I quite like Doctor Who. One of the common threads in the show involves the Doctor warning their companions that it is important not to meddle with the past in a way that might alter the future. Of course, what inevitably happens is that the Doctor and companions end up being compelled take action in order to ensure that everyone arrives at the end of the episode happy and healthy, with the bad guys banished, and the future of the planet assured.
As an enthusiastic and naïve 16-year old I was motivated to put medicine at the top of my university application because I “wanted to make a difference”. I’m confident that most people who work in healthcare share this to at least some degree. What does that actually mean? A common belief is that detecting risk factors for something means that we can then act and therefore prevent some “bad thing” from happening. In essence, we want to mess with someone’s timeline and prevent a particular version of the future from happening. This would earn our erstwhile time travellers a rebuke from the Doctor.
How do we reconcile the difference between these positions? Is it because, unlike a mythical Time Lord, healthcare practitioners are accurately able to predict the consequences of our actions so that what we do always ends well? Hardly. History is littered with stories of our disastrous efforts. For example, we introduced thalidomide in a well-intentioned attempt to ease the discomforts of early pregnancy but caused death and disability for thousands of children, and heartache for many families.
What about current efforts to drive down the stillbirth rate? No one disagrees with this as an important goal. Many high-income countries have recently introduced “bundles” of care, a collection of recommendations that aim at changing the future. These usually include the use of risk assessment of women during their labour and the use of CTG monitoring in an attempt to prevent the rare outcome of stillbirth during labour.
It is important to be mindful of the way in which our efforts might alter people’s futures. Might the prevention of a baby’s death result in the birth of a baby with a quality of life that is so poor that it raises questions about which was truly the outcome to be most feared? And what of the women who were not ultimately destined to have the “bad thing” happen but who were caught up in our risk screening net anyway and propelled into an altered future? They may have had caesarean section surgery and developed significant complications from the surgery, all of which might have been avoided by using intermittent auscultation rather than CTG monitoring .
I worry about the assumption that the answers to the problem of stillbirth fall squarely within healthcare. Let’s imagine a woman who gives birth 266 days after conception. During that time 6,384 hours have passed. If she receives exemplary care, she might have 10 hours of direct contact with a healthcare provider during her pregnancy, and another 14 during labour and birth. That’s less than 0.4% of the duration of her pregnancy. Why do we think that the answers to modifying her future lie in that 0.4% and not in the 99.6% of time that has nothing to do with healthcare?
Over the past 100 years there have been major advances in healthcare, and a significant improvement in mortality rates for women and their babies, both before and after birth. It is tempting to believe that the two are linked. However, the majority of the improvements we have seen happened because of significant changes in the 99.6% of women’s lives that has little to do with the healthcare system. Addressing poverty, unemployment, malnutrition, overcrowded and insanitary living conditions, racism, misogyny, and violence is what has driven these improvements.
Of course, this work is far from finished, even in high-income countries. I believe that ensuring that all women have access to the basic requirements for a healthy life and a life free from violence will have a far greater impact on stillbirth (and many other problems) than more risk screening and high-tech fetal monitoring approaches.
That’s an altered future I suspect even Doctor Who would approve of.