Are decision support systems working in maternity care?

Clinical Decision Support Systems (CDSS) are computer based tools that provide information to health professionals with the goal of shaping decision-making. On the positive side – they are intended to ensure consistency of practice, make risk assessment easier with the goal of improving healthcare safety. On the downside – they can interrupt people’s work, cause cognitive overload that results in poor attention and decision making, leading to delays in care and reductions in healthcare safety. It is therefore essential that CDSS are subject to research to explore whether or not they improve outcomes in maternity care.

A recent systematic literature review has looked specifically at the clinical impacts of CDSS used in maternity care settings (Cockburn et al., 2024). They searched for, and found 87 papers about 47 different systems. The research into these systems was done in many different ways, with 28% being randomised controlled trials (considered the gold standard for answering this sort of question). Most related to antenatal care (78%), just under half covered intrapartum care (44%) and only 5% looked at postnatal care. Sample sizes ranged from tiny (<50) to large (>500,000).

What were the systems being tested?

The kinds of clinical situation covered included:

fetal growth charts
depression screening
decision aids for vaginal birth after caesarean section and prenatal genetic testing
screening for septic shock
medication safety
screening and management of hypertensive disorders
early warning systems for deterioration of labouring women
screening for ectopic pregnancy
and more…

Several computer CTG interpretation systems were included on the list.

What did they find?

When data from the randomised controlled trials was combined, there was a not-statistically-significant trend towards better outcomes (OR 1.25, 95% CI 0.96-1.62). For non-randomised studies (such as before and after studies), the benefits did reach statistical significance (OR 2.92, 95% CI 1.24-2.30).

You have to dig into the fine print a bit to find the outcomes for studies relating to computer CTG interpretation, but it is there. Randomised controlled trials for the INFANT, 2CTG2, and Omniview-Sisporto systems found no benefit. A collection of studies reported on a system called qCTG, developed in Bulgaria and trialled in a small population, with some but not others showing benefits.

What this means

The authors of the review were appropriately cautious in their outlook about the potential for CDSS. They identified an increased potential for bias in 76 of the 87 studies – so the results of these studies, and of the meta-analysis might be due to factors other than the individual CDSS being tested. They also identified the possibility of publication bias. This is when only publications that report on a CDSS being effective make it to publication, so there may be “missing” studies showing a lack of effectiveness. And of course, many CDSS are introduced into clinical practice without ever having been evaluated in research.

The context in which these systems are introduced is also critical. Maternity care systems are complex and variable social beasts. Anyone who has worked in more than one hospital will recognise notable differences in organisational culture. The effectiveness or otherwise of introducing technology to modify people’s behaviour depends largely on the social context in which care happens.

While the initial impressions from this review about CDSS are favourable – it serves to highlight how little good quality, low bias, research is being done.

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References

Cockburn, N., Osborne, C., Withana, S., Elsmore, A., Nanjappa, R., South, M., Parry-Smith, W., Taylor, B., Chandan, J. S., & Nirantharakumar, K. (2024, Oct). Clinical decision support systems for maternity care: a systematic review and meta-analysis. EClinicalMedicine, 76, 102822. https://doi.org/10.1016/j.eclinm.2024.102822