© 2012 by Rebecca Dekker, PhD, RN, APRN

What is evidence-based care?

According to the American Medical Association, evidence based care means 1) being aware of the evidence (research) that is the basis of practice, 2) understanding the quality of the evidence, and 3) knowing whether or not the evidence should be applied to an individual’s situation, which takes into consideration the patient’s  personal values.1

How do we know what the best evidence is for care during pregnancy and childbirth?

One of the best resources for information on research-based care is the Cochrane Library. The Cochrane Library is known for their rigorous systematic reviews of the evidence; free summaries of articles are availlable to the public. (To read more about why systematic reviews such as the ones done by the Cochrane Library are the highest level of evidence, click here). Other esteemed sources of evidence include the U.S. National Library of Medicine’s PubMed (a free-to-the-public search engine that catalogues all peer-reviewed health research), and the U.S. Centers for Disease Control and Prevention.

What is the difference between standard of care and evidence-based care?

**9/4/12 8 PM EST Shortly after this article was originally published, I was enlightened by a reader as to the legal definition of standard of care (see comments below), and this paragraph has replaced what was previously published. The reader and I worked via email to revise this section. I always appreciate reader feedback and as you can see, it sometimes leads to improvements, alterations, or deletions of my material. 

“Standard of care” is a legal term that refers to how malpractice is decided. In the legal system, malpractice is considered a type of negligence. In order to be convicted of malpractice, a jury of average Americans (who do not always read research evidence) must decide if a situation has met 4 conditions: duty, breach of duty, harm, and causation. The second element, breach of duty, is what is known as “standard of care.” Prior to the early 1900′s, standard of care was legally seen as doing what is “customary.” However, more modern legal cases have re-defined standard of care to mean what a “reasonably prudent person” would adhere to.

Health care providers sometimes confuse the way they do things and cultural norms with the “standard of care.” Theoretically, providers should be able to defend, in court, a deviation from culture that is backed up by research evidence. We say theoretically, because first of all, care providers in court are not defending themselves to people who read research evidence, but to a jury of average Americans. Secondly, there is no standard legal precedence for how evidence-based guidelines are handled in court. Sometimes evidence-based guidelines are referred to, and sometimes they are deemed not applicable– it is handled on a case-by-case basis.

Adherence to “standard of care” allows care providers to continue to carry malpractice insurance and have hospital privileges. It would be ideal if standard of care was synonymous with evidence-based care, but the two concepts are subtly different: one is primarily a legal term and focuses on being reasonably prudent and preventing malpractice, and the other has to do with providing care that is based on best research. In the ideal word, these terms would mean the same thing, but unfortunately in our legal system, they do not.

When I first wrote this article, my intent was to compare current “standard of care” to “evidence-based care.” However, after receiving the above feedback from one of my readers and reading the legal definition of standard of care, I now think it is more prudent to compare care that is “routinely done” in the U.S. to evidence-based care.

Reference: Moffett P, Moore G. 2011. The standard of care: legal history and definitions: the bad news and good news. Western Journal of Emergency Medicine. 12(1): 109–112.

What is routine care during childbirth in the United States, and how does it measure up to evidence-based care?

To compare routine care to evidence-based care, we can look at statistics from the 2007 Listening to Mothers Survey, the U.S. Healthy People 2020 initiative, the U.S. Centers for Disease Control, the Cochrane Library, and other sources retrieved from PubMed. Portions of this table, which I wrote, have been previously published at ImprovingBirth.org (Reprinted with permission).

What is the state of evidence-based maternity care in the U.S.?

 Please take a look at this table to compare care that is typically provided in the U.S. to maternity care that is based on research evidence.

