Evidence-Based Midwifery Practice
In 2003, I had the privilege of attending the Cochrane Colloquium in Lyon, France. This is the annual meeting of the Cochrane Collaboration, an international, non-profit organization which makes available up-to-date, reliable information about the effects of interventions used for prevention, treatment, and rehabilitation in health care.
I was very excited to be a part of this event because I have been interested in the Cochrane Collaboration ever since I realized how strongly their systematic reviews of the research literature support the midwifery model of care. The participants at the meeting represented many countries and health-care disciplines. They work as volunteers to carry forward this very important work. The tone of the colloquium was very egalitarian – name badges had only names, not initials or credentials – and there were a number of participants from developing countries, many of whom were there with scholarship assistance from the organization. There were workshops for beginners,so I could attend, listen, learn, and not feel like a total ignoramus. I learned a lot, and everything I learned reinforced my admiration for this initiative. I hope to get involved in some of the activities of the Collaboration, and I hope that this report stirs other midwives to get involved as well. At the very least, I would urge you to visit the websites I have listed, to familiarize yourself with the reviews of the Pregnancy and Childbirth Group, and to use this information and other research evidence in your midwifery practice. Following is some information about the Collaboration. If you want to find out more, check the links.
The Cochrane Collaboration emerged in response to criticism of the medical profession by a British physician and epidemiologist, Archie Cochrane (1900-1988), who drew attention to our collective ignorance about the effects of many aspects of health care, and suggested that we all need up-to-date, unbiased analyses of reliable and relevant research studies. Cochrane realized that no individual can be expected to sift through these mountains of evidence to try to find out which forms of health care are more likely to do good than harm.
The Cochrane Collaboration was inaugurated less than a decade ago, but it has grown very rapidly. The first systematic reviews were in the area of pregnancy and childbirth, as the collaborators felt obstetricians were most likely to ignore research evidence in the practice of their specialty. There are now several thousand people in over 60 countries, mostly volunteers, contributing to reviews in almost every area of health care. The Collaboration is governed by an elected, 14-member steering group, which is supported by a small secretariat.
The Cochrane Collaboration is currently focusing on health problems prevalent in developing countries and which are common among poor people. Several reviews on these diseases are made possible through support from the United Nations and the UK Government Aid Programme.
The reviews are published in The Cochrane Database of Systematic Reviews, and can be revised and updated every three months if necessary. The Cochrane Database of Systematic Reviews is one of several databases contained in the Cochrane Library, an electronic product that is published quarterly on CD-ROM and the internet. The Cochrane Library has been widely acknowledged as the best single source of evidence about the effects of healthcare interventions. It is available in medical school libraries, many hospital libraries and some public libraries, as well as by subscription to individuals. You can get more information on the Cochrane website.
What kind of questions can the reviews answer for you?
Examples of questions that can be answered by a Cochrane review are,
- What is the best treatment for epilepsy?
- Does “kangaroo mothering” reduce morbidity in low birthweight babies?
- Does continuous support of the mother during labor improve obstetric outcomes?
- Should women with normal pregnancies be cared for by obstetric specialists?
Examples of healthcare problems that the reviews are not helpful with include
- General healthcare questions (causal, prognosis, epidemiology, etc)
- Statistics (prevalence and incidence)
- Primary research other than RCTs and CCTs
- Current research
The Cochrane Pregnancy and Childbirth Group publishes the Guide to Effective Care in Pregnancy and Childbirth, now in its third edition and available in five languages – English, Czech, German, Japanese, and Russian. Their website is at http://www.update-software.com/ccweb/cochrane/revabstr/g010index.htm.
The Cochrane Consumer Network leads the organization’s efforts to help people make well-informed personal health decisions, and to increase community knowledge about the effects of health care. The consumer website (http://www.cochraneconsumer.com) develops short consumer summaries of Cochrane reviews in collaboration with the reviewers.
http://www.ucsf.edu/sfcc/ is the website for the US Center for the Cochrane Collaboration, based at UCSF in San Francisco.
