 I would like to introduce the speaker, which is Ines Rosman. And Ines works as part-time researcher at the Flemish Federation of Midwives, VBOV, focusing on strengthening evidence-based midwifery care. She regularly writes research articles and recently led the development of two campaigns. Birth choices, shared informed decision-making about birth options with respect for your decision, and move freely swing your belly, freedom of mobility during labor and birth. In your own practice, Lava Yoga, Ines has been passionately supporting over the past seven years parents and children with yoga, mindfulness and body work from preconception to the first 1001 days postpartum. She is a certified perinatal yoga, baby yoga, baby massage and kid's yoga teacher. Ines works intensively with different body work techniques, such as craniosacral therapy, energetic body work and perinatal rituals. Her heart's wish is to support women to come home to themselves, as women, as mothers, partners, sisters, and to surrender to life transformational times with a large portion of malveness and humor and by building women's confidence in their intuition and feminine wisdom. She's particularly fascinated by restorative power of movement and rest. Ines grew up in Germany, but she has been living in Belgium for 16 years now. She is 45 years old and bobo, a proud mother of an 11-year-old son. Before Ines started to work as perinatal and childbirth worker, she used to be a globetrotter and worked for more than 10 years as an economist with a master of science. In development cooperation in English-speaking Africa and Southeast Asia. Okay, and now we will start the presentation. Okay, well thank you for this wonderful opportunity tonight to be able to present our findings from our systematic review of induction of labor. And we undertook that research on induction of labor here at the Flemish Association for Midwives throughout the whole of last year. And of course, many of our colleagues contributed to this research, and I'd like to highlight them as well here, which you can see here on the slide. So without them, this research wouldn't have been possible. The rising inductions of labor is a phenomenon which cannot be ignored anymore. And I'm sure that is a trend or a phenomenon which is also taking place in your country. And we believe that it's very crucial to investigate critically and thoroughly this phenomenon because induction of labor impacts a large population of women. In some countries, the rate of induction is about 20%, a fifth or 30%, like in our region in Flanders, in other countries it may be even higher than 40%. So it impacts a large share of pregnant women. Secondly, it's important because it has ethical consequences. Induction of labor impacts the rights of parents and the choices they have during labor and birth. Here in Flanders, for instance, if women are induced, they can only birth in the hospital. And they may not be able to take their own autonomous midwife with them into the hospital. So it has an impact on the range of choices women have. And as you will see in a minute, because the evidence on induction is not that straightforward, it's quite a complex shared decision making process. And throughout that process, it's very important that we always remind ourselves that we have the full respect of the choices of parents, whatever they may be. So in that sense, it's a very important phenomenon with ethical consequences on that shared decision making process. And of course, induction of labor is an intervention into the physiology of labor. And as such, it shapes the work midwives do. We do as midwives, we counsel and support women mostly in low-risk environments and we are four fighters of the physiology of birth. So if inductions are rising, this has an important impact on the work of midwives. And also it shapes, because of the large impact of large shares of populations of pregnant women, it shapes also the opportunity to actually experience a physiology, a normal or a better birth. And as such, as we will also see later on in our findings of our research, it has an impact on the maternal satisfaction and the birth experience. So it is also a mental health issue. And that was the reason why we in Flanders here wanted to investigate that trend in rising inductions, which was taking place here in Flanders more thoroughly. And before I try to get into the details of our systematic review, let me first explain a little bit more about our healthcare contacts so that you can place the findings we made in a bit more Flemish care context. In Flanders, which is a part or region of Belgium, most women birth in the hospital. If we look at the National Registry data, we see that only 0.8% of all births are taking place at home in 2021. And we also at the Association undertook our own registration over the past two years of all midwifery-led births in Flanders and Brussels. And we included not only home births, but also births which took place at a birth center, both at the hospital or outside of the hospital and a midwifery-led unit. And there we found that it was 1.67% in 2020. So either way, we see most women birth at the hospital, and also most women be at high or low risk accounts or by the gynecologist. And then generally we see a high medicalization context here in Flanders. Induction rates are 27%. C-section rates 22%. Hypozotomy 35% and epidural anesthesia is very high. So within that context that we are operating in, we saw that in the year of 2021, we were confronted with the situation of rising inductions. As you see here in the slide, induction rate rose from 23.8% in 2012 to 27% in 2021. We saw in 21 a huge variation across hospitals. So where some hospitals have induction rates of 14%, others had 40%. So a large variation across hospitals. We also saw that induction rates are highest among others, about 40 years old. Induction rates rise with the BMI and for women suffering from hypertension and diabetes. But most interestingly is that we saw that in the same period while inductions were rising, that C-sections actually also continued to rise from 19.7% to 22% in 2021. Also perinatal mortality did not improve. And induction of labors is the second highest contributor in preemie paras to C-sections. If we classify it according to the Robson categories, we see after repeated C-sections, inductions in preemie paras are the second highest contributor to C-sections. And that is very important to