What Is Evidence-Based Care and How Do You Get It?
This is part of our Better Care Series, short blog posts about best practices in reproductive healthcare. Each post explores a challenge that women may encounter during pregnancy, delivery or postpartum while offering up actionable solutions. No fluff. Just the info you need.
The Backstory
The United States spends the most on maternal healthcare, has the highest rate of medical interventions, and among the worst outcomes compared to other developed countries, including being the only one with a rising maternal mortality rate.
According to the latest research, 1 in 3 women have major abdominal surgery (e.g. cesarean section) during birth (2–3x the recommended rate), despite significant evidence of short and long-term risks to the mother, child and future pregnancies, and evidence that cesarean rates above 10% do not prevent deaths.
We pour a ton of money into healthcare, but women aren’t seeing the benefits. Why?
There’s a lot of different reasons that women aren’t having more positive, empowering, less invasive experiences, one reason is a failure to provide healthcare that is based on the latest clinical research. This post explores that topic.
What is Evidence-Based Care?
It takes a long time for the latest research to reach your doctors desk. It takes even longer for clinicians and hospitals to change their practices to reflect that evidence, especially when these new practices come at a higher cost to the hospital.
David Sackett an American-Canadian medical doctor and pioneer of evidence based medicine defines the practice as “integrating individual clinical expertise with the best available external clinical evidence from systematic research as well as the values, preferences and beliefs of the patient.”
To define that more clearly, evidence-based care occurs when three things are operating in balance:
Clinical Research: the basis for all medical practice, carefully considered based on its overall quality. Currently, the latest research takes a major backseat to the institution’s established ways of doing things.
Clinician Experience: used to interpret the latest research and determine how it applies to different patients and situations. Under the current paradigm this dominates care and is not often based on current best practices.
Patient Values & Beliefs: considered by the clinician when providing a recommendation for care. This is often overlooked or minimized in favor of how the hospital or clinician prefers to proceed, leaving patients feeling discounted and disempowered. This also occurs because there is a very real bias against women and an even greater bias against women of color in hospital settings.
There are countless examples of how evidence-based care is superseded by hospital procedure, but few more common than the frequent resistance to allowing for skin-to-skin contact between mother and child in the initial moments following birth.
Skin-to-skin contact is well-established as being integral in successful latching and breastfeeding while the baby is still alert; it supports the development of a healthy infant microbiome which improves resistance to infection and, frankly, is obvious when considering the feelings of the mother.
Another example is asking women to hold in their babies during critical stages of delivery when the doctor is unavailable to assist with a delivery, despite feeling the natural urge to push. Vice investigated the reasoning for this practice and the risks in a piece that came out in July.
Dana Gossett, chief of gynecology at the University of California, San Francisco Medical Center is quoted in the piece:
“The longer the pushing phase lasts, whether you’re actively pushing or sitting there, the higher the chances are for things like lower Apgar scores (which are a measure of how well the baby transitions), lower blood gases and lower oxygen level. We know those things are not good.”
These are just a couple of the instances in which hospital procedure takes precedence over quality of care. But, you shouldn’t be a passive recipient of the care you’re receiving. There’s a lot you can do to ensure that the decisions in your pregnancy and birth experience are grounded in the latest best practices.
Investigate Topics That Matter to You
This is really easy to say, but much harder to do. We get it. But, there’s an increasing number of resources out there that are working to distill the latest research findings down into bite-sized summaries that make it easier for women to take an active role in their own care.
Our favorite one of these resources is Evidence Based Birth, founded by Rebecca Decker PhD, RN. The blog covers tons of topics from the Effects of Epidurals on Breastfeeding to Pain Management During Labor. We’re also big fans of the podcast. Each episode covers a different topic allowing you to dig into areas that are most relevant to you. All of their content represents the most thorough examination of the entire spectrum of research we’ve been able to find, and they make it super accessible to a non-scientific audience.
Choose a Provider That Aligns with Your Beliefs
As people, we all have different views on health. Part of evidence-based care is taking into consideration the values and preferences of the patient. If we expect practitioners to take our preferences into account, we first need to be clear on them ourselves and then ensure they are communicated in advance.
The book Your Medical Mind, by Jerome Groopman and Pamela Hartzband does a great job of helping readers to understand where they fall on various continuums that make up their preferences around healthcare.
Use these three categories to get a better understanding of where you fall and remember, there’s no right or wrong answer:
Doubters vs. Believers: do you tend to be skeptical of new medical findings and advice (doubter) or do you tend to think that there’s always a clear medical solution to your problems (believer)?
Minimalist vs. Maximalist: do you prefer to avoid treatment if at all possible and think “less is more” (minimalist), or do you aim to control risk and outcomes through various kinds of intervention (maximalist)?
Naturalist vs. Technologist: do you believe that nature is best and that anything synthetic or artificial is potentially harmful (naturalist) or do you believe that science and modern technology improves outcomes (technologist)?
As Rebecca Decker points out, it’s important to think of these as a spectrum — you could fall on one end or somewhere in the middle, and that while you may possess a maximalist mindset in one medical context or situation (like a broken bone), it could change in another one (like birthing).
Understanding where you fall as it pertains to pregnancy and childbirth can help you to decide where you want to deliver your baby — in a hospital, birthing center or at home. Remember, depending on your insurance and where you live, you often have your choice in hospital or birthing location.
It will also help you to find caregivers that align with your beliefs about healthcare and the type of delivery you want to have. Use these dimensions to frame up questions when interviewing your care providers. For example, if a vaginal delivery is important to you, it’s perfectly acceptable to share this with your clinician and ask for information about their cesarean rate as well as compare it to other options.
Lastly, this can help you determine the types of individuals you want present to assist with and advocate for your preferences: midwife, doula, nurses, doctors, family members, etc. The better these individuals understand your values and beliefs, the better equipped they’ll be to support you.
In Closing
Understanding your beliefs and preferences is the first step in creating a birth experience that makes you feel comfortable but also empowered. Once you have a solid grasp on these things, communicate them to potential caregivers and advocates. Their responses will reveal a lot about how you can expect them to conduct themselves during your delivery. Caregivers that represent a good fit will demonstrate that they hear you and will do everything in their power to comply with your wishes.