Don’t change the future!
I quite like watching Doctor Who. One of the common threads in the show involves the Doctor warning their companions not to meddle with the present (our past) in a way that might alter the future (our present). Of course, what inevitably happens is the Doctor and companions end up being compelled take action 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.
Change the future!
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 most people working in healthcare share this drive to at least some degree.
What does that actually mean? There’s a common belief that by detecting risk factors for something or using a screening test we can then act and prevent some “bad thing” from happening, that would otherwise have been inevitable. 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 this is an important goal. Some high-income countries have recently introduced “bundles” of care, a collection of recommendations that aim at changing this possible future. These usually include 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 so poor 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 developed significant complications from a caesarean section, which might have been avoided by using intermittent auscultation rather than CTG monitoring .
Is more healthcare always the answer?
I worry about the assumption the best approaches to preventing stillbirth fall squarely within healthcare. Let’s imagine a woman who gives birth on her “due date” 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 healthcare providers 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 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 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 adding more risk screening and high-tech fetal monitoring approaches.
That’s an altered future I suspect even Doctor Who would approve of.
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Categories: CTG, Reflections, Stillbirth
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Birth Small Talk 
Wow! That time breakdown really makes sense!
It is So Hard to accept that we cannot escape Every Fate that may befall us, and I have always been really clear about what I can and cannot control in relation to pregnancy/birth/emergencies.
I know i am trained to monitor and see warning signs and respobd/refer, and how to act in an emergency however placentas and cords are Up To God. Those elements were determined long before anyone knew about the pregnancy or the birth unfolded.
Good discussion Kirsten 😊
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