Approximately 32.6% of labours in the UK are induced, either before or after the estimated due date (NHS Digital, 2018). This number has increased by 12.2% in the past 10 years (NHS Digital, 2018) and is likely to increase further due to a rise in more complex pregnancies with risk factors that indicate the need for delivery of the fetus. A further significant influence on induction of labour rates is the publication of the Saving Babies' Lives Care Bundle (O'Connor, 2016), which states an objective to decrease the stillbirth rate by 20% by 2020. By implementing the recommendations set out in the care bundle, there is a likelihood that induction of labour rates will increase and affect service demands (O'Connor, 2016).
However, it is widely recognised that most women want as much as possible to have a physiological and normal birth (Gammie and Key, 2014; Downe, 2017; Jay et al, 2018). Induction of labour has been shown to have a negative impact on women's experiences, often leading to dissatisfaction, increased pain, increased likelihood of instrumental births and obstetric interventions (O'Dwyer et al, 2015). Women have also reported neglect due to staff shortages, a lack of choice in care when undergoing induction of labour and a lack of privacy in the ward environment, which is typically where induction of labour takes place (Henderson and Redshaw, 2013). As a result, outpatient induction of labour services have become an attractive option to improve women's experience of induction of labour (Henderson and Redshaw, 2013). This supports the recommendations set out in Better Births (National Maternity Review, 2016), which called for high-quality, personalised and family friendly services to be provided to women and their families. Seven key recommendations were developed, one of which, ‘personalised care’, identified that women should be encouraged to make informed choices about their care, with clinical commissioning groups (CCGs) providing maternity services in a range of settings, including the home (National Maternity Review, 2016).
Outpatient induction of labour is a new concept in the UK and is usually only offered to women who are post-dates with no risk factors (Sharp et al, 2016). There is generally limited research on outpatient induction of labour and the research focus is often mostly medicalised, with a focus on safety, efficacy and the potential cost saving (Eddama et al, 2009; Kelly et al, 2013). However, the National Institute for Health and Care Excellence (NICE) (2008) stipulates that further research is also required into women's views on outpatient induction of labour, the advantages and disadvantages of the approach and whether it is acceptable to women.
This review aimed to provide a coherent approach to understanding women's experiences of outpatient induction of labour, which has received insufficient attention as a topic in its own right. Compiling a literature review and formulating a discussion will assist with a deeper understanding of outpatient induction of labour and women's experiences. This will assist with creation of recommendations for practice and will influence clinical decision-making. By understanding what is important to women, a service that is acceptable and meets the needs of women can be developed.
Method
A comprehensive literature review—defined as when ‘a range of research literature from a pluralistic source is sampled, reviewed, critiqued, analysed and interpreted’ (Siu and Comerasamy, 2013:15)—was chosen. CINAHL Complete, Scopus, MEDLINE and PsychINFO were searched, based on inclusion and exclusion criteria (Table 1) and a search strategy (Table 2). Although the primary source for literature was electronic databases, other methods of data collection were included (Figure 1). A total of 9 studies were included in this literature review following critical appraisal using a tool formulated by the Critical Appraisal Skills Programme (2017).
| Inclusion criteria | Exclusion criteria |
|---|---|
| Journal articles | Books |
| Conference papers | Literature not written in English |
| Expert opinions | Induction of labour and intrauterine fetal death |
| Non-published data (eg posters) | Non-human studies |
| Grey literature | Male participants |
| Audits | Non-empirical research (ie literature reviews) |
| Published in the past 10 years, unless seminal research | |
| Quantitative and qualitative research (empirical research) | |
| Literature written in English | |
| Induction of labour via any method | |
| Female participants | |
| Research conducted worldwide |
| Abstract | Title | Text | ||
|---|---|---|---|---|
| Labour OR labor AND induc* OR cervical priming OR cervical ripening | OR | Labour OR labor AND induc* OR cervical priming OR cervical ripening | AND | Experience* |
| AND | AND | |||
| Outpatient* OR home | Outpatient* OR home | |||
This comprehensive literature review offered a pluralistic approach, as research from both the positivist and interpretivist paradigms was included. A pluralistic approach avoided the risk of bias by not excluding literature that was relevant to the research question on philosophical standpoints. Reviewing different methods instilled further confidence that different dimensions on women's experiences of induction of labour had been explored (Oliver, 2012).
