Women's Childbirth Experiences in the WILL Randomised Trial: A Mixed Methods Analysis
Chronic or gestational hypertension complicates 7% of pregnancies, half of which will reach 37 weeks' gestation. Observational data suggest that early term birth (at 37 to 38 weeks) may reduce maternal complications (e.g., preeclampsia), Caesareans, stillbirth and costs of maternal fetal surveillance; however, early term birth may increase neonatal morbidity. There are no high-quality data on which to base timing of birth for this high-risk population.
The WILL trial (When to Induce Labour to Limit risk in pregnancy hypertension) aimed to address the optimal timing of birth for women with chronic or gestational hypertension at term gestational age, when women remain well and there is no evidence of pre-eclampsia. WILL was a multicentre randomised trial of 403 women with chronic or gestational hypertension, who were randomised at 37+0–6 weeks' gestational age to either ‘planned early term birth at 38+0–3 weeks’ gestation' (N = 201, intervention group) or ‘usual care at term’ (N = 202, control group); the trial was stopped early by the funder due to slower-than-anticipated recruitment during the COVID-19 pandemic. The clinical outcomes and costs favoured the intervention group. While in the intervention (vs. control) group, there was no difference in the co-primary outcomes of ‘poor maternal outcome’ (severe hypertension, maternal death, or maternal morbidity; 27, 13% vs. 24, 12%, respectively) or ‘neonatal unit admission for ≥4 h’ (14, 7% vs. 14, 7%, respectively), or Caesarean births (58, 29% vs. 72, 36%, respectively), there was a significant reduction in pre-eclampsia (56, 27.9% vs. 76, 37.6%, respectively) and costs for tests of maternal or fetal wellbeing (102.84, 95% CI −136.65 to −67.78).
In addition to clinical outcomes and costs, patients' experiences were evaluated in the WILL trial. As with all health policy, it is important that timing of birth recommendations be associated with positive psychosocial outcomes for women, particularly as dissatisfaction with the childbirth experience has been associated with negative consequences, such as on breastfeeding, infant bonding and postpartum mental health. In this article, authors described the experiences of women in the WILL trial, as evaluated by the Childbirth Experience Questionnaire (CEQ) and their associated free-text comments.
In intervention (vs. control) groups, the CEQ was completed by 177/202, 88.1% (vs. 180/202, 89.1%) participants, and 378 free-text comments were made by 93/177, 52.5% (vs. 98/180, 54.4%) participants. There was no significant difference in CEQ scores overall (3.1±0.4 vs. 3.1±0.4, respectively) or by domain (‘Own capacity’ [2.8±0.5 vs. 2.7±0.5, respectively]; ‘Professional support’ [3.7±0.5 vs. 3.7±0.6, respectively]; ‘Perceived safety’ [3.2±0.6 vs. 3.1±0.6, respectively]; and ‘Participation’ [2.6±0.7 vs. 2.7±0.6]). Most comments were positive (222/378, 58.7%), and about ‘Relational care and care interactions’ (CEQ ‘Professional support’). Neither the number nor positivity of comments appeared to differ between groups.
In this trial of 403 high-risk women with chronic or gestational hypertension, randomisation to planned early term birth at 38+0–3 weeks (vs. usual care at term) resulted in a similar childbirth experience overall, by CEQ domain, and whether labour induction or adverse outcomes had occurred. Just over half of women who responded to the CEQ provided free-text comments, and most were positive, particularly regarding ‘Relational care and care interactions’ (CEQ ‘Professional support’ domain). Also, most comments endorsed the ‘Conceptualising safety’ theme, even when labour induction did not go as planned. However, it was clear that labour induction was not always viewed positively, in both arms and across themes of ‘Capacity for autonomy over care’, ‘Experiences of labour and birth’, and the less frequently-endorsed themes of ‘Lack of shared decision-making’ and ‘Experience of participating in research’. Repeatedly, women described logistical issues related to initiation of labour induction, lack of information, the process not going as they had expected, uncontrolled pain, and not always being listened to.
For women with chronic or gestational hypertension who remain well at term gestational age, authors found no difference in childbirth experience between women randomised to planned early term birth at 38+0–3 weeks' gestation, compared with usual care at term. This was true regardless of initiation of birth, mode of birth, or pregnancy outcome, and in directed content analysis of free-text comments. Based on these findings, shared decisions about the timing of birth may be more influenced by differences in clinical outcomes and costs. Additionally, labour induction experiences may be improved with good information sharing and preparation, to facilitate a sense of ownership and control of labour.
Source: Sue Tohill, Katie Kirkham, Eleni Gkini; BJOG: An International Journal of Obstetrics & Gynaecology, 2025; 0:1–12 https://doi.org/10.1111/1471-0528.18257
