Thursday, May 19, 2011

What To Know Before You Go: Your hospital care probably won’t be evidence-based

by Birth Sense

What does “evidence-based” mean, anyway?  A popular term in health care circles these days, it refers to making sure that the procedures and protocols we follow are based on strong scientific evidence, rather than personal opinion or experience alone.  Yet many health care providers do not take time or make the effort to ensure that they are aware of and incorporate evidence-based medicine into their practices.  Why not?
  • They are busy, and it takes time to read and learn about new evidence and practices
  • They’ve always done something a certain way, and see no reason to change
  • They find their way of doing things more convenient than the evidence-based way
  • The evidence-based practice would take more time than the way they practice now
As the health-care consumer, you may think “So what?  What difference does it really make if my doctor breaks my water artificially, or wants me to be continuously monitored, or induces my labor?  Chances are that there will be no complications.”
I can certainly understand this line of thought, having struggled with it myself as a midwife.  For example, even though I know there is no evidence which supports artificial rupture of the membranes to accelerate normal labor, I am human.  I get tired and want to go home and be with my kids, just like anyone else.  The temptation is there, when we have those weak moments, to rationalize that everything will be OK, we’ve done it lots of times before without apparent ill effect, etc.  This way of thinking has a name:  the normalization of deviance.  It is a term coined after the 1986 space shuttle explosion.  NASA employees had been warned about potential problems with the O-rings when temperatures dropped too low, but because they had operated the shuttle in cold temperatures before, without apparent ill effects, they normalized in their mind the deviation from the evidence.
Here is a sample of commonly used childbirth procedures for which the evidence shows lack of benefit in normal labors, or even potential for harm:
  • artificially breaking the bag of water
  • inducing labor unless there is clear medical indication
  • repeat c-section because of prior c-section
  • automatic c-section for breech position of baby
  • administering pitocin to speed up labor
  • continual fetal monitoring
  • delivery in the supine position
  • immediate cord clamping
  • separation of mom and baby “just to get the baby dried off”
Consumers of health care can normalize deviations as well.  Take, for example, Reba.  She is pregnant for the first time.  She has read about induction of labor, and she knows that the evidence shows that her chances of a c-section rise to about 50% if she decides to agree to an induction of labor.  But Reba’s doctor seems so experienced, and he tells her that in his experience, everything turns out fine, and if it doesn’t, she would have had to have a c-section anyhow.  Reba decides to ignore the evidence and agree to her doctor’s suggestion of induction.
Or consider Sandy.  The doctor thinks her baby is big.  An ultrasound shows that the baby is about 9 lbs.  The doctor recommends a planned c-section.  Sandy doesn’t want a c-section, and she knows that ultrasounds can be a pound or more wrong.  Sandy also knows that other women in her family have had babies on the bigger side without any difficulty.  She knows the evidence does not support induction or elective c-section for a suspected big baby.  But she allows her doctor to persuade her to agree to surgery.
Situations like this happen every day, in hospitals all over the country.  What you have to decide is whether you are going to educate yourself on the best childbirth practices–or whether you are going to buy into the normalization of deviance, and do whatever your care provider suggests.  Even if the chance of a complication occurring is small, if it happens to your baby, your risk is 100%.  Don’t put yourself in a position of having to look back with regret at the choices you made.  I hope you will be strong, and hold firm for what you know is best for your baby.

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