ARTICLE OF THE MONTH
Guideline-centred care or woman-centred care? A debate and discussion
Midwifery practice, care giving and women’s subsequent experiences of birth are often implicitly or explicitly governed by the guidelines, which can be a source of tension for both midwives and women. This article will discuss key issues, such as the conflation of policies, protocols and guidelines, the impact on midwifery practice and the historical and cultural context of the development of guidelines to generate a discussion in which midwifery practice can move beyond a ‘guideline-centred’ approach.
Midwife Researcher and PhD Student at University of Central Lancashire
Midwifery practice, care giving and women’s subsequent experiences of birth are often implicitly or explicitly governed by the guidelines of our local trusts, which can be a source of tension for both midwives and women. For midwives, tensions can exist between their employer’s expectations of adherence to local guidelines and their professional obligations of providing up-to-date, evidence based care (Kotaska 2017). For women wanting care outside local guidelines, they may experience difficulty negotiating their choices (Kruske et al 2013; Feeley and Thomson 2016). In addition, guidelines can be conflated with policies and protocols, contributing additional sources of tension (Kotaska 2011). Therefore, this article provides an exploration of the key differences between policies, guidelines and protocols. Then, by drawing on historical and cultural components of the development of guidelines, it provides a discussion to guide midwives in their practice to move beyond a ‘guideline-centred care’ approach.
GUIDELINES, POLICIES AND PROTOCOLS
The conflation of policies, protocols and guidelines is problematic, as policies and protocols demand compliance, but guidelines should not; so it is imperative that midwives understand the difference. Policies require mandatory compliance and are normally associated with terms of employment (including sickness, uniform, handwashing, for example) (NHS 2006; Irving 2014). Midwife employees are contractually bound to comply with the policies set by their employer, and failure to do so could result in disciplinary action (Irving 2014). Protocols – otherwise known as processes or procedures – differ in that they are an agreed framework outlining the care that will be provided to women (or patients) in a designated area of practice (Irving 2014). Again, compliance is normally expected and associated with midwives’ terms of employment. Examples include anaphylaxis management, eclampsia management, cardiac arrest and food handling on a ward. Therefore, policies and protocols are usually non-negotiable.
Guidelines, however, differ: their purpose is to provide information that would aid in making decisions about intended goals (should do), beneficial alternatives (could do) and actions that would not create problems (won't hurt) (NHS 2006; Kotaska 2011; Kotaska 2017). Guidelines are often discretionary and require health care professionals to use their clinical expertise to apply the information in the guideline to provide the most appropriate care for individual women (Greenhalgh 2014). Furthermore, any application of the guidelines should be used in partnership with those receiving care, wherein their preferences must be taken into account and respected (Greenhalgh 2014; Kotaska 2017). Legally, women have the right to make autonomous decisions about the care they will accept, including the right to decline recommended care (Birthrights 2013a; Kotaska 2017). Therefore, health care professionals have a legal obligation to provide women with all the information that they will need to make a decision, and not just recommendations found in the guidelines (Kotaska 2011; Birthrights 2015; Kotaska 2017). To frame it another way, health care professionals should be ‘offering’ screening or treatment options alongside alternatives, with the final decision to be made by the woman.
In theory, understanding these differences is straightforward and can easily be applied to our practice. Yet the everyday experiences of midwives and women suggest that the reality is more problematic. Midwives fear employer reprisals or being held accountable for adverse events if the guideline is not followed to the letter (Griffiths 2009; Thompson 2013). Investigations will often compare care provided to the recommendations in local guidelines (Thompson 2013; Kruske et al 2013) and perhaps lack consideration of the wider issues of current evidence and women’s preferences (Griffiths 2009). Women can experience coercion and steering towards compliance to the guidelines (Kruske et al 2013; Shallow 2013; Birthrights 2013b; Kotaska 2017). This is not unique to maternity services and the over-reliance on guidelines has been widely critiqued across medicine (Greenhalgh 2014). However, it is important to understand the historical, cultural and political cofactors that have been involved with the development of guidelines and their relationship with evidence based medicine (EBM).
