Should Doctors Follow Statistical Analysis or Evidenced-Based Care in an Effort to provide quality care, in addition to quality education with their clients? (A research paper done for Anthropology of Women by Kelly Martin, November 2008.) All new ideas begin as small ideas. To say that a particular idea is not worthy of support, is to say that the idea has no relevance, no validity. Christopher Columbus said: “The world is round. (1)” No one believed him, but he truly was correct. Columbus did not wait for majority statistics of studies to be presented before he proceeded to explore his beliefs. He approached two different queens before he got what he wanted to start his journey across the sea. A majority vote in our American government is the current form of judicial decision making, but not a good way to establish relevant truth, because truth is not determined by majority vote. Truth is truth, whether it is part of the majority belief or not. What is “Evidence-Based” maternity care? This type of care uses the best available research on the safety and effectiveness of health care practices in able to help determine care decisions, for the most successful outcomes for mothers and newborns. Evidence-based care gives priority to care and practices that are the most effective, and at the same time the least invasive, in other words, care that causes no harm, whenever possible. Care that is applied in this way follows the framework of the doctor’s oath, in which the first part of the oath states that they will “First, do no harm”. In this way care considers the undesirable consequences of any doctors that have the motivation to “always do SOMETHING”. This means that maternal health practices that have shown to have proven adverse effects should be avoided, even when best available “evidenced-based research contains no clear benefit, but is simply based on inculturization, or traditional indoctrination. An evidence-based framework questions the wisdom of using any intervention that has an anticipated marginal benefit that contains the risk of exposing the patient to the possibility of greater risk of harm. To encourage the application of evidenced-based principles and to help guide maternity care decisions, care providers need to have access to the most accurate evidence regarding the safety and effectiveness of specific procedures, medications, and other interventions. They should require widespread distribution and accessibility to rigorous research results that demonstrate that the care being provided to each patient has been shown to work, and the benefits outweigh the risks. They should offer care that offers genuine benefits. What is the “Gold Standard” in evidence-based maternity care practices? Studies that adhere to this approach undergo rigorous, transparent, systematic review. Studies that have been conducted according to established guidelines that show discernment regarding both methodology and topic, are powerful tools for understanding best available evidence (Cochrane Methodology Register 2008; Mother et al. 2007; Sheikh et al. 2007). This type of review gives the most trustworthy knowledge about the beneficial and harmful effects of specific health interventions. These systematic review procedures encourage the limitation of investigator bias and error that can distort study results. A systemic review establishes the scope of practice parameters before evidence is analyzed, which is used as a guide for conducting the review. This involves a detailed search for any studies that meet explicit criteria for inclusion. In this way, the careful methodology used only allows better quality studies for review. Whenever possible, evidenced-based researchers pool data from the included studies using statistical techniques of meta-analysis to reach their conclusions. Systematic review of these studies should also be updated on a regular basis to ensure incorporation of new and relevant high-quality research, and to support and strengthen original study findings with new facts whenever possible. A recent Milbank Report describes the history, methodology, and uses of systematic reviews (Moynihan 2004), and another highlights the use of systematic reviews in policymaking (Sweet and Moynihan 2007) (10). Considering the careful analysis of evidence-based studies, and the meticulous combing of results, any previously published research study in maternity practice would be made invalid, unless the study is controlled; which means that “over 90% of the peer-reviewed, published articles in the journals of obstetrics, pediatrics, and medicine that relate to pregnancy and childbirth are invalid as applied.”(2) This also means that 90% of obstetric practices, as currently applied, are without valid scientific basis. It also means that most obstetricians have been trained to attend high-risk births only, should not attend normal, healthy births, regularly, but be available for back-up care in the event of complications that are beyond a midwifes scope of practice. Currently, there is an all-out effort by the members of the American Medical Association to compartmentalize maternal services into promoting the availability and application of high-risk technology as the only safe and healthy way for a woman to birth. Against the proven evidenced-based research that states that home birth, and birthing at birth centers with a midwife are just as safe, if not safer than hospital birth, they are trying to communicate incorrectly to the public that midwifery should be a source of “alternative birthing,” that is not as safe as a techno-hospital interventive birth. It also assumes that no woman is capable of birthing without being in a hospital. This effort has resulted in billions of healthcare dollars being wasted on maternity and newborn programs throughout the United States. These programs have succeeded in spending large amounts of public and private money, but failed to reach the positive outcomes that they were originally intended. They have succeeded in raising maternal and infant death rates in the United States, as well as cesarean section rates. There are many conscientious professionals who recognize