notice because you may have read or heard or been confronted by the fact as well that in the period around 2019, a lot of large scale randomized control trials took place. For instance, the arrive trial in the United States, the sweepest trial in Sweden, the index trial in the Netherlands, and also a number of systematic reviews took place in that same period. And they looked at the effects of induction of labor at 39 weeks or 41 weeks and they concluded that inductions would lead to lower C-section rates and to less stillbirths. And that is really something we need to be allowed about because many of the changes in the induction policies across several countries were inspired by those findings of those large scale RCTs. But if we look at the epidemiological trends at the moment, we actually see an opposite picture that C-sections continue to rise and that perinatal mortality isn't improving. So we need to be very critical of that. And given that context, we wanted to understand here in Flanders-Better what consequences are there, what is the evidence on inductions of labors and on maternal and neonatal outcomes on C-sections. And we first looked at, well, what is the evidence base that was available at that time. And we realized actually that in terms of national guidelines on inductions, we were in a situation that we were having very outdated guidelines on inductions of 2010. And we undertook a small survey, an informal survey across all our 53 maternity wards and hospitals in Flanders. Based on that informal survey, we saw that there was indeed a change in induction policies taking place where until 2019, most hospitals would follow the guidelines we have from 2010, which advise that an induction of labor is acceptable from 41 weeks onwards. So we saw that hospitals would induce or suggest an induction from 41 weeks, three days to five days until 2019. And afterwards, partly inspired by those many large-scale RCTs on induction of labor, we saw a trend that more and more hospitals are inducing women earlier, somewhere depending on the hospital between 40 weeks and 41 weeks and zero days. And indeed, our survey confirmed that there is a lot of variation across hospitals in terms of induction rates, as we saw already a moment ago, differing between 14 and 40%, but also a lot of variation between the indications used for inductions, but also the induction methods and the way the shared decision-making process is taking shape. So in that context, we thought, OK, well, if we don't have any recent national guidelines and given the fact that those RCTs and systematic reviews of that period of 2019 triggered the change in policy, we wanted to look at those evidence in more detail and preferably also include more recent evidence. So what we did is that we included in our systematic review of, we included clinical guidelines and scientific studies. And whereas the clinical guidelines we included, we saw that they were based on limited evidence. That means most of them they are based on RCTs, so randomized control trials, or systematic reviews of randomized control trials. They hardly included observational studies. So we decided in our systematic review that we also wanted to include observational studies. The other difference is that existing clinical guidelines across different countries are mostly based on evidence until 2019, 2020, and in our systematic review we try to include also studies up to 2022, so more recent evidence. And then we basically focused on three questions, three resource questions. First we looked at, OK, what is the effect of induction at 41 weeks on maternal and neonatal outcomes? And there we included seven guidelines, 15 studies, of which nine are observational studies. And the second question we looked at 39 weeks gestational age and what the effects of induction would be at that point in the pregnancy. And the third question we looked at was, what are the effects of induction of labor on the birth experience of women? And here we found a lot of studies, 39 studies, all looking at the different aspects and facets of the birth experience. In addition, we collected all sorts of stories, birth stories from others, from families. And as I said already, we also took into account the different clinical practices taking place across Flemish hospitals. Before I go into all the details of that, let me just point you to the website where we also have our systematic review available. The full version is in Dutch, but we prepared an English abstract or summary of the study. And if you are interested in more detail, we are more than happy to translate or assist you in finding the detailed statistical information or the conclusions. But as a result of that study on induction of labor, we also started our campaign, as Lisa already said, on birth choices. She had informed decision-making about your birth options with respect for your choice because we felt that one of the actions is to bring all that evidence in a way towards parents so that they can make better birth choices around induction versus expectant management. Let's have a look at the findings. I won't go into all the details, what you see here on the slide. I suggest that you take also the original article at hand and have all the statistical information and description of all the different studies. But if we look at the first two research questions, basically the conclusion here is that both at 39 weeks, that's the right column, and at 41 weeks, that the evidence is not clear. So there's no unambiguous evidence in favor or against induction of labor at 39 and 41 weeks. When we look at C-sections, when we look at different maternal outcomes and neonatal outcomes, so here we can conclude there is no clear evidence in spite of what we might think as a result of the different studies that took place around 2019. And that conflicting evidence or unclear evidence across studies has mostly to do with the type of studies which were undertaken. I'll come back to that in a minute and the way the studies were designed or the context, a care context in which they took place. And more generally, we see that recent evidence, so after 2020, and that evidence from the observational studies, which are included in our systematic review, they show more often no or unfavorable effects of induction. And that's very important to notice. And let me just point out a number of those study limitations, because it's very important to dig deeper