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By Tania Staras
In 1992 I was a 23-year-old history master’s degree student pregnant with my first child. In the days before the Internet I hunted around for books that would tell me about what was happening to my body and how I might experience pregnancy and birth. I bought a copy of Gordon Bourne’s book Pregnancy. He was an obstetrician; the book was authoritative and authoritarian. As someone trained to critique everything I read, even from my position as an ignorant primigravida, I just wanted to argue with him. I tried other books from the library; I found Balaskas’ work empowering and slightly overwhelming. And then I found A Guide to Effective Care in Pregnancy and Childbirth (Enkin et al 1989). I still have the copy I bought then. It was laid out in a clear and logical fashion, it wasn’t emotive or bossy, it didn’t make presumptions or think it knew my mind or body better than I did. It used clear and unambiguous language to discuss obstetrics and midwifery care and to set out the evidence underlying whole rafts of interventions and actions. It then sorted these into those which were harmful, those which were neutral (no evidence either way) and those which might do good or be efficacious. I found the book powerful and sensible. It also ignited my interest in maternity care; not simply as a pregnant woman who was part of the system, but as a researcher (at that time working on the history of fairgrounds) who had always vaguely assumed that medicine not only did what was ‘right’ but also knew what was ‘right’. The book was a shock because it made clear the extent of practice based on custom, opinion and belief. It made the case for research and evidence to form the bedrock of care rather than rumour and assumption.
The co-author of A Guide to Effective Care in Pregnancy and Childbirth, Murray Enkin, a Canadian doctor who died in June aged 97, was a true polymath whose influence on maternity care and debate has been far-reaching and hugely significant. Most women and healthcare practitioners in the UK today may not recognise his name or may vaguely feel that they have seen it somewhere, but his thinking and writing around care and around evidence-based practice has helped reframe maternity. In the 1980s and 1990s his work with Iain Chalmers and Marc Keirse in producing Effective Care in Pregnancy and Childbirth (Chalmers et al 1989) and the paperback summary, A Guide to Effective Care in Pregnancy and Childbirth gave practitioners and women a language for understanding what worked and didn’t work in maternity practice; and where the evidence was sound, equivocal or downright non-existent. As an extension of this work, he helped to develop the Cochrane Reviews as a way of standardising research synthesis reporting and linking it directly to current debates and policy. His work indirectly helped groups like AIMS to develop a confident and clear approach to issues in maternity care by highlighting the use of sound research and evidence. It also helped to develop a critique around areas of practice that were ill-informed by evidence.
Enkin was born in Toronto in 1924 and did his medical training there, graduating in 1947. He then undertook specialist training in obstetrics and gynaecology in New York before returning to Canada where his professional life was centred. He worked primarily in Hamilton and was one of the founding faculty members of the McMaster University Medical School. As a practitioner in women’s health, Enkin very much believed in the minimisation of intervention, which should be used sparingly. He was a passionate believer in what, in modern parlance, would be described as human rights in childbirth and which he saw as a humanitarian imperative. As has been noted above, he sought to achieve this through the lens of evidence. Working with both McMaster and the National Perinatal Epidemiology Unit at Oxford university, he created frameworks for evidence-based practice and developed the science and art of the randomised control trial, particularly for issues around the emerging speciality of perinatal care. I say ‘art’ deliberately because Enkin was most definitely not a stereotypical scientist. His understanding of broader ethical and philosophical issues was evident in the way that A Guide to Effective Care in Pregnancy and Childbirth was presented; even at the time, I was struck by the language used. Concepts such as ‘harm’ have deep ethical roots in medicine, going back to Hippocrates and the concept of ‘first do no harm’. In harnessing this language Enkin both signalled the historical depth of his thinking but also issued a challenge to practitioners happy to use technology or intervention simply because they could without wider thought for the ramifications. The sophistication of his thinking was undoubtedly aided by his engagement with the reality of practice but also through the intellectual companionship of his wife. Eleanor Enkin (who died in 2019) was a birth photographer who joined Enkin in his sabbatical to Oxford and in his work with Chalmers in the late 1970s. Together they established the Murray and Eleanor Enkin Lectureship, on humanitarianism in health care at McMaster University. They were also involved in and very supportive of the re-development of midwifery as a profession in Ontario in the 1990s.
Enkin was always very clear that any intervention had to do good if it was to be acceptable and that the wishes and expectations of women were central to effective care, not an optional extra. The Effective Care work was pioneering in that it not only considered clinical procedures but also attempted to account for the influence of social factors such as partners in the birth room or one to one midwifery care. For example, evidence suggested that continuous support for women in labour was ‘beneficial’, respecting their choice of place of birth was ‘likely to be beneficial’, there was ‘no evidence’ for routine blood pressure monitoring in labour, directed pushing was ‘unlikely to be beneficial’ and routine shaving and enemas in labour were ‘ineffective or harmful’ (Enkin et al 2001). Enkin and the Guides had the confidence not just to say what did or didn’t work, but also to be honest about where the evidence was lacking or unclear.
Evidence based practice has been a powerful positive force in maternity. It does, however, have issues and cannot solve every dilemma faced. As a midwife I am constantly aware of the paucity of ‘good’ evidence for much midwifery – as opposed to obstetric – practice. This is partly because RCTs (randomised controlled trials) and Cochrane, now seen as the gold standard of evidence, can only measure what can be measured. They leave to one side, unexplored, the huge areas of care which cannot be boiled down to figures and which rely on intuition and that nebulous concept, wisdom, rather than quantifiable data. Although indelibly associated with the concept of evidence and its use in practice, Enkin was aware of its limitations and later in his career began to explore other ways of understanding and developing practice which moved beyond counting and into the philosophy of science.
I still have the copy of A Guide to Effective Care in Pregnancy and Childbirth that I bought in 1992. Inevitability, and rightly, many conclusions have been refined or superseded by more recent research. But the clarity of the thought and the wisdom behind it are a lasting testament to Enkin as is the centrality of good evidence to good care.
Photo credit: McMaster University
Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E, and J Hofmeyr 2001 ‘ Care in Pregnancy and Childbirth: A Synopsis’ Birth 28:1 41-51
Tania Staras, PhD, RM
Principal lecturer in Midwifery
University of Brighton
 Editor’s note: A primigravida is a person who is pregnant for the first time.
AIMS supports all maternity service users to navigate the system as it exists, and campaigns for a system which truly meets the needs of all.
The AIMS Journal spearheads discussions about change and development in the maternity services. From the beginning of 2018, the journal has been published online and is freely available to anyone with an interest in pregnancy and birth issues. Membership of AIMS continues to support and fund our ability to create the online journal, as well as supporting our other work, including campaigning and our Helpline. To contact the editors, please email: firstname.lastname@example.org
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