Labor and Delivery   Procedures

Care that is Routinely Provided

Evidence-Based Recommendations

Notes

Surgical birth (Cesarean   section)

33% total2

27% first-time mother3

See Note

Researchers have not agreed on the best rate for   mother/baby outcomes. Surgical birth increases the risk of many different   negative health outcomes for women and babies. (Read more here). Healthy People 2020 has set a goal to lower   the first-time mother surgical birth rate to <24%3
Vaginal birth after   Cesarean (VBAC)

7-9%3

>18%3

Healthy People 2020 has set a VBAC goal of >18%;3 however, research   has shown that 74% of women who attempt a VBAC are successful.4 The National Institutes of Health state that VBAC is a safe and reasonable option for most women,4 but more than half of women who desire one cannot find a supportive care provider.5

Artificial induction of   labor

34%5

See Note

The U.S. Food and Drug   Administration has approved Pitocin (Cytotec is NOT approved) for labor   induction in women with Rh problems, maternal diabetes, preeclampsia at or near term, and premature rupture of membranes when delivery is indicated. Because of the risks, this drug is not FDA-approved for elective induction. Artificial induction of labor doubles the risk of surgical birth in first-time mothers.6

Artificial acceleration of   labor with Pitocin

47%5

According to the FDA, this should only be used in selected cases of stalled labor

Pitocin acceleration has not shown to improve health outcomes for women or babies. Although it shortens labor by 2 hours, this benefit must be weighed with the increased risk of uterine   hyperstimulation.7

Artificial breaking of the   waters to induce or accelerate labor

65%5

Not supported by evidence

Research evidence does not support artificial breaking of the waters (amniotomy) for labor induction.8 Artificial rupture of the membranes during labor does not shorten labor and is associated with a trend towards surgical birth.9

Routine electronic fetal   monitoring

94%5

Routine use is not supported by evidence.

This common procedure, often used for legal reasons, is associated with higher Cesarean rates10 and high   false-positive rates.11 Its only advantage is a decrease in newborn seizures, which are very rare (0.2%).10 The   evidence-based alternative is intermittent monitoring with a handheld Doppler10 (currently used in only 4% of births).5

Routine intravenous fluids

80%5

Routine use is not supported by evidence

This intervention does not   improve outcomes in women who are allowed to eat and drink.12, 13 It adversely affects   breastfeeding by causing an artificial drop in the newborn’s weight.14, 15

Not allowed to eat or   drink

60%5

Not supported by evidence

Research supports allowing   women to eat and drink during labor.16 The risk of   aspiration during an emergency surgical birth is less than being struck by   lightning.17

Not allowed out of bed

76%5

Not supported by evidence

Research has shown that   restricting movement lengthens labor, increases pain, and increases the   likelihood that an epidural will be needed.18

Laying down or  semi-sitting positions during pushing and birth

92%5

Routine use is not supported by evidence

Research has shown that   upright and side-lying positions are most beneficial for pushing and birth19

Water immersion

6%5

This intervention is   supported by evidence. Of those women who use water immersion, 91% find it somewhat or very helpful.5

Water immersion shortens labor and relieves pain. Unlike epidural anesthesia, water immersion has no known adverse effects.20

Continuous labor support   from a doula

3%5

The use of doulas is   supported by evidence. The majority of women (88%) who use a doula rate their   support as “excellent.”5

Women who receive continuous support from a doula are more likely to have spontaneous vaginal births and less likely to have epidurals, pain medication, negative feelings about   childbirth, vacuum or forceps-assisted births, and surgical births. In addition, their labors were shorter by about 1 hour and their babies were less likely to have low Apgar scores at birth21

What about maternal satisfaction? What if a woman requests care (such as artificial acceleration of labor with Pitocin) that is not  supported by evidence?

This question came from one of my readers on Facebook, and this brief segment was added on 9/3/12 at 9 PM EST. Whenever I review the research evidence behind a particular practice, I examine whether researchers measured maternal satisfaction. Sometimes satisfaction is measured, and sometimes it is not. In my detailed evidence-based reviews, I do mention whether or not a particular intervention is associated with an improvement in maternal satisfaction. Maternal satisfaction an important factor to take into account– along with other risks and benefits– when a woman and care provider discuss a course of action (or inaction) together.

Summary

In conclusion, the vast majority of U.S. women are not receiving evidence-based care during childbirth. Although there are outlier hospitals, birthing centers, and care providers who do provide excellent, across-the-board evidence-based care, there is clearly an overall need for routine care to match up more closely with evidence-based practices during childbirth. Next year, in September 2013, I plan to use the upcoming results from the 2012 national “Listening to Mothers” Survey to see whether we have improved in any of these measures listed above.

