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?
You can read the – now quite dated – second part of this article here. I have left these articles up because they relate to important issues, but for a more up-to-date discussion, please see my book, Vitamin K and the Newborn – or come and join our vitamin K online course, where we look at this question in much greater depth.