The epic failure of the evidence-based movement
“All procedures offered to a mother should be researched by herself so she can make an informed decision.”
(posted on Facebook on a thread about routine interventions)
“Make sure you hire a doula.”
(said by everyone)
Why are mothers being told to do their own research, find out more about their provider and their hospital, check out the alternatives, and make sure they can make an informed decision?
The pipe on my hot water tank sprung a leak and I called a plumber. Not once was I admonished to check into the possible things he might do to fix it and to decide if it was evidence based or if I should switch plumbers. He did a good job because if he didn’t, it would get around, and no one would hire him again.
And yet, mothers are urged to make sure they find out for themselves the risks of ultrasounds, what the science says about postdates, the risks of synthetic oxytocin (Pitocin/syntocinon), whether an epidural can cause problems, whether Friedman’s curve is actually useful for deciding on a “failure to progress” or if it’s a tool for the hospital to manage their time and resources, whether an induction for a big baby is evidence based, or if their provider supports a VBAC and what the risks are between VBAC and a repeat c-section. And if nothing else, hire a doula. And on it goes.
What’s behind this push for families to do their own research into the routines and interventions of birth? I think it’s been the epic failure of the evidence-based movement.
The expression “evidence-based medicine” was introduced in 1991 in an ACP (American College of Physicians) Journal Club editorial and was quickly embraced. Medical clinical practice has been historically referred to as the “art of medicine” where expert opinion, experience and authoritarian judgement were the foundation for decision-making. Medicine held a strong distrust of biomedical research, scientific methodology and statistical analysis (Sur, 2011). The problem was that medicine was lagging in accuracy and safety as other disciplines embraced these scientific tools. Obstetrics, in particular, was the medical discipline with the least sound practices, so much so, that Archie Cochrane awarded the discipline of obstetrics with the humiliating “wooden spoon” award in 1979. A decade later, A Guide to Effective Care in Pregnancy and Childbirth was published which seemed to usher in a new approach in obstetrics, and he agreed that it was time to withdraw his insult.
The most widely-accepted definition of evidence-based medicine is as follows:
“Evidence-based medicine [or care] is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett, 1996).
This sounds like the ideal where clients are both treated as individuals and are informed by the most current scientific information. However, this is not the experience of birthing mothers. Instead, mothers throughout the world, where obstetricians are the primary providers and hospitals are the primary birth location, are treated to what is largely a one-size-fits-all approach that resembles Henry Ford’s invention of the assembly line manufacturing plant (Perkins, 2004).
Policies that benefit the institution and the provider have replaced both common sense and holistic care. The widespread ban on VBACs (vaginal births after caesareans) in the US and the near universal unwillingness to support a vaginal breech birth speaks to the profit-before-sense kind of treatment that force women into increasingly unnecessary and risky surgeries without choice or individual care.
It’s also important to consider the limitations of “evidence-based” research. The randomised controlled trial (RCT) has been decided by committee to be the gold standard in research methodology. What this fails to recognise is that a birthing mother is an autonomous human who needs to be given a right to say what happens to her in birth. It’s unethical to randomly assign her to one arm of a research study without her ability to know what her choices are and to make an informed decision. Further, funding drives research. Only certain studies receive funding, which seldom extends beyond a brief time period. When interpreting research, one must consider the question being asked, the conditions under which it was asked, the parameters of the study, potential biases, limitations, and often, false conclusions (Ioannidis, 2005).
In the last several years, the rate of obstetrical interventions has increased dramatically without corresponding benefit. Increased interventions in low-risk mothers show an increase in neonatal morbidity (Dahlen, 2014). One would think that the evidence-based approach to maternity care would mean a reduced incidence of sick or hurt babies. Instead, money and profit has been a powerful motivator for increased use of interventions. It’s a well-documented fact that a mother in a private facility is more likely to have increased interventions and caesarean surgery than in a public facility. In other words, she’s more likely to have expensive services, like surgery, when she (or her insurance) has more money to offer (Dahlen, 2012).
