Alice Dreger and her partner Aron Sousa have a piece in Virtual Mentor, the American Medical Association’s ethics journal, about science and evidence in labor and birth.  This is very similar that to another piece that Dreger published in The Atlantic last year.  I highly encourage you to read the full article(s), but I want to highlight a few things Dreger and Sousa say here.

They point out

Many well-intentioned obstetricians still employ technological interventions that are scientifically unsupported or that run counter to the evidence of what is safest for mother and child.

These include (according to the AMA article) routine use of continuous electronic fetal monitoring (EFM) in most hospital settings, routine use of episiotomy by some obstetricians, not providing (or even suggesting) doulas as a matter of routine practice, and routine use of epidurals for pain relief (see my post on choice in technological and scientific pain relief options here).

In response, Dreger and Sousa propose that

we believe it would be better to think of childbirth not in terms of “natural versus medical” but rather “scientific versus unscientific.”

In her Atlantic article, Dreger also notes

Many medical students, like most American patients, confuse science and technology. They think that what it means to be a scientific doctor is to bring to bear the maximum amount of technology on any given patient. And this makes them dangerous. In fact, if you look at scientific studies of birth, you find over and over again that many technological interventions increase risk to the mother and child rather than decreasing it.

I have heard many women say that they want to birth where “everything” is available.  But the problem with having “everything” there is that it becomes very hard not to use it.  Obstetricians seem to view things like fetal monitors, Pitocin, and scalpels the way most people view potato chips and brownies.  If you know they are there, you want them.  You need them.  Even if you know they are bad for you (or your patient)–must…have…now!

None of this information is particularly new.  The scientific evidence has been around, sometimes for decades.  When it comes to things like episiotomy or bed rest during pregnancy, even ACOG got on board long ago with practice guidelines indicating that these interventions should be used only in unusual circumstances.  But that doesn’t mean obstetricians actually practice according to ACOG guidelines.

Dreger and Sousa say,

[Obstetricians apply technological interventions that are not evidence based] not because a well-informed pregnant woman has indicated that her values contradict what is scientifically supported, a situation that might justify a failure to follow the evidence. They do so out of tradition, fear, and the (false) assumption that doing something is usually better than doing nothing.

Interestingly, when women want to decline these interventions, whether there is a scientific rationale for them or not, they are often punished.

Insisting on science based practice should not be controversial.  But as has been evident in obstetrics for hundreds of years, (e.g. the Chamberlen forceps), technological secrets bring power.  Whether the technology works as practiced is irrelevant to preserving that power.

 

Updates:

read about evidence and elective induction here

read about evidence regarding bed rest in pregnancy here

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