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Heuristics may trump clinical evidence in the delivery room

Data from 86,000 US deliveries suggest that if the prior patient had complications in one delivery mode, the physician will be more likely to switch to the other — and likely inappropriate — delivery mode for the subsequent patient, regardless of patient indications, found a study in Science.

Clinical decisions made in the delivery setting as to whether to employ vaginal delivery or Caesarean section are often made under high pressure, and with great uncertainty, and have serious consequences for mother and baby. Manasvini Singh, health economist at the University of Massachusetts Amherst and author of the study, says physicians may sometimes rely not on scientific evidence, but on heuristics, or simplified decision rules, to aid complex decision-making, to determine their course of action, ultimately with sub-optimal effects on patient health.

Singh, an assistant professor of resource economics, analysed inpatient electronic health record data across 21 years at the obstetric wards of two academic hospitals, one large and urban, the other small and suburban. Overall, the data cover 86,345 deliveries by 231 physicians, and she looked for complications such as obstructed labour, postpartum haemorrhage, foetal distress, perineal laceration, umbilical cord complications and obstetric trauma.

She found that depending on the model specification, complications in a prior Caesarean delivery make the physician 0.6-2.4 percentage points more likely to switch to a vaginal delivery for the next patient, representing an increase of up to 3.4% in the probability of a vaginal delivery. Conversely, complications in a prior vaginal delivery make the physician 0.1-1.1 percentage points more likely to switch to a Caesarean for the next patient, representing an increase of up to 3.6% in the probability of a C-section delivery.

“Imagine that a patient’s vaginal delivery incurs a complication,” Singh said. “The doctor’s next patient now arrives for a vaginal delivery. Because of complications in the prior vaginal delivery, the physician will have a lower threshold, and therefore higher inclination, for deploying an emergency C-section during this next patient’s vaginal delivery, even if a Caesarean is not clinically indicated for that patient. As a result, this next patient will be more likely to deliver via C-section.

“Now, imagine the converse example. The physician’s prior patient has a Caesarean that incurs complications. Assume the next patient comes in for a vaginal delivery. Because of complications in the prior Caesarean delivery, the physician has a higher threshold, and therefore lower inclination, for deploying an emergency C-section during the vaginal delivery, even if a Caesarean is clinically indicated for that patient. As a result, this next patient will be more likely to deliver vaginally.

“There is no clinical reason why the delivery decisions for two separate patients, linked only by the accidental chance of being seen consecutively by the physician, should be causally related to each other,” Singh writes. “However, when faced with the complex decision of deciding whether the current patient is suited for a vaginal or a Caesarean delivery, physicians may instead be influenced, sub-optimally, by the outcome of the decision they made for their previous patient.”

Singh says that there are three reasons why physicians’ use of such heuristics is especially concerning.

“First, the serious and long-term effects of inappropriate delivery mode choices on the health of mother and child are well documented, making the use of heuristics especially risky,” she says. “Several global campaigns have even been launched to make delivery decisions more evidence-based. Second, switching delivery modes after a complication does not offer any guaranteed benefits, making it a potentially flawed rule.

“There is no evidence that switching delivery modes after a complication avoids further complications. Finally, patients are usually more averse to having inappropriate procedures performed on them than they are to receiving unnecessary tests, which suggests that we should hold greater reservations about the use of heuristics in this setting.

“Even without further evidence of patient harm, such deviations in delivery mode choices should be concerning given the long-term harm that inappropriate obstetric choices cause mother and baby.”

Study details

Heuristics in the delivery room
Manasvini Singh

Published in Science on 15 October 2021

Decisions about delivery
Heuristics, or simplified decision rules, have been found to influence decision-making in several settings. Singh found that when patients experience a complication during birth either via vaginal or Caesarean delivery, their doctors are more likely to switch to the opposite delivery mode for their next patient’s birth. There is also evidence that this heuristic may lead to worse patient outcomes.

Abstract
Clinical decisions made in the delivery setting are often made under high pressure and great uncertainty, and have serious consequences for mother and baby. Theories of decision-making suggest that individuals in such settings may resort to using heuristics, or simplified decision rules, to aid complex decision-making. This study investigates whether physicians’ delivery mode decisions (i.e., when to perform a vaginal versus a cesarean delivery) are influenced by such a heuristic.

Electronic health records spanning 86,000 deliveries suggest that if the prior patient had complications in one delivery mode, the physician will be more likely to switch to the other—and likely inappropriate—delivery mode for the subsequent patient, regardless of patient indications. There is evidence that this heuristic has small, suboptimal effects on patient health.

 

Science abstract – Heuristics in the delivery room (Open access)

 

See more from MedicalBrief archives:

 

If a doctor barely knows who a patient is, the consequences can be profound

 

Surge in the number of C-sections around the world

 

Induction at 39 weeks lessens likelihood of C-section

 

 

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