Medical malpractice liability is another factor that influences the high rates of interventions and lessens the choices and autonomy provided to mothers. When the clinician or the facility is worried about being sued, they are more likely to use interventions and perform surgery (Morris, 2015).
Further, there is a direct relationship between a surgeon’s malpractice premiums and the rate of caesarean surgeries. In other words, the more that the provider pays for insurance, the more that caesarean surgeries are performed and the fewer VBACs that are supported (Yang, 2009).
The rates of interventions vary widely across countries, regions and even hospitals, including caesareans (Kozhimannil, 2013), episiotomies (Graham, 2005), inductions (Tenore, 2003), and most every obstetric intervention. Certainly, differences in clientele would influence the rates of interventions in that a mother who is not well would have complications that require medical support. However, even that cannot explain the wide variation in obstetric interventions. The primary predictor of whether a low risk mother will receive a routine intervention is the kind of provider she has (Robinson, 2000).
ACOG (American Congress of Obstetricians and Gynecologists) themselves admit that only about 25% of their obstetrical practice guidelines are based in good quality research. The rest is based in poor quality studies, opinion, and habit (Wright, 2011). The SOGC’s (Society of Obstetricians and Gynaecologists of Canada) practice guidelines are not much different in content. And frankly, no matter what the evidence says, most mothers get what’s offered and that’s often outdated protocols based on poor quality information, or habit.
We’ve known for 30 years that routine episiotomy, cutting the perineum to make a larger passage for the baby at birth, causes increased 3rd and 4th degree lacerations, increased fecal incontinence, and increased pain that can last years (Thorpe, 1987; Borgatta, 1989; Klein, 1992; Signorello, 2000; Hartmann, 2005). While the rate of episiotomies has been falling in most locations, according to the Listening to Mothers III Survey (US), 17% of women still had this procedure (Declercq, 2013).
“During the 40 minutes of pushing, the doctor turned to my mother and said, “I’m cutting her” and I yelled and begged for her NOT to cut me. But she ignored me and did it anyways. When she started to stitch me up, once again, I was screaming and begging for her to stop because it was extremely painful. I didn’t even know they were supposed to numb you first until recently.” ~ Carol
Back in the 1940’s it became routine to deny a mother any food in labor since she was going to be put under general anesthesia for her birth. The concern was that she would vomit under anesthesia and then aspirate (breathe) in the vomit and possibly die from the complications. Interestingly, it’s also been know for almost 30 years that fasting during labour doesn’t ensure gastric emptying (an empty stomach) and instead increases the acidity in her stomach, which is more problematic. And in fact, the likelihood of a mother dying from aspirating vomit during an emergency caesarean under general anesthesia is about 7 in 10,000,000 births (Sleutel, 1999). Further, forced fasting leads to a longer pushing stage (Rehamani, 2012). No doubt that’s because labour burns up to 1000 calories per hour and the mother just gets tired from lack of nourishment.
The original recommendation in the 1940’s was based on worry and an attempt to exercise caution. There has been no corroborating evidence since then and any research has shown that eating and drinking brings comfort to mothers and reduces both pain and length of labour, so there is no reason to restrict the food they want (Singata, 2010). And yet, most mothers are not “allowed” to eat during labour when they birth in a hospital due to outdated and inflexible policies. Adding in a routine IV with glucose to replace real food just increases problems, as those newborns are more likely to have serious low blood sugar (Grylack, 1984). So why aren’t most mothers eating in labour? Because hospitals don’t change outdated practices when it’s still working for them. Not providing food for labouring mothers saves money.
There are so many non-evidence based routines happening every day including:
Caesareans for failure to progress based on outdated time limits (Laughon, 2012)
Routine induction at early term with a membrane stripping (Hill, 2008)
Routine induction for suspected fetal macrosomia (big baby) (Boulvain, 2016)
Induction for isolated (no other medical complications) oligohydramnios (low amniotic fluid) at term (close to your due date) (Manzanares, 2007)
Induction for isolated (no other complications) hypertension (high blood pressure) near term (Broekhuijsen, 2015)
Birthing on your back with your feet in the air or in stirrups, called a supine delivery (Terry, 2006)
Staying in bed for labour (Bloom, 2008)
Continuous electronic fetal monitoring (Alfirevic, 2013)
Mandatory surgery for a breech presentation (Louwen, 2016)
Immediate cord clamping (Hutton, 2007)
And on it goes.
