To Test or not to Test

During a rare quiet moment the other day I stumbled upon this article in the Toronto Star: ‘Over-testing can have a serious downside’. Written by Dr Sacha Bhatia, it’s a quick sum up of a phenomenon we are more than familiar with in the maternity care industry: that more tests and procedures do not equate to better outcomes. His article led me to the website for Choosing Wisely Canada, a new campaign by the CMA and the University of Toronto.  They are encouraging Canadian patients to think for themselves and ask their doctor 4 simple questions:

  1. Do I really need this test, treatment or procedure?

  2. What are the downsides?

  3. Are there simpler, safer options?

  4. What happens if I do nothing?

This is exactly what I encourage my clients to do – use their brain and ask intelligent questions. Think of a simple procedure like the Nuchal Translucency ultrasound most women have around 12 weeks and ask the 4 simple questions.

  1. Do you really need this procedure? This is a test that screens for Down Syndrome and other chromosomal abnormalities. For most women this is the first chance to have a look at their baby and they jump at the chance to do so. But do you really need this procedure? Will you abort a baby with Down Syndrome? If the answer is no then this is not a necessary procedure for you.

 

  1. What are the downsides? If the test indicates abnormalities, you will undoubtedly feel anxious and worried about your baby. The test generally used to confirm any issues is the amniocentesis which is a much more invasive and painful procedure with higher potential risks. So if you agree to the non-invasive NT test, you may find yourself in a position where you are forced to choose to undergo an amniocentesis to alleviate the stress brought on by the first test.

 

  1. Are there simpler, safer options? This test is already pretty safe and simple.

 

  1. What happens if you do nothing? If your baby is fine, then he will continue to be fine. If your baby has chromosomal abnormalities, he will continue to have chromosomal abnormalities.  So this test only affects your peace of mind. It’s up to you to decide if knowledge is power or if you would prefer to stay ignorant.

 

 

So you can see the Choosing Wisely Questions are pretty easy to apply to most maternity tests and procedures.  Take Continuous External Fetal Monitoring in labour:

  1. Do I really need this procedure? This monitors your baby’s heart rate continuously during labour. The research shows that continuous fetal monitoring holds no benefits over intermittent fetal monitoring, and in fact often creates problems. So no, you don’t really need this procedure.

 

  1. What are the downsides? The downside for you is that EFM limits your mobility and forces you to stay in bed or at least in your hospital room. If your hospital has portable wireless units you will have a little more mobility but you will still be expected to stay in range. Being tied down during labour is not ideal. It also steals your thunder, meaning that your caregivers will concentrate on what the monitor is telling them and ignore you.  Sometimes the information on the monitor will indicate fetal distress when there is none. Obstetricians err on the side of extreme caution, so any momentary irregularity in the tracing will cause them alarm.  The research shows that CFM does not actually catch things that IFM does not –but it does appear to cause distress in healthy obstetricians.

 

 

  1. Are there simpler, safer options? Yes, the simpler, safer option is intermittent monitoring with the EFM or even a Doppler.

 

  1. What happens if you do nothing? If your baby is in distress then no one will know. In this case occasional monitoring is the better choice over continuous monitoring or no monitoring.

 

So it’s wonderful that the CMA are on board with this initiative to stop overuse of unnecessary testing in medical care, but what is not wonderful is that

The Women’s Health section does not have a single word about maternity care.

Not a one.

So what’s up with that?

Now, Choosing Wisely had their inaugural meeting at the end of March, 2016, so I guess I should be a little kinder and give them a bit more time, but in the mean time if you feel like I do that there should be a large section on Obstetrics on their website, please visit their site and give them feedback! And please let me know what you said in the comments section below.

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