When Evidence Fails to Change Practice: Examining the Persistence of Continuous Fetal Monitoring

Using scientific evidence to guide medical practice seems self-evident but, in certain specialties, it has proven difficult to realize. Use of continuous electronic fetal monitoring (cEFM) during labor is a case in point: research has shown that when compared to intermittent auscultation (IA), use of cEFM in uncomplicated labors of healthy women offers no clinical benefit and may result in unneeded interventions, and yet it remains common practice in obstetric care. In this study, we used observations on a labor and delivery unit and interviews with key informants to investigate the factors that drive the use of cEFM in the face of contrary evidence. Our observations of clinician behaviors regarding the use of cEFM and documentation of the effect of unit workflow on decisions about monitoring allowed us to identify several factors that drive the non-evidence-based use of cEFM. These include fear of liability, training, hospital unit policies, perceptions of patient desires, and workflow on the unit. What we learned about the continued use of cEFM offers insight into other instances where evidence fails to be implemented in practice. Our recommendations for how to align fetal assessment during labor with research evidence include more and better education about modes of fetal assessment for expectant parents and clinicians, hospital policies that encourage reflection on research evidence when making clinical decisions, attention to the way policies and protocols discourage use of IA, and making visible the clinical and economic benefits of evidence-based practice.