(~ Longman (;roup UK Ltd 1992

Midwifery

EDITORIAL

Why do we continue to use ineffective types of care?

In the preface to the book Effective care in pregnancy and childbirth the editors state that care should be effective (Chalmers et al, 1989). To know that care is effective we have to base our care on practices which research has shown to be beneficial and it has been recognised for some time that, together with nursing, midwifery must become a research based profession (DHSS, 1972). Within obstetrics and midwifery there are plenty o f types of care which have been provided which research has subsequently shown to be of no value (see Appendix 4 in Chalmers et al, 1989). Using unevaluated forms o f care can cost the women in our care both financially and in the form of morbidity, and can cost health authorities/hospitals financially. One of the most recent examples of this is the use of the delivery chair. It was introduced, unevaluated, into many hospitals because it was thought to have the advantage of a simulated squatting position but did not impede 'the midwife, or doctor, who wanted to see and guard the perineum and to assist the delivery generally' (Romney, 1984). Although the midwives at Northwick Park Hospital recognised the need to evaluate the new piece of apparatus they considered it unethical 'to subject women to this recently introduced innovation' in a randomised controlled trial because the women would be denied the basic freedom of choice (Romney, 1984). In the subsequent (small) observational study nor disadvantages were found for those women who chose to deliver in the chair when compared to a group of women who delivered on the standard obstetric bed and there may even have been some benefits for those who delivered in the chair (Romney,

1984; 1987). However, in a subsequent randomised controlled trial at the same hospital (Romney, 1987) there was an increased incidence of post partum haemorrhage and perineal trauma in the g r o u p o f women delivering in the chair when compared with the women delivering in the obstetric bed. T h e increased blood loss was confirmed by another trial (Stewart & Spiby, 1989). My current concern about using a form of care which has not been shown to be of any advantage is the use of transcutaneous electrical nerve stimulation (TENS) for pain relief in labour. Although no study has shown it to be disadvantageous, no randomised controlled trial has shown it to be any better than conventional methods of pain control (Lee et al, 1990; Hardy, 1991). You may ask why I am concerned about the use of TENS if it has not been shown to do any harm. My concern is, firstly, that the acquisition of the relevant machines has a financial implication for hospitals and although a TENS machine may be relatively inexpensive it is nevertheless money which might be spent elsewhere. Naturally woman want the best for themselves and on the advice of their health care attendants, when delivering in areas where there is no TENS machine, have hired a TENS machine. Women have complained to me of this extra financial b u r d e n for something which was of no value. They also feel they have been 'conned' when they experienced no benefit. I am aware that there is a problem when the news of a new type of care/treatment reaches a community; everyone thinks it is the 'miracle drug' and they have an automatic right to it. Hardy (1991) reported that despite the fact that there 157

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was n o a d v a n t a g e in the use o f analgesia or in the d e g r e e o f p a i n e x p e r i e n c e d by the w o m e n u s i n g T E N S in h e r study, there was an i n c r e a s e d a n d i n c r e a s i n g d e m a n d for T E N S in C h e s t e r d u r i n g a n d s u b s e q u e n t to h e r study. T h e midwives at Northwick Park Hospital also faced this p r o b l e m in that w o m e n were going to the hospital so that they could use the b i r t h chair. Following their R C T the midwives at Northwick Park told all w o m e n asking to use the birth chair that their research h a d shown that w o m e n d e l i v e r i n g in the chair had a n increased i n c i d e n c e o f p e r i n e a l t r a u m a a n d post p a r t u m h a e m o r r h a g e w h e n c o m p a r e d with w o m e n d e l i v e r i n g in bed. We have a responsibility to e x p l a i n the f i n d i n g s of the research into the effectiveness o f T E N S as a m e t h o d of pain relief to the w o m e n i n o u r care so that they are n o t ' l a b o u r i n g u n d e r a d e l u s i o n ' a n d p u t to u n n e c e s s a r y cost. N e i t h e r are hospitals p u t to g r e a t e r expense. T h e r e are too m a n y non-effective delivery chairs collecting dust in l a b o u r wards t h r o u g h o u t the world. W e should n o t r e p e a t this with T E N S machines. ANN THOMSON

References Chalmers I, Enkin M, Keirse M J N C 1989 Effective care in pregnancy and childbirth. Oxford University Press, Oxford DHSS 1972 Report of the committee on nursing. HMSO, London HardyJ 1991 A randomised controlled trial into the use of transcutaneous electrical nerve stimulation (TENS) in labour In Thomson A, Robinson S, Tickner V (eds) Proceedings of 1990 Research and the Midwife conference. Department of Nursing, University of Manchester, Manchester Lee E W C, Chung I W Y, LeeJ Y Let al 1990 The role of transcutaneous electrical nerve stimulation in management of labour in obstetric patients. AsiaOceania Journal of Obstetrics of Gynaecology 16 (3): 247-254 Romney M 1984 Chair project In Tomson A, Robinson S (eds) Proceedings of 1983 Research and the Midwife conference. Department of Nursing, University of Manchester, Manchester Romney M 1987 The implications of research for midwifery practice and management and the training of midwives - the birthing chair: a random controlled trial In Robinson S, Thomson A (eds) Proceedings of 1986 Research and the Midwife conference. Department of Nursing, University of Manchester, Manchester Stewart P, Spiby H 1989 A randomised study of siuing position for delivery using a newly designed obstetric chair. British Journal of Obstetrics and Gynaecology 96:327-333

Why do we continue to use ineffective types of care?

(~ Longman (;roup UK Ltd 1992 Midwifery EDITORIAL Why do we continue to use ineffective types of care? In the preface to the book Effective care i...
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