Evidence-based maternity care means practices that have been shown by the highest quality, most current medical evidence to be most beneficial to mothers and babies (reducing incidences of injuries, complications, and death), with care tailored to the individual.
“Standard” or “routine” care (the care that the vast majority of women receives) in most hospitals in the U.S. is not evidence based. That is, it is not based on the most current, reliable scientific research.
Here’s a great article that outlines “what everyone ought to know” about evidence-based maternity care. This breaks it down in easy-to-understand examples, with good research and references.
But why don’t we practice evidence-based care?
The answer is not simple. There is no single place to point your finger.
Part of the problem is systemic.
It starts with medical and nursing education, where the focus is on what can go wrong during birth, not how to facilitate a normal, uncomplicated vaginal birth.
Here’s an example. Recently, a group of about 50 Labor and Delivery nurses from across the nation was asked how many had witnessed a natural or “physiologic” birth in their educational programs. About half raised their hands. When natural or “physiologic” birth was further defined as “undisturbed, without continuous electronic fetal monitoring, without I.V. fluids, with food or drink at will, freedom to move about and not confined to a bed,” the number of hands in the air dropped to one or two. This is standard education.
Part of the problem is public perception of birth.
For many people, “surviving” birth is the goal. They are not aware of the real benefits* of normal (vaginal) birth for moms and babies, and that the effects of traumatic, out-of-control birth experiences–even when they result in a physically healthy baby–can be devastating. As one midwife and childbirth educator said, “The goal of emerging from birth with body and baby intact is a bit of a no-brainer, really. … [But also] it is completely possible to support a woman to birth a child so she feels mentally healthy afterwards, without compromising safety in any way.”
When we reduce birth to the extraction of a fetus from a womb, without regard to the physical, emotional, and mental implications of how it happens, it can be seriously detrimental to the postpartum experience. This includes how women recover from birth, parent their newborns, relate to their partners, and make decisions about future births.
We believe that artificial induction and surgical births (c-sections) can be life-saving interventions when necessary. The more women who have these procedures unnecessarily or routinely, however, the more these procedures appear “normal,” instead of the medical procedures they are with real risks and consequences. More and more, women consent to have painful procedures and major surgery, with real health consequences, instead of being confident in their bodies’ abilities to naturally start labor and give birth to their baby.
Many women head for birth uninformed, unprepared, and afraid. And most women do not get the benefit of practices, drawn from reliable research, that are proven to work for managing the pain and easing the process of labor to make it as safe and smooth as possible.
Part of the problem is routines.
An example of this is routine electronic fetal monitoring–the hospital practice of hooking up a laboring woman to a machine that monitors the baby during labor, while limiting the mother’s movement and ability to manage pain. Research shows that routine monitoring increases the risk of Cesarean delivery, the risk of forceps/vacuum assistance, and the risk of needing pain medication–all without making birth safer for the mother or baby. The lower-cost, scientifically proven better option of intermittent auscultation is only used about 3% of the time.
It’s just one example of what one researcher calls it “high-tech, high-cost, low evidence-based care.” Read why it is used here, under the heading “If intermittent auscultation has the best outcomes, why don’t more hospitals use it?”
(Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006066. DOI: 10.1002/14651858.CD006066.)
From “Evidence Based Maternity Care, What it Is and What it Can Achieve”:
“Recent analyses substantiate the World Health Organization’s recommendation that optimal national cesarean rates are in the range of 5 percent to 10 percent of all births and that rates above 15 percent are likely to do more harm than good (Althabe and Belizán 2006). Participants in two large prospective studies of American women experienced cesarean rates that were compatible with this recommendation: both low-risk populations experienced cesarean rates of 4 percent and no observed increase in harms through use of care that enhanced physiologic labor (Johnson and Daviss 2005; Rooks et al. 1989).”
Althabe, F., and J.M. Belizán. 2006. Caesarean Section: The Paradox. The Lancet 368(9546):1472–73. doi:10.1016/S0140-6736(06)69616-5. Available at http://dx.doi.org/10.1016/S0140-6736(06)69616-5 (accessed November 21, 2007).
Johnson, K.C., and B.-A. Daviss. 2005. Outcomes of Planned Home Births with Certified Professional Midwives: Large Prospective Study in North America. British Medical Journal 330(7505):1416. doi:10.1136/bmj.330. 7505.1416. Available at http://dx.doi.org/10.1136/bmj.330.7505.1416 (accessed February 12, 2008).
Rooks, J.P., N.L. Weatherby, E.K. Ernst, S. Stapleton, D. Rosen, and A. Rosenfield. 1989. Outcomes of Care in Birth Centers: The National Birth Center Study. The New England Journal of Medicine 321(26):1804–11. Abstract available at http://content.nejm.org/cgi/content/abstract/321/26/1804 (accessed February 22, 2008).
Evidence-based Maternity Care Resource Directory by Childbirth Connection
As all branches of medicine review and update their guidelines for practice, so too has the American College of Obstetricians and Gynecologists reviewed their 438 guidelines. In summary, the findings were that “less than one third are based on good and consistent scientific evidence. Moreover, for every 10 references cited, not even 2 are a properly designed randomized clinical trial. The practice bulletins overview can be used by ACOG or the National Institute of Child Health and Human Development to focus and fund research in common obstetric and gynecologic conditions that lack adequately designed study.” American College of Obstetricians and Gynecologists Practice Bulletins Overview (published February 1, 2006)