Questioning screening: food for thought

small__3558561251Are you aware that the vast majority of the things that midwives do during antnatal and postnatal checks and when looking after women in labour are actually screening tests?  No matter whether we are checking a woman’s blood pressure, urine or haemoglobin levels, the height of her uterus, the size of her baby, or the dilation of her cervix in labour, we are effectively applying a screening test to see whether these things are ‘within normal limits’.

At the simplest level, screening could be said to be about scanning the horizon for things that are anomalous, or that might indicate a problem.  But this seemingly simple act can, as I noted in The importance of consent, carry risks of its own, and once you begin to analyse the concept of screening, some very tricky questions emerge.  These questions have been of interest to me for many years, and I have written (and talked) a lot about them in different arenas.  This post gathers together a number of my thoughts, books and articles on the subject of screening and links to all of the articles that I have written on this topic which are freely available on this website.

The Art of Questioning is an opinion piece which is now more than twenty years old.  It was the first article in which I argued that it might be helpful to break down the different interventions and tests that pregnant and birthing women are offered into different categories in order that we – whether as women, midwives and/or birth workers – can more clearly see what is being offered, with what intention and with what potential consequences.  I also wrote about these ideas in the AIMS booklet What’s Right For Me?  At the same time, I was applying some of the questions to topics such as anti-D, vitamin K and group B strep, with articles on the latter topic including The war on group B strep and an article that (had there been room on the page in the journal) would have been called Giant breakthrough in screening or great big stressor?, but which had to be abbreviated to Giant breakthrough or great big stressor? instead!  Another area I took issue with was Carbon monoxide testing: what choice?

small__4013357893In Screening and the Consequences of Knowledge, which looked in more depth at some of the areas that I had previously written about, including group B strep, I again pointed out how much of what midwives do can be considered as screening, and quoted Barbara Katz-Rothman (2001), who raised a really important point about the relationship between information and time:

“Prenatal diagnosis never tells anything one wouldn’t have found out later on anyway. It simply changes the timing. In having prenatal testing the woman seeks immediately the information she would have had eventually.” (Katz-Rothman 2001: 189)

The notion that we can screen for possible problems also relies on a number of assumptions; one being that we can effectively define the range of ‘normal’ in order to determine whether individual people fall into this camp. Yet,

‘”Normal”, as it pertains to childbirth, is problematic. Normal is defined as ‘‘regular, usual, typical, ordinary, and conventional; physically and mentally sound; free from any disorder; healthy.’’  It is a word that dichotomizes — if you are not ‘‘normal’’, then you must be abnormal, atypical, disordered, unhealthy, or irregular — and who wants those labels?’ (Powell-Kennedy 2010:199).

My concern with screening is not merely that of overdiagnosis or overmedicalisation.  I believe that putting too much store in the notion that there are measurable population norms which form helpful boundaries between the normal and the pathological can be very problematic.  I wrote quite a bit of my PhD on this area, and probably the best place to start with this is Post-term Pregnancy: The Problem of the Boundaries, but this idea is also discussed in a ‘Thinking Outside the Box’ article called Screening what are we missing?

In Reflecting on risk assessment, I noted the conflict between our desire to screen in the hope of being able to prevent unnecessary death or injury from things that might be predictable and/or preventable, in this case venous thromboembolism (VTE), and the notion that we should only be doing things with women’s full consent.  The trouble is that professionals are continually ‘risk assessing’ situations; this is a key element of what we do, so the lines aren’t very clear at all and there is much more work and thinking to be done here.

small__14222709026In Normality and Goalposts, I discuss issues relating to Holly Powell Kennedy’s point (above) about normality:

‘Holly’s commentary highlights the problem that arises when we create goalposts – or markers around what we consider normal.  The creation of a space which is determined to be normal (or, to continue using the metaphor, the goal) necessarily and unavoidably creates another space (everywhere except the goal) which is, for whatever reason, deemed to be not normal.  Yet there is a vast difference between the use of a goal in, well, say football, and the use of a similar kind of defined space in relation to birth. i can’t imagine that many Premiership referees would support a petition for goalposts which are individually flexible depending on the team, yet the need for flexibility is often debated when we consider the definition of what is normal in birth.’ (Wickham 2011: 50)

Again, the issues are not cut and dried:

‘Although many people have questioned the usefulness of the population-level goalposts that are an inevitable feature of systems of maternity care where guidelines and shared understandings are a necessary means of maintaining order, even those midwives who work autonomously and outside of systemic guidelines need to have criteria for determining whether a woman’s experience is normal or otherwise.’ (Wickham 2011: 50).

There is, however, still an awful lot that needs questioning at a very basic level, with one of the key issues for me being the way in which so many of the boundaries against which features women’s and babies’ bodies and experiences are measured are arbitrary, and based on tradition or convention rather than science.  This is discussed further in The importance of illumination and, although that is (at the time of writing) the most recent article I have written on this topic, I very much doubt that it will be my last!

 

Katz Rothman B (2001) Spoiling the Pregnancy: Prenatal Diagnosis in the Netherlands. In: De Vries RG, Benoit C, Van Teijlingen E and Wrede S (2001) Birth by Design. New York: Routledge. Chapter 9: pp 180-198.

Kennedy HP (2010). The problem of normal birth.  Journal of Midwifery and Women’s Health 55(3):199-201.

Wickham S (2011).  Normality and Goalposts.  Essentially MIDIRS 2(2): 50-51.

Horizon photo credit: kugel via photopin cc.  Calendar photo credit: eagle1effi via photopin cc.  Goal photo credit: Ulf Bodin via photopin cc

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