THE RISE OF GUIDELINES
The concept of EBM saw a dramatic rise during the 1980s, with the goal of applying the best available scientific evidence to health care practices/treatments to improve outcomes for patients (Greenhalgh 1998). In maternity, this was a positive shift away from practices that were not based in evidence, rather were based upon cultural (and sometimes harmful) practices (Kotaska 2011). The rise of EBM saw the development of hospital policies and guidelines: documents that provided health professionals with clear guidance on the best available courses of treatment or actions (Downe 2010). This was also an attempt to reduce practice variations, standardise practice and serve as a resource for staff to reduce reliance upon memory, which may be a source of error in clinical practice (Irving 2014). Therefore, the goal of EBM and the subsequent development of guidelines were intended to improve clinical practice and outcomes.
Historically, Sackett (1997) warned in the 1990s that to apply EBM effectively, clinical expertise was required to interpret and apply the best available evidence to the individual receiving care, while simultaneously valuing patient preferences and circumstances (Sackett 1997). However, in practice clinical expertise has been said to be eroded (Walsh 2006), wherein evidence from population studies is applied without critical application to the individual. Greenhalgh (2014) argues that evidence generated from population studies may not be directly translatable to a person’s unique circumstances and presentation of the condition. Additionally, Downe (2010) suggests that development of guidelines became rules for health workers to follow, defendable in court, should the situation arise (Downe 2010). This has in part created a culture where adherence to a guideline is prioritised over an individual’s autonomy for fear of litigation and/or disciplinary action against the practitioner (Griffiths 2009; Downe 2010). This has led to a shift away from an individualised care rhetoric wherein any deviation from standard care has to be justified (Griffiths 2009). Kotaska (2011) calls this ‘guideline-centred care’, which is in direct opposition to the woman-centred care approach that midwives should be adopting. Additional concerns relate to the assumptions that the research used to inform the guidelines was of good quality (Downe 2010). The infamous Hannah term breech trial provides a good example of poor quality evidence changing the practice of facilitating breech vaginal births to surgical births almost immediately, with far reaching consequences across the globe (Hannah et al 2000).
Downe (2010) also challenges the social constructs of EBM such as that it was founded within an essentialist positivist paradigm of science that appears to be authoritative, linear, risk averse and certainty-based. This runs contrary to what we know as midwives: that the nature of birth is complex, with multiple biopsychosocial factors that contribute to birth outcomes (Downe 2010; Kress 2010). Feminists argue that EBM was constructed within a patriarchal system marginalising the direction of research in women’s health and childbearing (Doyal 1995; Bell 2009). Moreover, there is a prevalence of inconsistencies across international guidelines, national guidelines and even between neighbouring hospital trusts (Hunter 2004), indicating that evidence is interpreted differently and wide variations exist between guidelines (Hunter 2004; Bell 2009), leaving health care professionals in a quandary.
FINDING A WAY FORWARD
Whilst EBM and the development of guidelines had noble intentions and are certainly of use to midwifery practice, I have highlighted some key issues that need our consideration so that we can adopt a ‘critical’ lens. By deconstructing the complex issues surrounding guidelines, midwives can be equipped to critically examine the tensions between professional and employee obligations and woman-centred care. Undoubtedly, midwives find themselves with multiple, competing pressures in their everyday work that can make the application of knowledge to care practices a challenge. However, I propose that these issues can be overcome in several ways: knowledge, understanding and action.
Firstly, I suggest that all midwives need to be familiar with their local guidelines. Sometimes guidelines are perfectly useful but the cultural norms of the unit might mean that the guidelines have not been implemented successfully. Additionally, it is useful to understand the guideline development process of your local trust, so get involved in order to collaborate and contribute with your colleagues, ensuring that your local guidelines are up-to-date and evidence based. Beyond local guidelines, midwives need to know and understand the evidence that contributes to a guideline. We need to do our own research, making use of the array of resources at our disposal: NICE, RCM, RCOG guidelines and journals, in order to improve our knowledge base.
Secondly, we need to understand the benefits and limitations of the guidelines and the evidence that informs our knowledge, all of which is essential to providing ethical woman-centred care.
Thirdly, we need to take collective responsibility to act on our knowledge and understanding; if a guideline is out of date, address this with your manager. When discussing options with women, you will need to offer your local guideline recommendations, but do use other evidence to inform your discussions. This is so that the woman can make a meaningful decision based upon accurate information. If a woman chooses to decline your recommendations, support and advocate for her, remembering that her legal rights supplant any guideline or evidence (Feeley 2017).
