Unintended Consequences

I’ve been thinking a lot about how modern medicine works, and an inherent flaw in its most cherished paradigm – evidence-based practice. Don’t get me wrong, I am a HUGE fan of evidence-based practice, and it enrages me daily how little of obstetric practice in particular is based on a proper scientific investigation. I am very much in favour of studying whether the things we do make empirical as well as theoretical sense.

But the problem with most of the research about clinical practice, is that it has the same problem we all have, of focusing on the immediate without always understanding the broader longer-term implications.

What I am talking about is “unintended consequences” – how in solving one problem, you can actually unintentionally cause another, far larger one.

But because of the timeframe of most medical research, the longer-term consequences may be entirely outside the scope of the study.

This came home to me today, as I was reading about a study that looked at the gut and skin microbiomes of babies born and fed in different ways. It found, quite worryingly, that not only did caesarean babies have a more limited microbiome in terms of diversity of the species of bacteria found, but that it was also comprised in part of some pretty scary hospital bugs, which were largely absent from the vaginally birthed babies. Likewise, breastfed babies had a healthier and more diverse microbiome than formula-fed infants.

This may sound like a curious and somewhat incidental finding, until you start looking at all the other research happening around the role our guts and gut microbiomes play in a huge number of aspects of our health. The gut microbiome is now known to have a massive role in whether or not we become obese – more perhaps than our rate of calorie consumption or exercise. The gut itself is the controller of a myriad of hormonal and chemical responses, which are implicated in mental health and states of mind, as well as fertility, heart health, insulin regulation and a number of other health-critical systems. Our understanding of what the gut and the microbes that live in it do for us is changing literally by the hour, and it is the next great frontier of medical research.

And at the same time, caesarean rates are still rising, pushed onwards by a mindboggling 50% increase in induction over the past few years in the UK. Why the sudden increase in inductions? It is a perfect storm fuelled on the finding of a major study that determined that statistically, babies born at 41+ weeks have an increased risk of stillbirth. But what all the hysterical coverage didn’t mention was that the rate, whilst double the rate of birth at 39 weeks, was still incredibly low – from memory, 0.8% as opposed to 0.4% -- in other words 99.2% safe as opposed to 99.6% safe. So on the presumption that, statistically, inducing hundreds of thousands of mothers at 39 or 40 weeks would prevent these late stillbirths (possibly a pretty dodgy presumption for a statistical study), a couple of hundred neonatal lives might be saved.

Now, saving neonatal lives is of course a really important goal. But my question is, at what unintended cost? Increased caesareans, increased instrumental deliveries, increased potentially traumatic experiences for mothers, fathers, partners and babies, increased suffering for many labouring women, increased knock-on effects on breastfeeding rates, infant bonding, postnatal depression and PTSD, which in turn have knock-on effects for mental, intellectual and physical health as these children grow up – for potentially hundreds of thousands of couples, not a couple of hundred. And now, perhaps lifelong implications for babies’ immune system development and overall health? Is this really wise, to solve one important problem but cause thousands more?

The other part of the perfect storm is the ongoing death of a thousand cuts of NHS maternity services. With the kind of resource pressure hospitals are under, the ability to predict and schedule needed workforce is a huge efficiency advantage, and inductions are schedulable in a way that spontaneous birth is not. Plus, obstetrics is the most litigated area of medicine, and practitioners and hospitals are far far more likely to be sued for what they failed to do than for what they did do, so medical concerns aside, the system is already stacked to favour intervention.

The truth is, our reproductive system is the characteristic of our species that has undergone the most intensive selection pressure in evolutionary terms of any trait, and evolutionarily, we have arrived at a truly optimal physiological solution, given the constraints of our peculiar big-brained bipedal bodies. It is an incredibly complex process hormonally, mechanically and physiologically, and extremely effective – when it is not interfered with. Disrupting one small aspect can have cascading effects across the whole system. Something as simple as turning on a bright light or making a negative discouraging comment can have a profound disruptive effect on the flow of hormones needed for optimal progress (let alone the intrusive practices associated with induction).

Because of this, I believe we meddle at our peril. The possibility of unintended (negative) consequences is larger in birth than in just about any other area of medicine I can think of – because more and more studies show that what happens during birth and in infancy can impact a person their whole life. We need to have really really good reasons before we interfere, and no intervention should happen “routinely” without a need (medical, physical, psychological, emotional or spiritual) specific to the particular circumstances of that pregnant person and their baby.