The first time Jessica White felt her daughter Grace kicking in her belly, she was flooded with joy — and relief. She had suffered five miscarriages in three years.
"When I felt her move, it was reassuring, and from that point, I had a really positive pregnancy."
As her due date approached, Jessica's obstetrician recommended an induction. An "induced" labour is when doctors and midwives bring on labour artificially, rather than waiting for it to start on its own.
Jessica's pregnancy wasn't considered high risk and she had hoped to go into labour naturally, but given her history of pregnancy loss she was apprehensive to question her doctor's advice.
"He explained to us that in any pregnancy — whether it's high risk or healthy — that the best clinical outcomes for both mother and baby would be [to have] an induction at 39 weeks," she said.
"Whilst I was in good health and had no complications, I was going to do what I was told was best."
The day before her baby's birth, Jessica had a balloon catheter inserted into her cervix to help dilate and prepare it for labour. The next morning, her waters were broken, and she was placed on a hormone drip to kick-start contractions.
At first, things progressed slowly, but as the drip was turned up, the pain became "excruciating".
An epidural brought some much-needed pain relief, but Jessica's labour slowed. By the evening, an emergency caesarean section became likely.
Hoping to give birth vaginally, Jessica asked her obstetrician for more time and when he returned two hours later, she was fully dilated and ready to push.
"After about 1.5 hours, [the obstetrician] said the baby wasn't going to make it through the birth canal on her own, so we needed to look at using forceps."
Jessica agreed, and with another two pushes, Grace was finally born.
"I was able to put my hands down and pull her up onto my chest … And that was the most amazing moment of my entire life."
Jessica remembers the birth as an "empowering" experience, but the recovery was much harder than she expected. At four weeks postpartum, she was diagnosed with a vaginal prolapse, which research shows is more common after a forceps birth.
She's since wondered whether the pain and cost of rehabilitating her pelvic floor could have been avoided.
"I will never know, if I ended up going into spontaneous labour at 40 or 41 weeks, whether I'd still need forceps.
"But I just think my body wasn't ready for labour … that little baby just wasn't quite ready to come out."
Induction on the rise
In Australia, the rate of labour induction has increased substantially: 44 per cent of first-time mothers were induced in 2021, compared with about a quarter in 2010.
In most pregnancies, labour starts naturally between 37 and 42 weeks, but doctors may recommend an induction to reduce the risk of complications, including stillbirth.
This happens most often if a mother has gestational diabetes, her waters break prematurely, or her pregnancy is prolonged.
Usually, induction is also recommended if a woman has high blood pressure or there are concerns her baby is too small (and may not be growing well) or too big (and may get stuck).
But routine induction of labour for women with uncomplicated pregnancies is not recommended before 41 weeks, according to the World Health Organization.
As part of a crowd-sourced investigation into maternity care, the ABC heard from women across the country who felt they were induced unnecessarily.
Others told us they had requests for induction denied or concerns about continuing their pregnancy dismissed — sometimes to the detriment of their own health or their baby's.
Part of the challenge, despite huge advancements in medical science, is that assigning risk in pregnancy and childbirth remains difficult.
Geelong-based obstetrician and Deakin University clinical lecturer Kara Thompson said part of the reason more women were being induced was because of the "changing risk factor profiles" of pregnant women.
Today, women giving birth are, on average, older and more likely to be overweight. Maternal choice also plays a role, she said: if, for example, a woman has experienced a difficult pregnancy, or has an increased risk of stillbirth.
But in some cases — as in Jessica's — induction is offered even to low-risk women at 39 and 40 weeks, because of a shift in the perception of its risks and benefits.
Changing risks and emerging evidence
The term "cascade of intervention" is a common refrain among midwives and maternity experts. It's the idea that by disrupting the normal physiological process of birth, induction creates the need for more intervention — from pain relief to an instrumental birth (involving forceps or vacuum extraction) to a caesarean section.
But Dr Thompson said there was "mounting evidence" that induction didn't increase the risk of subsequent intervention.
