From care plan to indication, general to specific – not the other way around
The term “medical indication” appears often in the world of healthcare. On the face of it, the concept seems simple enough. A medical indication is a condition that makes a certain plan of care advisable, something that provides a rationale for that choice. But language is a tricky beast and the concept of medical indications is sometimes used as a way to inappropriately exercise power. Today’s post is a ramble through and around some thoughts about the pitfalls of misusing the term “medical indication”.
Like many terms in healthcare, “medical indications” as a concept can have positive impacts, detrimental ones, and a whole lot of “well it depends” in between. Whether the use of this term is helpful or not depends in part on the direction that is applied in. An example will help illustrate what I mean.
Breech presentation around the expected date of birth is a medical indication for caesarean section. It is an accepted “rule” that caesarean sections are done only when there is a medical indication (more on that later). Being clear about why a caesarean section is being done helps communication within the healthcare team around some of the specifics of what might need to happen as part of the surgery (like manipulating the baby to get it through the incision, sometimes with the help of forceps) or that are less likely to be an issue (you wouldn’t typically have several bags of blood on standby when the indication is breech presentation, you would for placenta praevia).
Recording the indication for caesarean section helps healthcare organisations to analyse and understand what is going on in their service. If the rate of caesarean section is suddenly higher and you want to know why, the first step in getting answers would be to look at the reasons they were done – the indication. Knowing that most of that rise was due to breech presentation suggests particular lines of enquiry to follow through with. Are women being offered external cephalic version? Have the success rates of version changed, suggesting extra training might be required? Are women counselled appropriately about birth options and supported to access services for safe vaginal breech if this is what they decide?
So far, so good. These are appropriate and helpful ways to use the concept of a “medical indication”. Part of what makes this an appropriate use is the direction the information is being used in. We are going from the plan of care to the individual indication, and from bigger population of women who give birth by caesarean section to the specific individual women with a breech presentation.
Going in the other direction is not so great though. Telling an individual woman with a breech presentation that she MUST have a caesarean section because breech presentation is an indication for caesarean section is not how medical indications are meant to work. Medical indications provide categories that reflect individual decisions, they don’t make decisions for people, or remove the opportunity for healthcare users to decide about their healthcare. Using medical indications in this way constitutes an abuse of professional power.
But it works, right?
If a proposed plan of care has a list of medical indications attached to it, it is reasonable to expect that some robust evidence sits behind it. You would expect that someone with one of the things that appears on the list of indications who then follow through with the proposed care plan will do better than if they hadn’t done what was proposed. Sadly, is isn’t always the case that lists of indications are built on a sound evidence base.
Regular readers of my blog will know that there isn’t robust evidence that using CTG monitoring during labour for any specific indication (such as vaginal birth after caesarean section or meconium stained liquor) makes things better. Yet if you go to any maternity service in a high-income country that owns a CTG machine you will find a policy with a list of indications for CTG use. The existence of the list ends up implying that CTG monitoring must make things better, because there wouldn’t be a list if it didn’t work, right?
When we take a list of indications that have little grounding in evidence and get the direction wrong, we end up with what happens a lot in birth rooms in high-income countries. Women are told they should / need to / must have CTG monitoring because they have X thing that appears on the list of indications. This hides the fact that there is a decision to be made, the woman is the best person to make that decision, and that it is a tricky decision given the current state of the evidence base. This is another form of abuse of professional power.
A doctor said so
Medical indications exist somewhere on a spectrum between being written on tablets of stone, handed down to new doctors by a supreme being on a mountain top – to being completely made up on a whim. An individual doctor can’t actually simply make one up (no matter how much I might wish it, being a red head is not an indication for being first on the theatre list). There is a process involved in getting a thing more or less universally accepted and therefore making it on a list of medical indications. But that process is an inherently social process, subject to cultural and philosophical influences (knowledges, biases, paradigms, ideologies – call them what you wish for the impact you are aiming for).
When I was analysing documents for my doctoral thesis, I looked at how lists of indications in fetal monitoring guidelines reflected obstetric thinking. There is a propensity within obstetrics to view women’s bodies as the source of problems which prevent obstetrics from achieving its goal. For instance, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists Intrapartum Fetal Monitoring guideline (2019) says “there is a continual challenge in maternity care to maintain and improve current perinatal outcomes, as the age of first time mothers increases. In addition, hospitals have to cope with an epidemic of diabetes and obesity which are both associated with a worsening in perinatal outcomes” (p.1). In essence: if it weren’t for those pesky old, fat, diabetic women, we would have had the problem of perinatal mortality and morbidity solved by now. Hmmm.