that the current standards of practice aren’t in the best interest of the community at large. Many professional health care providers are seeking to provide services that truly benefit the consumer by promoting overall health, wellness, and safety. These professionals aren’t interested in supporting any system that undermines people and makes them dependant on the system itself. Despite these positive goals, many professional healthcare providers are no longer using evidence-based applied standards for truly normal, safe childbearing. There must be a revolution in maternity care and it must begin by examining and applying the most recent evidence- based care studies. This information must be released to the medical community and the public. If children are not born well, and mothers don’t experience a positive birth, bonding of the family is affected negatively, and all of society suffers. There is no justification in using medical practices that restrict a woman’s autonomy, her freedom of choice, and her access to her baby directly after birth. Interference with the natural process of pregnancy and childbirth is restrictive, doing more harm than good. Recently a trend has developed and more newly expecting parents are asking their care providers about their rates of technological interventions, such as their cesarean rate, episiotomy rates, and how often they use forceps or vacuum extraction. It is believed that women must have access to information that will help them to learn of the differences between care providers, and their approach to birth. This will enable to make an informed decision of which provider to choose that most closely matches their desires in childbirth. Even though statistical research that is based on group studies as evidence-based statistics may not always apply to individuals, these studies should be used as a relevant guide in studying the wider policies of maternal care. Providers must examine the differences between “open” and “closed” knowledge systems. Any knowledge system that wishes to remain responsive to changing events in a rapidly changing world must remain open to absorbing new information adapting itself to that new information. We must first establish what a “closed” knowledge system is, before we can do anything to change it. Individuals who are not challenged to “think beyond” their belief system, which is based on their own culture can, over time, lose the ability to process new ideas and can become rigid in their thinking. People can become resistant thinkers, unwilling to put time and energy into expanding their minds. This is known as by some brain theorists as “Stage One Thinking.” For Stage One thinkers, the world is only as wide as their surrounding culture. They only have one interpretation of reality. They use a “closed” knowledge system. Anthropologists call this way of thinking “Naïve Realism”, which is defined as “The notion that “my way is the only way there is.” (3) Most smaller societies before their exposure to Western culture, are naïve realists. An additional dimension to this is that across cultures through- out history, ritual has played a significant role in the creation of Stage One thinkers. Rituals enact a society or group’s core values and beliefs. Through rhythmic repetition and the use of powerful core symbols, ritual works to imprint core beliefs and the behaviors in the minds and bodies of its participants. Another way of approaching the cultural thinking aspect of a “closed” knowledge system is in a “Stage Two” thinker. Stage Two thinkers are known to anthropologists “ethnocentric” thinkers. Ethnocentric thinkers know that other ways of knowing and believing exist, and are able to acknowledge the difference between themselves and others; but are entirely certain their own way is better. Ethnocentric, stage two thinkers pity everyone who does not understand how much better their way is. Some ethnocentrists try to wipe out others who don’t believe as they do. They may even feel threatened by others who won’t consider their way. Ethnocentrism, like naïve realism, is also a “closed system,” that is being constantly reinforced by rituals that sustain that system. Biomedicine is itself an ethnocentric and closed stage-two system. Biomedical practitioners are constantly exposed to new information, but they tend to only use new information that already fits into their trained-in, pre-existing “professional” knowledge system. Physicians are socialized into biomedical ways of thinking, knowing, and believing for an average of four years in medical school, then in three years of residency, and sometimes longer if they attend sub-specialty training, such as an obstetrician/ gynecologist. Doctors thinking paths are established into what can be called the “technocratic model” of medicine. When doctors are faced with information that differs from their established training knowledge, information that does not flow easily along their pre-established thinking pathways, they are likely to ignore, or discount the information. They would have to be willing to take the time and energy to develop thousands of brand new thinking pathways, along which this new information could flow and become integrated into his cognitive system. Most obstetricians can barely keep up with the information that comes across their desks every day that updates them on the latest drugs and technologies (which simply solidifies what they already know). They are entrenched in a belief system that relies on drugs and technological interventions to manage birth, and they see no reason to exert the much greater amounts of energy it would take to incorporate new information from outside their technocratic paradigm. In cyborgifying childbirth, technomedicine creates problems for the patient by applying technological intervention, then solves the problem by using more technology. When the outcome is a healthy mother, healthy baby, technomedicine claims the credit. But when the outcome is not positive, the blame is placed on nature, or on God. This is in conflict with the fact that out of 100 women interviewed for Robbie Davis-Floyd’s book “Birth as an American Rite of