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Thursday
Aug112011

"guidelines are only as good as the evidence that underlies them"

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By ANaturalAdvocate

 

In the news lately has been an article entitled “Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’ Practice Bulletins.” This article rates the evidence behind the obstetrical and gynecological recommendations made by ACOG as A (“good and consistent evidence”), B (“limited or inconsistent evidence”), or C (“consensus and opinion”) - levels used by the College itself. These recommendations “are meant to synthesize the best available data and make practical recommendations for clinicians” and are implemented “[t]o guide physicians in the implementation of best practice.” 

The article itself admits the limitations of these recommendations from professional organizations, which are often used as “benchmark[s] for quality,” especially where high-quality evidence may be lacking. Given that these recommendations - which come from practice bulletins on topics from Operative Vaginal Delivery to Shoulder Dystocia and Fetal Macrosomia - “strongly influence the practice of obstetrics and gynecology,” it is imperative that “clinicians must remain mindful of the limitations of guidelines.” The authors do state that these recommendations should not take the place of clinical judgment, however. 

“Among the obstetrics recommendations, level A evidence was noted for 24.6% of the diagnostic recommendations, 46.7% of the counseling recommendations, 20.9% of the guidelines for evaluation, 27.4% of the treatment recommendations, and 4.2% of the guidelines concerning mode of delivery. For gynecology, level A recommendations were found for 29.0% of the diagnostic guidelines, 35.0% of the counseling recommendations, 24.2% of evaluation guide- lines, and 38.1% of those recommendations that addressed treatment.”

While obviously the expertise and training of the physicians forming these recommendations must be taken into account in deciding the weight of “consensus and opinion,” it is clear that many recommendations do not have the evidentiary backing that many consumers assume is present.

A press release from the Big Push for Midwives illustrates the practical effects of these recommendations:

WASHINGTON, D.C. (August 15, 2011)—A study published this month in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the organization’s clinical guidelines for OB/GYN practice meet the Level A standard of “good and consistent scientific evidence.” The authors of the study found instead that the majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on “limited or inconsistent evidence” and on “expert opinion,” both of which are known to be inadequate predictors of safety or efficacy.

“The fact that so few of the guidelines that govern routine OB/GYN care in this country are supported by solid scientific evidence—and worse, are far more likely to be based on anecdote and opinion—is a sobering reminder that our maternity care system is in urgent need of reform,” said Katherine Prown, PhD, Campaign Manager of The Big Push for Midwives. “As the authors of the study remind us, guidelines are only as good as the evidence that supports them.”

ACOG Practice Bulletin No. 22 on the management of fetal macrosomia—infants weighing roughly 8 ½ lbs or more at birth—illustrates the possible risks to mothers and babies of relying on unscientific clinical guidelines. The only Level A evidence-based recommendation on the delivery of large-sized babies the Bulletin makes is to caution providers that the methods for detection are imprecise and unreliable. Yet at the same time, the Bulletin makes a Level C opinion-based recommendation that, despite the lack of a reliable diagnosis, women with “suspected” large babies should be offered potentially unnecessary cesarean sections as a precaution, putting mothers at risk of surgical complications and babies at risk of being born too early.

“It’s no wonder that the cesarean rate is going through the roof and women are seeking alternatives to hospital-based OB/GYN care in unprecedented numbers,” said Susan M. Jenkins, Legal Counsel of The Big Push for Midwives. “ACOG’s very own recommendations give its members permission to follow opinion-based practice guidelines that have far more to do with avoiding litigation than with adhering to scientific, evidence-based principles about what’s best for mothers and babies.”

The Big Push for Midwives Campaign represents tens of thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives is to educate state and national policymakers and the general public about the reduced costs and improved outcomes associated with out-of-hospital maternity care and to advocate for expanding access to the services of Certified Professional Midwives, who are specially trained to provide it.

Media inquiries: Katherine Prown (414) 550-8025, katie@pushformidwives.org

 

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Reader Comments (26)

What percentage of practices exclusive to midwifery meet A level evidentiary guidelines? Zero?

August 16, 2011 | Unregistered CommenterAmy Tuteur, MD

That's a red herring.

I would be interested in hearing your thoughts on the actual Green Journal article, though.

August 16, 2011 | Registered CommenterJill

Amy: I couldn't say, because I haven't seen a study discussing it, although I'd be happy to post/review it, if you have one on hand. I agree with Jill that I'd like to hear what you have to say about this particular article.

August 16, 2011 | Registered CommenterANaturalAdvocate

From Jill, who is having trouble posting at the moment:

"My thoughts, not on the article but on how it might apply to
patients, is that most patients wouldn't care. If they have sought the
care of an OB-GYN, in my opinion they most likely trust consensus and
clinical experience because they placed themselves in the care of an
expert. Only when disagreements arise as to care would it be an issue,
and this would probably still apply only to a tiny percentage of the
patient population."

