EBB 3 – Why Is It So Hard to Get Evidence Based Care?

Dr. Rebecca Dekker – 00:00:00:

Hi everyone, on today’s podcast, we’re going to talk about the evidence-practice gap and why it’s so hard to get evidence-based care. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. So in the very first episode of the Evidence Based Birth® Podcast, I talked about my personal journey and why I started Evidence Based Birth®. Then in episode number two, we talked about the definition of evidence-based care and how it’s like a three-legged stool, including number one, research-based information to help you make decisions. Number two, having an experienced healthcare provider who can help you apply that evidence-based information. And number three, when the healthcare team actively asks about and honors the patient’s values, goals, and preferences. 

Now today we’re going to talk about the evidence-practice gap and why it can be so difficult to get evidence-based care during pregnancy and birth. Now researchers have found that it can take many years between the time when something has been proven repeatedly in medical research until it becomes routinely used in healthcare practices. So we have this problem, there’s a disconnect, a break between what we know people want, which is evidence-based care, and what they’re sometimes getting, which might be care that is often based on the status quo or on routines or traditions. Research shows that people want to be deeply involved in their own healthcare decisions. They want all the components of evidence-based care, all three parts of that three-legged stool. But research shows that many people who are receiving maternity care are not always getting evidence-based care. And this is a global problem, and it’s a big problem here in the U.S., where I’m located. So I wanted to share a few statistics with you from the United States so you can kind of get the landscape of what’s going on with this evidence-practice gap. I’m going to share three main statistics with you. The Cesarean rate, the VBAC rate, and then rates of several interventions that can happen in childbirth. 

So let’s start with the Cesarean rate. The Cesarean rate in the United States has risen drastically. It was only about 5% in the early 1970s. Then it rose to a high of 33% in 2009. And then it declined a bit in 2019, down to 31.7%. But since then, it has been rising. And in 2024, the Cesarean rate had risen again to 32.4%, which was the highest it’s been since 2013. Most of this increase in the Cesarean rate in the year 2024 was related to an increasing number of Cesareans being performed on Black and Hispanic women. So currently, a little less than one out of three people in the United States gives birth surgically by Cesarean. And although researchers disagree what the ideal Cesarean rate should be, we do know from the research that a high Cesarean birth rate increases the risk of health problems in the population for both women and infants, including bleeding after birth or hemorrhage, breathing problems in newborns, the risk of hysterectomy or having your uterus removed, infection, placental problems in future pregnancies, future infertility, uterine rupture in future pregnancies, pediatric asthma, and an increase in the rare risk of stillbirth in future pregnancies. So when a Cesarean is medically necessary, the benefits will clearly outweigh the risks. But research shows that Cesareans can also be overused. And there is general agreement that this is the case in the United States, and that when we can prevent a Cesarean, we should attempt to do so. The two main drivers of a high Cesarean rate include a high primary Cesarean rate and a low vaginal birth after Cesarean rate. So a primary Cesarean is a Cesarean in someone who’s never had a C-section before. So this includes people giving birth for the first time who have a Cesarean and people who had a vaginal birth in the past who have a Cesarean in a subsequent birth. So if the primary rate of Cesareans is going up, then the overall Cesarean rate goes up. But the other important contributor to the Cesarean rate is the VBAC rate. Vaginal birth after a Cesarean or VBAC is considered by researchers and health organizations to be a safe and reasonable option. It’s an evidence-based option for most people who’ve had a Cesarean in the past. 

