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“Asking different questions”: what if we are harming healthy childbearing women, and making sick childbearing women sicker?

Bahareh Goodarzi, Midwife and Researcher in the Netherlands

As a midwife, I notice that, in high income countries, more and more healthy pregnant women receive medical interventions and end up in hospital care.

In an effort to prevent and reduce risk, and ensure the health of mothers and babies, midwives and obstetricians increasingly intervene in the process of childbirth. In some cases, medical treatments are used routinely, even in healthy, uncomplicated pregnancies and births, for example episiotomy and induction of labour.[1]

This extensive use of medical interventions really worries me, because as a researcher I see an increasing amount of evidence that shows how medical interventions, medication and specialist care can harm healthy pregnant women and their babies.[1],[2]

Potential risk is not the same as actual risk. Medical treatments and doctors are meant to make sick people better, but they become a risk factor when applied on healthy women.

Many of the interventions used in maternal and newborn care are not evidence based, especially when it comes to applying them in healthy, uncomplicated pregnancies and births. We don’t always know if they actually help, whom they help and what harm they do.  We also don’t know what the long-term effects are for both women and their children[1]. As such, it might be justified to use the interventions to treat those women who are ill, but irresponsible to use them in healthy, uncomplicated pregnancy and birth. Because what we do know, is that the use of interventions increases the risk for more interventions, accumulating the risks of harm[1]. What if the risk does not come from the woman’s body, but from the maternity care she receives?

Just recently I attended The Normal Labour and Birth research conference in Ann Arbor, Michigan.[3] Researchers from different backgrounds – including midwives, obstetricians, epidemiologists, anthropologists and sociologists – emphasised that scientific studies predominantly focus on how to use medical treatments to prevent and cure illness. In contrast, researchers hardly pay attention to when not to use interventions, and the negative effects of these interventions when used on healthy women.[4],[5] Furthermore, research indicates that when the quantity of women receiving medical specialist care rises, the healthcare providers’ workload increases, and the quality of care decreases; the more women we treat, the worse we treat them.[6]

This makes me wonder about the negative effect of routine medical interventions in healthy pregnancy and birth on women who are sick and actually do need care. What are the consequences of not differentiating between women who do and don’t need medical interventions? What if we are making healthy women and babies sick, and fail to help sick women and babies get better?

And when something does go wrong, midwives, obstetricians and even women blame themselves, pondering on whether they should have done more; a question that also raised by women. But what if the problem is that we have done too much?

We need to start “asking different questions”.4 Instead of just focusing on when to intervene – because we don’t want to do “too little too late” – we need to critically think about when not to intervene, so that we don’t do “too much too soon”. [7] That’s why I am making a plea to redress the balance. We need to make sure women receive the right care, at the right time and at the right place, so that all women receive the care they deserve [1][4],[5].

And women and their partners need to know. They need to know that when they experience a healthy, uncomplicated pregnancy, unnecessary use of care in hospitals, interventions and medicine can be a risk factor for developing complications. Women need to know, so they too can start asking these different questions.

The time has come to start talking about the risks of unnecessary interventions. I made a spoken column to help start the conversation. I need to be clear about two things. First, I am not referring to interventions that are well researched and of which we know the benefits for healthy mothers and babies. Second, I am not blaming anyone, because no one is specifically to blame. Therefore, in the spoken column, I use the term ‘doctor’, referring to the entire maternal and newborn healthcare system.

I wish I could point fingers, because that would mean the solution is easy. But it’s not easy. It’s very complicated. That is why we need to do it together; women and their partners, midwives and obstetricians and everyone else involved in the provision of maternal and newborn care. Now, I am aware that it’s a difficult subject to talk about. But I feel we are obliged to do so. We owe it to ourselves and to our children.

This is my personal viewpoint, and not affiliated in any way to my employer.

Acknowledgement
Special thanks to Naomi Donner and Katie Digan for language editing.

Link to video column:

English: https://www.youtube.com/watch?v=dNwpP5aCKJc

Dutch: https://www.youtube.com/watch?v=WCBNnBKY514&t=9s

 

References

[1] Lancet series Midwifery, 2014, available via https://www.thelancet.com/series/midwifery

[2] WHO recommendations: intrapartum care for a positive childbirth experience, 2018. Available via

http://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/

[3] Normal Labour and Birth research conference, June 25-27, 2018, Ann Arbor. Available via https://normalbirthconference.com/

[4] Kennedy et al. 2016. Asking different questions: research priorities to improve the quality of care for every woman, every child. The Lancet: (11) e777-e779. Available via: https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30183-8/fulltext

[5] Kennedy et al. 2018. Asking different questions: A call to action for research to improve the quality of care for every woman, every child. Birth: 1-10. Available via https://onlinelibrary.wiley.com/doi/pdf/10.1111/birt.12361

[6] Ariadne Labs Mass. 2017. Designing Capacity for High Value Healthcare:The impact of design on clinical care in childbirth. Final report. Available via https://www.mhtf.org/document/designing-capacity-for-high-value-healthcare-the-impact-of-design-on-clinical-care-in-childbirth/

[7] Miller, S., Abalos,E., Chamillard, M., Ciapponi, A., Colaci, D., Comande, D., Diaz, V., Geller, S., Hanson, C., Langer, A., Manuelli, V., Millar, K., Morhason-Bello, I., Pileggi Castro, C., Nogueira, V., Robinson, N., Skaemer, M., PauloSuoza, J., Volgel, J. & Althabe, F. 2016. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. The Lancet (388)10056:2176-2192. Available via https://www.sciencedirect.com/science/article/pii/S0140673616314726

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