"guidelines are only as good as the evidence that underlies them"

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By ANaturalAdvocate


In the news lately has been an article entitled “Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’ Practice Bulletins.” This article rates the evidence behind the obstetrical and gynecological recommendations made by ACOG as A (“good and consistent evidence”), B (“limited or inconsistent evidence”), or C (“consensus and opinion”) - levels used by the College itself. These recommendations “are meant to synthesize the best available data and make practical recommendations for clinicians” and are implemented “[t]o guide physicians in the implementation of best practice.” 

The article itself admits the limitations of these recommendations from professional organizations, which are often used as “benchmark[s] for quality,” especially where high-quality evidence may be lacking. Given that these recommendations - which come from practice bulletins on topics from Operative Vaginal Delivery to Shoulder Dystocia and Fetal Macrosomia - “strongly influence the practice of obstetrics and gynecology,” it is imperative that “clinicians must remain mindful of the limitations of guidelines.” The authors do state that these recommendations should not take the place of clinical judgment, however. 

“Among the obstetrics recommendations, level A evidence was noted for 24.6% of the diagnostic recommendations, 46.7% of the counseling recommendations, 20.9% of the guidelines for evaluation, 27.4% of the treatment recommendations, and 4.2% of the guidelines concerning mode of delivery. For gynecology, level A recommendations were found for 29.0% of the diagnostic guidelines, 35.0% of the counseling recommendations, 24.2% of evaluation guide- lines, and 38.1% of those recommendations that addressed treatment.”

While obviously the expertise and training of the physicians forming these recommendations must be taken into account in deciding the weight of “consensus and opinion,” it is clear that many recommendations do not have the evidentiary backing that many consumers assume is present.

A press release from the Big Push for Midwives illustrates the practical effects of these recommendations:

WASHINGTON, D.C. (August 15, 2011)—A study published this month in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the organization’s clinical guidelines for OB/GYN practice meet the Level A standard of “good and consistent scientific evidence.” The authors of the study found instead that the majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on “limited or inconsistent evidence” and on “expert opinion,” both of which are known to be inadequate predictors of safety or efficacy.

“The fact that so few of the guidelines that govern routine OB/GYN care in this country are supported by solid scientific evidence—and worse, are far more likely to be based on anecdote and opinion—is a sobering reminder that our maternity care system is in urgent need of reform,” said Katherine Prown, PhD, Campaign Manager of The Big Push for Midwives. “As the authors of the study remind us, guidelines are only as good as the evidence that supports them.”

ACOG Practice Bulletin No. 22 on the management of fetal macrosomia—infants weighing roughly 8 ½ lbs or more at birth—illustrates the possible risks to mothers and babies of relying on unscientific clinical guidelines. The only Level A evidence-based recommendation on the delivery of large-sized babies the Bulletin makes is to caution providers that the methods for detection are imprecise and unreliable. Yet at the same time, the Bulletin makes a Level C opinion-based recommendation that, despite the lack of a reliable diagnosis, women with “suspected” large babies should be offered potentially unnecessary cesarean sections as a precaution, putting mothers at risk of surgical complications and babies at risk of being born too early.

“It’s no wonder that the cesarean rate is going through the roof and women are seeking alternatives to hospital-based OB/GYN care in unprecedented numbers,” said Susan M. Jenkins, Legal Counsel of The Big Push for Midwives. “ACOG’s very own recommendations give its members permission to follow opinion-based practice guidelines that have far more to do with avoiding litigation than with adhering to scientific, evidence-based principles about what’s best for mothers and babies.”

The Big Push for Midwives Campaign represents tens of thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives is to educate state and national policymakers and the general public about the reduced costs and improved outcomes associated with out-of-hospital maternity care and to advocate for expanding access to the services of Certified Professional Midwives, who are specially trained to provide it.

Media inquiries: Katherine Prown (414) 550-8025, katie@pushformidwives.org