Findings
In the 9 included pieces of literature (Table 3), five were conducted in the UK (Bollapradaga et al, 2009; Reid et al, 2011; O'Brien et al, 2013; Clarke et al, 2017; Britton et al, 2018), three were conducted in Australia (Henry et al, 2013; Turnbull et al, 2013; Wilkinson et al, 2015) and one was conducted in Canada (Biem et al, 2003). Although the research by Biem et al (2003) was published more than 10 years ago, it was frequently cited in other included literature and research papers on the topic of outpatient induction of labour and therefore considered to be a seminal piece of research.
| Source | Country | Type of study | Method of induction |
|---|---|---|---|
| Biem et al (2003) | Canada | Quantitative, RCT | Inpatient vs outpatient, PGE2 controlled release |
| Bollapradaga et al (2009) | UK | Quantitative, RCT | Outpatient, IMN vs placebo |
| Turnbull et al (2013) | Australia | Quantitative, RCT | Inpatient vs outpatient, PGE2 gel |
| Henry et al (2013) | Australia | Quantitative, RCT | Inpatient vs outpatient, Balloon outpatient, PGE2 pessary inpatient |
| Reid et al (2011) * | UK | Qualitative, Interviews | Outpatient, IMN vs placebo |
| O'Brien et al (2013) | UK | Qualitative, Interviews and diaries | Outpatient, PGE2 controlled release |
| Wilkinson et al (2015) | Australia | Quantitative, RCT | Inpatient vs outpatient, Balloon |
| Clarke et al (2017) | UK | Audit | Outpatient, PGE2 controlled release |
| Britton et al (2018) | UK | Audit | Outpatient, PGE2 controlled release |
RCT: randomised controlled trial; IMN: isosorbide mononitrate.
Five studies used the quantitative methods of randomised controlled trials (Biem et al, 2003; Bollapradaga et al, 2009; Turnbull et al, 2013; Henry et al, 2013; Wilkinson et al, 2015), two of the studies were qualitative and used interviews (Reid et al, 2011; O'Brien et al, 2013) and the remaining two were audits (Clarke et al, 2017; Britton et al, 2018). It is evident that qualitative data on women's experiences of outpatient induction of labour are underrepresented despite this method being commonly used to determine experiences (Baker, 2014). The two qualitative articles were the core studies in this literature review, as they exclusively aimed to find the experience of women undergoing outpatient induction of labour. Comparably, the quantitative papers examined women's experiences as well as additional factors such as effectiveness, economic outcomes and safety. These studies had a greater focus on women's experiences than the two qualitative forms of research (Biem et al, 2003; Turnbull et al, 2013; Henry et al, 2013).
The most used method of induction of labour in the studies was prostaglandins (PGE2), although this varied, from PGE2 pessary, to PGE2 gel, to a controlled release variation of PGE2. Bollapradaga et al (2009) and Reid et al (2011) (a sub-study of Bollapradaga et al (2009)) both used isosorbide mononitrate. Isosorbide mononitrate is now no longer used in the UK, and PGE2 as a controlled release variation is the most popular choice for outpatient induction of labour (Sharp et al, 2016) followed by balloon catheters (Diederen et al, 2018).
This literature review found three main themes: the home as a positive setting for outpatient induction of labour, the value of outpatient induction of labour in promoting normality and the importance of receiving reassurance during outpatient induction of labour.
The home as a positive setting for outpatient induction of labour
This was the predominant theme formulated from all the research articles. All studies illustrated and concluded that women valued the home as an induction of labour setting, thus showing that women's experience of outpatient induction of labour was positive. Biem et al's (2003) study identified a satisfaction score of 56% for outpatients and 39% for inpatients during the initial 12 hours of induction (P=0.008). This demonstrated confidence that women were more satisfied in the outpatient setting. Turnbull et al (2013) indicated a higher satisfaction score in the outpatient setting (although the statistical difference was smaller) with a mean difference of -0.16. These two studies had the largest sample groups in all of the nine included pieces of literature: Biem et al's (2003) research had a sample size of 299 women, while Turnbull et al (2013) had a total sample size of 823 women. Both studies used PGE2 as a method of induction. There were differences in the method of data collection: Biem et al (2003) opted for an automated computer based interview using a numbered rating scale, while Turnbull et al (2013) opted for a worded rating scale and the Edinburgh Postnatal Depression Scale. Biem et al (2003) acknowledged that rating satisfaction on a 10-point scale was subject to bias and was difficult to interpret, as although a difference of one point might indicate a statistically significant result, uncertainty lies around clinical significance of this. Turnbull et al's (2013) questionnaire was completed 7 weeks after the birth; therefore, it was possible there was recall bias.