Passage”, 70 out of 100 women either actively sought, or were generally comfortable with having a birth incorporating intervention. Technological interventions, from electronic monitoring to vacuum extraction, were stated as giving women a sense of safety, reassuring them that they were receiving the best that technocracy had to offer. They believed that the application of technology assured them of a healthy mother, and a healthy baby. In truth, the use of technology can not guarantee a positive birth outcome. The use of technology may give some women the “feeling” that everything that can be done, is being done. But in reality, the doctors closed knowledge thinking says: “If it can be done, it MUST be done, whether it is necessary or not!” They feel that they are being paid to do a job, and must earn their keep. They need to be “in control” of both the woman and the birth. In this way, the evidenced-based knowledge is not applied. This results in a limitation in the range of choices within childbirth, which is contrary to what the health care field would have consumers believe. According to Holly Richards in “Cultural Messages of Childbirth,” Western cultural attitude toward birth is fear-based.” (4) Since the beginning of the Industrial Revolution, the emerging health care technocracy has sought to dominate and control nature. The more we are able to control nature, including our own natural bodies, the more fearful we become of the aspects of nature that we can’t control. We have been inculturalized to fear the birth process. Doctors answer to this fear is to improve it, control it, and make it seemingly safer by applying technology. As a result of this fear and the combined lack of public knowledge, some women feel that they have no choice but to abide by the power and control held within the institution of a hospital. They feel that no matter how clear they are as a patient in expressing their desires for their own birth experience, or how strong and assertive they are, that the institution has its own agenda, momentum and rhythm that can’t be thwarted. Some believe that the “institution” sweeps aside women’s needs, and negatively changes how people relate to each other. However, the evidenced-based facts still stand that women are more comfortable when they have control of their own decision-making within the birth process. This view comes against the symbolic image of the hospital as a powerful entity dictating laboring women’s behavior and experience in childbirth. This symbolism then begs the question, how can facilities meet each individual’s needs within the varying birth arenas and cultures? Activism is one of the answers to this question. According to the report: “Mother and Child 2000: Returning Birth to Women”, (12 October 1996 Dublin) (10), one of the challenges to those working in the different fields of birth advocacy and activism is how to bring the childbirth debate into the wider arena. How do we provide Transparency in Maternity Care, thereby increasing individual knowledge and shedding a different light on the concept of control, risk, and risk management. The distribution of evidenced-based studies and professional evaluations of performance, are critical to supporting and enabling expectant parents to make informed choices. The tone and content of information given to women is crucial in establishing the context in which choices can be made. Natural birth advocates wish to encourage all pregnant mothers to explore all of their options, and have access to true and accurate information. One of the options that is not presented within the technocratic view of births, is the option of having a “natural child birth.” This option is often unappreciated and goes unnoticed as a choice by most American birth giving women. In a 2002 Harris poll survey of 1,800 American women, designed by the “Maternity Center Association”, the study showed that “63% of survey respondents received epidurals, while 93% received electronic fetal monitoring, and many other forms of technological intervention during labor. Over 90% of those surveyed expressed satisfaction with their childbearing experiences.” (www.maternitywise.org). (6) Because of the traditional high rate of standard hospital interventions, most women “assume” that they will birth within a hospital. Risk and safety are often difficult to discuss, as a result of the strong cultural and medical meanings attached to birthing. The technocratic model of childbirth focuses almost exclusively on the physical well-being of the mother and baby, without presenting the actual evidence-based risks attached to each intervention. While it goes without saying, women want to remain healthy and have healthy babies, and think that the only way to do that in Western Society is to birth in a hospital, with a doctor. The United States spends more money on maternity services than any other country in the world. We have the highest rates of infant death in all of the developed nations. We also have one of the lowest successful vaginal birth rates in the world, and the high rate of cesarean section creates greater health risks to both mother and baby, both during the birth, and postpartum. Despite the importance of providing information on evidence-based studies within perinatal community, patient safety and the overuse of medical technology continues to rise without improvement on maternal and infant outcomes. Studies have shown that the inappropriate use of procedures, medications, tests, and restrictions in labor and delivery, have undoubtedly increased maternal and infant morbidity and mortality within the medical community. Because of this, it is important that we open the door to communication between care providers and patients. We need to ensure “transparency” in maternity care. This will require a shift from the status quo. The “Transparency in Maternity Care Project” was birthed in February of 2006 by the Grassroots Advocates Committee (GAC) of the Coalition for Improving Maternity Services (CIMS). This is a group of volunteers that are dedicated to insuring public access to quality of care information that is evidenced-based, and specifically