are perfectly healthy and the pregnancy has no complications.

As you probably know, induction of labour significantly increases the chance that a woman will need further interventions, and that she will end up with a forceps/caesarean delivery.

While that has its place (I was induced myself for medical reasons),
I believe that this policy takes away choice (it is a brave woman/couple who refuse when their obstetrician is presenting death as a viable consequence) and lets us off the hook for the real problem.

Women and babies are not at risk because of their physiology, they are at risk because of systemic racism and inequity in maternity services.

If you agree that this policy is blatantly racist, please please submit a comment form. Feedback from individuals doesn't usually carry much weight but we're hoping for power in numbers. This seems to have gained momentum very late, and the deadline is 5pm today.

• Go to: www.nice.org.uk/guidance/indeve ... ml-content

• Download the comments form (link in section 3) and complete.

• You can also download the draft guidance (link in section 2) for a read. The relevant bit is highlighted in the extract below. And yes, that means that any single one of those factors is justification for induction.

Isn't this recommendation aiming to address the health inequality that leads to poorer outcomes for BAME mothers and babies?

It is. But the question is what’s causing that health inequality and whether increased intervention is the answer, given that induction carries risks in itself.

Sorry OP, the consultation paper is saying pretty much the opposite of what you think.

More research into this issue and related issues like the apparently shorter gestation seen in some ethics groups is really important. A recommendation made without high quality evidence that will really impact on the care of all BAME women fails again to centre research, good care and the women themselves at the heart of their care.

@MissChanandlerBong90

Isn't this recommendation aiming to address the health inequality that leads to poorer outcomes for BAME mothers and babies?

It is. But the question is what’s causing that health inequality and whether increased intervention is the answer, given that induction carries risks in itself.

It does seem possible part of the inequality is to do with medical research having treated white women as the default. That's part of what those articles I'm linking to are discussing.

If black women, on average, have a natural pregnancy length of 39 weeks, they won't be recognised as 'overdue' until they're a week more overdue than white women.

I think the document looks fine.

It is a recommendation that induction should be considered in certain circumstances backed by evidence.

There is also quite rightly a recommendation that the woman's preference should be supported if she chooses not to be induced.

@BarbieJ how can they undertake any scientific research that isn’t influenced by systematic racism.

The majority of studies that look at induction vs spontaneous labour is categorised as ‘poor quality’ because it’s almost impossible to have a control group, there are so many societal factors.

I think this is a half arsed attempt to address the poorer outcomes that BAME women experience in maternity care. When what’s actually needed is a better quality and more considerate care.

To those saying that induction should only be ‘considered’ not necessarily recommended. How many women do you know who actually refuse induction when a doctor says it should be considered. Some do, but from what I’ve seen many women don’t like to go against the advice of a doctor.

Just to add that it's particularly depressing if midwives are misinterpreting and misrepresenting the proposals.

How many women do you know who actually refuse induction when a doctor says it should be considered.

If you read the preceding section to 'consider' it gives guidance on the approach for a) the doctor to consider (so before even a conversation with the mother and b) how to discuss with the mother appropriately.

Sure, there's often been too much dogmatism used by doctors in making these decisions. But the whole point of this document is to address this.

Page 24 explains why this consideration has been included, based on audit data. Evidence based for the safety of mother and baby, absolutely not racist.

Are you looking for things to be offended by?

I read that page and I’m not as confident as you. It says:

‘22 The committee were aware that certain groups of women may be at higher risk of
23 adverse events with prolonged pregnancy and that these women may benefit from
24 earlier induction. The committee noted that in their knowledge and experience,
25 women from the Black, Asian and minority ethnic family background, women with
26 BMI of 30 kg/m2 or more, women aged 35 years or more, and women who had
27 assisted conception were at a higher risk of adverse events in a pregnancy that was
28 prolonged beyond term. The committee were aware that this is consistent with
29 national audit data.

1 As there was no evidence to identify the optimal timing of induction in these groups
2 the committee made a research recommendation.’

That just says that some groups of women, including BAME women, are at higher risk of adverse events if their pregnancies go beyond term. That’s not news, obviously. It’s just a fact.

The question is why is that the case (in respect of each group), and whether intervention at 39 weeks is the answer (in respect of each group).

What a mess of an OP. You have entirely misrepresented the consultation paper.

I would think that imposing a definition of 'full term pregnancy' that only really applies to white women would also be pretty racist.

Exactly. This paper is the opposite of racism. Racism is expecting black women to conform to a norm for white women, which doesn't fit their own pregnancies.

@NotSoNice75

“Women and babies are not at risk because of their physiology, they are at risk because of systemic racism and inequity in maternity services.”

Do you have any data to back up the above, because it’s a pretty damning statement?

Do you really believe the nhs treats bame mothers differently purely because of the colour of their skin and there are no physiological or socio economic factors?

If this is a measure taken to address the “health inequality “ then surely it’s the opposite of racism? Although I do agree more research is probably needed as to the reasons for the disparity of outcomes.

[quote PinkPlantCase]@BarbieJ how can they undertake any scientific research that isn’t influenced by systematic racism.