Now, if the VBAC rate goes down, that means that repeat Cesareans are going up. And so the overall Cesarean rate goes up. The VBAC rate in the United States dropped from a peak of 28% in the mid-1990s down to 7% in the year 2009. This means that 93% of people in 2009 were having repeat Cesareans. The VBAC rate has slightly increased and is currently at 14.2%. In a study published in 2018 by Sakala et al. called the Listening to Mothers in California study, they found a repeat Cesarean rate of 85%. And they asked women in the study who’d had a prior Cesarean if they were interested in a VBAC with this pregnancy. And about half the women said, yes, I was interested in a VBAC. But only half of those said that VBAC was an option. So when the researchers asked those who said VBAC was not an option, why was this the case? Why were you not able to have a VBAC? And more than six in 10, 66%, reported that their provider did not allow VBAC, and nearly one in four, 23%, stated that their hospital did not allow VBAC. While 28% identified a need for a Cesarean in their most recent birth. I’ve talked with many birth workers about this statistic and they confirmed with me verbally what I’ve seen in the research in that there seems to be an increase in providers who say, no, I will not support you having a VBAC. Another study published by Basile Ibrahim et al. in 2020 found that families who want a VBAC have to go to extraordinary lengths in order to get one. In this study, they recruited more than 1,700 US-based participants who were pregnant after a prior Cesarean. This was a mixed method study, meaning they collected both statistics and they collected stories from the women in the study. The overarching theme was that women had to fight in order to get a VBAC. And the main barrier was a lack of supportive healthcare providers and the problem of bait and switch was commonly described. 

For those of you who are not familiar with that concept, it’s when a healthcare provider says, yes, I will support you in this type of birth, but then when it gets closer to the time of birth, they withdraw their support or they state that there’s some reason they can no longer support the birth that you want. I thought one important quote from a participant was this. She said, during my second pregnancy, my OB was extremely unsupportive regarding my choice to try for a VBAC. She told me my pelvis was too small and if I tried for VBAC, my baby would get stuck and die. End quote. This participant went on to have a VBAC, but they had to get a different healthcare provider in order to have that kind of birth. And this was a common theme in the study, the participants who had a VBAC often had to switch providers in order to get the birth that they wanted. The participants also talked about the importance of doulas in helping them have a VBAC. So we’re going to come back to this in a little bit, but if VBAC is an evidence-based option, it’s even supported in healthcare guidelines. Why is it so hard to find a supportive provider? Why do we have an evidence-practice gap? And I want to talk more about the why in a little bit. Before we do, I want to share a few more statistics on interventions that highlight the evidence-practice gap. And these have to do with interventions. Continuous electronic fetal monitoring is used in 84% of labors in the United States, even though research does not support its use. Instead, research shows that continuous electronic fetal monitoring has very high false positive rates and that it’s a big contributor to the overall high Cesarean rates that we have today. About half of women in the United States are restricted to bed during labor, and this is definitely not evidence-based. 

In fact, research shows it’s harmful to keep someone on bed rest during labor. Also in the United States, 95% of patients still give birth lying on their back or semi-sitting. And research shows that these positions can increase the risk of harm to both mother and baby, particularly the lying on your back position or the lithotomy position where you’re lying on your back with your feet in stirrups. In addition to overuse of some of these non-evidence-based interventions, the evidence-practice gap also includes underuse of beneficial evidence-based interventions. For example, research strongly supports the use of doulas for improving birth outcomes, including lowering the Cesarean rate. But right now doula care is only used at about 9% of births. One simple intervention that has been shown to reduce pain and have other benefits in labor is the use of a birth ball, which might cost $20 or $30 for a first-time purchase. But these are only utilized in about 10% to 20% of births. And then I would also be remiss if I didn’t talk about the evidence on midwives and how research has shown in many studies over the world that midwifery care improves health outcomes, but midwives only attend about 12% of births in the United States. So as you can see, the evidence-practice gap is a huge problem. So why do we have an evidence-practice gap? For me, this is the million dollar question, something I’ve been pondering for years and trying to figure out as much as I can. I want to start off by saying I personally know a number of midwives, physicians, and nurses who are working so hard to bring evidence-based practices into their facilities. And they often run into a lot of difficulties in doing that. Now, there are a few places around the world where change has gone smoothly and evidence-based practice is the norm. But the vast majority of healthcare workers that I know who are trying to create change in hospitals and make birth better are having a really hard time. 