related to maternity care providers and institutions. Part of the project includes a voluntary national research project known as: “The Birth Survey”. The Birth Survey is an on-line questionnaire that “Asks women to provide feedback about their birth experience, with a particular doctor or midwife, within a specific birth environment. (7)” Responses will be made available on-line to other women in the community who are trying to decide where, and with whom to birth. This survey, paired with evidenced-based experiential data and official statistics from each states Department of Health will list the published and unpublished obstetrical intervention rates at each facility. To participate, please go to www.thebirthsurvey.com. (7) Although institutes, universities, and activists are engaged in research and development of projects to increase health care transparency, there are currently no other significant consumer-led national efforts underway that share health care or maternity care information, other than the “Transparency in Maternity” project. It is critical for Western medicine to maintain a long-term, life-course focus when planning and providing care for babies and mothers. Currently, there is a vast body of research being done that present possible lifelong effects of the current techno-medicine practices for babies of the medical, physical and social environment from conception through pregnancy and birth, and into the postpartum period. This research focuses on the early period and heightened fetal sensitivity that could impede optimal human development, or actually generate harm. Many papers review specific topics within this work on the “Developmental Origins of Health and Disease” (see for example: Csaba 2007; Davis and Sandman 2006; Gluckman and Hanson 2006; Gluckman et al, 2005; Grandjean and Landrigan 2006; Heindel 2006; Horta et al, 2007; Johns, Jauniaux and Burton 2006; Lewis, Poore, and Godfrey 2006; Olsen 2000; and Tchernitchin et al, 1999) (11). This evidence-based research suggests the importance of the detailed assessment and possible long-term effects of the overuse of medical technology. It is a priority to for expecting parents to consider new study information during the process of choosing a care provider, and a birth location. Evidence finds that medical interventions used during childbirth may be associated with long-term maternal and infant damage (Odent 2006) (11). Another new study review contains current research on “Understanding the mechanisms and effects of medical and environmental exposures in the perinatal period, and to distinguish perinatal exposures from teratogenic exposures during early pregnancy and early gestation” (Csaba 2007; see also Tchernitchin et al, 1999) (11). The implication of this study is that interventions should only be used when there is a well-supported rationale for doing so. It found that decision-making processes in maternal care should take into account known harms, and recognize the potential for harms that have not yet been established or well-publicized. In other words, it suggested that doctors should follow their medical vows and “first do no harm”. Without question, all women should be provided with access to reliable evidenced-based information on perinatal and postnatal care, and care providers. Any patient expecting a baby should be informed and have the individual ability to weigh their medical options well before labor begins. In the labor process, there should be a strict, rigorous adherence to using informed consent processes during labor. As a result of the high influence of cultural and personal values and preferences, women should have the ability to exercise their right to informed choice and be able to choose a care path involving lesser likelihood of harm than other possible paths. It is inappropriate for clinicians, administrators, and other professionals to recommend, encourage, or give priority to the use of care practices that have been proven through evidence-based studies, cause increased risk of harm to mothers and newborns. It is essential to improve the distribution of information to the general public, to enable them to make informed choices. There is no substation to be found for the positive benefits to expecting parents in the usage of Transparency in Maternity Care. Bibliography (1) Stewart, David, PhD. “How New Ideas Become Accepted”; from “The Five Standards of Safe Childbearing”, NAPSAC International, Copyright 1981. (2) Enkin, Murray; Keirse, Marc J. N.C.; Neilson, James; Crowther, Caroline; Duley, Lellia; Hadnett, Ellen; Hofmeyr, Justus; through Oxford University Press, Third ed., 2000, “A Guide to Effective Care in Pregnancy and Childbirth”. (3) Davis-Floyd, Robbie. Article: “Ways of Knowing: Open and Closed Systems. Article appears in Midwifery Today 69 (Spring): 9-13. (4) Davis-Floyd, Robbie. Article: “Technologies of the Exterior, Technologies of the Interior: Can we Expand the Discourse of Reproductive Studies? University of Wisconsin Press, 2000, pp. 277-300. (5) Article: “Culture and Birth: The Technocratic Imperative”. Published in the “International Journal of Childbirth Education”; 9(2): 6-7, 1994. (6) Article: “Women’s Decision-Making Around Home Birth”. AIMS Journal, Vol. 8, No. 4; Winter 1996/7. AIMS, the Association for Improvements in the Maternity Service. www.midwiferytoday.com. (7) Article: The Birth Survey: Transparency in Maternity Care from a posted article by the Changemakers.net. Web address: http://www.changemakers.net/en-us/node/1072. (8) Sakala, Carol; and Corry, Maureen P. “Evidence-Based Maternity Care: What it is and What it Can Achieve”. Published by the Reforming States Group, with a grant from Milbank Memorial Fund, and presented by the Childbirth Connection, 2008. (9) Goer, Henci. “Obstetric Myths Versus Research Realities: A Guide to the Medical Literature”. 1995, pp. 350-360. (10) Stewart, David, PhD. “The Five Standards for Safe Childbearing”. Copyright 1981 by NAPSAC International. (11) Davis-Floyd, Robbie. “Birth as an American Rite of Passage”. Copyright 1992 by University California Press. |
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