Tuesday, December 7, 2010

The Standard of Care Conundrum

When you think of the Standard of care in obstetrics, what comes to mind? Obviously your views on pregnancy and birth will dictate what you think the standards of care in obstetrics should be. However if you were to look up what the standard of care means in obstetrics, you'd get wide variety of definitions. Most commonly there are two schools of thought. The first is the Legal definition. This applies to the various standards of practice that should be done in order to maintain a good legal standing. For example, continuous fetal monitoring is considered a good way to indicate to a court of law (if you are doctor who finds him/or herself on defense there) that you gave proper standard of care to a mother whose baby ended up stillborn. The other school of thought is defining the term as the means of care that would be rendered by the majority of well-trained individuals. The latter is a little more tricky because it begs the question; which well-trained individuals are we talking about? Furthermore, with this definition, who sets the standards? Certainly many would say ACOG, but we must remember there are guidelines ACOG encourages that even members of their own group refuse to practice. It's also worth noting that not all practitioners, namely skilled and trained midwives, agree with some if not most of the practice guidelines set forth by ACOG.

The most compelling of the two main definitions is the implications for promoting the practice of defensive medicine. For those who are not familiar with the term, defensive medicine is basically medical practices designed or applied to avert the future possibility of malpractice suits. Let's take for instance the example I gave before of continuous fetal monitoring. Research and evidence shows that this practice is not only often times applied unnecessarily for every woman in labor, but in fact can cause more harm than good. Continuous fetal monitoring is connected with increased risk of false alarms, unnecessary interventions, increased need for pain medication, and even an increased risk of cesarean section. Yet with all the research that shows that intermittent monitoring with a doppler is just as effective and safe, doctors still apply continuous fetal monitoring with an EFM to many if not every woman, largely due to the fact that it protects them in case of a law suit.

One can now ask how policies such as continuous fetal monitoring be considered the Standard of Care if they can cause so many complications? Furthermore, how can true standards be set if there is not clear cut understanding of who has the authority to set them, or if they aren't guided by the best evidence? These questions expose what I like to call the Standard of Care Conundrum. It's the inherent flaw of our maternal health care system. Sure on the surface they all seem like gold standards, that is until you asked the dreaded three letter question: Why? Why exactly does a woman with a normal pregnancy have to be strapped to a bed throughout her labor? Why is it standard and widely accepted that a mother have a non-medically indicated induction at 39 weeks? Why is the cord clamped immediately after birth? Why, why, why? If any of the answers to these questions come from a place of legal protection to the physician this should be unacceptable! If any of the answers are skirted, ignored, or meet with an explanation from the stone ages of birth practices this should be unacceptable. Furthermore, if your questions breed contempt or agitation from your physician, not only should this be unacceptable, but you should run for yours and the life of unborn child!

Now we come to what the answer to all of this is? While many would say home birth is the answer, I strongly disagree with this. Home birth is the answer for some (I am having one this winter myself) and it's an option certainly every woman should be able to explore, but it's not the answer for all. Nor should it be. We have a system adopted long ago that was always broken. As much effort that is applied in making home birth a viable option for all women who can choose it, should be put into repairing that broken system. We need to fix it so that it becomes a viable option for women who want it, and an acceptable alternative for those who must choose it due to complication with their pregnancy. In short, as consumers we need to see to it that better standards are set and applied. These standards should not only put the safety of mother and baby first, but honor the mother's desire to birth in a way that she chooses. It's important for us not shy away from the fact that if we truly want better standards we are going to have to demand them. Change only going comes from the voices of dissent!

- American Academy of Family Physicians, May 1, 1999