Photo Credit: Mama Loves
By Amy Wood, Contributing Writer
There has been a lot of talk recently about evidence-based care during pregnancy, labor, and birth- meaning that the care you are receiving is actually based on scientific evidence and the individual needs of the mother and baby. There are groups such as Improving Birth, which advocate for such care and work to inform women as to what evidence-based care involves and which routine procedures do not meet that standard.
This is a great work, but often applies to low-risk mothers…so if you aren’t low-risk, where can you turn? How can you determine what is evidence-based care for your unique situation?
3 Steps to Ensure Evidence-Based Care When You Have a High-Risk Pregnancy
It would be nice if the care that a doctor gave you could automatically be trusted to be evidence-based, but unfortunately that is not the case. When I was pregnant for the first time I heard a lot about the “standard of care” for diabetics, and the implication was that this was the medically appropriate way to care for my situation. Therefore, if I had a different idea of how I would like my care to be handled it was not appropriate, even unsafe, as it was going against the standard of care they were offering me.
But over the years I have learned that the standard of care for your situation may not reflect what is actually evidence-based care. It may not even be what the American College of Obstetricians and Gynecologists (ACOG) recommends.
Here’s a quick example from a low-risk situation: almost all hospitals have mothers on continuous fetal monitoring during labor, it’s a standard procedure and recommended by many doctors, but it’s not actually evidence-based care for low-risk mothers. Continuous monitoring has not improved outcomes and may actually lead to an increase in complications.
So much is known about evidence-based care for low-risk moms, but what about high-risk moms? How do we find out what is evidence-based care and whether that is consistent with the standard of care that we are told we must follow?
We all have different high-risk situations. I am high-risk based on a pre-pregnancy condition that I manage well- but I know that many mothers are surprised to learn that due to an unforeseen issue with their pregnancy they have moved into high-risk territory. I have been able to do things a certain way, or decline unwanted procedures, that mothers in other situations may not be able to do. The good news is that there is a way for all of us to find out what is evidence-based care in our unique situations.
Standard of Care vs. Evidence-Based Care
Throughout my first four pregnancies I wasn’t exactly sure how to determine what was evidence-based care, I was just insistent that I be treated like a normal pregnancy, as long as everything was progressing normally and I found a very respectful care provider who worked with me on these things and agreed that this would be appropriate for me.
During my fifth pregnancy I started asking more questions about a procedure that I had complied with for all of my previous pregnancies- fetal non-stress testing. I understood why this was recommended for diabetic mothers, but I was curious as to where the frequency of testing and the gestational age it is recommended to begin came from- what was the evidence behind this procedure?
I asked my doctor at one of my routine appointments and he provided me with a huge book of ACOG’s guidelines relating to all different kinds of situations, including pre-gestational diabetes. He let me borrow the book so I could read over everything in the chapter relating to my situation and look into the research cited at the end of the chapter.
I eagerly took the book home, read through the entire chapter that night, and eventually settled on a mutually agreeable plan for fetal testing during the last few weeks of my pregnancy. But what I found out about some other aspects of my situation made me furious! One of the things I had always been told was that I would have to be induced at 37-38 weeks because that was the standard of care for mothers with type 1 diabetes. I did not want this and did not think it was appropriate as long as my blood sugar was well controlled and the baby and I were both doing well. Imagine my absolute shock when I read in ACOG’s guidelines that:
“Early delivery may be indicated in some patients with vasculopathy, nephropathy, poor glucose control, or a prior stillbirth. In contrast, patients with well-controlled diabetes may be allowed to progress to their expected date of delivery as long as antenatal testing remain reassuring.”
This was actually exactly what I had always asked for — to wait for labor to begin spontaneously as long as my blood sugar was well controlled and the baby was doing well. I had always been told that I could not do that because it goes against the standard of care (implying that to do so would be dangerous). Yet, ACOG states that there is no indication for early induction for a mother with well-controlled diabetes.
What I was being told was standard of care didn’t line up with what is true evidence-based care.
Another example — all the doctors I had seen recommended that I have a fetal echocardiogram because babies born to mothers with diabetes have a higher risk of heart defects. This was again put forth to me as the standard of care for my situation. I understood the higher risk of heart defects, but had always declined the procedure, preferring instead to have a normal anatomy scan around 20 weeks and move forward with the echocardiogram only if the normal scan indicated some kind of abnormality. Regarding echocardiograms, ACOG states:
“Echocardiography also may be indicated in cases of suspected cardiac defects or when the fetal heart and great vessels cannot be visualized by ultrasonagraphy.”
Fetal echocardiography is only indicated in some situations, not across the board for all mothers with diabetes. Once again, what I was told was the standard of care didn’t line up with what is true evidence-based care.
Ensuring Evidence-Based Care
Clearly, just because something is considered to be the “standard of care” doesn’t mean it is actually evidence-based care, and this difference is critical. So what can you do?
Here Are 3 Steps to Help You Ensure That You Are Receiving Evidence-Based Care During Your High-Risk Pregnancy
#1: Ask to See the ACOG Practice Bulletin For Your Situation
ACOG’s practice bulletins are the clinical management guidelines that they suggest be followed and a book compiling these practice bulletins should be available in your doctor’s office. There should be a chapter on your situation and a list of references at the end of the chapter. While you may not always agree with everything that ACOG concludes, this is a great starting place. If your doctor isn’t willing to share this information with you then look for another care provider who is. If you aren’t able to borrow the book from the office ask to make copies of the pages you need.
#2: Investigate the Cited Medical Studies Listed at the End of the Chapter and Search For Other Related Studies on Your Own
After reading the relevant information in the book investigate the medical studies cited in the reference section. If you are unable to access the medical studies cited then ask your doctor to help you get them so that you can understand the full picture (he or she should have access to the full text of the studies). Take advantage of cites such as PubMed to search for other studies that relate to your situation. In doing this I found another, more recent study that concluded that waiting for spontaneous onset of labor, even beyond 40 weeks gestation, is appropriate for mothers with diabetes as long as fetal testing is normal.
Print out these studies for your own reference and to go over with your doctor. I keep a simple folder with the printed ACOG practice bulletin regarding maternal diabetes and any other relevant studies I have found on my own.
#3: Compare ACOG’s Practice Bulletin and the Evidence Gathered From the Medical Studies to What Your Doctor Recommends and if it isn’t Consistent Show Them the Discrepancy and Ask for Evidence-Based Care.
Once you have gathered this information you can compare it to the care you are being offered by your doctor. Remember that there is often a difference between the claimed standard of care and true evidence-based care. Also keep in mind that there can be a lot of variation between mothers and their situations even if they have the same high-risk condition- you should always be treated as an individual, even with evidence-based care in mind. If you find that an aspect of your care is not being handled in an evidence-based way then bring the studies with you to your next prenatal appointment so that you can discuss it with your doctor and ask for evidence-based care.
I know that it can be daunting to think of doing such a thing, but a good doctor will be willing to discuss these things with you and address any of your questions and concerns, if your doctor isn’t willing to do such a thing then consider finding a different doctor. If you’re like me, taking a support person with you when having these discussions with your doctor may help to ease your nerves.
When you have a high-risk pregnancy you have more to consider than low-risk moms, but that doesn’t mean that you must blindly follow whatever any doctor recommends that you do. You still deserve to be treated like an individual and offered evidence-based care, which may or may not be consistent with the so-called “standard of care.” By working through these three steps you will be well on your way to understanding what evidence-based care looks like in your situation and finding a doctor who will provide such care to you.