I once wrote a post about Dr Who and alternative universes, highlighting the way that people make meaning of their individual experiences. It is important for health professionals to reflect on the way we make meaning because it is easy to slip into what are known as cognitive biases. We can’t always avoid these, but it does help to have examples of these biases to increase the chance that we will catch them before we act on them in ways that are not helpful.
Alencar Neto, Farina, and Nunes Sampaio proposed a new cognitive bias in 2021, and I think it helps make sense of the current obsession with CTG monitoring in maternity services. They named their bias for Schrödinger’s Cat. This bias is defined as:
a situation in which a physician takes a decision and requests an exam or procedure that was unnecessary and puts the patient through an unforeseen risk. After the procedure, if there is a good outcome, the patient will be grateful for it. However, if there is a bad outcome, he would still be grateful for their efforts in trying to find the etiology. This cognitive bias will, most of the time, favor the therapies over the decision of not to treat.
The authors provide examples of several possible different timelines (a bit like my Dr Who suggestions) that reinforce beliefs that ineffective therapies work.
I think the Schrödinger’s Cat cognitive bias works for CTG monitoring as well. Let’s look at some possible timelines and see how it might play out.
Timeline 1.1. A woman has CTG monitoring and her baby is born alive. Both she and her care providers belief that CTG monitoring is effective is reinforced.
OR
Timeline 1.2. A woman has CTG monitoring and her baby dies. One common way that people make sense of this is to blame one or more clinicians for not having correctly interpreted the CTG. The belief that CTG monitoring is effective in preventing death if only it were used correctly is reinforced.
Timeline 2.1. A woman has intermittent auscultation, and her baby is born alive. She is considered to have been lucky to have got away with such a risky decision. The belief that CTG monitoring is effective remains unchallenged.
OR
Timeline 2.2. A woman has intermittent auscultation, and her baby dies. This is considered as proof of unprofessional practice, and the belief that CTG monitoring would have prevented this from happening is reinforced.
As you can see, in the moment that the decision to use, or not, CTG monitoring is made, two possible futures exist simultaneously – the survival of the baby or its death (fortunately rare). Research shows that each of these two possible futures are just as likely to occur regardless of which fetal monitoring method is chosen (Alfirevic et al., 2017; Small et al, 2020). All too often, evidence is set aside in favour of the Schrödinger’s Cat bias which assumes the best outcome is more likely to occur if CTG monitoring is used, and the worst outcome is more likely if intermittent auscultation is used.
Cognitive biases are tricky. It is very difficult to spot when you are in the midst of one, particularly when the bias is one that is held to be true by the culture in which we operate. Generating and using sound research findings are the only way that we can open the box and see whether the cat is actually alive or dead.
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References
Alencar Neto, J., Farina, E., Nunes Sampaio, M. (2021, Jan). Schrödinger’s Cat Bias: A New Cognitive Bias Proposed. Cureus 13(1), e12697. doi:10.7759/cureus.12697
Alfirevic, Z., Devane, D., Gyte, G. M. L., & Cuthbert, A. (2017, Feb 03). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, 2(CD006066), 1-137. https://doi.org/10.1002/14651858.CD006066.pub3
Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2020, Sept). Intrapartum cardiotocograph monitoring and perinatal outcomes for women at risk: Literature review. Women and Birth, 33(5), 411-418. https://doi.org/10.1016/j.wombi.2019.10.002
Categories: CTG, EFM, IA, Philosophy
Tags: cats, cognitive bias, heuristics, Schrodinger's cat
Birth Small Talk 
A fascinating article Kirsten and along your perspective on the matter. Regrettably because CTGs are concreted into the institutional and medico legal reviews , it is hard to have any rational discussion on the matter, The other problem is that the research itself is often problematic because of the lack of blinding and the preexisiting biases in which context the research is done , along with this is the vested interests (i.e.money- e.g Infant study).
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