Evidence based care, as the name suggests, is providing healthcare that is proven by scientific evidence to be beneficial. Defined as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’. ‘Well I should hope so!’, I hear you cry; ‘as if Doctors/ Nurses/ Midwives are just making it up as they go along?!’. Hopefully not, but like with everything in life it’s never as black and white as that!
So why am I blogging about such a seemingly boring subject? Well, delivering evidence based care is a subject that is really close to my heart because I recognise how fundamental it is to upholding one of the founding principles of healthcare – do no harm. I find the idea that a care provider that is there to care for you is actually causing you harm both uncomfortable and difficult to accept. However, far too often in maternity services we do things that inadvertently do cause harm.
Don’t get me wrong, I’m not suggesting that clinicians do these things knowingly; nor would I suggest for a minute that any of my colleagues come to work to do anything other than their best for mums and babies. But far too often in maternity services (and wider society!) we forget that pregnancy and birth are normal, yet momentous and remarkable, life events for the vast majority of women. I’ve mentioned before in another blog, the founder of the Cochrane Library (a library of research dedicated to helping deliver evidence based care) and general evidence based care aficionado awarded maternity services a wooden spoon award for basically being a bit rubbish at providing evidence based care. It’s a real dilemma as there is absolutely no denying that access to midwives (and doctors, where required) improves outcomes for mums and babies the world over. Improvements to the quality and frequency of antenatal care have contributed significantly to the reduction in maternal mortality over the last century. However, the scope and purpose of good antenatal care pathways (such as we have in the UK) are to monitor. To check that everything seems to be developing ‘normally’. And of course, there are wide variations of ‘normal’, sometimes it is difficult to know what is unusual, yet normal, and what is actually ‘abnormal’. This is where the evidence should kick in, but unfortunately it doesn’t always.
Using prolonged pregnancy as an example – pregnancies extending beyond 42 weeks of gestation are considered prolonged. Why? Who decides? How did they decide (I must have driven my mentors mad as a student with all of my questions 🤓, I started reading the evidence - picking it apart as far as I could and I did a Masters in Clinical Research to help satisfy this curiosity, but I’m still curious!)? When you read the evidence that informs the NICE guideline* on how to ‘manage’ prolonged pregnancy, it’s poor quality - a lot of it is based on case reports which are not really good enough by today’s standards. It’s old - only two studies since 1990. It’s not generalisable to UK populations - a lot of it was carried out in the developing world, where things may be done differently and potentially less safely. It’s biased – women were included who shouldn’t have been included, they compared apples and oranges, so to speak. I’m not suggesting that there is no such thing as prolonged pregnancy or that there are no risks associated with it - there is some evidence after all. I’m merely saying that the truth is on this issues is that we don’t really know the answer. For some women it will be abnormal to be pregnant beyond 42 weeks, for others not. What I can say with certainty is that the evidence is not compelling enough for how many women are induced for prolonged pregnancy and certainly not compelling enough for the ridicule that women are sometimes subjected to for declining induction.
Consequently, it is clear that receiving evidence based care can often be tricky in maternity services! A lot of the time things are done because that is the way they have always been done or because it appears the evidence supports it. However, it may well be the case that on further scrutiny the evidence supporting a particular decision isn’t terribly compelling, but that’s not the same as not having any evidence.
So, in the absence of a true evidence base to justify interventions what can we do? The next best thing in my humble opinion is to take the time to explain what we do and don’t know to women and their partners so that they can decide what feels like the right option for them. Unfortunately in a cash strapped, time poor NHS this isn’t always easy, and we don’t always have time on our side to make a decision (although more often than not you do have enough time!). Historically medicine has also utilised a fairly paternalistic approach and assumed that women want to be told by a doctor what to do. While I am happy to report this has changed a lot since I started out, there are still a few clinicians (young and old, male and female) who need a gentle reminder that women have a right to choose. There are also a number of things you can do before you have your baby that will definitely help!
1. Do your research – it’s never been so easy to find information as on the web (be discerning though, there is some utter nonsense out there too!). You don’t have to know in detail exactly how you want everything to be, but if there are things you feel very strongly about, read up on them and include them in your birth plan.
2. Find some good quality antenatal classes – I try very hard to consolidate my decade of knowledge and experience into 10 hours, although it is rather tricky!
3. Join / contact / read Association of Improvements to Maternity Services (AIMS) – they have been campaigning for improvements to maternity services for years and are an absolute treasure trove of good quality well informed resources and advice.
All of these things will help you to get evidence based care, but what’s even more important is that the care you are receiving is right for you. We are all individuals with different attitudes to risk and different preferences. By taking the time to do a bit of research we enable ourselves to take responsibility for our birth which in turn helps us to have the experience that we want, i.e a positive one! So what are you waiting for – start swotting today!
*NICE is The National Institute for Health and Care Excellence and they produce national guidance on care pathways in the UK. They were only established in 1999 which is just a few years before I started my training, before that the difference in care pathways would have varied enormously from one hospital to another!