The majority of studies that look at induction vs spontaneous labour is categorised as ‘poor quality’ because it’s almost impossible to have a control group, there are so many societal factors.

I think this is a half arsed attempt to address the poorer outcomes that BAME women experience in maternity care. When what’s actually needed is a better quality and more considerate care.

To those saying that induction should only be ‘considered’ not necessarily recommended. How many women do you know who actually refuse induction when a doctor says it should be considered. Some do, but from what I’ve seen many women don’t like to go against the advice of a doctor.[/quote]
Most research on childbirth is subject to the same problems with control groups.

That doesn't mean we should simply accept that no further research can be done.

It sounds like a positive step against racism in that more attention is being paid to what is safer for BAME women.

I also think it's naive to presume the NHS couldn't possibly be institutionally racist. A lot of medicine is based on a default white body, even down to basic things like talking about skin going blue.

To those saying that induction should only be ‘considered’ not necessarily recommended. How many women do you know who actually refuse induction when a doctor says it should be considered. Some do, but from what I’ve seen many women don’t like to go against the advice of a doctor.

But the doctor (or more likely midwife) will be advising that induction should be considered, not that it should be done. I imagine that means that there will be a discussion about the pros and cons so that the mother can make an informed decision.

It does seem possible part of the inequality is to do with medical research having treated white women as the default. That's part of what those articles I'm linking to are discussing.

If black women, on average, have a natural pregnancy length of 39 weeks, they won't be recognised as 'overdue' until they're a week more overdue than white women.

Oh absolutely - I think it’s very plausible that in general (not just in maternity) the treatment of the white male body as the default impacts on healthcare outcomes for women, BAME people, and in particular, BAME women.

But I can’t see anywhere in the draft guidance that the potential differing length of gestation is the rationale for this change. Because if there’s solid evidence that that is the case it seems to me it should result in a wholesale restructure of maternity care for BAME women and their babies - it surely impacts on many aspects of their care, not just the optimal time for induction.

I’ve only read the guidance on my phone so may have missed it.

The question is why. It says on page 6-7:

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 or above, age 35 years or above, with a black, Asian or minority ethnic family background, or after assisted conception). Take into account:
the risk of complications
The woman’s preferences
the woman’s previous obstetric history

To me this reads that IF a woman has more risk of complications (one of those risks is ethnicity, but also age, assisted conception), consider earlier induction (rather than later at 41 weeks). I think the aim would be to prevent the complications. So to me it doesn’t sound racist.

I am BAME and pregnant. If I was in that situation, I’d want to explore elective c-section + sterilisation option with obstetrician as I’m on 3rd pregnancy.

As long as the risks are explained and choice is given, I don’t see an issue. It would be good to ensure that the full range of choices is discussed with each woman though (of all ethnicities and with language support if required).

Oh, I follow you.

I don't know to what degree they usually explain the reasons behind advice, though? It would certainly be helpful if they did!

OP, you say the policy is to recommend but the picture you link to says consider.
I think you don't actually know what you are talking about at all.

Sorry OP but I think it’s a good step forward. As a Chinese Asian woman I am at higher risk than white women for birth complications due to western diet producing bigger babies than historically. My smallest baby was two pounds heavier than my mothers largest baby (she had seven of us). So the birth complications of bigger baby in small stature women....shoulder dystocia, breech birth, 3rd degree tear, etc.

The systemic racism is in ignoring the higher risk and doing nothing it’s not systemic racism to recognise that we are actually at higher risk based on evidence and then consider appropriate interventions.

My only concern, is the guidance does seem to lump us all together when the risks for Chinese Asian women like myself are very different from Caribbean Black women for example. A one size one approach fits all would be racist,...but I think the source you are quoting is sure to have more detail and specifics than what you have shown here so as to not do this and take an individual risk approach.

@NotSoNice75

If you read the actual draft guidelines on the link, it refers to "recommendations".

OP I think that you do not know how to read NICE guidelines. Their recommendation is to consider to pros and cons of induction in the presence of certain known risk factors. They are certainly not recommending induction for all BAME women at 39 weeks. Your post is incorrect and inflammatory.

Have you read all the associated evidence documents and the relevant references in those documents to the papers pertinent to the recommendation, @NotSoNice75?

It would be more helpful to post the relevant sections from the evidence and links to the papers so people can critically assess those to decide whether the recommendation is appropriate or not.

@NotSoNice75 I think you're misunderstanding the guidance.
One of the issues identified is that there is a "one size fits all" model of healthcare based on the "Caucasian" experience. I see this as trying to address this and recognising that some BAME are at higher risk of complications, therefore induction at 39 weeks may be the most sensible plan.
There is nothing about BAME women being forced into having an early induction. This is one of those situations where a bit of information has been misunderstood and is now going to cause unnecessary panic

I thought the recommendation was actually based on the fact that induction of labour is suggested too late for BAME mothers and is currently based on the needs of white women.
This has resulted in poorer outcomes for BAME mothers babies.
Or have I completely misunderstood?

@Watermelon221

Do you have any data to back up the above, because it’s a pretty damning statement?

Explain why there have been lots of reports and no action then.