when you look at the different study results and to understand why maybe the results in an RCT, a randomized control trial, might be different from the outcomes in an observational study. So what we noticed in our systematic review, first of all is, of course, RCTs are evidence which tend to have a higher quality of the evidence when compared to observational studies, because RCTs are looking at the effects of interventions in an ideal world, whereas observational studies are looking basically at the effects of an intervention in real life. So RCTs may not be that interesting or may not be that applicable to real life or daily healthcare situations, because they take place in an ideal world. And to give you maybe two examples to explain a bit more what I mean. So for instance, when you looked at the arrive trial, that's a randomized control trial, which compared induction of labor at 39 weeks, compared to expectant management in the United States, which was heavily criticized. And one of the critical points was that if you looked at the C-section rates in the RCT, the arrive trial, you saw the C-section rate of 18%, whereas if you looked at across the United States, most of the times in different regions, C-section rates were much, much higher between 37% and 40%. So that basically may imply that healthcare providers that take part in a randomized control trial in this trial, in the arrive trial, may have been following much more strict the protocol than they would have been doing in daily life. And that's important to notice. Another example is, for instance, a new study which just a couple of months came out by Bruinsma et al. It is an observational study which has taken place alongside the index trial in the Netherlands and the index trial basically looked at that time at a randomization, splitting women at random into a group of induction and into a group of expectant management, but that new study, new observational study basically split groups according to their preference. That means they split groups in a way that if I, as a pregnant woman, preferred induction, I would be put in the group of induction and treated with an induction. If I preferred expectant management, I would be treated with expectant management. And what we found in that study was that, first of all, if you look at the preference of women, most of the women actually want to wait. Most of the women prefer to go spontaneously into labor. They don't want to be randomized into an intervention, either induction or expectant management. And in that study, you also saw that women who prefer to wait may be mentally and physically more healthy. And if women are treated according to their preference, then you see that there are actually hardly any differences in C-sections or stillbirths between induction and expectant management. So it matters what the preferences are of the women and it matters for the effects of induction versus expectant management. So you see here already what the difference in the type of studies and the design has on the findings of such a study. Just to mention another obstacles or limitations we found in those studies which might explain the difficulty and the conflicting evidence is that many of those studies, RCTs, it was actually not really known which induction methods were used. We also saw huge differences in the definition of the intervention and the control groups. Some studies use the next week's method, others use the index week method, still others use some sort of combination of the two. And some of the studies took place in a midwifery led context while others took place in the physician led context and that all may seem to play a role in those findings of those studies. So in that sense to round that off we found no clear, no straightforward evidence of either favorable or unfavorable effects of induction of labor either at 39 or 41 weeks. But what we can say here is that given the many study limitations very important to dig deeper and we hope that with our systematic review by including also the recent studies since 2020 and also the evidence from observational studies that this might help to shed some new light on the mantra which may have been used quite strongly since 2019 on the effects of induction on C-sections and still births. Then when we looked at our last question what are the effects of induction on maternal birth experience here the evidence is quite straightforward. Most of the studies and as I said we found 35 interesting studies that we found that induction has a higher chance of negative birth experience and why is that? Why do women experience an induction or tend to have a more negative birth experience? A lot of factors play a role and the most important one seems that women are dissatisfied with the shared decision-making process. That means many women felt that they don't get all the information they don't get balanced information they don't get evidence-based information not only on the advantages and risk of induction but also on the alternatives which is waiting, which is expected management. Women also felt that the care paths that make are difficult if you want to refuse induction they also often felt that the recommendation for an induction was rather binding and not a real choice they had sometimes they even felt pressured into being induced and that there was insufficient respect if they didn't want to be induced. Another aspect of that birth experience is that women who were induced often felt a sense of loss and that sense of loss can have different aspects just to mention two. One which came out of the studies quite often is that women feel a sense of loss because they give up their original wish for a natural birth. As I said already a minute ago the study which was taking place in the Netherlands but also other studies we found indicate that the majority of the women lived spontaneously. In that sense induction may give a feeling or a sense of loss of that original wish to spontaneously birth the child. And also women often felt a sense of loss of control and autonomy because of course induction of labor has implications depending on the induction method used on the time you spend in the hospital but also on freedom of mobility because of higher pain sensations you might need an epidural and that has all sorts of consequences. Women felt that they must fit into a routine protocol and many of the women indicated that they struggled with the higher pain