The knee-jerk effect in maternity care

Midwives, doctors and others working in maternity care are all too aware that adverse outcomes tend to have a lasting effect, even (and perhaps sometimes especially) when they are unpredictable or unpreventable.

But I am just not referring to the impact they have on the families and caregivers involved, which is huge and deserving of much discussion.

Events which ended in tragedy or a near-miss scenario are also often the catalyst for significant changes in approach or policy, most often involving a narrowing of the boundaries of what is considered acceptable, or normal.

We see the effects of this in rising intervention rates, as well as from what women, families, and birth workers report about their experiences.

A global phenomenon

I have seen this time and time again in different countries and areas of care.

In my experience, it is most likely to happen where two or more similar adverse events occur in a unit in a relatively short time period. When this happens, it is awful, but statistically not that unlikely in centralised maternity services which mean than thousands of women give birth in a particular unit or Trust every year.

But I have also seen changes in approach and/or policy after just one adverse outcome.

The response tends to be something like this:

“Right, everyone. We had an unwanted outcome after a woman had been in labour for twelve hours / planned a VBAC / got in the pool (or whatever was ever-so-slightly unusual about the situation). We must learn from this and limit all labours to eleven hours / caesarean section / land, so that nothing bad happens again.”

This is irrespective of whether there is any evidence that such a limitation would have saved or prevented harm coming to that particular mother or baby.

Or whether it would would save or prevent harm coming to any future mothers or babies in the same situation.

It’s also usually irrespective of any risks of the alternative course of action (and everything has risks) and what the effects or downsides of such a policy might be on others.

More harm than good

It is understandable that we want to do something when an adverse event happens, but what we do may lead to more harm than good.

I am certain that others will also have witnessed this kind of knee-jerk reaction to an adverse event.

Such reactions can mean that all of the decision-making processes that have been carefully built up over time in order to ensure that policies are collective and evidence-based are simply ignored.

An instant ban on certain practices may be brought in, often to the dismay of both staff and women.

Changes in comfort zone

The effects of this phenomenon aren’t always so obvious though.

The comfort level of individual practitioners may temporarily shift after a poor outcome. This can lead to a lower tolerance for uncertainty or for particular situations.

Ideally, we need to respond to this with concern, and by providing safe spaces for practitioners to work through their thoughts and feelings.

These days, however, midwives and doctors who have experienced an adverse event are more likely to be bombarded with paperwork, risk assessments and questions than TLC.

This creates an additional problem, too. Because while people are VERY quick to bring in new rules, boundaries and targets, they are FAR slower to make a plan to evaluate their effectiveness (which means they rarely get assessed to see if they worked – often they don’t) or to set a date to reconsider whether they should continue.

This means that the new rules and boundaries often stick, whether or not they are effective, useful, respectful, evidence-based or kind.

The failure of systems to create the means of evaluating and ditching old rules, targets and guidelines also leads, somewhat ironically, to another problem. Staff get really bogged down in trying to keep up with the tens or hundreds of new rules or bits of paperwork that they are obliged to complete. And they (a) have less time for direct care and (b) struggle to find time for their core tasks because they are too busy doing things which have been brought in to try and prevent the “one in a million” events. That leads to many more problems for everyone, and it’s not a logical approach.

Why aren’t we looking at this?

This phenomenon has never been give enough attention, even though a study by Riddell et al (2014) evidenced the problem.

The researchers looked at the effect of uterine rupture on a hospital’s future rate of vaginal birth after caesarean (VBAC).  Using data from the US Nationwide Inpatient Sample, they looked at changes in VBAC rates, trial of labour (sic) rates and VBAC success rates over time.

Their findings were significant:

‘Before the occurrence of a severe uterine rupture, there were an estimated 60 successful vaginal deliveries for every 100 women with a previous cesarean delivery who entered labor. In the month after the rupture, the trial of labor success rate decreased by an estimated 25 cases per 1,000 labors (95% confidence interval [CI] 6–44/1,000, P=.01) before returning to baseline. The percentage of women with a previous cesarean delivery who attempted vaginal delivery did not significantly change after the rupture. Overall, there were 17 more cesarean deliveries per 1,000 women with a previous cesarean delivery (95% CI 4–31/1,000, P=.01) in the month after the uterine rupture.’ (Riddell et al 2014: 1175)

This evidences that just as many women were still wanting VBACs, and were starting out in labour hoping and intending to have a VBAC, but fewer of them achieved this after another local woman had recently experienced uterine rupture.

The effects of change

Riddell et al (2014) conclude – though of course this is informed speculation, as research can only tell us that something happened, not why it happened – that ‘the decrease in the trial of labor success rate after a recent uterine rupture is likely the result of short-term changes in risk evaluation’.

Knowing this doesn’t necessarily make things any better for the women who were more likely to have been told they needed a caesarean section soon after another woman had experienced a uterine rupture.

But if I have learned one thing about birth-related decision-making from my years of studying this area, it is that it is rarely as rational as some people claim.

Human factors are always present.

If we could acknowledge that, then perhaps we could move towards a more honest approach. In which we acknowledge our humanity, concede that decision-making is just as much an art as a science, and admit that there are many things we do not know.

And perhaps we could look at the bigger picture and the knock-on effects that such decisions have on the experience of women, babies, families and those who care for them.

Where do we go from here?

A 2023 study called for a strengthening of open disclosure, which is a part of the problem here. We have a culture focused on blame, in which midwives and others are denigrated, and where physiological birth is under threat; these all play a part in this problem.

The approach that is currently being taken to investigations of problems is not helping either. Too often, staff are blamed for deeper, systemic and cultural issues, and made to focus on targets which take them further away from giving direct, safe, kind care to women and families.

What can you do?

There are things that you can do to respond to this issue, depending on your situation.

If you are receiving care:

If a recommendation feels rushed or overly restrictive, it’s reasonable to pause and ask: “What evidence is this based on, and what are the alternatives?” More on that here, and in my books.

You can also ask whether a recommendation is being made because of population-level rules or because of your own individual situation. These are not the same thing.

If you are employed within the system:

When a new rule or restriction is introduced after a rare adverse outcome, take a moment to ask where the evidence comes from and whether it has been evaluated. Start conversations with colleagues.

Even small acts, such as naming uncertainty honestly in conversations with women and families, help prevent fear-based policies from quietly becoming “normal practice”.

If you are a birth worker who is not employed by the system:

Help women and families understand the difference between evidence, guidelines, and local rules.

Discuss the difference between practices that are precautionary rather than evidence-based.

Point them to resources, books, and information that they can read and then carry with them, to refer to if needed.

When fear rather than evidence drives policy and practice, everyone loses.

Responding to rare adverse outcomes with blanket rules may look like safety, but it usually isn’t. Evidence-based maternity care depends on our willingness to pause, reflect, and resist knee-jerk reactions when they don’t serve women or families.

Knee-jerk responses deserve to be noticed, named, and questioned before they quietly reshape care.

If you’d like to know more:

What’s Right For Me?

 

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Books to help you become informed and make the decisions that are right for you…

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