Are “medical indications” a form of manipulation?

From time to time, I encounter women saying some version of “I’ll only have (insert birth intervention here) if it is medically indicated“. I completely understand the sense in which this is meant – that if something bad is highly likely to happen, and the proposed intervention is highly likely to stop that bad thing happening, then it makes sense to choose the intervention. People use this language as short hand for saying they are happy to have an intervention when it is actually needed and not just because it is on a menu of options available to them. It’s not the idea that women are able to decide to make use of birth interventions when they are appropriate that I’m taking issue with here.

What is a medical indication?

The idea I want to bring out into the daylight, is how the concept of something being medically indicated can be used to manipulate women’s decision making. A medical indication is typically something that makes a certain plan of care advisable, and is used to explain and justify that choice. For example, having severe preeclampsia is a medical indication for induction of labour. I have written before about that way the list of medical indications is created is 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.

From current pathology to maybe a chance of future pathology

For some situations, like severe preeclampsia, there is an actual pathological process going on. And the proposed intervention is an effective treatment for that pathology, backed by some fairly solid research. Back when I was a brand new doctor, most of the conditions on the lists of medical indications were pathologies and the interventions they were tied to were effective treatments. Placenta covering the cervix? Caesarean section. Postpartum haemorrhage? Medications to contract the uterus.

It was more straight forward for women to make a decision to take up a medical recommendation for an intervention as there was clearly something actually going wrong, and there was an effective treatment for it. But over time there has been a shift towards a risk management mindset. Obstetricians still treat pathological processes, but the majority of the treatments they now propose are about attempting to avoid a pathological process from getting starting in the first place.

A lot of what now happens in maternity care is to check the woman’s situation off against one long list of risk factors, looking for clues that something bad might be waiting for her future self. First baby? Risky. Older than 40 years. Risky. Conceived with IVF? Risky. Not Caucasian? Risky. None of these are diseases, but the way obstetrics uses risk factors has tended to give these things the same significance as having a disease. As a consequence they have become things that must be treated.

And so interventions are then proposed. Extra ultrasound scans. New medications. Induction of labour. Caesarean section. These make sense in the face of actual pathology where the potential for benefit is extremely high, and the risk of intervening is much less than the risk of not doing so. But once we slip into managing future possible risks, things get less clear.

Many of the bad outcomes that maternity professionals are trying to prevent are excruciatingly uncommon. For example, stillbirth in labour affects about 0.02% of women who are around about their due date. To make a difference you need to use the intervention on a very large number of women. Many of the proposed interventions do shift the dial in the right direction, but only by a tiny amount. For example, the bundle of interventions tested in the UK to see if it could reduce severe perineal trauma did bring the number down – but the difference was 3 fewer women in 1000.

Maternity professionals can sometimes present interventions based on risk managing rare outcomes with the same kind of enthusiasm and vigour as they do for interventions that treat pathological processes. Women who are presented with an intervention and who are told that it is medically indicated can be left in a situation where they need critical thinking and research skills to be able to tell whether they have a disease process and are being offered an effective treatment, or whether they have a marginally higher risk and are being offered something that is marginally effective and has additional risks attached to it.

Let me bring this back to CTG monitoring for labour

Once a serious pathology has developed – like uterine rupture, cord prolapse, or abruption – starting a CTG will have no impact on the outcome. It does not treat these conditions. Urgent birth is the treatment, and faffing about connecting the CTG only delays when this can happen.

CTG monitoring is about risk managing the quite small chance that the fetus will develop sufficiently low oxygen levels to result in serious harm. At best, it is maybe marginally effective at reducing the chance this will happen. At worst, it is likely that it is completely ineffective and increases the chance of complications, particularly for the woman.

So when I see women saying they’ll agree to CTG monitoring when it is medically indicated, it makes me uncomfortable. What I see is women who are vulnerable to being manipulated by someone telling them that CTGs are medically indicated. The list includes things like being older, preterm, post-term, have more or less fluid around the baby, having had IVF, or a caesarean section, or an episode of reduced movement five weeks ago, and so on. Yes, these are all considered medical indications for CTG use. But there is absolutely no research at all showing that CTG monitoring in labour reduces the chance of something bad happening for women with one or more of the things on this list.

If you are pregnant you’ll be wanting to make good decisions. That means being able to tell the difference between a recommendation for a highly effective intervention when something is wrong, and a marginally effective intervention being suggested in the hope that it might reduce your marginally increased chance that something might go wrong in the future. Whether you encounter maternity professionals who help you to navigate this, or ones who will make it hard for you to tell the difference is largely a matter of chance. It annoys me no end that women have to undertake the equivalent of “birth university” to be confident they are making good choices, as this should be the responsibility of their maternity professional(s).

Let me help you

For those of you who find yourself in exactly this situation, trying to decide about fetal monitoring in labour – I have made this process of getting access to the evidence really easy for you. I pulled it all together in my Fetal Monitoring: The Basics course. To make it even more affordable I have just dropped the price for lifetime access from $97 to $47 AUD. You can sign up anytime and gain immediate access. Click this link to find the answers to all your questions about the course!

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