“I remember telling my first doctor that I didn’t want or need rhogam at 27 weeks. I had researched it and because both my husband and I were negative blood type, it was impossible to have a positive baby. She told me I had no choice. It was mandatory.” ~ Joanne
How bad is it?
Consider that in the survey, Listening to Mothers III (US) (Declercq, 2013)
80% did not eat during labour
68% of mothers birthed on their backs
55% did not walk or move around during active labour
44% were induced for the reason that they were merely at term
16% were induced because the doctor was worried about a large baby
11% were induced because the doctor was worried about low fluid at term
10% had their public hair shaved for a vaginal birth
and when making a decision to have a repeat c-section rather than attempt a VBAC 63% said it was the doctor who made the decision
According to BORN Ontario (Niday Perinatal Database) 2005-2006 to 2009-2010 (BORN, 2011)
Inductions have risen from 21.8% in 2005-6 to 25.2% in 2009-10. A 15.6% increase in just 4 years cannot be explained by a massive shift in maternal-fetal wellbeing, but rather speaks to how quickly practitioners choose an intervention on a broad scale.
The rate of repeat c-sections increased 28.6% over that same time period
57.6% of elective repeat caesareans were performed before 39 weeks
18.3% of mothers had an episiotomy.
The caesarean section rate has increased every year across Canada from 18.7% in 1997 to 27.5% in 2014 where repeat surgery makes up more than half of this rise (CIHI, 2016). It seems that scheduled, profitable, daylight obstetrics is the driver behind this as there has been no new evidence of increased risk or harm to mothers or babies from VBAC births in the last several years.
What is stunning is that in spite of the evidence based movement, maternal mortality has risen in the US between 1990 and 2013 from 12 deaths per 100,000 to 28 per 100,000. Lack of consistent obstetrical practices has been identified as a major concern in this rising rate (Agrawal, 2015). And given the high rates of caesarean surgery, often due to policy or insurance premiums, it’s necessary to count the cost in lives lost due to excessive rates of surgery. Postpartum death is 3.6 times higher after a surgical birth than a vaginal birth (Deneux-Tharaux, 2006).
In Canada, maternal mortality increased from 6 per 100,000 in 1990 to 11 per 100,000 in 2013. The question that begs to be answered is, where does the shocking increase in surgical birth fit into this decline in maternal safety?
In 2007, Venezuela became the first country to define obstetric violence through the Organic Law on the Right of Women to a Life Free of Violence.
In this law, obstetric violence is defined as:
“The appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.”
The following acts, executed by care providers, are considered obstetric violence:
1. Untimely and ineffective attention of obstetric emergencies;
2. Forcing the woman to give birth in a supine position, with legs raised, when the necessary means to perform a vertical delivery are available;
3. Impeding the early attachment of the child with his/her mother without a medical cause thus preventing the early attachment and blocking the possibility of holding, nursing or breast-feeding immediately after birth;
4. Altering the natural process of low-risk delivery by using acceleration techniques, without obtaining voluntary, expressed and informed consent of the woman;
5. Performing delivery via cesarean section, when natural childbirth is possible, without obtaining voluntary, expressed, and informed consent from the woman.
Obstetric violence is global and systemic (WHO, 2014). Having procedures performed that introduce risk without their knowledge or consent routinely violates mothers. Having her membranes broken in a healthy labour without indication, or having synthetic oxytocin unknowingly introduced into their IV, being forced onto her back for delivery, or having her genitals cut against her wishes are just the tip of the iceberg.
