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Decision-making & uncertainty in health – why more research doesn’t always help

Updated: Nov 8, 2018

by Tari Turner

Globally, postpartum haemorrhage (bleeding after giving birth) is a major killer of women, the biggest cause of maternal death and responsible for many tens of thousands of deaths each year. In well-resourced settings, deaths from postpartum haemorrhage are rare, largely because an injection of oxytocin is all that is needed to prevent bleeding and save lives.

So it seems obvious that we should be making sure that oxytocin is universally available – that would solve the problem, right? Well, no, actually. While there is certainly a case for improving access to oxytocin, to be effective it needs to be kept refrigerated and be delivered by injection requiring a skilled health worker. Both fridges and skilled health workers can be hard to find in many health settings. So for those settings another approach is needed.

It feels like we had just about settled on that other approach – misoprostol. Misoprostol comes as a tablet, and doesn’t require refrigeration. Excellent. It’s not as effective as oxytocin, and has some side effects, but it’s definitely better than nothing in settings where the alternative is nothing. But…

The big "but" for misoprostol is that if it is taken prior to delivery, that is, earlier in pregnancy, it can result in miscarriage. Health policy makers have been understandably concerned about this risk.

To overcome these concerns, the health community has spent the last 10 years developing, piloting and testing ways to safely get misoprostol into the hands of the women who need it. This has meant setting up procurement systems, training community health workers and many, many rounds of discussion with communities and decision-makers. It was a lot of work, but progress was being made. And now…

And now a bright, shiny, new trial has been published in The Lancet that throws a spanner in the works. The WOMAN trial (I love a good acronym) included more than 20,000 women in 21 countries. It found that a simple chemical, transexamic acid, substantially reduced death due to bleeding after childbirth. Obviously this is a huge win. But…

The thing about this study is that transexamic acid was delivered by injection, which kind of gets us right back to where we started. The authors, and there are a lot of them, acknowledge this and “urge” further research to see if transexamic acid can be effectively delivered in other forms, but for now we just don’t know.

So where does that leave us?

While the WOMAN trial is potentially a fantastic step forward for treatment of postpartum bleeding, it’s only a slight exaggeration to say that for decision makers wanting to know how to develop health systems to combat deaths from bleeding, in the developing world where most of them happen, it’s essentially useless.

Could transexamic acid be the next big thing in treating bleeding and save thousands of new mum’s lives? Possibly, but it’s definitely not ready for a community health worker to pick up of the shelf just yet. And while we wait to find out, decisions still need to be made because, devastatingly, women will keep on bleeding to death in the meantime.

This situation is a big deal in itself, but it also highlights a more pervasive issue.

We are all (myself included) very quick to proclaim the merits of using research evidence to support health decisions. Evidence-based decision-making is, appropriately, the order of the day. Decisions about how we deliver healthcare and what healthcare we deliver should be informed by the best available research evidence. But the reality is always more complicated that how it is described on the box.

Ideally research should enable decision makers to make well-informed, evidence-based decisions by reducing uncertainty. By ruling out options that have been shown to be ineffective and providing support for demonstrably effective options, research should bring clarity and focus to healthcare choices.

The postpartum haemorrhage example highlights that this isn’t always the case. Research doesn’t and shouldn’t always make our decision making processes simpler. Sometimes good research brings new options to the table, sometimes it contradicts previous thinking, sometimes it shows us that the truth is a good deal more complex than we would like it to be.

The truth, however, remains the truth, and research remains our best tool for discovering it.

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