The vast majority of women in the U.S. do not receive childbirth care that lines up closely with evidence-based care. This image depicts a woman who is receiving Pitocin induction, IV fluids, continuous electronic fetal monitoring, nothing to eat or drink, and restriction to bed. Image source: Robenjoyce

 References

1. Guyatt G, Rennie D, Evidence-Based Medicine Working Group., American Medical Association. Users’ guides to the medical literature : A manual for evidence-based clinical practice. Chicago, IL: AMA Press; 2002.

2. Martin JA, Hamilton BE, Ventura SJ, Osterman MJ, Kimeyer S, Matthews TJ, Wilson EC. Births: Final data for 2009. National Vital Statistics Reports. 2011;60

3. HealthyPeople.gov. Healthy people 2020: Maternal, infant and child health. 2012

4. Cunningham FG, Bangdiwala S, Brown SS, Dean TM, Frederiksen M, Hogue RC, King T, Lukacz SE, McCullough LB, Nicholson W. National institutes of health consensus development conference statement: Vaginal birth after cesarean: New insights. Obstet Gynecol. 2010;115:1279-1295

5. Declercq ER, Sakala C, Corry MP, Applebaum S. Listening to mothers ii: Report of the second national u.S. Survey of women’s childbearing experiences: Conducted january-february 2006 for childbirth connection by harris interactive(r) in partnership with lamaze international. The Journal of perinatal education. 2007;16:9-14

6. Zhang J, Troendle J, Reddy UM, Laughon SK, Branch DW, Burkman R, Landy HJ, Hibbard JU, Haberman S, Ramirez MM, Bailit JL, Hoffman MK, Gregory KD, Gonzalez-Quintero VH, Kominiarek M, Learman LA, Hatjis CG, van Veldhuisen P. Contemporary cesarean delivery practice in the united states. American journal of obstetrics and gynecology. 2010;203:326 e321-326 e310

7. Bugg GJ, Siddiqui F, Thornton JG. Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour. Cochrane Database Syst Rev. 2011:CD007123

8. Bricker L, Luckas M. Amniotomy alone for induction of labour. Cochrane Database Syst Rev. 2000:CD002862

9. Smyth RM, Alldred SK, Markham C. Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev. 2007:CD006167

10. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (ctg) as a form of electronic fetal monitoring (efm) for fetal assessment during labour. Cochrane database of systematic reviews. 2006:CD006066

11. Nelson KB, Dambrosia JM, Ting TY, Grether JK. Uncertain value of electronic fetal monitoring in predicting cerebral palsy. The New England journal of medicine. 1996;334:613-618

12. Coco A, Derksen-Schrock A, Coco K, Raff T, Horst M, Hussar E. A randomized trial of increased intravenous hydration in labor when oral fluid is unrestricted. Family medicine. 2010;42:52-56

13. Kavitha A, Chacko KP, Thomas E, Rathore S, Christoper S, Biswas B, Mathews JE. A randomized controlled trial to study the effect of iv hydration on the duration of labor in nulliparous women. Archives of gynecology and obstetrics. 2012;285:343-346

14. Chantry CJ, Nommsen-Rivers LA, Peerson JM, Cohen RJ, Dewey KG. Excess weight loss in first-born breastfed newborns relates to maternal intrapartum fluid balance. Pediatrics. 2011;127:e171-179

15. Noel-Weiss J, Woodend AK, Peterson WE, Gibb W, Groll DL. An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss. International breastfeeding journal. 2011;6:9

16. Singata M, Tranmer J, Gyte GM. Restricting oral fluid and food intake during labour. Cochrane database of systematic reviews. 2010:CD003930

17. National Weather Service. Lightning safety. 2012

18. Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews. 2009:CD003934

19. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2012;5:CD002006

20. Cluett ER, Burns E. Immersion in water in labour and birth. Cochrane Database Syst Rev. 2009:CD000111

21. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2011:CD003766

 

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