Other helpful websites on evidence-based medicine:
http://www.biomedcentral.com; BioMed Central contains online journals which publish peer reviewed research across all area of biology and medicine, with immediate, barrier-free access for all.
http://www.biomedcentral.com/1471-2393/about; BMC Pregnancy and Childbirth (ISSN 1471-2393) is an online journal publishing research articles after full peer review. All articles are published, without barriers to access, immediately upon acceptance. The journal is published by BioMedCentral Ltd, Middlesex House, 34-42 Cleveland Street, London W1T 4LB, UK.
http://intl.highwire.org/lists/freeart.dtl; Free Online Full-text Articles
http://goldenhour.co.il/; this Israeli site is a “medical gate” for the daily use of physicians and researchers in all fields of medicine. Their goal is to promote and improve the practice of evidence-based medicine. Has a section on statistics for the non-statistician, a list of search engines, links to the best evidence-based medicine sites and to sites that publish clinical practice guidelines, pearls for the Palm (Pilot)…
http://www4.ncbi.nlm.nih.gov/PubMed/; PubMed, a service of the National Library of Medicine, provides access to over 11 million MEDLINE citations back to the mid-1960’s and additional life science journals. PubMed includes links to many sites providing full text articles and other related resources.
http://www.pubmedcentral.nih.gov/; PubMed Central is a digital archive of life sciences journal literature managed by the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM). It is not a journal publisher. Access to PubMed Central (PMC) is free and unrestricted.
http://www.nelh.nhs.uk/; The National Electronic Library for Health Programme is working with NHS Libraries to develop a digital library for NHS staff, patients and the public. This is a pilot website.
http://www.medibank.com.au/cochrane/quicksearch/search.asp; a gateway to the Cochrane Consumer Network. The Cochrane Consumer Network is a non- profit organization that aims to help people make informed decisions about health care. Cochrane health reviews are summaries of trials on health care treatment, advice or self-care. There are reviews of both conventional and complementary (alternative) therapies, as well as health system and policy issues.
http://www.liv.ac.uk/lstm/ehcap/evidenceupdate_pregnancychildbirth.html; Evidence Update provides you with the essential information from those Cochrane Reviews that look at healthcare interventions relevant to people living and working in low and middle-income countries. These two page summaries are in a user-friendly format. They will guide through the systematic review process and help you understand the results and implications for practice. At the moment, there are not a lot of topics covered, but this site promises to be very useful as it is developed.
http://www.liv.ac.uk/lstm/bbimainpage.html#purpose; The Better Births Initiative is a project of the Effective Health Care Alliance Programme (EHCAP), a DfID funded work programme co-ordinated from the International Health Division, Liverpool School of Tropical Medicine. Effective basic care at delivery improves survival of mothers and their infants. Reliable research evidence provides midwives and doctors with knowledge to improve services, but the challenge is converting this to action. Descriptive studies in several countries have shown that obstetric care quality could be dramatically improved if health workers focus changing practice around a handful of routine procedures.
The Better Births Initiative aims to improve care though better use of available evidence. It focuses on a few procedures that are important to health and women’s experience of labour, and where change can happen with existing resources.
Care should be humane and comfortable for women. An added advantage is that this will enhance the reputation of the service, encourage women to attend, and contribute to better health in the mother and baby. Greater use of services is a key step in reducing the half a million maternal deaths in developing countries each year.
The Better Births Initiative began in 2000, and has been adapted for implementation in a variety of settings, including services in South Africa, China and Zimbabwe. It has been developed by a network of individuals that want to see obstetric care in developing countries change for the better.
http://www.shef.ac.uk/~scharr/ir/netting/; Netting the Evidence is intended to facilitate evidence-based healthcare by providing support and access to helpful organisations and useful learning resources, such as an evidence-based virtual library, software and journals.
http://www.jr2.ox.ac.uk/bandolier/; Bandolier is a print and Internet journal about health care, published at Oxford University, using evidence-based medicine techniques to provide advice about particular treatments or diseases for healthcare professionals and consumers. The content is ‘tertiary’ publishing, distilling the information from (secondary) reviews of (primary) trials and making it comprehensible.
Helpful texts on Evidence-Based Midwifery:
Guide to Effective Care in Pregnancy and Childbirth, Third Edition; Enkin M, Keirse JM et al, Oxford University Press, 2000.
Obstetric Myths Versus Research Realities: A Guide to the Medical Literature; Goer H, Bergin & Garvey, 1995.