Are consumers at the bottom of the evidence pyramid?

January 17th, 2010 by avatar

I have argued (herehere, and here) that strategies that involve increased participation by women and families in maternity care hold major potential for improving our rather dismal maternal and infant health outcomes.

A study reported in the current issue of The International Journal of Gynecology & Obstetrics highlights a major obstacle to implementing consumer-led health strategies: lack of comparative effectiveness research supporting their use.

The researchers analyzed all Cochrane Systematic Reviews addressing pregnancy, childbirth, newborns, or children up to age five. They categorized each systematic review by the level of consumer involvement versus health care system involvement the intervention required. They found that 62% of Pregnancy and Childbirth reviews, 94% of Neonatal reviews, and 71% of Children’s Health reviews addressed interventions that involved no consumer participation, such as cesarean surgical techniques, or intensive care treatments. Interventions that could be implemented within the community (such as nutritional programs) or that involved woman- or family-centered health care (e.g., labor support techniques, family-centered pediatric approaches) were far less likely to be studied. The researchers concluded:

The vast majority of research is performed on interventions that are solely in the realm of the providers. Maternal and child health research needs to be directed toward innovative interventions involving consumer participation, particularly those that can be implemented in middle- and low-income countries where the accessibility and quality of the health systems are poor.

This study highlights one of the major systemic biases we see in research. When so much of our research comes from academic medical institutions, what happens outside of those institutions – even if it has a far greater potential impact on the health and wellbeing of the institution’s beneficiaries – doesn’t get studied much. Nor do interventions that can happen within institutions (e.g. doula support in labor) but challenge the institutional hierarchy, which too often puts patients and families at the bottom.

One area in which we need far more research is perinatal education. Few studies evaluate strategies to educate, engage, and inform women. In addition, according to a review in the current issue of The Journal of Perinatal Education, even when researchers do evaluate perinatal information giving and education, they tend to evaluate approaches that accommodate medical concepts of efficiency (e.g. leaflets or DVDs) rather than meet women’s own stated needs and preferences (e.g. opportunities to discuss options in depth with their care providers or in small peer groups facilitated by knowledgeable professionals).

Pregnant women and new mothers are avid seekers of health information – online, in childbirth education classes, from health care providers, and in their communities. This natural impulse to take responsibility for their health, connect with other women, and engage in their care is currently being overwhelmed by the application of one-size-fits-all maternity care policies, including mandated cesarean surgery for women with risk factors or more subtle threats to autonomy like restricting mobility, denying access to food and drink, and excluding family members and other support people from care settings.

Empowered, informed, engaged consumers, individually or collectively, can be effective at overcoming these barriers to safe, effective care. In fact, it sometimes seems to be the only force driving meaningful change. Fifty years ago, the American Society for Psychoprophylaxis in Obstetrics (now Lamaze International) helped lead a charge to let fathers into the delivery room and challenged the harmful, demeaning childbirth routines that prevailed as standard practice. Just last month, CNN reported the happy outcome for a woman who avoided cesarean surgery she did not need or want. In advocating for her own care, she has inspired a generation of other women facing vaginal birth bans in their own communities.

Consumers are the least powerful contingent in the health care system, even though our knowledge, attitudes and actions could be the most important influence on our own health and safety. It’s time for major paradigm shifts in research, policy, and practice.


Belizán, J. M., Belizán, M., Mazzoni, A., Cafferata, M. L., Wale, J., Jeffrey, C., et al. (2010). Maternal and child health research focusing on interventions that involve consumer participation. International Journal of Gynecology & Obstetrics, 108(2), 154-155.

Nolan, M. L. (2009). Education and information giving in pregnancy: A review of qualitative research, The Journal of Perinatal Education, 18(4), 21-30.

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  1. | #1

    Amy, so glad to see this post! I’m going to begin an “Intro to Birth Options” here in the Chicago, IL area next month and can’t wait to read more of the research cited in your article to add to my presentation. Thanks, as always, for an insightful post that will help educators give parents the tools to empower them to make informed decisions.

  2. | #2

    I think it goes way beyond the maternity services – the culture you speak of exists throughout medicine. Patients are “cases” who have procedures “done to” them – this is much easier for doctors than actually engaging the patients in decision making.

    One thing the NHS (in the UK) is doing well is establishing a network of breastfeeding support groups, where pregnant and new mothers can speak to more experienced mothers about infant feeding, birth and anything else they are curious about. Mothers talking to mothers is such a powerful way to transmit information. I suppose LLL might perform a similar function in the US.

  3. | #3

    Thanks Amy for this great post about the role of consumers in improving maternity care! The Big Push for Midwives Campaign is a consumer led group of advocates who support expanding access to Certified Professional Midwives and out-of-hospital maternity care.

    We are engaged and empowered to educate the public and policymakers about the reduced costs and improved outcomes associated with out-of-hospital maternity care and Certified Professional Midwives. Ensuring that care provided by CPMs is safely and legally available empowers women; those who opt for out-of-hospital birth with a CPM as well as those who choose to give birth in a hospital.

  4. | #4

    I can’t agree with this post more. I’ve noticed this as I’ve tried to find research on how to help a woman emotionally through labor and birth. It’s frustrating, because there isn’t much out there. I found that while I was researching pushing positions the same thing was true. While I found numerous articles on the procedures done and the physical outcomes, there wasn’t much on how to help the women emotionally, or what she can do to help herself.

  5. avatar
    Carol Van Der Woude
    | #5

    As I read your post, Amy, I recalled a small study that was done in Chicago. The Chicago Health Connection had a pilot project during 1996 – 2000. Doulas worked with single, low income teens. There was a significant decrease in the rated of c-section, epidurals and an increase in breastfeeding. The site is:
    http://www.rwj.org/reports/grr/029806.htm We need more patient centered studies!

  6. | #6

    Carol – your comment made me realize that I shouldn’t have suggested that there is a lack of research on doula care. There are quite a few studies and a Cochrane systematic review showing benefits and no risks. We do need more doula research conducted in the current obstetric climate, however, as well as research on specific support techniques or approaches to doula care.

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