And yet, no one is holding the industry accountable. Obstetrical societies (ACOG, SOGC, et. al.) maintain a powerful lobbying presence with government to ensure that public policies and government spending are favourable to their industry. An absence of adequate oversight has allowed this industry to escalate their intrusion into healthy pregnancies to the point where 1 in 3 mothers say their births were traumatic and up to 1 in 10 mothers are grappling with postpartum PTSD as a result of their birthing experience (Beck, 2011).
“I had a successful VBAC in a hospital. The next thing I know, an entire arm, up to her elbow, shoots into my vagina and uterus without any warning. I felt every inch of my placenta being ripped out of my uterus. I screamed at her to stop. Instead, the nurse pinned me down. PTSD robbed me of the next year of my life.” ~ Marie
The fact that the industry will not hold those providers and those institutions accountable for dangerous, outdated, and at times, abusive practices is simply stunning. Lateral violence (bullying, insults, coercion, sabotage, and even physical assault) within the industry keeps whistle blowers from speaking up, in particular nurses (Jackson, 2010). Nurses are especially vulnerable to lateral violence as the vast majority of nurses have been victims, most often from senior nurses (Christie, 2014). This impacts their delivery of care to their patients and patient safety. In hospitals, nurses are the primary contact with the birthing family and the one in the best position to advocate for her patient and to report abusive or outdated care. Abusive behaviour within the nursing profession has contributed to preventing them from appropriately dealing with this failure on the part of the industry to give mothers the care they need and deserve.
The birth monopoly
Through clever marketing and expensive lobbying, obstetrics has gained a monopoly on birth. In most developed nations, hospitals have cornered the market on birth services and obstetricians, although more expensive and associated with more adverse outcomes in low risk populations, are the primary provider for most women. In places where midwifery is integrated into the health system, meaning they can facilitate a transfer to a hospital where her client will be accepted and the transfer is respectful and seamless, mothers have better outcomes at home with a midwife (Hutton, 2009).
Physicians themselves are punished for providing true family centred care and risk losing hospital privileges for supporting a homebirth where the money doesn’t reach the institution. Like a dangerous cult, adherents (obstetricians) have even pursued a court order to force a mother to undergo mandatory caesarean surgery or called in child protective services to apprehend the children of mothers who disobeyed their dictates (Diaz-Tello, 2016).
“After 2 attempted homebirths that ended in caesareans, I was told that no midwife or doctor would support plans to have a homebirth VBAC. I could attempt a hospital VBAC but I would have to “fight” for it. To plan to attempt a vaginal birth at the same hospital, knowing that I would have to resist the system and medical staff every step of the way, was a recipe for failure and emotional distress.” ~ Lainie
A few good folks
This is an industry-wide problem. However, there are truly wonderful individual providers who are doing their best to provide sensitive and individualised care with the best information they have. And they deserve credit, respect and thanks. Both doctors and midwives are routinely refused the opportunity to serve their clients in the manner they wish, perhaps through offering vaginal breech support, or not inducing according to policy when there is no medical indication. Yet these brave providers offer this care in the face of potentially sabotaging their opportunities for career advancement.
These providers are in high demand and are sometimes vilified by their colleagues whose excessive interventions bring more money into the industry coffers. They are shining diamonds in a deep mine and they make a difference in the lives of those fortunate enough to find them.
Individual nurses have taken the brunt of institutional hostility for advocating for their clients, for reporting unsafe practices, and for holding their colleagues to a higher standard. These are the professionals who deserve support and accolades.
Indeed, the evidence-based movement has been an epic failure that has left families reeling from their inability to influence their providers or the system that has set itself up to “save” her and her baby.
Families are paying the price
The true failure of the evidence-based movement has been the toll exacted on birthing families through lack of autonomy, lack of choice, excessive interventions, excessive surgery, birth trauma, and lives lost.
Due to the failure of the industry to deliver on their promise, we’ve entered the age where evidence based-medicine has become the responsibility of the consumer. Birthing families are urged to learn what their provider won’t learn or won’t practice.
