Monday, April 06, 2009

evidence based maternity care

In the context of current discussion about birthing without a professional attendant (which is known as free birthing, pure birthing, self birthing, and probably others) a blogger-mother wrote,
"If evidence based care is the best antenatal and labour care, and some evidence based care leads to interventions, and intervention - any intervention - is perceived as a terrible thing, then if no one checks you or you baby, ..."

This statement has prompted me to explore the meaning of evidence based maternity care.

The statement suggests that some women are avoiding professional monitoring in pregnancy and birth because they don't want to know. Every investigation and test, no matter how seemingly trivial, is done so that action can be taken if it is deemed the best course of action. Knowledge brings responsibility. Every time I put my hands on a woman's abdomen to palpate the baby, I am responsible for my response to what I discover in that palpation.

Over the past few decades some basic maternity care rituals have changed in the light of evidence. Mothers 30+ years ago were given enemas and shaved - sometimes all visible pubic hair and everything as far back as the anus; sometimes just below the pubic ridge. Either way, the regrowth was unpleasantly itchy (speaking from experience), and the chance of cuts from razors was fairly high. Enemas were to empty the lower bowel. These measures were apparently to prevent germs from contaminating the birth, which was treated as an operation site, with green sterile drapes.

World Health Organisation declared in 1985 (Fortelesa Declaration) that there was no evidence supporting enemas and pubic shaving, and in 1996 (Care in Normal Birth: a practical guide) listed enemas and pubic shaving to be "practices which are clearly harmful or ineffective and should be eliminated".

The removal of enemas and shaves from standard maternity care was relatively successful (some people today 'choose' these procedures) but other 'non-evidence based' positions that have been promoted for decades are ignored by many professional maternity services. These include, for anticipated normal birth: continuous fetal monitoring, induction of labour, amniotomy, vbac, lithotomy position ...

Current discussion over the choice some women have made to give birth at home without a professional midwife in attendance focuses on the big issues of potentially avoidable death and damage to the mother or child. Today's news reports that Sydney Dr Andrew Pesce "said he was aware of at least four deaths and another four homebirth babies who sustained possible brain damage since last July." The report does not differentiate between planned homebirth in the professional care of a midwife, and the DIY unattended version. Evidence from Australian and other sources support planned homebirth in the professional care of a midwife for women who are low risk and come into spontaneous labour at term to be no more likely to experience adverse outcomes than those of similar status in hospital maternity care.

It's no good hiding behind a sweeping statement such as "babies die in hospital too". The decision making process that midwives use, regardless of our practice setting, is to try to identify babies and mothers for whom intervention is likely to improve outcomes. This is where midwives are constantly reviewing our practices, so that we can act quickly and decisively when we need to; but also so that we can understand the scope of normal birth, without unnecessary interferance. A woman who is well at term, in spontaneous labour, and progressing well without needing pain relief should expect a well baby. If the baby is not coping well with the stress of labour, the midwife is able to identify the problem when listening to a baby's heart sounds after a contraction. There may also be signs of potential problems in the colour or consistency of the amniotic fluid. A midwife will make professional judgments, and give advice, on what she sees.

There are aspects of the maternity care world today that are like the scary 'wonderland' world of Alice. Issues become enormous, or tiny, without warning or reason. The person with power makes nonsensical edicts. Alice is caught up in a wild stream of frightening experiences.

In my vision I have made Alice's sister her midwife, going with her in her journey towards birthing her child,
"Alice returned to the grassy bank in the golden afternoon light and decided not to go down that rabbit hole again. She stayed above ground and with her sister accompanying her, ..."

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