Most of the indications for intrapartum CTG monitoring were “derived by consensus of the Working Party”(p. 7), which is quite some way along the spectrum from being handed down by a supreme being and much closer to being made up on a whim. When citations to evidence were provided, I followed these back to the source. And discovered that these didn’t provide robust evidence for the presence of increased risk for an outcome that CTG monitoring might be able to fix.
Some situations that are known to be associated with higher risk were not on the list (younger age, nulliparity, low educational level, the use of advanced reproductive therapy for conception for example). No reason was given for their absence. And risks known to be associated with poorer perinatal outcome that are located within the health care system rather than the bodies of birthing women were also not on the list (unsafe organisational culture, lack of competent clinicians, inadequate staff numbers or inappropriate skill mix for example). The reason for this absence is perhaps easier to guess. I suspect that suggesting that women should have CTG monitoring because the obstetrician on call today hasn’t been to a CTG update in six years, or the shift roster is down three midwives, would be met with outrage rather than compliance.
It is important therefore, to remember that lists of indications are not in themselves proof from on high that the proposed care plan is the right option for someone with a listed indication. Critical thinking skills have not gone out of fashion, and are not likely to anytime soon.
Is it ethical to withhold or limit access to plans of care when there is no medical indication?
I’ve made it clear that it is not OK to coerce someone into a plan of care simply because something about them appears on a list of medical indications. Does that mean that the opposite holds true? That it is unethical to exclude or limit access to a particular care plan on the basis that the person doesn’t have a listed medical indication? I think the answer is once again, “well it depends”.
If the list of indications has been really well constructed so that anyone who will derive a benefit from the proposed care plan appears on it, and anyone who doesn’t have an indication is more likely to experience harm rather than benefit, then the answer would be no. It would not be unethical to withhold that treatment. Giving someone antibiotics for an uncomplicated common cold is more likely to lead to personal harm, or harm at a population level due to antibiotic resistance, for example. Saying no to someone asking for a prescription for antibiotics would not be inherently unethical.
But as we have seen, the social processes used to generate lists of indications are rarely that robust. In maternity care, misogynist beliefs about women’s bodies ooze into every corner of what we do. Health outcomes for women are deprioritised in the face of outcome for the fetus / baby, and outcomes relating to psychological and social aspects of women’s lives are often ignored entirely. I think this is part of the reason that the question of whether women should be able to request to give birth by caesarean section in the absence of a medical indication has been discussed for decades with no clear resolution.
Women who ask to give birth by caesarean section when there is no medical indication may have specific healthcare outcomes in mind – such as prolapse prevention when there is a strong family history of this. It might be that at some point in future, the folks that make up the stone tablets agree that this can now go on the list of indications. It seems inappropriate to deny a choice that might no longer be controversial in the future because it has now made the list.
For other women, the plan to give birth by caesarean section might arise from misinformation about the procedure, the possible complications, and the potential benefits. It seems equally inappropriate for a maternity professional to not address any misunderstandings before checking again whether the woman wants to make a different decision in the face of this information. There is therefore no one size fits all resolution for how maternity professionals should proceed when a woman makes a request for a care plan like a caesarean section when there is no medical indication. I do however, have one suggestion that I do believe applies universally.
We should abandon using lists of indications as fixed rules, and consider them as simply the starting point of a well evidenced, respectful conversation aimed at reducing the knowledge gap between birthing women and their maternity care professional(s). Whether the decision is about which type of fetal monitoring to use in labour, whether to plan to birth to that breech presenting baby vaginally, to have a caesarean section when there isn’t a recognised indication for one, or something else, the decision is the woman’s to make. Our task as professionals (and it is no mean feat) is to listen in order to know the woman, their social and clinical context and their goals for care; have a detailed and up to date knowledge of the evidence base for practice; develop and use skills in non-coercive communication in the face of clinical uncertainty; locate or develop resources to support decision-focussed conversations; and to clearly document the conversation and the woman’s decision.
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. (2019). Intrapartum fetal surveillance clinical guideline. 4th Edn. https://ranzcog.edu.au/statements-guidelines https://ranzcog.edu.au/statements-guidelines
- Interested in reading more history?
- Models of maternity care and conversations about fetal monitoring
Categories: Breech birth, CTG, EFM, Feminism, Language, Philosophy, Reflections
Tags: breech, caesarean section, decision making, ethics, guidelines, medical indications
fabulous, clear-thinking stuff!