When they are caught in a system run by dinosaurs, they are told that they didn’t do their research, they didn’t hire a doula, or they didn’t advocate for themselves. And the industry eats this up. They tell mothers to come in with a birth plan, all the while knowing that they see a birth plan as a direct route to more interventions (Grant, 2009).
A switch to a midwifery model of care with midwives providing the bulk of maternity services would mitigate some of these issues, as they’re more likely to use evidence-based care and to engage in informed consent and mother-centred care (Sandall, 2016). However, a profitable industry with well-paid lobbyists won’t give up power and control easily. Obstetrics is currently a one-stop shop that provides a drive-through experience where everyone gets what’s on the menu.
You’ll note that when drawing attention to the need for mothers to do their own research or cautioning them to learn more about their provider before they consent to a routine, we hear total nonsense from industry members about not scaring mothers, not spreading misinformation, going with the flow, staying off the internet, and trusting the professionals. What they should be doing is apologising for aiding and abetting outdated protocols and industry-favourable policies that hurt mothers and babies and that it’s time to hold themselves accountable and rise to a higher standard.
Indeed, the evidence-based movement has been an epic failure that has left families reeling from their inability to influence their providers or the system that has set itself up to “save” her and her baby.
"I left the care of midwives when I caught them in lies and practices that went against informed choice. Despite what the medical system would have you believe, I had a wonderful and safe VBAC at home without a medical professional." ~ Chahna
The grassroots move to a new paradigm
Humans are resilient and they’ve always found a way to step away from systems that feel oppressive and to form communities that chart a path that honours their values, despite the risk of persecution. The rise of the DIY (do it yourself) birth movement, also called freebirth, unassisted, or family birth is a grassroots response that sees families taking care of each other outside of the obstetrical industry. There’s been a rise in unassisted homebirths in Sweden, Australia, Canada, the US, and Finland in response to the biomedical approach to birth and lack of autonomy for birthing mothers (Holten, 2016).
Of course, the obstetrical industry sees this as an exceptionally dangerous movement. Yet, their warnings may not match up with the experiences of the families themselves and may be more related to their position as a monopoly than the evidence of the safety of birth outside of their oversight.
In an anonymous online survey from December 2014 until September 2015, mothers who planned an unassisted birth responded (O’Day, 2016).
857 respondents from around the world
1449 babies born
1444 births (5 sets of twins)
1339 babies were born “unassisted”, meaning that there was no licensed attendant present although there might have been family, friends, doulas, or unregistered midwives.
The primary reason for choosing an unassisted birth was that they were led by their intuition (80.24%). The next most common reason was their dislike of hospitals (77.32%). They were also concerned for their newborn’s safety within a hospital setting (72.2%) and did not want to repeat a prior bad hospital experience (51.83%).
The results were interesting in the extraordinarily positive outcomes.
There were no maternal deaths
The neonatal death rate was 2.2 per 1000, which is comparable to the US rate of 2.97 per 1000
The caesarean rate was 1.24%
Of those who attempted a VBAC, 100% achieved it
Of those who had a VBAC, just over one quarter had had more than one previous caesarean
One third of the mothers had no prenatal services with a licensed provider, also called ‘prenatal care’ (this doesn’t account for community care and wellness measures)
Over 70% had no monitoring throughout labour and birth, i.e. no one listening to the baby’s heartbeat or routine vaginal exams
Just over 2% transported the newborn to a medical facility within the first week, mostly for breathing concerns
3.52% of the mothers transported for medical help after the baby was born primarily for postpartum haemorrhage
Certainly, this is a self-selecting group who responded to this survey. However, given that some of them were “high risk” in that they had had previous caesareans, had no prenatal care, and 5 were expecting twins, these results are seldom found within the medical obstetrical industry.