So why is that? Well, there are a variety of reasons, and we could probably spend hours kind of trying to figure all of them out. But I think a big piece of it has to do with paternalism and the strict hierarchical top-down power structure in our healthcare system. Paternalism is a word that gets thrown around a lot, but a lot of people don’t know the actual definition. So I’m going to share it with you because I think it’s really enlightening. Paternalism is defined as the policy or practice on the part of people in positions of authority that restricts the freedom and responsibilities of those who are subordinate to them in the subordinate’s supposed best interest. So there is a heavy element of paternalism in maternity care. There are a lot of incentives to get clients to conform to routines, and there are sometimes penalties if a client does not conform. Paternalism affects anyone who’s pregnant, but it also impacts providers and other healthcare workers in the system. For example, a provider who wants to provide evidence-based care might be penalized if they support their client’s wishes for care that’s based on the evidence and the client’s values, goals, and preferences. 

I’ll just give you a quick example. Let’s say you have someone who’s pregnant, and they’ve decided they do not want continuous electronic fetal monitoring while they’re in labor. They want something that they feel is more evidence-based, and that is intermittent auscultation with the handheld Doppler device. Now, their provider might be supportive of that, even if they’re a little uncomfortable with it because perhaps it was not something that they were trained on, but the provider educates themselves and decides that, yes, I can support that. But what if the people higher up in the hierarchy are not supportive of that? Hospital lawyers, hospital administrators, they may make threats to that provider and say, we’ll take away your privileges to practice here because they’re worried about legal liability. So they may be imposing their fears of legal liability over the client’s safety and best interests. And if the client says, well, I don’t care, I’m still not going to conform to your policies. That puts everybody in the system under a lot of pressure. Now, all of a sudden, you have this provider who has received threats to take their privileges away, which means they not only can’t practice at that hospital, but they likely won’t be able to practice at any hospital. So you have to understand that creating change in a system like that, where there’s such a strict power hierarchy and such an emphasis on legal liability, that everybody in this system is under a lot of pressure, and really nobody is happy. And this kind of goes back also to the VBAC issue that I talked about earlier about how there’s been an increase in providers who say they will no longer support VBAC. 

And again, a lot of that pressure may come from the system. Perhaps their malpractice insurance says we won’t cover you anymore if you attend VBACs. Or maybe the hospital says you can only attend VBACs if you are in-house in the hospital, the entire labor, which for a 24 to 48 hour labor might not make any sense for that provider’s family life or their work life balance. So paternalism impacts everybody in the maternity care system, and it’s really a systemic problem that requires a systemic solution and a big cultural shift. And I go into a lot more detail about the hierarchy, about paternalism, in our course How to Help Families Get Evidence-Based Care. That is available to evidence-based birth pro members. And we have a more in-depth version of that class for evidence-based birth instructors. But really one of the main problems is that when you have this top-down power structure, the people at the quote unquote bottom of the hierarchy may feel like they don’t have the power to create change. They may feel feelings of inferiority or insecurity. They may feel like they’re not worthy of making these changes or that they’re up against such powerful forces that what they do won’t make a difference. In addition, I have seen sometimes when healthcare workers try to make change, their changes or their suggestions may be squashed by people higher up in the authority chain. What’s another complicating factor is that people in the middle or the bottom of the hierarchy may fight amongst themselves because they feel so much stress. They’ve been watching their clients receive substandard care. They themselves feel like they have so much heavy responsibility. They feel very little power. So they take their helplessness and lash out at other people who are at their same level on the hierarchy. 

This is called horizontal violence and it’s well documented in research in both midwifery and nursing. Horizontal violence is also anecdotally seen among doulas as well. And so horizontal violence can mean things like gossiping, backstabbing, sabotaging other people’s work. In nursing, we often say that nurses eat their own young. When you see a nurse bullying a new nurse and belittle them. And this is something that’s not talked about enough, but it’s very common in these hierarchical power structures where nurses feel like they don’t have power, so they take out their frustration on each other. In fact, even as a nurse myself, I experienced this as a new nurse and I knew that nurses eat their own young. It was like a common saying among nursing students, but I didn’t truly understand why until I got to graduate school. And a professor finally explained to us that horizontal violence occurs when people have a lot of responsibility, but feel very little power to create change. So I do believe that there are solutions to these systemic problems and that we can all come together and focus on what we have in common. And that is what we want is the best health and the best outcomes for families and for babies as well. And I do believe we can all do our part to focus on family centered care and some ways that we can do this include finding, rediscovering our own internal sense of strength and power. Processing our own internalized feelings of oppression and building bridges with others, using better communication, building teams and gathering allies who are all in this fight together. We also need to address cultural changes. We need to make changes at the policy level or the legislative level or at the systemic level, such as with malpractice insurance coverage. 

