Um, how the hec do I make ‘evidence based birth choices’?!

In an extract from the Positive Birth Book, Milli Hill gives the information every pregnant woman needs.

You might be familiar with the idea of making decisions in pregnancy or labour that are ‘evidence based’. This generally means that the decision is founded on the best research that has been done on the topic. For example, if you are going to be induced because you are 42 years old and have been told that it’s not recommended that you go past 40 weeks pregnant, you want to know how your doctor or midwife knows this to be true.

You want to know that somebody, somewhere has looked into this and studied loads of knackered old pregnant women like you and worked out that induction definitely is the safest and best decision you can make.

You want to know that their recommendation has an ‘evidence base’. In other words, that their house of advice is build on sturdy and robust foundations. It’s not just a random opinion. Make sense?

Of course, if there really was just a nice kindly boffin somewhere, studying a group of 40-something preggos and noting on his clipboard why the 50% who got induced had a fabbydabby birth and the other half all died an unspeakable death, then this whole evidence based birth thing would be super simple. Clear cut, black and white, and really really helpful.

Unfortunately, it’s a bit more complicated than that. The fact is, there are kindly boffins all over the world researching every angle of pregnancy and birth on a regular basis. This research is conducted in different ways, with different sized groups of people, in different parts of the world, in different decades of history. Some of this research may ask one question – for example, do we get a better outcome for the baby when we induce women over 40? – but not ask another question – for example, did the women in the study know their midwife or not? So we won’t ever know if those women who had poor outcomes in that particular study might have had better outcomes if they had been looked after by someone they had met before, and who they really trusted.

In other words, all evidence is created equal, but some is more equal than others. The Royal College of Obstetricians and Gynacologists (RCOG) deals with this by grading their guidelines according to how strong the evidence they are based on actually is. Grade A, for example, is what they consider to be top quality evidence, usually based on something called a Randomised Controlled Trial – that’s where similar people get different interventions (or none) and the results are compared. Then Grades B and C are based on less strong evidence like reviews of the existing literature on a topic, and finally Grade D is given to the guidelines based on case reports and expert opinion.

Shockingly, only about 9% of the RCOG guidelines are based on Grade A evidence! And even more shockingly, only about 50% of their guidelines are based on Grade B, C and D evidence! Hang on a mo, I hear you say, that leaves about another 40% of their guidelines unaccounted for, what evidence are they based on?! Here’s a revelation for you. They’re not based on any evidence. 40% of the guidelines are based on the recommendations of the people who develop the guideline, according to their clinical experience. In other words, they are based on opinion, not evidence.

The reason I’m taking you on this slightly complex tour through the workings of RCOG is to get across a wider point: even the top experts in birth and evidence don’t have all the answers. If you’re pregnant, it’s important to keep asking questions of your care providers, and try to find out on what evidence they are basing the advice they are giving you. It’s also important to know that even if the advice is based on a particular piece of evidence, it doesn’t automatically mean that that evidence is top quality. And it’s also possible that the advice you are being given is based on no evidence at all, just personal opinion.

Of course, just because we don’t have the research to back up our opinion, doesn’t make it automatically wrong, either. Midwives and obstetricians who spend their working lives dealing with labouring women will have a huge amount of knowledge and lived experience that we need to respect and trust. In emergency situations in particular, we will always be glad to be in their capable hands. But if there is not an emergency, it’s really ok to ask questions and do your own research on your options.

When making pregnancy choices, it can be really hard to get a clear picture or decide on the right course of action. There is rarely a situation that is ‘black and white’. Even if there is a really robust study about your particular dilemma, this study didn’t include a very important person – you! Every woman is different. You might be over 40 and in the pink of health, really physically fit, totally confident in your body and in a geographical area that offers one to one midwifery care. Or you might be over 40, obese, diabetic and really worried about giving birth in your local overstretched obstetric unit. You need to think about your own personal circumstances, and also factor in how you intuitively feel about this birth, in your heart of hearts. That’s not very evidence based, you might say, but then again, neither are some of the RCOG guidelines.

If you want to take a look at some of the evidence for yourself, here are some suggestions for good resources.

Your health care provider. The person recommending a certain course of action should be able to point you to the evidence upon which this suggestion is based.

NICE guidelines. These guidelines are put together by teams of academics, professionals and service users, are based on the best available evidence, and are regularly reviewed and revised. NICE is a UK public body and part of the Department of Health; however, practitioners in many other parts of the world look to NICE to find the best standards of practice, so, if you are reading this book and are beyond the UK, you may still find NICE guidelines useful and highly applicable to your situation. Particularly useful is CG190. Google ‘NICE CG190’ or search for “NICE guideline _____’ and fill in the blank with the issue you need more information about. Alternatively visit and use their search box – select NICE guidelines in the dropdown menu.

Cochrane Reviews. Cochrane reviews are internationally recognised as the highest standard in evidence-based health care resources. Search in google for ‘Cochrane review ______’ and fill in the blank with the issue you want to know more about, eg ‘Cochrane review induction of labour’. Alternatively visit and use the search box.

RCOG Green-top Guidelines. Guidelines for UK obstetricians on pretty much every pregnancy and birth scenario. Visit and use their brilliant search facility, either to search the Green-top Guidelines, or explore the drop down menu to find other guidelines and reports, including the NICE guidelines.

ACOG and SOGC. The American College of Obstetricians and Gynacologists (ACOG) and the Society of Obstetricians and Gynacologists of Canada (SOGC) have practice bulletins and guidelines that can be found at and respectively.

Which? Birth Choice. Want to know how your local hospital compares to the national average when it comes to everything from numbers of caesareans to your chances of having stitches? Find information about where to give birth and a wide range of stats on all of your nearest units, searchable by postcode at

Evidence Based Birth. American website written by researcher Rebecca Dekker, which give a really accessible overview of the evidence relating to many of the major birth choices and dilemmas.