Once I decided not to continue prenatal care with the registered midwives, I was easily able to avoid trauma triggers and enjoy my pregnancy a lot more. The birth of my third baby was awesome! I was free to move around the whole house, I could eat or drink when I felt like it, I didn't have a single exam and I slept when I felt tired. I wasn't alone, but the people who were there didn't disturb me in any way. I never once wanted drugs for pain or to go to the hospital, it wasn't an option for me. My daughter had the best birth. No trauma, drama, drugs, strangers or tearing. Just a simple, healthy, happy family birth. ~ Sandra
As consumers have come to understand that the onus for evidence-based medicine has fallen on their shoulders, they’ve responded with outreach and connection. Online groups connect families to each other where they share research, studies, tips and encouragement. They share their medical history with one another and offer suggestions for self-care as well as recommendations for those providers and traditional birth attendants who support clients with holistic and scientifically sound care.
In-person groups are gathering to teach one another the physiology of birth, the mechanics of a vaginal breech birth, how to resolve a shoulder dystocia or a head entrapment, and to practice neonatal resuscitation skills.
Doulas are investing in advanced education and research skills to support their clients’ wishes for the evidence, access to their provider’s practice guidelines, and community connections and alternative care. Doulas are becoming specialists in supporting self-advocacy, research-based information, and helping clients connect to the services they need and want.
And as we learn more, we’re also discovering the importance of our microbiome and the epigenetic expression of our DNA where today’s one-size-fits-all comes across as pure buffoonery.
Taking back birth
We are at a crossroads in human history that will unfold over time. The “take back birth” movement is gaining momentum and this is being met with religious like zeal from the industry and its adherents in its opposition. They preach a different gospel where the modern medicalisation of birth and wholesale institutionalisation of birthing women has “saved” them. It’s a gospel that doesn’t hold up to scrutiny but nonetheless forms the lexicon of our culture (Tew, 2013).
So what can families do in light of the epic failure of evidence-based medicine?
Perhaps the answer lays in common sense.
Common sense dictates that if frequent prenatal visits and testing is upsetting, that the individual could just choose to bypass many of them. Science affirms that prenatal testing, no matter the results, increases maternal anxiety (Allison, 2011). Prenatal anxiety is a risk factor for postpartum PTSD after a traumatic birth (Söderquist, 2009). Maternal anxiety is also associated with poorer birth outcomes (Kumari, 2014). And skipping those visits actually has no adverse outcome on the mum and baby and only affects the provider’s pocketbook (Walker, 2001).
Common sense tells us that if a technology is useful for breaking up tissues such as cysts, scar tissue or kidney stones because it moves cells, then it might not be entirely safe for developing fetuses. Many parents are wary of ultrasound and their instincts tell them to bypass this routine. In fact, routine and frequent ultrasounds can contribute many problematic issues and has still not shown any benefit to mothers and babies, however it does increase inductions and caesareans (Cohain, 2011).
Common sense tells us that if we don’t want the gloved hand of someone we’re not in an intimate relationship with in our vaginas, we might want to decline as it may be more problematic than helpful (Lenihan, 1984).
Common sense suggests that if a hospital isn’t your cup of tea then birthing at home is a reasonable option (NICE, 2014).
Common sense and science are often aligned beautifully and generally support an individualistic approach to wellness, including birth, which takes into account a birthing mother’s physical, social, spiritual, and relational complexities. And as we learn more, we’re also discovering the importance of our microbiome and the epigenetic expression of our DNA where today’s one-size-fits-all comes across as pure buffoonery.
It’s going to be interesting to see how the medical industry responds to this growing grassroots movement. No doubt, lobbyists will pursue legislation to force mothers into the system for profit under the guise of “safety” which will drive families deeper underground. And should the numbers of families who choose to give birth outside the system actually have an impact on the profit margin of hospitals and obstetrical practices, then we’ll see a swift shift to “evidence-based” and “family-centred” care.
Until then, those good providers will do the best they can. Doulas will equip their clients with science and resources. And families will connect to support one another on this journey.
Evidence-based care has been an epic failure for parents but a mighty gold strike for the industry as they’ve cashed in on an illusion.
“I wish I knew then that I had the power to say NO. This is my body and we’re going to do this my way.” ~ Janice
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