Celebrating Black History Month: Honouring Black Midwives, Nurses and Obstetricians — and Why It Matters to Real Birth
17 October 2025
Intervention, Informed Choice, and Why the First Birth Matters
Abstract
Induction of labour (IOL) rates in the UK have risen steadily over the past decade, alongside increasing caesarean section rates and declining spontaneous onset of labour. These trends have developed within the context of national maternity safety initiatives, including the Saving Babies’ Lives Care Bundles, and repeated system-level reviews highlighting the importance of personalised, informed care. Despite sustained efforts to improve outcomes, stillbirth rates have plateaued in recent years and maternal mortality has increased. This journal article examines national trends in induction, mode of birth, and stillbirth; explores the significance of the first caesarean; and considers how informed antenatal preparation and labour support may contribute to improved outcomes and experiences for women and babies, including the early postnatal transition.
Introduction
UK maternity care has undergone substantial change over the last decade. Induction of labour, once a relatively infrequent intervention, now accounts for approximately one third of births in England, while caesarean section rates continue to rise and spontaneous onset of labour becomes less common (NHS England, 2024). These changes have occurred alongside increasing clinical complexity, workforce pressures, and heightened focus on risk identification and prevention.
For midwives and student midwives, understanding these trends is essential. Decisions about induction, monitoring, analgesia, and mode of birth are now routine components of maternity care pathways, particularly for first-time parents. However, national reviews have consistently highlighted that safety is not determined by intervention alone, but by how care is communicated, experienced, and individualised (NHS England, 2016; Ockenden, 2022).
National Trends in Onset of Labour and Mode of Birth
NHS England maternity statistics demonstrate a sustained increase in induced onset of labour over the past ten years, rising from approximately 26% of births in 2015 to around one third of births by 2023–24 (NHS England, 2024). Over the same period, caesarean section rates have risen steadily, while spontaneous onset of labour and vaginal birth have declined.
When viewed together, these measures illustrate a clear population-level shift in how births begin and how they are completed. Importantly, these data are descriptive rather than explanatory. They do not indicate causation, nor do they capture individual clinical context, but they provide essential background for understanding contemporary maternity care.
Onset-Based, Not Indication-Based, Reporting
National induction of labour data reported by NHS England are onset-based rather than indication-based. Births are categorised according to how labour began — spontaneous, induced, or caesarean before labour — without routinely capturing the clinical indication for induction (NHS England, 2024).
As a result, national statistics cannot distinguish between inductions undertaken for clear medical reasons (such as hypertensive disease, fetal growth restriction, or reduced fetal movements) and those offered for broader risk-management or organisational reasons, including post-dates pregnancy or service capacity pressures. While onset-based reporting enables consistent national trend analysis, it limits interpretation of causality and appropriateness. Rising induction rates therefore cannot be assumed to reflect increasing pathology alone and should not be used in isolation to assess quality or safety of care. There are risks and benefits to this intervention, these should both be clearly discussed with women and people being offered induction.
Induction of Labour, Intervention, and Caesarean Birth
The relationship between induction of labour and caesarean birth is complex and frequently misunderstood. Randomised controlled trials comparing induction with expectant management in selected populations have demonstrated that induction does not necessarily increase caesarean rates (Middleton et al., 2018). However, real-world national data indicate that a substantial proportion of induced labours — particularly in nulliparous women — result in caesarean birth (NMPA, 2024).
Induction often alters the physiology and experience of labour through cervical ripening, pharmacological augmentation, increased monitoring, and longer labour duration. These factors increase the likelihood of escalation to operative birth, particularly in first labours, where physiological labour patterns are still being established.
The Significance of the First Caesarean
The first caesarean section represents a critical inflection point in a woman’s reproductive life. Women who have a caesarean in their first pregnancy are significantly more likely to have caesarean births in subsequent pregnancies, either electively or following attempted vaginal birth after caesarean (VBAC) (RCOG, 2015).
National guidance indicates that spontaneous labour is associated with higher VBAC success rates, while induction or augmentation following a previous caesarean increases the likelihood of repeat caesarean and other risks (RCOG, 2015). At a population level, rising primary caesarean rates together with increasing induction therefore contribute to sustained growth in overall operative birth rates over time, reinforcing the importance of supporting first births carefully and thoughtfully.
Stillbirth Prevention and the Saving Babies’ Lives Care Bundles
The Saving Babies’ Lives Care Bundles (SBLCB) are embedded within contemporary maternity care pathways and have strengthened approaches to fetal surveillance, smoking cessation, and risk recognition (NHS England, 2023). These initiatives have improved awareness and earlier identification of potential complications, and even small percentage reductions in stillbirth represent individual lives and families and should not be minimised.