The evidence from the two qualitative studies (Reid et al, 2011; O'Brien et al, 2013) also indicated that women's experience of outpatient induction of labour was positive, as women described their dislike of the hospital setting:
‘I hate it. I just hate the hospital … That's what I dreaded. I think the hospital panics you a little bit, doesn't it? I'd just sooner get in there, get it done and get out.’
‘It's much more relaxed being at home than it is being in the hospital environment where you, no matter what they say, you're not ill but you end up feeling ill because you're in that environment, it's much better to have it at home, you can sit and relax, feet up, visitors whenever you want.’
There was also strong recognition of how the home environment provided comfort and convenience. Four of the nine studies reported on women's ability to sleep, which appeared to be a common factor in determining women's experiences of outpatient induction of labour. In their study, Wilkinson et al (2015) found that 75% of the women reported that they did not have a good night's sleep. The authors also found that this was more common in the inpatient group (91% of whom reported poor sleep) compared to the outpatient group (68%). The response rate of the questionnaire was 70%; however,Wilkinson et al (2015) did not collect feedback regarding women's acceptance of outpatient induction of labour until 4 weeks after the birth, which is a potential factor for recall bias.
Henry et al (2013) compared inpatient and outpatient groups using different methods of induction of labour. The inpatient group had PGE2, which causes uterine stimulation, while the outpatient group had a balloon catheter, which does not (Henry et al, 2013). This may explain why the inpatient group reported more pain during the intervention than the outpatient group (58% vs 26%, respectively), which could have influenced the finding that the inpatient group had less sleep. Therefore, it is difficult to determine whether the difference in environment or the method of induction of labour was an influence on sleep.
The value of outpatient induction of labour in promoting normality
This theme was demonstrated by two emergent sub-themes that demonstrated support for normality. Firstly, outpatient induction of labour encouraged control and freedom and gave women the ability to continue day-to-day activities. It also contributed to the physiology of labour by allowing unrestricted mobilisation and a home environment, which is strongly associated with ‘normal’ labour and birth. The findings suggest that women felt strongly about maintaining independence, which allowed them to continue their existing lifestyle and uphold cultural normality. There was a sense of empowerment associated with being at home during the process of induction of labour. Consequently, the home was seen as more than just a location and had a meaningful association with specific practices and experiences (Oster et al, 2011). The home was found to be associated with physical, individual, social and symbolic factors that in turn produce an ideal environment when compared to the unfamiliar medicalised environment of the hospital (Oster et al, 2011).
Three of the nine studies identified the value of outpatient induction of labour in promoting normality, as illustrated by the following extracts:
‘I just wanted that whole being-in-labour experience because I felt like that got took away from me a little bit last time because it was so managed. It was like, you're being induced, now you're having an epidural, now you're having this, now you're having forceps … I didn't really get a say … I was desperate just to take control of the experience myself … just being able to experience it by myself and deal with it by myself … I didn't get my whole water birth experience and all the rest of it, but it was kind of half way between the two because it was as close as going into labour naturally as I could have got.’
‘I was just [doing] housework and tidying my room and fixing all the wean's [baby's] stuff oot aw the time as well.’
The study by Turnbull et al (2013) showed a small statistically significant finding that outpatient induction of labour provided more control than inpatient induction of labour, with a mean difference of -0.13.
The importance of receiving reassurance during outpatient induction of labour
This theme demonstrated that women's experiences were not exclusively positive, with emergent sub-themes related to anxiety, the ability speak to a midwife or the hospital, and regular contact with a professional while at home. The negative experiences of some of the women were to some extent overlooked by almost all the researchers as a meaningful finding due to small numbers and statistically insignificant findings.
