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A damning indictment of maternity care

The awful irony about maternity care, as an important new report from the US makes clear, is that it is the field that helped launch the evidence-based health care revolution.

The irony arises because is a field which is rife with examples of non evidence-based practice. Interventions which have been proven to be of benefit are not routinely implemented, while other interventions are widely used despite being ineffective or potentially harmful.

The report, Evidence-Based Maternity Care: What It Is and What It Can Achieve, is co-published by Childbirth Connection, the Reforming States Group, and the Milbank Memorial Fund.

While the report is firmly focused on US practice, many of its arguments are extremely relevant for Australia.  Just substitute “Australia” for “US” in the following excerpts, and see if it rings true…

“A large, growing body of systematic reviews is available to help clarify effects of maternity practices, yet these valuable resources are grossly underutilized in policy, practice, education, and research in the United States.

Practices that are disproved or appropriate for mothers and babies in limited circumstances are in wide use, and beneficial practices are underused.

Rates of use of specific practices vary broadly across facilities, providers, and geographic areas, in large part because of differences in practice style and other extrinsic factors rather than differences in needs of women and newborns.

These gaps between actual practice and lessons from the best evidence reveal tremendous opportunities to improve the structure, process, and outcomes of maternity care for women and babies and to obtain greater value for investments…

Although most childbearing women and newborns in the United States are healthy and at low risk for complications, national surveys reveal that essentially all women who give birth in U.S. hospitals experience high rates of interventions with risks of adverse effects…

Many maternity practices that were originally developed to address specific problems have come to be used liberally and even routinely in healthy women. Examples include labor induction, epidural analgesia, and cesarean section. These interventions are experienced by a large and growing proportion of childbearing women; are often used without consideration of alternatives; involve numerous co-interventions to monitor, prevent, or treat side effects; are associated with risk of maternal and newborn harm; and greatly increase costs.

Mothers, babies, and purchasers would benefit from giving priority to effective, safer care paths and using risky interventions for well-supported indications only or when other measures are inadequate.

The following practices would instead be consistent with the framework of this report: avoiding induction for convenience; using labor support, tubs, and other validated nonpharmacologic pain relief measures and stepping up to epidurals only if needed; and applying the many available measures for promoting labor progress before carrying out cesarean section for “failure to progress.”

Such protocols would require considerable change in many settings, but would lead to a notable reduction in the use of more consequential procedures and an increase in cost savings. Available systematic reviews also do not support the routine use of other common maternity practices, including numerous prenatal tests and treatments, continuous electronic fetal monitoring, rupturing membranes during labor, and episiotomy.

Systematic reviews also clarify that many effective maternity practices with modest or no known adverse effects are underutilized. Greater fidelity in providing these forms of care would lead to improved outcomes for many mothers and babies. In pregnancy, such care includes prenatal vitamins, smoking cessation interventions, measures for preventing preterm birth, and hands-to-belly maneuvers to turn fetuses to a head-first position before birth.

The many beneficial, underused practices around the time of birth include continuous labor support, numerous measures that increase comfort and facilitate labor progress, nonsupine positions for giving birth, delayed cord clamping, and early mother-baby skin-to-skin contact.

Best available evidence also supports providing access to vaginal birth after cesarean (VBAC) for most women with a previous cesarean.

Systematic reviews also identify many strategies for increasing both establishment and duration of breastfeeding and effective ways to treat postpartum depression. However, comparing current maternity care practice and performance in the United States to lessons from the best available research and to performance benchmarks reveals large gaps.

Consistent with common patterns of innovation in medicine (McKinlay 1981), obstetric practices such as episiotomy (Graham 1997) and electronic fetal monitoring (Graham et al. 2004; Hoerst and Fairman 2000) were adopted prior to adequate evaluation. Implementation of best evidence has proven to be extremely difficult following adequate evaluation.

Therefore, many practices that are disproved or appropriate for mothers and babies only in limited circumstances are in wide use. Conversely, numerous beneficial practices are underused because they offer limited scope for economic gain, are less compatible with predominant medical values and practices, have only recently been favorably evaluated, or due to other reasons.

Beyond average overall gaps between evidence and practice, use of specific maternity practices varies broadly across facilities, providers, and geographic areas. This is primarily due to differences in practice style and other extrinsic factors rather than differences in needs of mothers and newborns.

These gaps between where we are and what we could achieve present opportunities to improve the structure, process, and outcomes of care for mothers and babies and to obtain greater value for investments.”

Comments 2

  1. Joan Halford says:

    Is this true? Not using evidence-based practice? If so it is shocking and there is no wonder a lot of women are sceptical and opting out of the system. Can there still be a field of medical practice that systematically thumbs its nose at research and evidence? I find these allegations hard to swallow, yet on the other hand women and medicine have such a gory history that it is quite on the cards.

    Talk about playing into the hands of the quasi-religious home-birthing movement. Most women may not know why, but many have a strong sense that hospital births are not being done in the best way, albeit often with little clue as to the relative risks and benefits. Time to lift your game, fellas. Tell us the truth. Some of us incubators are sceptics who have studied science. If it turns out you are just as waffly as the touchy-feelies, we’ll be onto you.

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Australian Palliative Care Conference
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