The Precautionary Principle is used by environmentalists, and more recently by public health experts, to provide a general framework to prevent unintended harm (American Public Health Association [APHA], 2001; Kriebel & Tickner, 2001). The main elements of the principle include not moving forward with an action if there is risk of harm, but uncertainty exists as to full scope and direct cause-and-effect links; shifting the burden of proof for efficacy and minimal risk of harm to proponents of an action; considering and evaluating many types of feasible alternatives; and increasing participation in the decision-making process of those involved or those who could potentially be affected (APHA; Kriebel & Tickner). As per the principle (APHA), declarations using lack of evidence that a clinical practice, procedure, or technology is unsafe as the basis for being allowed to proceed should be replaced by a requirement that the initiator of the request provide rigorous evidence of safetyand efficacy in advance. This shift in the burden of proof promotes safer care.
The concepts of the Precautionary Principle, if applied to maternity care in the United States, would lead to significant reconsideration and productive conversations about how we provide care to mothers and babies (Buckley, 2015). They could be the foundation for important change. Many routine, but unnecessary, interventions could be minimized or even eliminated.
Two new publications offer more evidence to suggest unnecessary interventions are not in the best interests of childbearing women and their babies: Intrapartum Care: Care of Healthy Women and Their Babies during Childbirth (National Institute of Health and Care Excellence [NICE], 2014) and Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care (Buckley, 2015). All those who provide care during the childbirth process should review these publications (links are provided in the references) with consideration of how changes could be made. Banish thoughts that these types of changes are not possible and focus on what could be done. Clinical and administrative leadership teams in each perinatal service should convene groups to identify a timeline andplans for change for various unnecessary practices. Childbearing women should be invited to participate.
The time is right for bold moves. Government and private payers of healthcare are questioning reimbursement for unnecessary interventions and nonevidence-based care. Regulatory agencies and quality organizations are promoting measures to evaluate various aspects ofmaternity and newborn care. Influential professional organizations representing maternity caregivers and consumers have successfully reduced elective births before 39weeks and are promoting changes in practice to minimize unnecessary cesarean birth. Many healthcare consumers and clinicians are ready for change. Consider taking a leadership role in making these changes happen. Recruit others to join your efforts. Mothers and babies will benefit significantly.
The Precautionary Principle Applied to Maternity Care
* rigorously verify benefits of proposed interventions before initiation (new clinical practices, interventions, and technology should be well studied for efficacy and safety prior to adoption)
* limit routine practices to those of proven benefit to mothers and babies
* avoid interventions for convenience of women, providers, or systems
* initially use less invasive measures when actual or potential clinical problems are noted; move to more consequential interventions only as needed
* involve childbearing women as active participants in decision making about their care and make sure they have adequate information at the appropriate literacy level to make healthcare decisions for themselves and their babies.
Adapted from: Buckley, S. J. (2015). Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Washington, DC: Childbirth Connection
References