Title: Does this systematic review arrive at wrong conclusions?
Holistic view of training of intrapartum fetal monitoring and importance
of its content.
Re: Kelly S, Redmond P, King S,
Oliver-Williams C, Lame G, Liberati E et al. Training in the use of
intrapartum electronic fetal monitoring with cardiotocography:
systematic review and meta-analysis. BJOG 2021;
https://doi.org/10.1111/1471-0528.16619.
Dear Editor,
The impressive systematic review by Kelly et al1 using
robust and up-to-date methodology may leave clinicians puzzled. The
American Statistical Association has stated a fundamental principle in
2018, ‘No definitive conclusions should be primarily based on
statistical modelling without wider balanced nuanced reasoning’.
Moreover, 800+ scientists and statisticians pondered, ‘How does
statistics often lead scientists to deny differences clear to
see/experience?’2 Kelly and
co-workers1 after examining 64 studies and 13
randomised-controlled-trials (RCTs) inform obstetricians that there is
failure to demonstrate evidence that training of intrapartum fetal
monitoring (IFM) works, root of a crisis. if some meaningful conclusions
cannot be drawn from five RCTs of reasonable quality showing benefit,
then this goes against the thesis of this review.1 Has
everyone missed some magic formula for a high-quality study showing
definitive benefit of training, especially given that it is difficult to
prove the benefits of IFM itself? The idealistic description in the
review with multiple goals does not seem to offer such a formula.
Focussed studies on specific issues of training or new ideas would of
course be practical and welcome/desirable.
The PROMPT-group3 has made major ground-breaking
contribution establishing multidisciplinary-team-based skills-drill
training. The review1 makes brief mention of some
objections to the content of the training as its scientific validity is
more important for outcomes and litigation. The only high-quality study
of IFM training and practice (by PROMPT-group)3 shown
to improve perinatal outcomes dates to 1998 – 2003, which importantly
taught the contemporary truthful pattern-recognition of centrally
important fetal heart rate decelerations as “majority early
(benign-reflex like head-compression) and minority variable
(cord-compression)”.4 The PROMPT or other groups may
be unable to repeat similar study (definitive proof) because of the
confounding from current substantial pre-existing training. Crucially,
the British guidelines now use an untruthful unscientific
pattern-recognition of “no early and majority variable decelerations”
shown to detect only 30% acidaemic babies under practice
conditions,4 in contrast to the older British
study.3 The review1 is completely
silent about this current “Orwellian reality-control and
double-think”. The St Georges group provides good evidence that their
cardiotocography (CTG) training is well-absorbed by the
trainees.1 However, the so-called physiological CTG
training has been shown as ‘anti’-physiological with major risk to
fetuses.4 Fortunately, simple gut-instinct of the
birth-attendants would over-ride some grossly harmful
training.4
This review1 may have come to a wrong
conclusion/recommendation that, ‘Awaiting better data, CTG-training
should follow the evidence-base for maternity training: local,
multi-professional with integrated teamworking and support-tools’. Most
British hospitals previously held half-day comprehensive IFM training
sessions as local team-based activity like the older British
study,3 but have moved away from these in recent years
(sporadic non-mandatory small-scale CTG-review meetings excluded).
Notwithstanding the consclusions1, most
birth-attendants are now mandated to complete approved web-based IFM
training-modules once a year individually commonly in the comfort of
their homes. Most British hospitals have pragmatically adopted these
centralised all-inclusive on-line IFM training programmes (not just
support-tools) because of several obvious practical and quality
advantages; and are not seeking a high-quality study proving superior
perinatal outcomes, whether realistic or not.
Disclosure of interests: No conflict of interest or funding to
declare.