We hear a lot about evidence-based care, but just as with ‘shared-decision making‘, it is often misunderstood.
Evidence-based care is comprised of 4 components:
- The best available research evidence (ie population level understanding, which requires multiple sources)
- The level of skills, training and experience of the care provider
- The values and circumstances of the decision maker (in this case the pregnant, labouring and birthing, mothering woman)
- The abilities of the facility (ie what equipment is available)
Evidence-based care is only as good as the weakest link: components 2 and 4.
This creates a context of poor outcomes, dissatisfied mothers, families and workers and an illusion of choice.
The narrative we are sold is that birth is dangerous, and component 3 is used as the ‘scapegoat’. We blame women for being too young, too old, too fat, too demanding, too educated, not educated enough, too rich, too poor, too black, too foreign, too risky, too isolated, not making the right life choices, being too damaged, carrying trauma…you get the point.
In most cases, however, components 2 and 4 are under-resourced and restrictive. These components are either lacking skills and training (i.e. of skills, training in breech birth, breastfeeding education, or experience with normal physiological birth) or resources (not enough staff, not providing the best evidence-based model of care: which is continuity of midwifery carer, no baths, restrictive policies). And this is called Standard Care. The context for this standard is an underskilled and under resourced system.
In the standard of care, any deviation from the very narrow limits of what can be provided will render the woman the reason for a poor or unsatisfactory outcome. This standard will only improve with consumer demand.
Respectful Maternity Care is individualised care
Respectful Maternity Care takes the focus off the system, and onto the woman: The individual.
What matters to you. What do you need? How can we accommodate that? How do we work together to ensure that you are heard, and supported?
For this to occur, we need continuity of midwifery carers in community-based settings. We need the midwife we choose to be able to recognise and understand our needs, values and context and then provide us with options. This may be to bring obstetric care into our team. This may be to choose a path that leads to death or injury. We need this to be ok. We need a conversation where the woman can fully understand all the possible pathways, for better or worse. And she gets to decide what better and worse is. Then the system provides the level of care needed and when needed. Rather than using the system’s limitations to justify forcing a woman onto a particular path, the system must provide the appropriate opportunities. In addition to this, the system also needs to change from an insurance-driven blame game to an individual-honouring, humanised service.
The main reason this evidenced change is not happening is reflective of society’s values. Society has devalued mothering and has medicalised birth. This processing of women during their maternity time disregards the incredible and very human transition they are undergoing. By pathologising and paternalising maternity care, we have created a society-level acceptance that all that matters is an alive baby.
Ignoring the mountain of evidence, devaluing the decision makers, and failing to resource fullscope practice has led to rapidly rising rates of intervention, without improving outcomes. We know that more often than not recommended care is not in the best interest of women, but in managing an underskilled and under resourced system.
The graph ‘How does Australian Maternity fare?’ shows data from 2019 as reported by the Australian Institute of Health and Welfare. The largest circle depicts the outcomes for low risk women in standard hospital care (ie the best Australia has to offer). The World Health Organisation, as long held that when maternity services are in the best interest of women, we can expect to see a caesarean rate of no more than 15% and an episiotomy rate of no more than 10%. As you can see, Australia is well over these expectations, and we are anticipating much higher rates in 2020 and 2021. By contrast, the outcomes as recorded in a Midwifery Group Practise offering home birth and continuity of midwifery carer are also shown (which are not reported in the AIWH reports, possibly because such data does not reflect well on the maternity system). These outcomes show rates well below WHO expectations, and are reflective of what happens when women receive respectful care.