However, national data indicate that stillbirth rates in England have remained relatively stable at approximately 3.9–4.0 per 1,000 births in recent years (ONS, 2024). This suggests that while SBLCB interventions play a vital role in improving safety, their impact is shaped by broader system factors, including workforce capacity, continuity of care, access to timely assessment, and persistent inequalities. Stillbirth prevention should therefore be understood as a multifaceted endeavour rather than the outcome of a single intervention or policy.
Ethnicity, inequality, and stillbirth risk
National data demonstrate persistent inequalities in stillbirth rates by ethnicity in the UK. Babies born to women from Black and some Asian ethnic backgrounds experience significantly higher stillbirth rates compared with those born to White women (ONS, 2024; MBRRACE-UK, 2024). These disparities have been consistently highlighted in national maternity reviews and confidential enquiries, which emphasise that ethnicity itself is not a biological risk factor, but rather reflects the cumulative impact of structural inequality, differential access to care, communication barriers, and delayed recognition or escalation of concerns (NHS England, 2016; Ockenden, 2022). Importantly, evidence indicates that improving listening, continuity, and culturally responsive communication may play a critical role in addressing these inequalities. Within this context, supporting women to be informed, confident, and able to articulate concerns is not only central to personalised care, but also to equity and safety within maternity services.
Interpretation of combined onset, outcome, and stillbirth trends
Figure 4, illustrates national trends in onset of labour, mode of birth, and stillbirth rates over the past decade. Over this period, rates of induction of labour and caesarean birth have increased steadily, while spontaneous onset of labour and vaginal birth have declined. In contrast, the stillbirth rate, shown on the same timeline, has remained relatively stable, fluctuating around 3.9–4.0 per 1,000 births. While these measures are reported using different units (percentage of births for onset and mode of birth, and rate per 1,000 total births for stillbirth), their combined presentation highlights a clear shift towards increased intervention alongside a plateau in stillbirth reduction at a population level. These trends should be interpreted descriptively rather than causally and considered within the wider context of national safety initiatives, system pressures, and evolving approaches to risk management in maternity care.
Maternal Mortality and System-Level Risk
Recent confidential enquiries have reported a statistically significant increase in maternal mortality in the UK between 2017–19 and 2020–22 (MBRRACE-UK, 2024). Leading causes of death include thrombosis and thromboembolism, cardiac disease, and infection, including COVID-19.
These findings emphasise that maternal deaths are rarely attributable to a single clinical decision or mode of birth. Instead, they reflect complex interactions between medical risk, recognition, escalation, and system responsiveness. While mode of birth alone does not explain maternal mortality trends, the cumulative risks associated with repeat surgical birth remain an important consideration within population-level planning and counselling
Learning from Maternity Reviews: Information, Listening, and Choice
Successive maternity reviews, including Better Births and the Ockenden Review, consistently highlight failures in communication, listening, and continuity as central contributors to poor outcomes and experiences (NHS England, 2016; Ockenden, 2022). These reports emphasise that safety is not solely determined by clinical intervention, but by how care is delivered, explained, and experienced by women.
Supporting women and people to understand their options in labour — including the potential benefits and implications of induction, monitoring, analgesia, and mode of birth — is therefore a core component of safe maternity care, rather than an optional enhancement.
Informed Preparation, Experience, and Early Postnatal Outcomes
Evaluative evidence suggests that informed antenatal preparation, continuity of care midwifery, and effective labour support are associated with improved engagement, communication, and adaptability during labour. When women enter labour with a clearer understanding of physiological processes and potential interventions, they are better positioned to participate in shared decision-making and to navigate changes in care.
Positive birth experiences are also associated with improved postnatal wellbeing, including maternal mental health, infant feeding, bonding, and early neonatal physiological regulation. These early experiences play a critical role in supporting the newborn’s transition to extra-uterine life and shaping longer-term family wellbeing
In this way, informed preparation should be understood not as an alternative to clinical intervention, but as a complementary safety mechanism that supports timely escalation, trust, and continuity of care.
Conclusion
Rising induction and caesarean rates in UK maternity care must be understood within a broader system context that includes national safety initiatives, workforce pressures, and evolving approaches to risk. While interventions such as induction of labour and caesarean birth remain essential components of modern maternity care, evidence from national reviews and service evaluations highlights the central role of informed choice, communication, and continuity in shaping both outcomes and experiences.
For midwives, supporting women to enter labour informed and supported — particularly in first births — represents a powerful opportunity to improve safety, experience, and the early postnatal transition for women and babies alike.
References
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