sensations as a result of inductions and that led to the fact that they ended up having an epidural in his teacher which in turn limited the freedom of mobility they might have been even more monitored with CTG and a cascade of interventions was set off. So that's what women generally made them more dissatisfied and as I said a minute ago also in those studies on the birth experience and maternal satisfaction we saw that the preferences and the characteristics of women may play a role in that sense of being satisfied with an induction. So this is something we really really need to consider when talking to parents about inductions and when discussing the different birth options that the birth is more than just a healthy baby the birth experience, the psycho-emotional aspects of the birth are as important and it seems from the studies that this plays a very important role when women are being induced. We also found a number of studies which looked at the experience of healthcare providers there were not many but what we found here is that healthcare providers are generally concerned of course that more and more women are induced earlier that there is no consensus both within midwives, first line, second line but also cross professions, gynecologists and obstetricians and pediatricians in terms of indication methods and indications and terms and generally healthcare providers feel very demotivated to understand the evidence of induction. There are too many studies as we saw I mean we already included more than 40, 50 studies in this review so it's very difficult to also understand and have the skills of interpreting the studies right and healthcare providers felt that they also don't have the right skills to bring across such a complex birth choice and how to communicate and counsel women and parents in their process and there's generally a huge lack of decision aids on induction. So what can we conclude from our systematic review? Well first of all and it might seem obvious but if we look at the discussions which take place nowadays here also in the Flemish context is that we always have to remember induction is an intervention an intervention into the physiology of childbirth and it has eatrogenic effects it has effects on the freedom of mobility it has effects on epidural anesthesia it has effects maybe on fetal monitoring and etc and it has effects in the short term and long term on babies as well and although maybe for specific indications inductions of labor may make sense the routine induction of large populations before or at 41 weeks is however madness and not evidence based and that's really something we need to bring home to different professions within our profession and we also see that there is an increasing number of medical indications used to justify induction without solid evidence the recent studies of the last year which have taken place on gestational diabetes on whether women with an elevated BMI or which are older than 35 years old or phytomacrosomia might be indications for inductions but there the evidence is not clear and so we need to be very careful in using those indications as a reason to suggest induction of labor to parents also what we found very important in that whole dialogue and if you read the guidelines in more detail they also make that point that some risks for mother and child may increase after 41 weeks including stillbirths but first of all they are very low and secondly this is a continuum it's not that we suddenly at one day at 41 weeks and zero days suddenly have this elevated risk for mother or baby it's a continuum and we actually do not know at what point in time that might be increasing exactly for that specific woman because after all there is a huge physiological variation in the estimated due date some studies indicate that ethnicity and the weight of mothers and the parity and et cetera all play a role in determining the estimated due date so if we induce routinely large scale of large amounts of pregnant women this seems rather madness also recent studies show and that are all aspects we think are very important to take into that dialogue across different professions is that a lot of studies show the beneficial effects of going into spontaneous labor the natural like oxytocin versus synthetic oxytocin how that impacts the way women deal with labor how that impacts the progress in labor and also the risk of induction medications some studies take place recently on the effects of synthetic oxytocin on uterine contractions and the blood flow to the uterus and how that affects the stress level and anxiety levels of women so that's something we shouldn't underestimate in that discussion so generally to round off we think it's very important whenever we talk about induction to parents that it needs to be a shared decision making process and we first need to understand what are the vision or the values or the preferences of women the experience and the possibilities that shape that discussion and we really need to carefully weigh possible risks on stillbirth or neonatal morbidity while on the other hand there are also potentially disadvantages of inductions of labor and how to weigh that and what that means to parents is up to the parents to decide so as a healthcare provider we can provide the information and it's our duty to provide objective information evidence-based information and in that sense we can facilitate in that discussion with the parents so to round off here it's important to whatever the evidence is to translate that towards individualized woman-centered care yeah okay thank you okay we have five minutes to go if there's any questions we have time to take one I I have one a quick one how do you engage with this difficult discussion with other healthcare providers yeah I would be very interested in how in your country or in your healthcare context how you engage in that difficult dialogue with gynecologists with patricians, with pediatricians with psychologists because for us this is an important issue but how to engage in such a difficult conversation we would love to hear your experiences good practices, do's and don'ts okay thank you very much and well maybe it was to give my email address Eliza to yeah let me just check you yes so if women or if participants have still more questions or want to share experience you can reach me at this email address well this is the Dutch about this one below here okay thank you very much Ines