There was a range of ways in which the women and their fetuses were observed and assessed during induction of labour at home, although some of the studies did not mention how the women were observed or monitored (Table 4). The fetal heart rate was monitored in two of the cases where cardiotocography was used (Biem et al, 2003; O'Brien et al, 2013), and cardiotocography would have meant that the presence and frequency of contractions were assessed. The cases where women were asked to contact the maternity unit did not specifically state what the women were asked, yet the method of observation used after discharge home is likely to have a direct effect on the women's experience of outpatient induction of labour. To ensure fetal wellbeing, O'Brien et al (2013) used wireless monitoring that relayed the fetal heart to the hospital to be reviewed hourly by a midwife. The following extracts demonstrate the need for women to have reassurance when at home:
‘I found in the hospital you get monitored so many times throughout the day, whereas this I felt like I was being monitored constantly.’
| Source | Method of observation once discharged home |
|---|---|
| Biem et al (2003) | Women returned after 12 hours for cardiotocography |
| Bollapradaga et al (2009) | Not stated |
| Reid et al (2011) | Not stated |
| Turnbull et al (2013) | Relied on the women calling or returning to hospital if there were any concerns or queries |
| Henry et al (2013) | Not stated |
| O'Brien et al (2013) | Wireless monitoring relayed the fetal heart to the hospital, where it was reviewed hourly by a midwife (‘remote continuous monitoring’) |
| Wilkinson et al (2015) | Relied on the women calling or returning to hospital if there were any concerns or queries |
| Clarke et al (2017) | Women were to call the hospital at 12 hours post-discharge home to check wellbeing |
| Britton et al (2018) | Women received a phone call at 6 hours post-discharge home |
However, this type of monitoring did not reassure everyone, as could be seen from the following extract:
‘My main concern was to make sure that someone was definitely going to be watching the monitor. I wasn't going to be sent home and then she'd be like, “Oh, I'll get to that in a minute, I'm too busy”. That was my main concern, that I would still be watched—because you don't want anything to go wrong, you know, if the baby seems in distress or anything.’
Discussion
The method of induction used would have undoubtedly influenced the women's experiences of outpatient induction of labour, as each method has different side effects. Although researching women's experiences of one method of outpatient induction of labour may have increased reliability and validity of results, it could also have led to bias. This is because this article did not intend to have a medicalised focus: instead, the emphasis is on the environment in which induction of labour takes place, meaning that the method of induction is arguably of less importance for the purposes of this literature review. Despite the wide range of methods used for induction of labour, the research included in this literature review still has the potential to inform local processes, as the themes relate to the setting of outpatient induction of labour, as opposed to the method. Nonetheless, this review has identified that further studies need to be conducted on women's experience of outpatient induction of labour with controlled release PGE2 and the balloon catheter, both of which are becoming increasingly popular as methods of outpatient induction in the UK.
The inclusion criteria for women undergoing outpatient induction of labour varied between the studies. Turnbull et al (2013) and Wilkinson et al (2015) included women who were diabetic and overweight, while Biem et al (2003) included women who had hypertension. Outpatient induction of labour is generally considered to be acceptable for women with uncomplicated pregnancies and therefore is unlikely to be suitable for those women with complex medical conditions (Vogel et al, 2017). As the criteria for the participants varied between the included studies, the results of this literature review may have limited generalisability in relation to recommendations for outpatient induction of labour services. However, the women's medical condition may not have affected their induction experience, as they underwent the same procedure as those with uncomplicated pregnancies.
Although the support for outpatient induction of labour is evident, barriers to offering an outpatient induction of labour service remain. O'Dwyer et al (2015) conducted a quality improvement project at a large UK hospital as a result of poor patient experience and complaints arising from the induction of labour process. They designed an outpatient induction of labour service, which included a more streamlined and operational way of providing care, and as a result increased outpatient induction of labour rates from 3% to 33%. Their findings indicated that there were several barriers to offering such a service, including:
Collecting staff feedback, encouraging widespread engagement and having a dedicated outpatient induction of labour area led to the increased uptake in outpatient induction of labour. These findings will help formulate recommendations to implement an outpatient induction of labour in places with similar barriers.