And finally, I believe personally that we need a lot more love in the maternity care system all around the world. There are so many hurting people in labor and delivery units. So research shows that about one in three labor and delivery nurses and one in three midwives has current symptoms of post-traumatic stress disorder from traumatic things they’ve witnessed in labor and delivery. And physicians are not exempt from trauma. Many of them are traumatized by their residency training, which can be abusive, or by lawsuits that they’ve been involved in or by other things they’ve witnessed in labor and delivery. So how can we expect people that are hurting like this to effectively create change. On a broad scale, if we have so many healthcare workers who are hurting so deeply, and then we also have patients in the maternity care system, moms, dads, birthing people, partners, they as well can then be hurt by the system. So I think we all need to have our eyes open to the fact that there are a lot of hurting people in this system and that we can do our parts by discovering our own internal power and showing warmth to everybody that we meet in this system. Also, it can be helpful to understand what intersectionality brings to this conversation. Intersectionality is a term that was first defined by the American feminist, legal scholar, and civil rights advocate, Kimberlé Williams Crenshaw. She used the term intersectionality to describe when you have overlapping or intersecting systems of oppression, domination, or discrimination. 

So we’ve already talked about that top-down hierarchy in the healthcare system. But hierarchies can occur on a multidimensional basis, like a 3D or 4D basis. So we have been focusing kind of on one part of an injustice and saying things like, well, you know, it’s just not fair that families are at the bottom of the hierarchy or that midwives have less power than physicians or that nurses feel like they don’t have enough power in the hierarchy or doulas. However, the intersections often go overlooked. For example, you might be a midwife and be lower down on the traditional hierarchy in the healthcare system, but you might also be a woman. So you’re not only facing the medical system hierarchy, but you’re also facing sexism. If you’re also black and if you’re queer, so if you are a black queer woman midwife, then you’re facing four intersecting systems of oppression, giving you a unique experience that somebody else might not understand that you’re going through. Other overlapping parts of the system really include a lot of isms like classism, genderism, heterosexism, and we have issues of citizenship, sizism, ableism, or any other category in which people can use discrimination against you. So we have to understand and appreciate there are multiple systems and multiple hierarchies at play here. Now, all of these problems contributing to the evidence-practice gap might seem a little heavy to you and you might starting to be feel like a little… Downhearted at this moment. I just want to give you some encouragement and let you know that although we do have this evidence-practice gap. And although a lot of people still cannot reliably get access to evidence-based care, I am personally seeing some improvements around the world. The past 13 years, as I’ve watched Evidence Based Birth® grow, and I’ve been involved in the global birth community, I’ve seen actually quite a few improvements around the world. One great example is with skin-to-skin care after Cesarean. It used to be that it was routine or traditional that when you have a Cesarean, you are immediately separated from your baby. And if you wanted to do skin-to-skin care, also called kangaroo care with your baby, you would have to wait multiple hours. And it was not an option to do it in the operating room at all. That was considered impossible. But now hospitals across the United States are beginning to offer this service and in many other places around the world as well. 