August 16, 2011 | Registered CommenterANaturalAdvocate

Amy: "What percentage of practices exclusive to midwifery meet A level evidentiary guidelines? Zero?"

Really?

August 16, 2011 | Unregistered CommenterAmanda

Amanda, there's a pattern I see online in discussions that could fall within the area of birth politics. People are discussing midwives critically and someone pops in and keeps asking, "Oh yeah, but what about obstetricians and hospital birth? Answer me!" Similarly, when details of the practice of obstetrics or hospital birth is being questioned, someone throws the "BUT WHAT ABOUT OUT OF HOSPITAL MIDWIVES?", which is less relevant than the former in that 99% of births take place in hospitals. I know this pattern of behavior well. I can pull up a bunch of links to posts on which I've pulled that crap.

If anyone wants to discuss home birth with Amy, you know where to find her.

Let's keep it on topic. This is an interesting subject, no?

August 16, 2011 | Registered CommenterJill

"That's a red herring."

Okay, so you acknowledge that there are no Level A guidelines to support any practice exclusive to homebirth midwifery. Therefore, it's hardly a red herring.

The press release is a classic in homebirth advocacy because it depends, like most things in homebirth advocacy, on DELIBERATELY MISLEADING lay people.

It sounds like an indictment (and it is meant as an indictment) to say that only one-third of ACOG guidelines meet Level A standards (as opposed to Level B or C). But it doesn't sound so bad when you acknowledge that ZERO practices exclusive to homebirth midwifery meet Level A standards.

... and 0% meet Level B guidelines; and even 0% meet the lowest level, Level C guidelines. That's because there is NO evidence of any kind to support the practices exclusive to homebirth midwifery. You know it, I know it and The Big Push for Midwives knows it. They're counting on the fact that most lay people don't know it.

The ultimate irony? The Level of Evidence for the actual paper that The Big Push is quoting, Level III, is the lowest possible level!!

August 16, 2011 | Unregistered CommenterAmy Tuteur, MD

"Really?"

If there are any, feel free to name them and to demonstrate that they meet the criteria for Level A guidelines.

August 16, 2011 | Unregistered CommenterAmy Tuteur, MD

Although I know the truth in the above article, it is disheartening to see it in print. What it all comes down to is your OB's expert opinion, with limited backing from scientific evidence. As with any one person's opinion, it is biased due to experience and education. Midwives are no different. I've seen homebirth midwives make scary mistakes, and I've seen OBs, in hospital make scary mistakes. It's because we are all human, and fallible. I've also seen fantastic OBs and fantastic homebirth midwives.

What we need is uniform continuing education requirements and oversight. (Navelgazing Midwife wrote a good bit about this recently). Nothing guarantees a standard of care. However, each of the specialties (OB, CNM, CPM, LM, etc) need to have their own, appropriate, evidence-based guidelines. Each set of letters gives the bearer different privileges, and differing levels of care. If you know the scope of your ability you know when transfer of care is required. That goes both up the scale for high risk births, and down the scale for low risk births.

so, I've digressed a bit. The big question becomes - how do you enforce the evidence-based standards of care? Statistics are great, but how do reframe a hospital system such that all of your OBs follow the same standards, when you know there are exceptions to every rule? When sometimes a gut feeling is more important than numbers. When a bit of confidence and faith in a mother can result in a vaginal birth, rather than a c-section? Sometimes quality of care isn't meausred in numbers, but in the happiness of the mother (and father!) who delivered that baby.

One of the reasons I became a Lamaze Educator, as opposed to other flavors of childbirth educator, was because of Lamaze's focus on "evidence-based practices". I teach my moms to ask questions, request studies, get second opinions, discuss birth plans well in advance, etc. Although the burden of proof is on the care provider, mothers still need to ask for the back up data. Trouble is, they usually don't.

"Although I know the truth in the above article, it is disheartening to see it in print."

The press release is a deliberate lie, meant to trick women and it has already tricked you:

Please explain the difference between Level A, B and C guidelines and how that differs from "no evidence."

Please list 5 practices that are exclusive to homebirth midwifery that meet Level A guidelines.

Can you name ANY practices exclusive to midwifery that meet Level A guidelines?

PS: Nothing in Lamaze is based on any scientific evidence and the only people who are unaware of that fact are NCB and homebirth advocates. Don't believe me? Find one of their recommendations that meet Level A guidelines. Hint: There are none.

August 16, 2011 | Unregistered CommenterAmy Tuteur, MD
This blog is all done!
Thanks for wanting to comment. This is an archive of a blog that once was. Take care! Jill