Strengths
Fink (2010) explains that triangulation in research enhances rigour (and therefore the validity of the findings) by using a variety of data collection methods and theoretical perspectives. Triangulation was used in this literature review by collecting both non-empirical and empirical data and a combination of qualitative and quantitative paradigms, which therefore meant approaching data from different perspectives (Siu and Comerasamy, 2013). This pluralistic approach helped to reduce bias.
Limitations
The methodological perspectives of the included studies were varied, specifically in relation to the method of induction of labour used. This may have influenced the findings of the research. To improve generalisability of the results of this literature review, it may have been preferable to include those studies that used one specific method of induction of labour. However, if the focus were to be solely on women's experiences of outpatient induction of labour using a specific method, this would have reduced the total number of studies used in the literature review, which would have resulted in less meaningful conclusions. The method of induction would have undoubtedly affected women's experiences of outpatient induction of labour—this is not to be ignored; however, it was the influence of the home setting itself that was the focus of this review. Therefore, if the focus was only on one method of induction of labour, the literature review would not have been comprehensive, due to limited available literature.
Recommendations
There needs to be further research into the safety of outpatient induction of labour. The highest amount of claim pay-outs in the NHS arise from maternity care, so there are understandable concerns regarding the lack of research on the safety of outpatient induction of labour. Outpatient induction of labour is distinct and different from other NHS outpatient services and has a greater focus on service user involvement and partnership, which supports the underpinning philosophy of midwifery care.
Further research into the views of clinicians and partners on outpatient induction of labour is required. Research also needs to be conducted into the method of observation and monitoring once the woman has been discharged to the community setting. This needs to be assessed from an aspect of both safety and feasibility, gathering women's views alongside an ongoing risk assessment (Smith, 2017).
NICE (2014) encourages the development of an audit tool when forming an outpatient induction of labour service; however, only 72% of NHS Trusts that had an outpatient induction of labour service were found to have an audit in place (Sharp et al, 2016). An audit would serve as a useful tool to analyse a contemporary service, and would enable wider comparative research into outpatient induction of labour with other NHS Trusts. This would enable sharing of findings on a broader scale, allow lessons to be learnt and recommendations to be implemented, and encourage the development of a clear protocol and patient pathway before outpatient induction of labour becomes fully integrated into clinical care (Sharp et al, 2016).
Conclusion
Gaining insight into the women's experiences of outpatient induction of labour is important, due to the fast pace at which maternity care is changing to meet women's needs as well as service demands. The literature on women's experience of outpatient induction of labour demonstrates that the home is a positive setting for induction, as it gives a sense of comfort and is preferable over a hospital setting. The home enables women to achieve a more normal experience to what was initially expected when the decision to induce labour was made. This provides women with a sense of control and freedom, which is important for psychological health and wellbeing. When compared to inpatient induction of labour, women were shown to feel more relaxed, to have the ability to sleep and were able do tasks that removed their focus on the induction itself. In view of these positive findings, outpatient induction of labour is a popular option for women. In contrast, for some women, being at home caused anxiety and there was a lack of understanding as to how best to monitor and supervise women and the fetus at home, which affected the reassurance that women felt once they were home.
Although recommendations suggested the need for a clear protocol and patient pathway in view of regional variations, it is evident that adopting a one-size-fits-all approach is not always appropriate, as women's responses vary and require a more individualised approach. Frontline staff are more aware than ever of the direct effects of patient-centred care and increasing women's participation in maternity care, so it is important that reasonable choices are offered to women to enhance their experience. Women's preferences for labour and birth are complex, and this review provides information for health professionals to improve the experience for women, whether they have an outpatient or inpatient induction of labour. Outpatient induction of labour is not considered suitable for all women undergoing induction of labour, but research into women's experiences of outpatient induction can be applied to an extent for women undergoing inpatient induction, for example, by allowing partners to stay overnight and improving the hospital environment to make it homelier, similar to what is implemented in birth centres.
The literature review has identified themes similar to those in other research papers and therefore can be argued to have provided data saturation. Further research is required into outpatient induction of labour, particularly in relation to safety, cost, effectiveness and the view of the service for women, partners and clinical staff. There are appropriate means of doing so before these services are fully implemented in clinical care.