A few other changes I’ve seen include doulas becoming a household term and being much more accepted in hospitals by nurses. I’m seeing much more people being mobile in labor and nurses understanding the importance of people getting up and moving around in labor. I’ve seen more hospitals become permissive of eating and drinking in labor. And I mean drinking fluids, not drinking alcohol. However, eating is often still quote-unquote forbidden by some hospitals if you have an epidural or if you’re being induced. And those restrictions are not evidence-based and we’re still having to fight those. I’m seeing nurses in general being way more supportive of upright labor and birthing positions. Nurses are becoming skilled and using tools like peanut balls and birth balls. Hospital staff are working to avoid separation of mother-baby after birth. There is rooming in is considered the standard where you keep your baby with you. And there’s much more support for lactation than there used to be. There’s also less stigma around midwives. More people know what a midwife is. So these are examples of some changes. And I believe that these changes have really come both from the ground up and the top down. And that’s because it comes from families who are demanding this type of evidence-based care. And by the way, these families are often being educated by doulas and childbirth educators. So the people who would quote-unquote be at the bottom of the hierarchy are actually driving a lot of this change because they’re demanding it. And then you have people towards the top of the hierarchy, physician champions, midwife champions, and nurse champions, who are helping their clients navigate the system and helping them get these types of evidence-based care whenever possible. But at the same time, change is hard. There’s no doubt about that. And many of you who are listening or watching may find yourself still in a system that you feel is outdated. It’s more based on traditions, routines, and paternalism than the evidence. 

So in the meantime, how are you supposed to help yourself or help your clients? Well, I think just recognizing the paternalism in the system can be really helpful because when you face it or you run up against it or you see horizontal violence, you’ll understand what’s going on. And when you can name something, you take away some of its power when you can see it for what it is. Also, you need to really remember and teach everyone you know that patients always have their own internal source of power. They have the right to bodily autonomy and they have the right to inform consent and refusal. This means that patients in the healthcare system have the right to say yes or no to things that are suggested without feeling pressured or coerced. If families can recognize, you know, what is evidence-based care? What is respectful maternity care, then they may be better able to switch when they realize that they’re in a situation where they’re not going to get evidence-based care. And really the ideal situation that families should be looking for is when you have a care provider who lays out alternatives for you in a decision that you’re making, including the option of doing nothing. This provider would discuss potential benefits and potential harms with you, actively ask you what you prefer and then honor and respect your final decision. 

So if you enjoyed this conversation about evidence-based care from episodes one, two, and three, I’d like to invite you to come spend some time in our community at Evidence Based Birth® and learn about different ways you can get involved. We have several options. We have the Evidence Based Birth® Pro Membership, which has a doula mentorship, midwifery brunch and learns, monthly trainings, as well as a library of a lot of different trainings on different topics with continuing education hours. We also have the Evidence Based Birth® Instructor Program for birth workers and healthcare workers who want to get more deeply involved at Evidence-Based Birth® and be able to teach their own Evidence Based Birth® Childbirth Classes and workshops. And then if you’re a parent, we have the Evidence Based Birth® Childbirth Class as well. So I’d also like to invite any of you listening to continue following us on these podcasts, the EBB, as we talk about the evidence. And we often focus on that first leg of the three-legged stool, all about the research evidence on different practices. But we also bring in elements of change by interviewing experts in the field about what they’re doing. And we also share lots of birth stories about families and how they advocated for themselves to get evidence-based care. So what I personally am really passionate about is bringing change to the system so that more people can access Evidence-based care, the three-legged stool we’ve been talking about. And so here on the Evidence Based Birth® Podcast, stay tuned, subscribe, keep listening, and you’re going to learn so much. You can build up a powerful reservoir of evidence-based information that you can use to talk with healthcare providers and families in your community. 

Remember, knowledge is power. And here at EBB, we are excited to be a part of building up the knowledge in our community. Thank you so much. And I’m so excited to continue going on this journey with you on the Evidence Based Birth® Podcast. Today’s podcast was brought to you by the Evidence Based Birth® Professional Membership. The free articles and podcasts we provide to the public are supported by our Professional Membership program at Evidence Based Birth®. Our members are professionals in the childbirth field who are committed to being change agents in their community. Professional Members at EBB get access to continuing education courses with up to 23 contact hours, live monthly training sessions, an exclusive library of printer-friendly PDFs to share with your clients, and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans, as well as scholarships for students and for people of color. To learn more, visit ebbirth.com/membership.