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)
This is a realistic approach to care, taking into account all aspects of what is possible. In most cases, we find that components 2 and 4 are very limited and restrictive. These components reflect on either a lack (ie of skills, training in breech birth, of breastfeeding education, of experience with normal physiological birth) or a lack of resources (not enough staff, not providing the best evidence-based model of care: which is continuity of midwifery carer, no baths, restrictive policies).
Evidence-based care is only as good as the weakest link – which is components 2 and 4.
These components will only improve with consumer demand, but we have come to accept the short comings of our health care system as standard practice. The narrative we are sold is that birth is dangerous, and often it is component 3 that 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. Whatever the standard of care is, any deviation from the very narrow limits of standard (ie acceptable) will render the woman the reason for a poor or unsatisfactory outcome.
Context-based care takes the focus off the system, and onto the woman. The individual.
In context-based care we ask what matters to you. What do you need? How can we accommodate that? How do we work together to ensure that the woman is heard, and supported?
For this to occur, we need continuity of midwifery carer. We need the midwife we choose to be able to recognise and understand our needs, values and context, 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 to take place 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, when it is needed. Rather than using the limitations of the system to justify forcing a woman onto a particular path, the system is forced to provide the appropriate opportunities. In addition to this the system also need to change from an insurance-driven, blame game, to an individual-honouring, humanised service.
The main reason that this change is not happening, is reflective of the values of society. 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.
The reality of this then means that for component 3 – which relates the context of the woman – we have a majority that do NOT value themselves, they do not consider the need to take responsibility or do anything other than follow the recommended care. With rapidly rising rates of intervention, we know that this recommended care is not in the best interest of women, but in running an efficient 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 context-based care.
To better understand how you can claim your power (by taking responsibility) in your maternity care, find out what Birth Cartography is: video here.