This is the third and last in a series of linked posts that serve as signposts to resources for those who wish to look at questions relating to anti-D. The first post in this series offered a few resources for gaining a basic understanding of the issues, the second post linked to and considered the Cochrane reviews of this area, and this third post reflects upon the other side of the picture that I have considered in my own work.
If you haven’t read the other two posts or don’t already know the background to this area, I would recommend you do so, because I think it is important to understand the context of the work which sought to reconsider this area. The most important things to know are
- the work which led to the current anti-D programme was phenomenal, and anti-D is an incredible resource which has saved the lives of babies by preventing isoimmunisation, and
- no-one, least of all me, is recommending that rhesus negative women should decline anti-D.
So why question this wonderful, life-saving and useful product at all?
I have four answers to that. One: I think it is always important to think about what we are doing, whether we are a parent deciding whether to give a medicine to a child or a health care professional framing a decision for that parent. Two: while the medical model viewpoint is a very valid one, and certainly Western medicine is very effective in areas such as trauma care, it is not the only valid viewpoint on health and healing, and I think we have much to learn from considering other perspectives. Three: anti-D, like all blood products, carries risks, both from the blood itself and from other substances used with it, such as preservatives. These risks include rare but serious consequences such as anaphylactic shock and viral infection. The people who make such products take extreme care to reduce the risks of viral infection as much as possible, but we can never eradicate that risk.
Four: is so significant, at least to me, that it deserves a paragraph of its own. Not long after I became a midwife, I began to meet women who asked me if anti-D was really necessary. It had also occurred to me that this was the one intervention that I had never heard anybody question; which was significant because I had been educated in the first exciting years of research-based practice, by and with some amazing midwives who were questioning an awful lot of things and encouraging us to do the same. My first instinct was to go to the original research trials that had evaluated the effectiveness of anti-D, and there I learned something that probably changed my life. I learned that, while the results of those studies showed that anti-D was effective (in that a very high percentage of women in the intervention groups who received it did not become isoimmunised), the same results showed that, in the control groups, only around 10% of women became isoimmunised without anti-D.
At the point where these results emerged, the medical world had two choices. They could have said, ‘wow, this is interesting … let’s do more research so we can work out which women need anti-D and which don’t … after all, anti-D is a blood product and our basic tenet is ‘first do no harm‘ so we don’t want to give this to more women than is necessary…’ Or they could have said, ‘wow, this is interesting …. anti-D is effective on a population basis … let’s give it to the entire population of rhesus negative women who have given birth to a rhesus positive baby…’
I absolutely understand and respect that most people are happy to go along with whatever their midwife or doctor recommends, and that it is very difficult for midwives and doctors to recommend any course of action other than anti-D.
I also absolutely understand and respect the position of the women I have met who say, ‘but what if I’m in the 90%? I don’t want to have a blood product if I don’t need it!’
It is those women for whom I undertook my research and analysis of this area.
The two key articles which outline my research are freely available on this website: Anti-D: Exploring Midwifery Knowledge considers the issues around postnatal anti-D and is a summary of the work on which my book, Anti-D in Midwifery: panacea or paradox? was based. A proportion of the issues covered in the chapter in this book on antenatal anti-D are discussed in another (free) article, Routine Antenatal Anti-D – An Overview of the Evidence.
I acknowledge that all three of these resources are now a few years old but, because the research they consider is also historical and it is extremely unlikely that there will be any more trials looking at the question of postnatal anti-D, I consider that much of their content is still valid. I recently discussed issues relating to The Age of Research in AIMS Journal.
I am not planning another significant publication (or update of an existing publication) in this area at the moment, but I remain very interested in it and when I write about issues or studies on this website I always tag them, so if you click on the ‘anti-D’ tag in the cloud on the right hand side of this page, you will find everything else that I have written on here.
Read more in my book: Anti-D in Midwifery: panacea or paradox?