One particularly influential study called the ARRIVE trial looked at whether inducing healthy, first-time mothers at 39 weeks was of benefit to themselves or their babies.
The randomised study of 6,000 women found induction made no significant difference to the risk of death or serious complications for babies, but — contrary to popular belief — slightly reduced the likelihood of women needing a caesarean section.
"The ARRIVE trial is level A, excellent evidence — which is incredibly hard to get in pregnancy settings — that induction in and of itself doesn't increase the risk of caesarean, and in fact, may well decrease the risk in some settings," Dr Thompson said.
As doctors have come to understand the benefits of induction, she said it has become "ethically harder" not to offer what has been "demonstrated to be a safe intervention".
Concerns about overuse of induction
But not all maternity experts agree, and some have significant concerns about the dwindling number of women being encouraged to go into labour on their own.
Zoe Bradfield, a senior midwifery research fellow at Curtin University, is among those troubled by Australia's high rate of induction.
"For some people, induction of labour is a lifesaving intervention … so it needs to form part of our contemporary healthcare practices," Dr Bradfield, who is also vice president of the Australian College of Midwives, said.
But there is no evidence, she added, that low-risk women should be routinely offered labour induction unless it is clinically justified.
Dr Bradfield acknowledged that the ARRIVE trial provided "useful information" but stressed that it had several limitations.
"Does it mean that we should — as a blanket rule — go around and offer every single woman, 39 weeks in, induction of labour? Absolutely not."
Induction isn't without its risks. Occasionally, it doesn't work (which may mean a C-section is necessary), it can affect a baby's heart rate and, in rare instances, cause the uterus to tear or trigger excessive bleeding.
Australian data shows that in 2021, a higher proportion of women who were induced went on to have a C-section or instrumental birth than those who went into labour without intervention.
Similarly, a NSW study found first-time mothers who were induced were more likely to have an instrumental birth, C-section, epidural and/or episiotomy (an incision made to widen the vaginal opening during birth).
But Dr Thompson said historical data — and observational studies like the NSW one — weren't meaningful when trying to understand the risks and benefits of induction.
"The data is a reflection of the increased risk factors of the people having an induction … it is absolutely not showing any causation," she said.
"Often people look back and trace it to that initial intervention. But there's no evidence that induction increases any of those subsequent outcomes."
Another recent study from the University of Melbourne found induction of labour at 39 weeks decreased the risk of perineal injury and instrumental birth and was associated with fewer neonatal complications.
Recognising the impacts of birth trauma
Still, Dr Bradfield rejected the idea that induction could be thought of as a wholly safe intervention.
"We really haven't done a good job to ask women whether they feel that [birth] has been a safe process for them. And of course, safety extends beyond physical safety."
In the ARRIVE trial, women who were induced reported feeling more in control of their birth.
Birthing a better systemBut for many women, induced labour is more painful than labour that starts on its own, Dr Bradfield said.
Artificial contractions may come on quickly and more intensely, and the increased foetal monitoring and drip means women are sometimes less able to move around or use other forms of pain relief, such as a bath or shower.
In 2021, researchers at Western Sydney University surveyed almost 9,000 Australian women and found rates of birth trauma were higher among women who were induced in NSW compared to those who experienced spontaneous labour.
A senate inquiry into birth trauma was launched earlier this year after dozens of women complained about their treatment while giving birth. Allegations included the inappropriate use of labour induction.
Inside the health system
While concern about the wellbeing of babies and mothers explained part of the rise in inductions, Dr Bradfield said "non-clinical" factors were also driving intervention rates up.
"The pressure that we put around timing is far more institutionally driven and systems-oriented than [it is] us wrapping good care around the individual woman in front of us."
In some cases, she said, hospital policies related to labour induction were so bluntly enforced that women sometimes received unnecessary or inappropriate care.
"We're blanket-applying interventions to broad groups of people without an appreciation for individual women's criteria."
Individual practitioner preferences also play a role, as do the availability of resources, and whether a hospital is public or private.