The topic of guidelines is one that is seemingly straightforward; however, complexities and tensions that affect midwifery practice and women’s experiences of birth exist. This article has provided midwives with an overview of the current issues and some practical steps so that we can move beyond a ‘guideline-centred care’ approach to perform midwifery with women at the centre of our care.
Bell S (2009). DES daughters: embodied knowledge and the transformation of women's health politics, 1st edition. Philadelphia: Temple University Press.
Birthrights (2013a). Consenting to treatment, UK: Birthrights. www.birthrights.org.uk/library/factsheets/ Consenting-to-treatment.pdf
Birthrights (2013b). Facing criticism: child protection and maternity care, UK: Birthrights. www.birthrights. org.uk/library/factsheets/Facing-Criticism.pdf
Birthrights (2015). UK supreme court upholds women’s autonomy in childbirth: Montgomery v Lanarkshire health board, UK: Birthrights. www.birthrights.org.uk/2015/03/uk-supreme-court-upholds-womens-autonomy-in-childbirth-montgomery-v-lanarkshire-health-board/
Downe S (2010). ‘Beyond evidence-based medicine: complexity and stories of maternity care’. Journal of Evaluation in Clinical Practice, 16: 232-237.
Doyal L (1995). What makes women sick: gender and the political economy of health, 1st edition. London: MacMillan Press Ltd.
Feeley C (2017). ‘No means no! Let’s talk about consent’. The Practising Midwife, 20(4): 25-27.
Feeley C and Thomson G (2016). ‘Tensions and conflicts in 'choice'. Women's experiences of freebirthing in the UK’. Midwifery, 41: 16-21.
Greenhalgh T (1998). ‘Narrative based medicine in an evidence based world’. In: Greenhalgh T and Hurwitz B (Eds). Narrative based medicine: dialogue and discourse in clinical practice, 1st edition. London: BMJ Books.
Greenhalgh T (2014). ‘Evidence based medicine: a movement in crisis?’ British Medical Journal, 348: 1-7.
Griffiths R (2009). ‘Maternity care pathways and the law’. British Journal of Midwifery. 17(5): 324-325.
Hannah ME, Hannah WJ, Hewson SA et al (2000). ‘Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial’. The Lancet, 356: 1375-1383.
Hunter B (2004). ‘Conflicting ideologies as a source of emotion work in midwifery’. Midwifery, 20: 261-272.
Irving A (2014). ‘Policies and procedures for healthcare organizations: a risk management perspective’. Patient Safety and Quality Healthcare, October 13th. www.psqh.com/analysis/policies-and-procedures-for-healthcare-organizations-a-risk-management-perspective/#
Kotaska A (2011). ‘Guideline-centred care: a two-edged sword’. Birth: Issues in Perinatal Care, 38(2): 97-98.
Kotaska A (2017). ‘Informed consent and refusal in obstetrics: a practical ethical guide’. Birth: Issues in Perinatal Care, doi: 10.1111/birt.12281.
Kress S (2010). ‘Chaos and complexity – a discussion of the impact of nonlinear science on contemporary childbirth’. MIDIRS Midwifery Digest, 20(4): 431-435.
Kruske S, Young K, Jenkinson B et al (2013). ‘Maternity care providers' perceptions of women's autonomy and the law’. BMC Pregnancy and Childbirth, 13: 84. doi: 10.1186/1471-2393-13-84.
NHS (2006). Using protocols, standards, policies and guidelines to enhance confidence and career development, London: NHS.
Sackett D (1997). ‘Evidence-based medicine’. Seminars in Perinatology, 21(1): 3-5.
Shallow H (2013). ‘Deviant mothers and midwives: supporting VBAC with women as real partners in decision making’. Essentially MIDIRS, 4(1): 17-21.
Thompson (2013). ‘Midwives' experiences of caring for women whose requests are not within clinical policies and guidelines’. British Journal of Midwifery, 21(8): 564-570.
Walsh D (2006). ‘Risk and normality in maternity care: revisioning risk for normal childbirth’. In: Symon A (Ed). Risk and choice in maternity care: an international perspective, Philadelphia: Elsevier.
Back to top