From time to time, I get feedback from people who are surprised / disappointed / angry / annoyed that I’m not a member of a guideline writing group taking on fetal monitoring guidelines. It is true – I’m not.
It seems like a reasonable thing to expect me to do, right? I’m across the evidence and I often write about what is wrong with existing guidelines. Why would I not want to participate in making them better? Am I incredibly lazy, stupid, or arrogant, or is there something else behind this?
Here is what I know about how guidelines happen
My PhD research used an approach known as Institutional Ethnography. The goal of any research that uses this approach is to understand how things happen they way they do. I looked at how guidelines happened at the hospital where I did my research, but not much of that material ended up in my thesis and I haven’t published any of it. Here’s a brief run down of some of the things I learned.
Professional organisations use guidelines to achieve the goals of the organisation and that varies from one organisation to the next. While the stated goal is to improve healthcare, that’s not the primary purpose of guideline writing. For some organisations, guidelines are a way to get and hold onto power and authority, and when coupled with an education package for sale they provide a way to generate income.
Obstetric organisations (RANZCOG here in Australia, RCOG in the UK, ACOG in the US, SOGC in Canada, FIGO in Europe, etc) use guidelines to demonstrate that they are an important voice in healthcare provision. It helps them to maintain power over midwifery and nursing. NICE is one exception to the rule, in that they are a non-obstetric organisation writing fetal monitoring guidelines (in the UK), though the guideline they have produced looks just the same as if an obstetric group wrote it. The other outlier is the World Health Organization – the only guideline to not recommend CTG use. You might like to have some guesses about the professional backgrounds of the writing teams and of the leaders responsible for the choices about what ends up in guidelines and how that explains why the guidelines are the way they are.
For health services, guidelines are a way to protect the organisation against legal costs and reputational damage. They largely transfer legal responsibility from the health service onto the individual health professional. If you are a health professional, and you don’t follow the policies and guidelines of your employer, you risk being the scapegoat for any poor outcome (even when the evidence backs up your care).
When a team get together in 2024 to write a fetal monitoring guideline, they aren’t going to start from scratch with a detailed review of the evidence base. They are going to grab copies of other guidelines that already exist, and if all those guidelines say pretty much the same thing, they’ll cut / paste / edit a bit and – JOB DONE! Why would you not align yourself with all the other authorities and “borrow” their approaches to protect and promote your organisation?
No guideline writing team will generate a guideline that undermines the goals of the organisation they are generating that guideline for. If an individual member attempted to do this, they would be shuffled out the door. If by some strange miracle, the entire team tried to significantly upend guidance without there being a large shift in the evidence base or in professional opinion about good practice, the organisation would likely overwrite their guidance, or bury the guideline where it would never see light of day.
Guidelines don’t generally create new standards for good practice. Guidelines largely reflect what the commissioning organisation believes will help them achieve their goal (of authority or protection, or both).
Here’s a story from personal experience
There was a time I was deeply invested in attempting to change a fetal monitoring guideline. Or more accurately, prevent a change to a new fetal monitoring guideline. I’m not going to tell you when, where, who – as the aim here is not to shame the organisation.
The existing guideline had been working well. It was worded in a way that gave women a high degree of autonomy about their choice of fetal monitoring method. The obstetricians and midwives who had worked with the guideline for years had written and refined it, and it served them well. It worked well for women using the hospital. There were no adverse outcomes due to appropriate application of the policy.
Then the private hospital was acquired by a different company. And they wanted to standardise the fetal monitoring guideline so it was the same as all the other private hospitals they owned. The new policy removed a lot of autonomy from both birthing women and the professionals providing care. Collectively, we resisted and refused to ratify the policy at our regular meetings. We collated evidence and presented it to the hospital executive to support the existing policy. (You might get a clue here about when the evidence for CTGs became such a passion project for me at one point in my past…)
This standoff persisted for over a year, until the parent company ran out of tolerance for it. We were issued an edict that the policy would be changing and they removed our authority to ratify (or not) the policy. We could could accept it, or find a new place to work. They even paid to take all the obstetric staff out to an expensive restaurant and plied us with alcohol, while their (now quite drunk) lawyer attempted to (unsuccessfully) convince us we were all wrong to try to block the change.
The new guideline was forced in and it had nothing to do with evidence and everything to do with offering legal protection to the parent company. There were other reasons for my departure from that hospital soon after, but this was a large part of that decision.
So here’s why I don’t consider fetal monitoring guideline writing to be a useful investment of my time and expertise
If the process worked as we imagine it should, guideline writing teams should know and make use of the evidence. These are people who know how to do research, read research, interpret research, and apply research to practice. They don’t need me to parachute in with an explainer about the evidence. At worst, the writers of the existing guidelines know about, and actively choose to not make use of, the evidence. More likely, they choose not to look deeply at the evidence base because the cognitive dissonance of discovering everything you thought you know to be true isn’t true, is profoundly disturbing. So they choose not to engage with the existing evidence and simply repeat the common myths.
I know that strong social forces shape the guideline development process. Adding me to a guideline writing team would either result in me being forced to comply with the production of an uncontroversial, business-as-usual guideline (and I would walk away with significant moral injury) or I would be subject to all sorts of subtle and not so subtle manipulations to get me to say what they want to hear, or have me leave the team. And neither of those seems like a great way to spend my time.
Actually, I am contributing to guideline change
I believe I can be most effective in generating changes in guidelines by sitting outside organisations and being persistent in pointing out what needs to change. When other people start to get on board and they also start pointing out what needs to change, and that voice gets loud enough that organisations start to fear loss of reputation and authority – that is when things will start to shift. I’m playing the long game.
I also generate research findings that can be used in guideline writing. And I have quietly and anonymously provided wording to people who are on guideline writing groups that they can make use of. Keeping several degrees of separation between me and the outcome helps me avoid emotional damage from being in the thick of it all.
Want to help?
Next week I’ll share my suggestions about what should be in your local hospital policy. I’ll offer you a template to critique your existing policy so you can 1. Understand it better and 2. Offer suggestions for improvement. Subscribe to the blog so next week’s list ends up in your email in box!
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- Would you trust a computer to decide when to do a caesarean section?
- What would a good fetal monitoring policy look like?
Categories: CTG, EFM, Reflections
Tags: Evidence, Guideline, policy
Birth Small Talk 
I really appreciated this email Kirsten.
I’m going to print it out and take it to my pregnancy yoga class. There are quite a few women who are researchers and would take the time to read this.
Thanks for what you do Tessa
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