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What do we mean by
effective care?
Women who receive care, professionals who provide care, and those
who pay for care, all want that care to be effective. Although everyone
agrees with this in principle, there is much less agreement about what
actually constitutes effective care in pregnancy and childbirth. Contro-
versies arise from differences in opinion both about what we want to
achieve and about the best way to achieve it.
What we most want to achieve depends on what we think is most
important. Different communities, groups, and individuals may have
different opinions about this. Some may give priority to each womans
personal experience of childbirth, even if this might mean some sacri-
fice in terms of safety. Others may aim to minimize perinatal morbidity
and mortality no matter how much this may increase the mothers risk
or discomfort. Still others, primarily concerned about the rising costs
of care and the limited resources available, consider efficiency and cost
savings to be the most important objectives. All of these goals are
important, but often they involve trade-offs. Not surprisingly, the
diversity of aims and priorities has resulted in widely differing recom-
mendations for care during pregnancy and childbirth.
This variety of views about the objectives of care helps to explain the
different ways in which the effects of care can be measured. Some
choose ratings of womens satisfaction with their care as the most
important measure of its effectiveness, while others concentrate on
direct measures of death, disease, and disability. Still others focus
on surrogate or indirect measures of the babys well-being, such as
fetal heart-rate tracings or estimates of the acid-base status of umbil-
ical cord blood, in the belief that they can be translated into indices of
real health.
These differences of opinion are clearly revealed by the widely differ-
ing care practises seen among otherwise similar countries, communi-
ties, and institutions, from one care-giving discipline to another, and
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SOURCE: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and
Justus Hofmeyr. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford, UK: Oxford University
Press, 2000.
DOWNLOAD SOURCE: Maternity Wise website at www.maternitywise.org/prof/
Oxford University Press 2000
from individual to individual. Countless examples come to mind: the
different methods used to assess the risk status of the mother and the
well-being of the fetus; the place, if any, for routine iron or vitamin
supplements during pregnancy; the usefulness of cervical examination
at each antenatal visit; the value of routine ultrasound visualization of
the fetus; the need for bed-rest for women with an uncomplicated twin
pregnancy; the appropriate indications for the use of forceps, vacuum
extraction, or cesarean section. The list is endless.
A number of other factors may help to explain these variations in
practice. Some relate to differences in the populations served, or in the
needs or circumstances of childbearing women and their babies.
Others result from differences in resources, including personnel,
hospital beds, and equipment. Still others reflect differences in culture,
tradition, status, fashion, and political correctness. There may be
differences in the need to provide opportunities for clinicians in
training to gain experience; in the extent to which malpractice litiga-
tion is feared; in the way that caregivers are paid. Commercial pres-
sures from pharmaceutical companies, equipment manufacturers, and
others, may also influence practice.
This Guide to Effective Care in Pregnancy and Childbirth relates to
none of these factors. Rather, the information it contains refers to the
specific effects, beneficial or harmful, of the various elements of care
that may be carried out during pregnancy and childbirth. Knowledge
about these effects is required by everyone who provides or receives
that care. It is essential for making informed choices among the
available alternatives.
Evidence-based care has been defined as the conscientious, judi-
cious, and explicit use of current best evidence in making decisions
about the care of individual patients. In the next chapter, we outline
the rationale, the materials, and the methods that we used to find and
relate the current best evidence, and how we arrived at the conclusions
we present in the rest of this book.
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