NSW data shows that in 2021, just 10 per cent of women at one private hospital in Sydney's north went into spontaneous labour, compared to 46 per cent of women at a regional public hospital two hours' drive away.
Advocates for maternity reform have argued that increasing rates of intervention are being driven by a risk-averse medical culture, and that women are not always aware they can decline an intervention.
Balancing the risks
Becca Morton gave birth to her third child in 2022 and said the pressure she faced to get an induction – and her choice to eventually do so – left her traumatised.
"Had this been my first birth experience, I wouldn't have the children I have now, because I never want to go through that again."
Becca's two eldest children were born after their due dates in uncomplicated vaginal deliveries, so she was surprised when, in the final weeks of her third pregnancy, an induction was recommended.
"The midwife made comments around my size and felt I needed to go back and do the diabetes test again."
The result came back negative, but Becca's midwife expressed concerned about her baby's size and recommended she get induced at 39 weeks.
Becca was reluctant, but after being warned about the risks of continuing her pregnancy, felt she had no other choice.
"As soon as you're told that the risk of proceeding with a natural birth is that your child may get stuck, die, have injuries … I just don't know how you say, 'I hear you, but no.'"
After a long and difficult labour — during which Becca said she felt unheard, and that her pain was ignored — she was told by her obstetrician that her baby wasn't in the right position and that "no amount of pushing" would get him out.
Later, when baby Forrest was born via an emergency C-section, Becca was too unwell to hold him — something she still struggles to come to terms with today.
"Everyone in the room got to hold him before me. Every instinct in my body was screaming."
Looking back, she feels she wasn't given adequate information to make informed decisions.
"There's a balance of risk, and it's about what risk you're prepared to accept when you've got all the information.
"What I wasn't given the opportunity to do was to balance that risk."
The great maternity debate
The debate over Australia's rising induction rate is, in many ways, emblematic of a much bigger, thornier question that often sees midwifery and obstetric philosophies clash: What is the appropriate level of intervention during childbirth?
And to what extent is birth a normal, physiological process versus a medical event that must be managed?
"The reality is we've seen this escalation in intervention but what we've not seen is a commensurate improvement in maternal and neonatal outcomes," Dr Bradfield said.
"That tells us that we've probably reached the point where we've tipped the scales in terms of actually providing benefits, and we're into the territory where we could be causing harm."
But Dr Thompson said modern obstetric care had made pregnancy and birth "safer than it's ever been".
"There's no doubt that the package of obstetric care needs to be constantly assessed and looked at to make sure we're getting that balance right," she said.
"But if we were to significantly wind back the quality and frequency of care that we're offering, the evidence tells us that would be associated with an increase in adverse outcomes."
In Australia, the overall perinatal mortality rate has remained largely unchanged since the early 2000s.
There has, however, been a reduction in the rate of late stillbirths (after 28 weeks' gestation) and neonatal deaths.
"That is a double achievement when you think about the fact that, based on the increasing prevalence of risk factors, we would expect the stillbirth risk to be increasing," Dr Thompson said.
While opinions may differ on appropriate levels of intervention, there is broad consensus among maternity experts that shared decision-making between clinicians and parents is critically important.
Each family brings a unique set of values, preferences and previous experiences to pregnancy and birth, with different acceptable levels of risk.
"There's no doubt that some women are very motivated to avoid induction … and that should absolutely be respected," Dr Thompson said.
"No-one should ever feel pressured or forced into having any intervention, in the same way no-one should feel pressured or forced into not having an intervention they wish to have."
Dr Bradfield said part of the solution to improving shared decision making and reducing birth trauma was to expand midwifery "continuity of care" models.
"It improves outcomes for women and babies, it generates higher rates of satisfaction for women across the board … and it's cheaper than standard public care.
"Why are we not making this the default model of care?"
Jessica and Becca hope that sharing their birth experiences will encourage other women to learn about their choices in pregnancy and birth, and figure out what feels right for them.
"From miscarriage, to trying to get pregnant, to what happens in the birth suite … I just wish all of these things were talked about more."
This story is part of the ABC's Birth Project.
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