Deconstructing prophylaxis

Is prevention better than cure? In this article, Sara Wickham looks at the idea of prophylaxis; doing things to try to prevent disease and danger.

It has long been thought that ‘prevention is better than cure’ and many of the things we routinely do in our lives are aimed at preventing disease and danger. If we get into a car, we put our seat belt on; we try to eat five servings of fruit and vegetables each day; and we follow Tufty’s exhortations to stop, look and listen before crossing the road. The institutions around us also insist that we follow their health and safety advice, so we trot along to hospital fire lectures, give our full attention to cabin crews as they wrestle with lifejackets and oxygen masks and console screaming children who are too short to be allowed on the roller coaster.

Many of these things are only sensible, but I find it interesting that we have become so well trained in following the rules of prevention that we ~ as a society ~ haven’t always stopped to think about whether some of these rules are right for us.  We are, in fact, so well-trained that many of us feel guilty if we don’t follow the guidelines: if, for instance, it gets to bedtime and we have only eaten three portions of veggies, or if we have spent the whole day on the sofa eating “naughty” chocolate instead of going to the gym.

This cultural trend towards prevention has, of course, spilled over into maternity care and pregnant women are advised not to eat, drink and smoke certain things, and expected to avail themselves of a whole raft of preventative measures. The very act of entering a modern maternity care system can be viewed as a safety measure in that some women see this as putting their trust in professionals who will guide their decisions, just as we put our trust in pilots and trust that they will tell us if and when we need to put our head between our knees.

Depending on where you are in the world, these prophylactic measures include routinely withholding food or fluids from labouring women, routinely managing the third stage of labour, routinely giving vitamin K, anti-D or antibiotics and even simple things like cord care.  In many cases, the problem being prevented can be potentially serious (such as in the case of haemorrhagic disease, now known as vitamin K deficiency bleeding) but it will only occur in a very few babies. But, unlike wearing your seatbelt on the plane, which at worst means you can’t get into a comfortable position to sleep, the preventative measures offered to pregnant women often carry risks of their own.  Prophylaxis literally means “prevention of disease” and with all of these measures, there are a number of questions which need to be considered:

  • BASELINE RISK: What percentage of women / babies will actually end up with the condition that the prophylaxis is intended to prevent? (The woman can then decide how this level of risk feels to her: it is also useful for women to know if anything can be done to treat the condition if it does occur).
  • EFFICACY: How effective is the prophylactic intervention? (Many women believe that interventions offer a 100% guarantee; as we know, this is very rarely the case).
  • SIDE-EFFECTS: What are the potential side-effects and risks of the prophylactic intervention? (A woman can then decide whether she is willing to take on these risks, or make a decision between the risks of the disease or the risks of the intervention).

One of the major issues for midwives here is that the issues are so complex, and part of the complexity is due to the fact that, while many of the prophylactic interventions in use in maternity care can be challenged, and while many midwives are aware that prophylactic interventions are not always the panacea they are thought to be, these challenges are often based on different issues.  For instance, there is little question of the efficacy of both vitamin K and anti-D but there are some questions around risk, whereas the idea of starving labouring women can be challenged on the grounds of efficacy, risks cause by the intervention and a low risk of the condition actually occurring. Medically managing the third stage is not always as efficacious as we might think, carries a risk of side-effects and may be less vital in the West, where we are usually able to treat PPH, than in other areas of the world.

Then there are the many things we do in the name of prophylaxis, but which have not really been evaluated; for instance, routine cord care or offering advice about eating or avoiding certain foods. Perhaps the time has come when we need to take a deeper look at these issues and ask ourselves whether it is better to offer Tufty-type care, which warns of every possible danger, or to look at other possibilities?

One of the reasons I asked this question is that I have noticed two things occurring in our society, perhaps as a backlash to the cultural emphasis that has been placed on safety.  Both have potentially significant implications for midwives.

First of all, as far as the wider safety rules are concerned, it seems that more people are challenging these in choosing to decide for themselves.  There is a backlash against the recent banning of see-saws in some areas (which have been removed from parks in case children hurt themselves) and a number of teachers’ groups are challenging the ruling that they must not hug children on the grounds that this denies children essential human contact.  Even senior politicians are coming out against the idea of a “nanny state” (At the time of writing this article, current issues included John Reid’s comments on the banning of smoking and some of the responses to the part of the Government gambling bill which means that children may no longer be allowed to try and win teddy bears in arcades in case this creates an addiction to gambling).

Instead, more people are supporting the idea that, as long as others are not harmed, people should be able to decide to take risks with their own lives and health if they choose.  Many are choosing to make a distinction between the really useful prevention rules (i.e. wear your seat belt and don’t run around with a pen in your mouth) and those which they consider guidelines: it is good to eat lots of vegetables, but sometimes chocolate is good and often guilt is not.   Moreover, we are realising that these rules are not guarantees and are seeing some of the paradoxes inherent in some of the rules.

Secondly, the past few years has seen a massive leap in the level of interest in ‘dangerous’ sports and activities such as bungee jumping (albeit with all kinds of safety harnesses attached).  Is this also a reflection of a desire to eschew the safe life, perhaps in response to our over-protective society?

I suspect that aspects of both of these trends are also occurring in maternity care.  Over the past few months, I have heard midwives note that women today are more questioning than ever. It is now not only the case that women make complaints when they are not given treatment that they felt should have been offered (which is one of the things we have always feared in the maternity services, leading to our tendency towards over-treatment and routine intervention), but an increasing number of women are complaining that they or their babies were given treatment which they later felt to be unnecessary.

Unassisted birth is happening more in the US than the UK at present, but it is happening in the UK.  I recently heard Elizabeth Davis speak about how this is something midwives need to pay close attention to: if we are not offering the kind of service that women want, they are bound to go elsewhere ~ not because they are being deviant, or seeking to harm their babies or themselves, but rather as a last resort because they cannot get the kind of care they really want.

It would seem that the decline of universal prophylaxis ~ at least where this is defined as routine prevention rules which are applied to everybody in the same way ~ has now begun.  Within the last few years, we have seen one move, at least in theory, from the idea of policies to the idea of guidelines, which sought to address issues around the need to individualise care.  As more people in the wider world challenge the idea that safety and the prevention of danger are the bottom line, and realise that absolute safety is rarely attainable, this is going to influence attitudes towards the maternity services.  With any luck, the realisation that other aspects of life, such as love, spirituality and compassion, are also important, might mean that we can re-consider some of the philosophical tenets on which maternity care is based.

 

This article was originally published as Wickham S (2005). Deconstructing prophylaxis – part 2. TPM 8(2):31 and Wickham S (2005). Deconstructing prophylaxis – part 1. TPM 8(1):35.
 photo credit: tubblesnap Twas Dark via photopin (license)

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